Second Courses of Transcranial Magnetic Stimulation (TMS) in Major Depressive Episodes for Initial Responders and Non- Responders

@#Background: Transcranial Magnetic Stimulation (TMS) is effective in major depressive episodes (MDE). However, MDE may follow a chronic, relapsing course, and some individuals may not satisfactorily respond to a first course of TMS. Objective: To investigate the outcome of second courses of TMS. Method: A naturalistic investigation—we prospectively studied 30 MDE in-patients and routinely collected information, including pre- and post-treatment with Six-item Hamilton Depression Rating Scale (HAMD6), a six-item Visual Analogue Scale (VAS6) and the Clinical Global Impression-Severity (CGI-S). Two categories of patients were considered: i) those who had remitted with a first course, but relapsed, and ii) those who had not remitted with the first course. Results: Thirty individuals received a second TMS course. The mean time to the second course was 27.5 weeks. Based on the HAMD6, 26 (87%) achieved remission after the first course, and 22 (73%) achieved remission after the second course. Furthermore, based on the HAMD6 results, of the four patients who did not achieve remission with a first course, three (75%) did so with a second course. Conclusion: In MDE, a second course of TMS is likely to help those who remitted to a first course and then relapsed, as well as those who did not achieve remission with a first course.

Suicide: What the General Public and the Individual Should Know

Background: The predominant, current western view is that all suicide is the result of mental disorder. This view is much too narrow and does not admit extensive information regarding the social, economic, and forensic factors (among many others) which may contribute to completed suicide. A consequence of this narrow view is that prevention strategies mainly focus on the detection and treatment of mental disorder. A preferred approach is to place greater emphasis on public health approaches to suicide prevention.Objective: To develop and suggest a body of information which may be useful in a public health approach to suicide.Conclusion: It is suggested that the following be available to the general public: i) suicide is a fact of life which should be minimised, ii) suicide has many different triggers, iii) most people who take their lives are able to make decisions, and iv) increased public discussion and understanding of suicide is desirable. Five pieces of information that may be useful to those contemplating suicide include: i) don’t murder the part of you that wants to live, ii) suicide actions may leave you alive but disabled, iii) suicide hurts other people, iv) suicidal impulses do pass if you hold on, and v) suicide is a waste.

Suicidal Thoughts in the Novel Don Quixote

Background: During the last century suicide has been medicalised. This restrictive view has been challenged, and the wisdom of experts from beyond medicine is being valued. Fictional literature is a source of information regarding the human experience. Objective: To extend our understanding of suicide and suicidal thinking by examining the early-17th Century Spanish novel, “Don Quixote”. Method: Various translations were examined for accounts of suicide, suicidal thinking, and associated behaviour. Results: There were no accounts of completed suicide. There was one statement indicating the belief that suicide could be triggered by mental disorder. There were five statements indicating that suicidal thinking could arise in situations of distress. Such distress arose from the actual/potential loss of a loved person, suffering by another person, and relentless sleep deprivation. There is one account of a person pretending to attempt suicide and achieving a self-inflicted wound, not with the intention to self-murder, but to impact the disposition of another person. Conclusion: The observation that in early-17th Century Spain suicide was acknowledged as means of dealing with distress is consistent with findings from other periods, and the present day. This strengthens the position that suicide can occur in the absence of mental disorder.

Suicide In Shooting Galleries

Aim: To better understand the mental state of people who complete suicide in shooting ranges/galleries. Method: The public record was searched via the web using various search engines and the words “suicide shooting gallery” and “suicide shooting range”. When names of individuals appeared, they were used to further search for information about the event, paying particular attention to any evidence suggesting the presence of mental disorder. Results: Twenty-two cases were located. Nineteen (83%) were male and the average age was 36 years, with a range from 21 to 75 years. We present 6 case vignettes: in 3 there was evidence of mental disorder, while in the other 3 there was no evidence of mental disorder. Conclusion: Like the people who complete suicide in other locations, some of the people who complete suicide in shooting ranges/galleries are suffering from mental disorder, while some are not, and other triggers are present.

The Predicaments of People Whose Suicide was Captured on Film

Background: Although suicide is commonly linked with mental disorder, the notion that suicide may occur in response to predicaments has been the subject of much recent study and attention. A predicament in this context refers to an uncomfortable situation from which escape is difficult. We aimed to examine the predicaments of people whose suicide was captured on film and displayed on the public record. Methods: The authors’ extensive private library and the web were explored for examples of suicide on film. The authors viewed the films and associated records, and extracted and listed details of the suicides. Results: Six individual cases and two groups (totalling 2200 plus individuals) were identified. The individual cases were Thich Quang Duc (1963), Christine Chubbuck (1974), Budd Dwyer (1987), Daniel Victor Jones (1998), Michael Marin (2012) and Jordon Romero (2012). The two groups were the Japanese Kamikaze pilots of 1944/1995, and those who jumped from the burning “Twin Towers” on September 11, 2001. One of the six individuals has evidence of a mental disorder, and all (individual and group cases) were in potent social/environmental predicaments. Conclusion: Both psychological autopsies and our clinical experience suggest that suicide is often associated with mental disorder. Nevertheless, social/environmental predicaments may lead to suicide. This study suggests that individuals whose suicide is captured on film are often seeking public exposure of their fatal act.

