Tatiana Falcone (editor) - Suicide Prevention: A Practical Guide for the Practitioner
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Suicide Prevention: A Practical Guide for the Practitioner: summary, description and annotation
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This volume is a guide for the hospital workforce related to suicide prevention. Written by experts in the field, this text is the only one that also includes the revised DSM-5 guidelines. It is also the first to cover both prevention in one concise guide, offering a well-rounded approach to long- and short-term prevention.
The book begins by establishing the neurobiology of suicide before discussing the populations at risk for suicide and the various environments where they may present. The book addresses the epidemiology, including groups at heightened risk; etiology, including several types of risk factors; prevention, including large-scale community-based activities; and postvention, including the few evidence-based approaches that are currently available. Unlike any other text on the market, this book does not simply focus on one particular demographic; rather, the book covers a wide range of populations and concerns, including suicide in youths, racial minorities, patients suffering from serious mental and physical illnesses, psychopharmacological treatment in special populations, and a wide array of challenging scenarios that are often not addressed in the very few up-to-date resources available.
Suicide Prevention is an outstanding resource for psychiatrists, psychologists, hospitalists, primary care doctors, nurses, social workers, and all medical professionals who may interface with suicidal patients.
The book begins by establishing the neurobiology of suicide before discussing the populations at risk for suicide and the various environments where they may present. The book addresses the epidemiology, including groups at heightened risk; etiology, including several types of risk factors; prevention, including large-scale community-based activities; and postvention, including the few evidence-based approaches that are currently available. Unlike any other text on the market, this book does not simply focus on one particular demographic; rather, the book covers a wide range of populations and concerns, including suicide in youths, racial minorities, patients suffering from serious mental and physical illnesses, psychopharmacological treatment in special populations, and a wide array of challenging scenarios that are often not addressed in the very few up-to-date resources available.
Suicide Prevention is an outstanding resource for psychiatrists, psychologists, hospitalists, primary care doctors, nurses, social workers, and all medical professionals who may interface with suicidal patients.
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Tatiana Falcone (editor)
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Part I
Introduction
Introduction
Springer International Publishing AG, part of Springer Nature 2018
Tatiana Falcone and Jane Timmons-Mitchell (eds.) Suicide Prevention1. Neurobiology of Suicide
Tatiana Falcone 1
(1)
Epilepsy Center/Psychiatry Department, Neurological Institute - Cleveland Clinic, Cleveland, OH, USA
(2)
Neurologic Institute, Cleveland Clinic, Cleveland, OH, USA
(3)
Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
(4)
Pontificia Universidad Javeriana, Bogota, Colombia
Tatiana Falcone (Corresponding author)
Email:
Migle Staniskyte
Email:
Fernando Espi Forcen
Email:
Jaime Vengoechea
Email:
Contributed equally
Keywords
Suicide Cytokines Adolescents Biomarkers Inflammation Neuroinflammation# Equal Contribution
Introduction
Suicide is a serious global mental health problem. Every 40 seconds a person takes their own life, meaning that at least 800,000 suicides occur worldwide every year []. Despite major advances in identifying risk factors, little is known about how these factors may interact with each other, or what biological triggers may influence suicidal behavior, therefore making suicide very difficult to predict at an early stage.
Epidemiology
In the last 45 years, the rate of suicide has increased by 60%. In 2008, the number of deaths by suicide exceeded the number of deaths by homicide (535,000) and war (182,000) combined [].
The lifetime risk of suicidal ideation is 13.5%, the lifetime risk of suicidal ideation with a plan is 3.9% and the lifetime risk of suicide attempts is 4.5% [].
To date, suicide is a major public health problem. Around 80% of patients who died by suicide denied suicidal ideations during their last communication with the hospital or health-care provider [].
Clinical Predictors of Suicidality
Over the last 20 years, research has u ncovered important clinical factors for risk and protection of suicide [].
It remains unclear how patients transition from having suicidal thoughts to attempting suicide. Interpersonal negative life events in the week prior to the SA have been identified as an important influencing factor in these adolescents [].
