Charting the success of neuronavigation in brain tumor surgery: from inception to adoption and evolution.

PURPOSE: Neuronavigation, explored as an intra-operative adjunct for brain tumor surgery three decades ago, has become globally utilized with a promising upward trajectory. This study aims to chart its success from idea to adoption and evolution within the US and globally. METHODS: A three-pronged methodology included a systematic literature search, impact analysis using NIH relative citation ratio (RCR) and Altmetric scores, and assessment of patent holdings. Data was dichotomized for US and international contexts. RESULTS: The first neuronavigation publication stemmed from Finland in 1993, marking its inception. Over three decades, the cumulative number of 323 studies, along with the significantly increasing publication trend (r = 0.74, p < 0.05) and distribution across 34 countries, underscored its progressive and global adoption. Neuronavigation, mostly optical systems (58%), was utilized in over 19,000 cases, predominantly for brain tumor surgery (84%). Literature impact showed a robust cumulative median RCR score surpassing that for NIH-funded studies (1.37 vs. 1.0), with US studies having a significantly higher median RCR than international (1.71 vs. 1.21, p < 0.05). Technological evolution was characterized by adjuncts, including micro/exo/endoscope (21%), MRI (17%), ultrasound (10%), and CT (7%). Patent analysis demonstrated academic and industrial representation with an interdisciplinary convergence of medical and computational sciences. CONCLUSION: Since its inception thirty years ago, neuronavigation has been adopted worldwide, and it has evolved with adjunct technology integration to enhance its meaningful use. The current neuronavigation innovation pipeline is progressing, with academic and industry partnering to advance its further application in treating brain tumor patients.

Suicide-related internet use among mental health patients who died by suicide in the UK: a national clinical survey with case-control analysis.

Background: Suicide-related internet use (SRIU) has been shown to be linked to suicide. However, there is limited research on SRIU among mental health patients, who are at 4 to 7 times increased risk of suicide compared to the general population. This study aims to address this gap by exploring the prevalence of SRIU among mental health patients who died by suicide in the UK and describing their characteristics. Methods: The study was carried out as part of the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Data were collected on sociodemographic, clinical, suicide characteristics and engagement in SRIU of patients who died by suicide between 2011 and 2021. The study utilised a case-control design to compare patients who engaged in suicide-related internet use with those who did not. Findings: The presence or absence of SRIU was known for 9875/17,347 (57%) patients; SRIU was known to be present in 759/9875 (8%) patients. The internet was most often used to obtain information on suicide methods (n = 523/759, 69%) and to visit pro-suicide websites (n = 250/759, 33%) with a significant overlap between the two (n = 152/759, 20%). Engaging in SRIU was present across all age groups. The case-control element of the study showed patients who were known to have engaged in SRIU were more likely to have been diagnosed with autism spectrum disorder (OR = 2.13, 95% CI: 1.43-3.18), have a history of childhood abuse (OR = 1.70, 95% CI: 1.36-2.13) and to have received psychological treatment (OR = 1.43, 95% CI: 1.18-1.74) than controls. Additionally, these patients were more likely to have died on or near a salient date (OR = 2.11, 95% CI: 1.61-2.76), such as a birthday or anniversary. Interpretation: The findings affirm SRIU as a feature of suicide among patients of all ages and highlight that clinicians should inquire about SRIU during assessments. Importantly, as the most common type of SRIU can expand knowledge on suicide means, clinicians need to be aware of the association between SRIU and choice of methods. This may be particularly relevant for patients approaching a significant calendar event. Funding: The Healthcare Quality Improvement Partnership.

Neural and behavioral markers of inhibitory control predict symptom improvement during internet-delivered cognitive behavioral therapy for depression.

Poor inhibitory control contributes to deficits in emotion regulation, which are often targeted by treatments for major depressive disorder (MDD), including cognitive behavioral therapy (CBT). Brain regions that contribute to inhibitory control and emotion regulation overlap; thus, inhibitory control might relate to response to CBT. In this study, we examined whether baseline inhibitory control and resting state functional connectivity (rsFC) within overlapping emotion regulation-inhibitory control regions predicted treatment response to internet-based CBT (iCBT). Participants with MDD were randomly assigned to iCBT (N = 30) or a monitored attention control (MAC) condition (N = 30). Elastic net regression was used to predict post-treatment Patient Health Questionnaire-9 (PHQ-9) scores from baseline variables, including demographic variables, PHQ-9 scores, Flanker effects (interference, sequential dependency, post-error slowing), and rsFC between the dorsal anterior cingulate cortex, bilateral anterior insula (AI), and right temporoparietal junction (TPJ). Essential prognostic predictor variables retained in the elastic net regression included treatment group, gender, Flanker interference response time (RT), right AI-TPJ rsFC, and left AI-right AI rsFC. Prescriptive predictor variables retained included interactions between treatment group and baseline PHQ-9 scores, age, gender, Flanker RT, sequential dependency effects on accuracy, post-error accuracy, right AI-TPJ rsFC, and left AI-right AI rsFC. Inhibitory control and rsFC within inhibitory control-emotion regulation regions predicted reduced symptom severity following iCBT, and these effects were stronger in the iCBT group than in the MAC group. These findings contribute to a growing literature indicating that stronger inhibitory control at baseline predicts better outcomes to psychotherapy, including iCBT.