Suicide and Forced Marriage

Background: The prevailing view that the vast majority of those who complete suicide have an underlying psychiatric disorder has been recently challenged by research on the contribution of “predicaments”, in the absence of mental illness, to suicide. In this paper, we sought data to support the notion that forced marriage may lead to suicide without the presence of psychiatric disorder. Method: Historical records, newspapers, and the electronic media were searched for examples. Results: Two examples from ancient times and six from the last hundred years were located and described. Conclusion: These cases suggest that forced marriage may lead to suicide and complements earlier findings that loss of fortune, health, liberty, and reputation may lead to suicide in the absence of mental disorder.

Financial Loss and Suicide

The current Western psychiatric wisdom states that suicide is always or almost always associated with mental disorder. Careful Asian studies are casting doubt on this conclusion. Using information from the public record (newspapers, coroner’s reports, and various web-based sources), we sought evidence that, in the absence of mental disorder, suicide may be associated with major financial loss. Reports of 15 individuals who completed suicide following major financial loss were identified, thus an association between these events is supported.

Suicide and the Publicly Exposed Pedophile

Background: Current clinical wisdom is that the vast majority of those who complete suicide suffer from a mental disorder. Uncritical adherence to this belief may limit our understanding and restrict the full range of prevention activities. We aimed to examine the public record for accounts of suicide by men who had been, or were about to be, investigated or apprehended for “sex only” child sex offences, with a view to presenting a collection of case histories, and identifying examples of suicide in the apparent absence of mental disorder other than pedophilia. Methods: The public record (hard and electronic copy) was examined. Results: Twenty case histories were identified of men with no apparent mental disorder (other than pedophilia) who completed suicide shortly after exposure or threatened public exposure and/or early or potential legal punishment. Conclusion: This evidence strongly suggests that exposure or threatened public exposure of pedophilia and/or early or potential legal punishment creates a predicament, which may lead to completed suicide.

A Pilot Investigation of the Operationalized Predicaments of Suicide (OPS) Framework

Background: Suicide may be conceptualized as an escape from intolerable predicaments, in particular, mental illness and environmental stressors. The operationalized predicaments of suicide (OPS) is a 4 category framework designed to assist in the classification of suicide. The objective was to examine whether this framework is potentially useful. Method: 18 psychiatrists from 6 different countries examined 12 written coroners’ reports of suicide and rated each report according to the OPS. 16 of these raters then also completed a qualitative questionnaire regarding the framework. Results: In 89.8% of cases the raters where able to make a decision regarding the drivers which led to the suicides. The respondents displayed modest inter-rater correlation (Kappa = 0.42; P < 0.0001). In the qualitative section, respondents supported the face validity of OPS and considered it potentially useful. Feedback allowed improved wording of the OPS instructions. Conclusion: The OPS has potential as a useful framework. The OPS instructions have been improved and further studies are justified.

Medicalisation of Suicide

Medicalisation is the misclassification of non-medical problems as medical problems. A common form of medicalisation is the misclassification of normal distress as a mental disorder (usually a mood disorder). Suicide is medicalised when it is considered a medical diagnosis per se, when it is considered to be secondary to a mental disorder when no mental disorder is present, and when no mental disorder is present but the management of suicidal behaviour associated with distress is believed to be the sole responsibility of mental health professionals. In the West, psychological autopsies have led to the belief that all or almost all suicide is the result of mental disorder. However, there are reservations about the scientific status of such studies. The actions of psychological autopsy researchers, coroners/magistrates, police, policy writers, and grieving relatives all contribute. Medicalisation of suicide has the potential to distort research findings, and caution is recommended.

Neuroimaging in the Field of Psychoses

This review looks at the recent findings in the neuroimaging of the psychoses, with a view to clarifying the question of the unitary versus the two-disorder theory of psychosis. Schizophrenia is associated with significantly more cortical grey matter loss than bipolar disorder. The distribution of these losses is different; schizophrenia is characteristically associated with loss of the medial and middle frontal, the superior temporal gyri, and the dorsolateral prefrontal cortex, while bipolar disorder has particular loss in the medial frontal gyrus and the anterior cingulate cortex. Both disorders were associated with extensive white matter deficits. In summary, neuroimaging indicates different patterns of grey matter loss for schizophrenia and bipolar disorder. However, neuroimaging of white matter reveals a good deal of overlap between these two disorders. Thus, neuroimaging does not suggest a unitary psychosis or a two-psychosis model, instead it suggests a two-dimensional psychosis field, on which disorders are located according to two dimensions, the degree of grey matter loss and the degree of white matter abnormality.