Category: Psychiatry

 — Men and women who have had contact with the criminal justice system — even if they have never received a jail or prison sentence or a guilty verdict — appear to have a significantly higher rate of suicide than the general population, according to a report posted online that will appear in the June print issue of Archives of General Psychiatry, one of the JAMA/Archives journals.

Most published research on suicide and the criminal justice system focuses on prisoners during their incarceration or soon after release, according to background information in the article. Few studies have investigated the risk of suicide among offenders who are not imprisoned. "Some have suggested that community offenders could be even more vulnerable than prisoners," the authors write.

Roger T. Webb, Ph.D., of the University of Manchester, England, and colleagues used national registries to identify 27,219 Danish individuals (18,063 men and 9,156 women) who died by suicide between 1981 and 2006. They also selected 524,899 controls matched by age, sex and time (in other words, the control patients were alive when their matched case died). They then linked this data to another national registry to determine which individuals had exposure to the criminal justice system after 1980.

More than one-third of men who died by suicide (34.8 percent) had a criminal justice history, compared with 24.6 percent of controls. For women, 12.8 percent who died by suicide and 5.1 percent of controls had exposure to the justice system.

The risk of suicide was highest among those who had received custodial sentencing (time detained in prison). However, compared with those who had never been exposed to the justice system, suicide risk was elevated even among those who had never received prison time or a guilty verdict. Suicide was most strongly associated with sentencing to psychiatric treatment and with charges conditionally withdrawn, proceedings in Denmark similar to suspended sentences.

The prevalence of psychiatric admission was high among individuals who had been exposed to the criminal justice system and then died by suicide, especially among women. The risk of suicide was especially high among those with a criminal history who were younger, who had been charged for violent offenses and whose contact with the criminal justice system was recent or repeated.

"We believe that our findings of rising suicide risk with increasing recency and frequency of contact point toward a strong independent effect of criminal justice history," the authors write. "Thus, exposure to the criminal justice system in itself may contribute to elevating a person's suicide risk, rather than simply reflecting the traits and characteristics of people who come into contact with the system."

"The need for developing more far-reaching national suicide prevention strategies is indicated," the authors conclude. "In particular, improved mental health service provision is needed for all people in contact with the criminal justice system, including those not found guilty and those not given custodial sentences. Our findings also suggest that public services should be better coordinated to tackle co-occurring health and social problems more effectively."

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Journal Reference:

1. Roger T. Webb; Ping Qin; Hanne Stevens; Preben B. Mortensen; Louis Appleby; Jenny Shaw. National Study of Suicide in All People With a Criminal Justice History. Arch Gen Psychiatry, 2011; DOI: 10.1001/archgenpsychiatry.2011.7

Due to the recent economic crisis, an increase of health inequalities between socio-economic groups has been noticed in both developed and developing countries.

The World Health Organization, the World Bank and the United Nations Development Programme have all reported these inequalities and emphasized its importance and made this issue a priority.

There is evidence that such inequalities not only affect general health, but have a particular impact on mental health.

A new study, published in World Psychiatry, the official journal of the World Psychiatric Association (WPA), examined the data of the Korea National Health and Nutrition Examination Survey (KHANES), for the period between 1998 and 2007. The aim of the study was to measure income-related inequalities in depression, suicidal ideation and suicide attempts in South Korea and to trace their changes over a 10-year period (1998-2007).

The study data was obtained from a representative sample of the South Korean population through face-to-face interviews, gathering information about socio-economic status, health condition, and health behaviour (e.g. exercise, smoking, alcohol consumption). Information on depression and suicidal behaviour was obtained through self-report of whether the respondents had (a) been diagnosed with depression, (b) had ever felt like dying in the past 12 months, and (c) had ever attempted suicides in the past 12 months.

This study shows that the three psychopathologies (depression, suicidal ideation and suicide attempts) were more highly concentrated in lower income groups across years. This inequality observed was more pronounced in recent years, especially for suicide attempt. This means that the lowest income groups have the highest risk of depression, suicidal ideation and suicidal attempt.

Moreover, during this period, the suicide rate rose dramatically from an average of 13.0 per 100,000 to 26.0. This is the highest rate among countries belonging to the Organization for Economic Cooperation and Development (OECD). This may reflect an acute response to the economic crisis in the late 1990s.