Simplifying synthesis of the expanding glioblastoma literature: a topic modeling approach.

PURPOSE: Our study aims to discover the leading topics within glioblastoma (GB) research, and to examine if these topics have "hot" or "cold" trends. Additionally, we aim to showcase the potential of natural language processing (NLP) in facilitating research syntheses, offering an efficient strategy to dissect the landscape of academic literature in the realm of GB research. METHODS: The Scopus database was queried using "glioblastoma" as the search term, in the "TITLE" and "KEY" fields. BERTopic, an NLP-based topic modeling (TM) method, was used for probabilistic TM. We specified a minimum topic size of 300 documents and 5% probability cutoff for outlier detection. We labeled topics based on keywords and representative documents and visualized them with word clouds. Linear regression models were utilized to identify "hot" and "cold" topic trends per decade. RESULTS: Our TM analysis categorized 43,329 articles into 15 distinct topics. The most common topics were Genomics, Survival, Drug Delivery, and Imaging, while the least common topics were Surgical Resection, MGMT Methylation, and Exosomes. The hottest topics over the 2020s were Viruses and Oncolytic Therapy, Anticancer Compounds, and Exosomes, while the cold topics were Surgical Resection, Angiogenesis, and Tumor Metabolism. CONCLUSION: Our NLP methodology provided an extensive analysis of GB literature, revealing valuable insights about historical and contemporary patterns difficult to discern with traditional techniques. The outcomes offer guidance for research directions, policy, and identifying emerging trends. Our approach could be applied across research disciplines to summarize and examine scholarly literature, guiding future exploration.

American Association of Neurological Surgeons/Congress of the Neurological Surgeons Section on Tumors Guidelines: Assessing Their Impact on Brain Tumor Clinical Practice.

Clinical guidelines direct healthcare professionals toward evidence-based practices. Evaluating guideline impact can elucidate information penetration, relevance, effectiveness, and alignment with evolving medical knowledge and technological advancements. As the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors marks its 40th anniversary in 2024, this article reflects on the tumor guidelines established by the Section over the past decade and explores their impact on other publications, patents, and information dissemination. Six tumor guideline categories were reviewed: low-grade glioma, newly diagnosed glioblastoma, progressive glioblastoma, metastatic brain tumors, vestibular schwannoma, and pituitary adenomas. Citation data were collected from Google Scholar and PubMed. Further online statistics, such as social media reach, and features in policy, news, and patents were sourced from Altmetric. Online engagement was assessed through website and CNS+ mobile application visits. Data were normalized to time since publication. Metastatic Tumor guidelines (2019) had the highest PubMed citation rate at 26.1 per year and webpage visits (29 100 page views 1/1/2019-9/30/2023). Notably, this guideline had two endorsement publications by partner societies, the Society of Neuro-Oncology and American Society of Clinical Oncology, concerning antiepileptic prophylaxis and steroid use, and the greatest reach on X (19.7 mentions/y). Citation rates on Google Scholar were led by Vestibular Schwannoma (2018). Non-Functioning Pituitary Adenoma led Mendeley reads. News, patent, or policy publications were led by low-grade glioma at 1.5/year. Our study shows that the American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Tumors guidelines go beyond citations in peer-reviewed publications to include patents, online engagement, and information dissemination to the public.

Molecular profile and clinical outcome of adult primary spinal cord glioblastoma: a systematic review.