Neurobiology
Recently, more attention has been given to the biological mechanisms of suicide. Among various studies, the discovery of low 5-HIAA levels in the cerebrospinal fluid (CSF) of suicide attempters opened a gate to a bulk of research in this direction over the last decade. Today, most of the research studies have focused on the role of serotonin abnormalities in suicide , other possible theories are also investigated; the stress-induced response involving the hypothalamic-pituitary-adrenal axis, the locus coeruleus norepinephrine system, and the opioid endogen system and the role of inflammation are pieces that complete the puzzle in the complex neurobiological mechanism of this pathology. The field goals have changed with the information learned from genetic studies, where similar genes might be involved in different psychiatric disorders and similar specific symptoms might have common specific biological pathways. Also other environmental factors such as stress and adverse childhood ex periences which can alter the neuroimmune network in youth can predispose to suicide later in life.
From some of the neurology research, we have learned that the initial changes in the brain from many of the neurological diseases can appear years (even decades) before the initial symptoms appear. In psychiatric disorders, changes in the brain appear many years before, we are observing any clinical symptoms. Early stress and inflammation can slowly impact the neurovascular unit, trigger neuroinflammation, and continue the cycle, altering the blood-brain barrier, perpetuating the neuroinflammation and the psychiatric symptoms.
One of the first articles to explai n the role of inflammation in mental illness was published in 1947 at the psychosomatic medicine journal; in the paper, Harry Freeman and Fred Elmadjian found a decreased lymphopenic response to glucose administration in subjects with psychosis vs. controls. Since the discovery of cytokines in 1957 as proteins secreted by cells that signal an inflammatory response, the role of inflammation in mental illness has been an object of study in psychiatry.
Biomarkers of Suicidality
Multiple studies have evaluated bi ochemical, genetic, and epigenetic changes in patients who had completed suicide [].
Serotonin
Decreased levels of serotonin have been reported in suicidal patients. Some of the initial neurobiological studies of suicide evaluated the serotoninergic system, in the brain or in tissue. Perhaps serotonin is one of the most studied neurotransmitters in patients with mood disorders and suicide. It is still not clear, if some of the findings in the serotonin abnormalities are related to depression or are specific to suicide [].
Historically, low levels of 5 hydroxiindolacetic acid (5 HIAA) were first described on the CSF of patients with serious suicide attempts [].
The investigators concluded that lower levels of 5-HIAA in the CSF of suicidal patients predicted higher risk for suic ide in the future and also that patients with lower levels of 5-HIAA were more likely to attempt suicide using more violent means [].
In a similar study, 211 adolescents who had attempted suicide were evaluated using psychometric scales to evaluate violen ce, aggression, depression, impulsivity, and anxiety. The levels of 5HT were measured in the blood and were found to be lower in the control group. Authors concluded that lower levels of 5HT combined with psychometric measures could potentially be a peripheral marker to help stratify the risk among adolescents reporting suicidal thoughts [].
Some studies in the serotonin receptor and the serotonin transporter (SERT) have also described pre- and postsynaptic changes in the prefrontal cortex of those who had committed suicide; other groups that tried to replicate the same finding were unable to replicate the study [].
Another important point in favor of the serotonergic theory was the study on patients who had attempted suicide (especially those with high lethality attempts) and the poor response to the fenfluramine challenge, an indicator of central serotonin activity, independent of the psychiatric diagnosis [].
Noradrenergic System and Suicide
There is some evidence of an important relationship between the levels of stress and suicidal ideation. The noradrenergic system is a key regulatory component of the stress response. Some postmortem studies have demonstrated increased mRNA expression of alpha 2A-adrenoceptors, serotonin receptors, and mu-opioid receptors in the brain of suicide victims [].
Dopamine
Is not clear yet if dopamine plays a crucial role in suicide, other than some of the reports of lower regulation of dopamine in the patients with MDD [].
Acetylcholine
At present, there is no co nclusive evidence that changes in the cholinergic activity have a role in suicidal behavior [].
Neurotrophins and BDNF
Stress as one of the important mechanisms that precipitate depression is not completely understood. Important to understand is the reason why there is a delay in the response to antidepressant medication, even when these treatments reach the brain fairly efficiently [].
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