This study showed clear existence of significant pro-rich inequalities in the prevalence of depression, suicidal ideation and suicide attempts. These inequalities have doubled over the past 10 years, in parallel to the widening income inequalities following the economic crisis.

Young adults who are lesbian, gay or bisexual (LGB) are at far higher risk for severe mental health problems than their heterosexual peers. New research from Concordia University suggests that the stress of being rejected or victimized because of sexual orientation may disrupt hormonal responses in lesbians, gays and bisexuals.

Recently published as a doctoral thesis in clinical psychology, this investigation examined environmental risks and protective factors that counterbalanced them in LGB youth. "Compared to their heterosexual peers, suicide rates are up to 14 times higher among lesbian, gay and bisexual high school and college students," says Michael Benibgui, who led this investigation as part of his PhD thesis at Concordia's Department of Psychology and Centre for Research in Human Development.

"Depression and anxiety are widespread," he continues. "To learn why this occurs, we studied the physiological impact of homophobic social environments on a group of healthy young LGB adults."

Self loathing, stress hormones and bullying linked

The study examined the link between living in a homophobic environment and 'internalized homophobia,' e.g., feeling negatively about oneself because of one's sexual identity as LGB.

Individuals who experienced more LGB-related stress — arguments about sexual identity, bullying or discrimination — had higher internalized homophobia and showed increased production of the stress hormone cortisol compared to peers in more positive environments.

What's more, LGB youth who showed more internalized homophobia and abnormal cortisol activity also experienced increased symptoms of depression, anxiety and suicidal thoughts. "This study is among the first to clearly link the experience of homophobia with abnormal cortisol activity," says Benibgui.

Benibgui says abnormal cortisol activity in LGB youth, combined with the vicious cycle of stress, could be further influenced by a complex set of biological, psychological and social factors. "This study shows a clear relation between abnormal cortisol levels and environmental stressors related to homophobia," he says.

Protective factors of social networks

Benibgui also identified protective factors that can help safeguard mental health in young gays, lesbians and bisexuals. His research confirms that social support from parents and peers have protective effects. "LGB young adults who experienced more homophobic discrimination, yet felt accepted and supported by their peers, showed very few symptoms of depression," he says.

These findings underline the impact — both physical and mental — that homophobia may have on LGB young adults. "The effect on mental health of bullying in schools has received much attention," says Benibgui. "Our study supports the notion that homophobic bullying can lead to physical and mental health problems."

Preventative interventions are needed to protect vulnerable lesbian, gay or bisexual youth, Benibgui stresses, to discourage homophobic and heterosexist behaviors from peers and communities.

Paul Hastings, a former Concordia psychology professor who supervised Benibgui's thesis research, says that this study should push the conversation about the impact of homophobia.

"This study is one part of a much larger and greatly needed dialogue on the impacts that prejudice, discrimination and victimization have on healthy development and well-being in young people," says Dr. Hastings, an international member of the Centre for Research in Human Development and now a professor at the University of California, Davis. "We need to promote acceptance and respect for the diversity of our population — including sexual diversity — at all levels: government, community, schools and homes."

"Mental Health Challenges and Resilience in Lesbian, Gay and Bisexual Young Adults: Biological and Psychological Internalization of Minority Stress and Victimization," was authored by Michael Benibgui, Ph.D., as his doctoral dissertation in clinical psychology at Concordia University. Professor Paul Hastings, Ph.D., now at University of California, Davis, was project supervisor.

Adult children of divorce are more likely to have seriously considered suicide than their peers from intact families, suggests new research from the University of Toronto

In a paper published online in the journal Psychiatry Research, investigators examined gender specific differences among a sample of 6,647 adults, of whom 695 had experienced parental divorce before the age of 18. The study found that men from divorced families had more than three times the odds of suicidal ideation in comparison to men whose parents had not divorced. Adult daughters of divorce had 83 per cent higher odds of suicidal ideation than their female peers who had not experienced parental divorce.

The link between divorce and suicidal ideation was particularly strong in families where childhood stressors like parental addiction, physical abuse, and parental unemployment also occurred. For women who had not experienced these adverse childhood experiences, the association between parental divorce and suicidal ideation was no longer significant. However, even in the absence of these childhood stressors, men who had experienced parental divorce had twice the odds of having seriously considered suicide at some point in their life compared to men from intact families.