OBJECTIVE: Primary spinal cord glioblastoma (scGB) is a rare and aggressive spinal glioma, making up 7.5% of such cases. Whereas molecular profiles associated with improved overall survival (OS) are well studied for cranial glioblastoma (GB), the molecular characteristics of scGB are less documented. This review sought to document the molecular signatures of scGB, explore current treatment strategies, and evaluate clinical outcomes. METHODS: A systematic literature review following the PRISMA guidelines searched the PubMed, Embase, and CENTRAL databases (January 1, 2013, to October 14, 2023) using glioblastoma-, spine-, and genetics-related keywords. Inclusion criteria were English-language articles on humans with histologically confirmed primary scGB, excluding drop metastases. Data on demographic characteristics, treatments, molecular profile, and outcome were extracted. RESULTS: Over 10 years, 71 patients with adult primary scGB were reported in 31 papers. Most patients were located in Asia (53%) and the United States (23%). The median (range) age was 32 (24-47) years, with 61% of patients male. Tumors occurred primarily in the thoracic region (42%). Clinical presentation included motor deficits (92%), sensory deficits (86%), neck/back pain (68%), and bowel/bladder dysfunction (59%). Patients underwent subtotal resection (51%), gross-total resection (GTR) (23%), and biopsy (26%). Postoperative adjuvant treatment included concomitant external beam radiation therapy (XRT) and temozolomide (TMZ) in the majority of cases (66%), as well as palliative care without adjuvant treatment (17%). The molecular signature of scGB was similar to its cranial counterpart in terms of MGMT-promoter methylation (40% increased methylation) and higher for mutant TERT (50%) but decreased for wild-type tumor protein p53 (41% decreased mutation). Median (range) OS was 10 (6-18) months, and median progression-free survival (PFS) was 7 (3-10) months. PFS was significantly higher in patients treated with XRT/TMZ: median 15 months vs 4.5 months (95% CI -1.32 to 22.56, p < 0.05). CONCLUSIONS: Primary scGB remains a rare disease with notable variations in treatment, potentially influenced by geographical availability. The observed molecular profile, when compared to that of cranial GB, emphasizes the need for further genomic validation and data collection. Surgical advancements to overcome the challenges of accomplishing GTR may contribute to improved OS.

Affective visual circuit dysfunction in trauma and stress-related disorders.

Posttraumatic stress disorder (PTSD) is widely recognized as involving disruption of core neurocircuitry that underlies processing, regulation, and response to threat. In particular, the prefrontal cortex - hippocampal - amygdala circuit is a major contributor to posttraumatic dysfunction. However, the functioning of core threat neurocircuitry is partially dependent on sensorial inputs and previous research demonstrates that dense, reciprocal connections exist between threat circuits and the ventral visual stream. Further, emergent evidence suggests that trauma exposure and resultant PTSD symptoms are associated with altered structure and function of the ventral visual stream. The present review discusses evidence that both threat and visual circuitry together are an integral part of PTSD pathogenesis. An overview of the relevance of visual processing to PTSD is discussed in the context of both basic and translational research, highlighting the impact of stress on affective-visual circuitry. This review further synthesizes emergent literature to suggest potential timing-dependent effects of traumatic stress on threat and visual circuits that may contribute to PTSD development. We conclude with recommendations for future research to accelerate the field towards a more complete understanding of PTSD neurobiology.

Perception of Young European Otolaryngologists toward Transoral Robotic Surgery in Head and Neck Oncology and Surgery.

Background: To investigate the perception of young European otolaryngologists (OTOs), i.e., head and neck surgeons, toward transoral robotic surgery (TORS). Methods: Members of the Young Confederation of European Otorhinolaryngology-Head and Neck Surgery and Young Otolaryngologists of International Federation of Otorhinolaryngological Societies were surveyed about TORS perception and practice. Results: The survey was completed by 120 young OTOS (26%). The most important barriers to TORS were robot availability (73%), cost (69%), and lack of training (37%). The participants believed that the main benefits include better surgical filed view (64%), shorter hospital stay (62%), and better postoperative outcomes (61%) than the conventional approach. Head and neck surgeons considered cT1-T2 oropharyngeal cancers (94%), resection of base of tongue for sleep apnea (86%), or primary unknown cancer (76%) as the most appropriate indications. A total of 67% of TORS surgeons assessed themselves as adequately trained in TORS. Conclusions: Young European OTOs report positive perception, adoption, and knowledge of TORS. The cost-related unavailability and the lack of training or access are reported to be the most important barriers for the spread of TORS.

What is the cognitive footprint of insular glioma?