"This study suggests that the pathways linking parental divorce to suicidal ideation are different for men and women. The association between parental divorce and suicidal thoughts in men was unexpectedly strong, even when we adjusted for other childhood and adult stressors, socioeconomic status, depression and anxiety,"says lead author Esme Fuller-Thomson, Sandra Rotman Chair at U of T's Factor-Inwentash Faculty of Social Work and Department of Family and Community Medicine. "Females whose parents had divorced were not particularly vulnerable to suicidal ideation if they were not also exposed to childhood physical abuse and/or parental addictions."

Explanations for why men might be more negatively impacted by parental divorce are varied. However, researchers believe it could be due to the absence of close contact with a father which may occur post-divorce. Previous studies have linked the loss of father-figures with adverse developmental outcomes in boys. "It may be that the link between parental divorce and suicidal ideation in men is mediated through factors we cannot control for in our analyses such as childhood poverty or parental depression, both of which are more prevalent in divorced families,"says U of T masters graduate and study co-author Angela Dalton.

Fuller-Thomson cautions that "these findings are not meant to panic divorced parents. Our data in no way suggest that children of divorce are destined to become suicidal."

Researcher's note that the findings need to be confirmed by others using prospective data before any public health recommendations can be made. However, if confirmed, they would have significant clinical implications for professionals working with families experiencing parental divorce.

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Journal Reference:

1. Esme Fuller-Thomson, Angela D. Dalton. Suicidal ideation among individuals whose parents have divorced: Findings from a representative Canadian community survey. Psychiatry Research, 2011; DOI: 10.1016/j.psychres.2010.12.004

A recent study by Merikangas and colleagues published in the January 2011 issue of the Journal of the American Academy of Child and Adolescent Psychiatry (JAACAP) shows that only half of adolescents that are affected with severely impairing mental disorders ever receive treatment for their disorders.

The researchers found that approximately one third of adolescents with any mental disorder received services for their illness (36.2%). Disorder severity was significantly associated with an increased likelihood of receiving treatment, yet only half of adolescents who were identified as having severely impairing mental disorders had ever received mental health treatment for their symptoms.

In the article titled "Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey-Adolescent Supplement (NCS-A)," Dr. Merikangas and colleagues examined the rates of treatment for specific mental disorders in the NCS-A. The NCS-A is a nationally representative, face-to-face survey of adolescents aged 13 to 18 years in the continental United States.2 Diagnostic assessment of DSM-IV mental disorders were measured using a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview. The service questions for adolescents and parents were primarily derived from the Service Assessment for Children and Adolescents (SACA).

The authors examined rates of treatment for DSM-IV disorders, and correlated the severity, number of disorders, and comorbidity in a nationally representative sample of 6,483 adolescents 13 to 18 years old for whom information on service use was available from an adolescent and a parent report. Sociodemographic correlates were also evaluated. The NCS-A is a nationally representative, face-to-face survey of 10,123 adolescents aged 13 to 18 years in the continental United States.2 Diagnostic assessment of DSM-IV mental disorders were measured using a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview.

Treatment rates were highest in those with attention-deficit/hyperactivity disorder (ADHD) (59.8%) and behavior disorders, such as oppositional defiant disorder (ODD) and conduct disorder (CD) (combined 45.4%). The picture is more discouraging for those adolescents with anxiety, eating, or substance use disorders for whom less than 20% received treatment. 1 Furthermore, the investigators found that Hispanic and non-Hispanic Black adolescents were less likely than their White counterparts to receive services for mood and anxiety disorders, even when such disorders were associated with severe impairment. In the article, Merikangas and colleagues comment, "marked racial disparities in lifetime rates of mental health treatment highlight the urgent need to identify and combat barriers to the recognition and treatment of these conditions."

Reflecting on the lack of treatment for adolescents with severe mental disorders, Merikangas and colleagues state, "National shortages of mental health specialists for children remain widely prevalent. Recruitment, training, and promotion of child and adolescent mental health professionals remain leading priorities. Strains on available treatment resources are likely to grow as coverage is extended to large groups of currently uninsured American young people."

The National Comorbidity Survey Adolescent Supplement (NCS-A) and the larger program of related NCS surveys are supported by the National Institute of Mental Health (U01-MH60220) and the National Institute of Drug Abuse (R01 DA016558) with supplemental support from Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation (Grant 044708), and the John W. Alden Trust. The NCS-A was carried out in conjunction with the World Health Organization World Mental Health Survey Initiative.

This work was supported by the Intramural Research Program of the National Institute of Mental Health. The views and opinions expressed in this article are those of the authors and should not be construed to represent the views of any of the sponsoring organizations, agencies, or U.S. Government.

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Journal References:

1. Kathleen Ries Merikangas, Jian-ping He, Marcy Burstein, Joel Swendsen, Shelli Avenevoli, Brady Case, Katholiki Georgiades, Leanne Heaton, Sonja Swanson, Mark Olfson. Service Utilization for Lifetime Mental Disorders in U.S. Adolescents: Results of the National Comorbidity Survey–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 2011; 50 (1): 32 DOI: 10.1016/j.jaac.2010.10.006
2. Kathleen Ries Merikangas, Jian-ping He, Marcy Burstein, Sonja A. Swanson, Shelli Avenevoli, Lihong Cui, Corina Benjet, Katholiki Georgiades, Joel Swendsen. Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 2010; 49 (10): 980-989 DOI: 10.1016/j.jaac.2010.05.017

 Vanderbilt University researchers may have found a clue to the blues that can come with the flu — depression may be triggered by the same mechanisms that enable the immune system to respond to infection.

In a study in the December issue of Neuropsychopharmacology, Chong-Bin Zhu, M.D., Ph.D., Randy Blakely, Ph.D., William Hewlett, M.D., Ph.D., and colleagues activated the immune system in mice to produce "despair-like" behavior that has similarities to depression in humans.

"Many people exhibit signs of lethargy and depressed mood during flu-like illnesses," said Blakely, director of the Vanderbilt Center for Molecular Neuroscience. "Generally these have been treated as just a consequence of being physically ill, but we think there is likely to be something more brain-centric at work here."

Blakely and his colleagues previously reported that inflammatory cytokines can enhance the activity of the serotonin transporter (SERT), which regulates the supply of the neurotransmitter serotonin in the synapse, or gap between nerve cells.

Elevations in SERT activity remove serotonin from brain synapses at an enhanced rate and, based on studies in animal models and man, would be predicted to increase the risk for mood and anxiety disorders. Indeed, a class of antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) — Prozac, Zoloft, etc. — work by blocking the ability of SERT to eliminate serotonin.

In the current study in mice, the researchers triggered pro-inflammatory cytokine production. Within 30 to 60 minutes, SERT was activated in the brain and the animals displayed despair-like behavior.

Remarkably, this behavior was not observed when cytokine production was triggered in mice lacking the SERT gene. Similarly, a drug that blocks inflammatory molecule signaling also prevented stimulation of SERT and the despair behavior. "It's as if these inflammatory molecules are an 'anti-Prozac,'" Blakely said.

In their paper, the researchers cautioned that "we do not presume that changes in SERT activity alone are sufficient to induce the full spectrum of depression traits, nor that our animal model can reproduce all the elements of a complex neuropsychiatric disorder."

"Nonetheless, we were able to identify a mechanism that may be a engaged, even without inflammation, to impact risk for depressive illness," Blakely said.

More study is needed. Identifying genetic variations in the SERT activation pathway, for example, might suggest additional sources of genetic risk for depression. "Our work suggests that novel therapies targeting inflammation-linked pathways may be of use in the treatment of mood disorders," he said.

Zhu is research associate professor of Pharmacology, Blakely is the Alan D. Bass Professor of Pharmacology and professor of Psychiatry, and Hewlett is associate professor of Psychiatry and Pharmacology.

Other contributors were Vanderbilt research assistant Kathryn Lindler, and Lynnette Daws, Ph.D., and Anthony Owens, both at the University of Texas Health Science Center at San Antonio.

The study was supported by the National Alliance for Research on Schizophrenia and Depression (NARSAD), and by a Conte Center grant from the National Institute of Mental Health.

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Journal Reference:

1. Chong-Bin Zhu, Kathryn M Lindler, Anthony W Owens, Lynette C Daws, Randy D Blakely, William A Hewlett. Interleukin-1 Receptor Activation by Systemic Lipopolysaccharide Induces Behavioral Despair Linked to MAPK Regulation of CNS Serotonin Transporters. Neuropsychopharmacology, 2010; 35 (13): 2510 DOI: 10.1038/npp.2010.116