Cognitive impairment has a profound deleterious impact on long-term outcomes of glioma surgery. The human insula, a deep cortical structure covered by the operculum, plays a role in a wide range of cognitive functions including interceptive thoughts and salience processing. Both low-grade (LGG) and high-grade gliomas (HGG) involve the insula, representing up to 25% of LGG and 10% of HGG. Surgical series from the past 30 years support the role of primary cytoreductive surgery for insular glioma patients; however, reported cognitive outcomes are often limited to speech and language function. The breath of recent neuroscience literature demonstrates that the insula plays a broader role in cognition including interoceptive thoughts and salience processing. This article summarizes the vast functional role of the healthy human insula highlighting how this knowledge can be leveraged to improve the care of patients with insular gliomas.

Transgenerational effects of early life stress on the fecal microbiota in mice.

Stress in early life can affect the progeny and increase the risk to develop psychiatric and cardiometabolic diseases across generations. The cross-generational effects of early life stress have been modeled in mice and demonstrated to be associated with epigenetic factors in the germline. While stress is known to affect gut microbial features, whether its effects can persist across life and be passed to the progeny is not well defined. Here we show that early postnatal stress in mice shifts the fecal microbial composition (binary Jaccard index) throughout life, including abundance of eight amplicon sequencing variants (ASVs). Further effects on fecal microbial composition, structure (weighted Jaccard index), and abundance of 16 ASVs are detected in the progeny across two generations. These effects are not accompanied by changes in bacterial metabolites in any generation. These results suggest that changes in the fecal microbial community induced by early life traumatic stress can be perpetuated from exposed parent to the offspring.

Ecological Momentary Assessments of Trauma-Related Intrusive Memories: Potential Clinical Utility.

As the global prevalence of trauma rises, there is a growing need for accessible and scalable treatments for trauma-related disorders like posttraumatic stress disorder (PTSD). Trauma-related intrusive memories (TR-IMs) are a central PTSD symptom and a target of exposure-based therapies, gold-standard treatments that are effective but resource-intensive. This study examined whether a brief ecological momentary assessment (EMA) protocol assessing the phenomenology of TR-IMs could reduce intrusion symptoms in trauma-exposed adults. Participants (N=131) experiencing at least 2 TR-IMs per week related to a DSM-5 criterion A trauma completed a 2-week EMA protocol during which they reported on TR-IM properties three times per day, and on posttraumatic stress symptoms at the end of each day. Longitudinal symptom measurements were entered into linear mixed-effects models to test the effect of Time on TR-IMs. Over the 2-week EMA protocol, intrusion symptom severity (cluster B scores) significantly declined (t = -2.78, p = 0.006), while other symptom cluster scores did not significantly change. Follow-up analyses demonstrated that this effect was specific to TR-IMs (t = -4.02, p < 0.001), and was not moderated by survey completion rate, total PTSD symptom severity, or ongoing treatment. Our findings indicate that implementing an EMA protocol assessing intrusive memories could be an effective trauma intervention. Despite study limitations like its quasi-experimental design and absence of a control group, the specificity of findings to intrusive memories argues against a mere regression to the mean. Overall, an EMA approach could provide a cost-effective and scalable treatment option targeting intrusive memory symptoms.

An Optimization Approach for Creating Application-specific Ultrasound Speckle Tracking Algorithms.

OBJECTIVE: Ultrasound speckle tracking enables in vivo measurement of soft tissue deformation or strain, providing a non-invasive diagnostic tool to quantify tissue health. However, adoption into new fields is challenging since algorithms need to be tuned with gold-standard reference data that are expensive or impractical to acquire. Here, we present a novel optimization approach that only requires repeated measurements, which can be acquired for new applications where reference data might not be readily available or difficult to get hold of. METHODS: Soft tissue motion was captured using ultrasound for the medial collateral ligament (MCL) of three quasi-statically loaded porcine stifle joints, and medial ligamentous structures of a dynamically loaded human cadaveric knee joint. Using a training subset, custom speckle tracking algorithms were created for the porcine and human ligaments using surrogate optimization, which aimed to maximize repeatability by minimizing the normalized standard deviation of calculated strain maps for repeat measurements. An unseen test subset was then used to validate the tuned algorithms by comparing the ultrasound strains to digital image correlation (DIC) surface strains (porcine specimens) and length change values of the optically tracked ligament attachments (human specimens). RESULTS: After 1500 iterations, the optimization routine based on the porcine and human training data converged to similar values of normalized standard deviations of repeat strain maps (porcine: 0.19, human: 0.26). Ultrasound strains calculated for the independent test sets using the tuned algorithms closely matched the DIC measurements for the porcine quasi-static measurements (R > 0.99, RMSE < 0.59%) and the length change between the tracked ligament attachments for the dynamic human dataset (RMSE < 6.28%). Furthermore, strains in the medial ligamentous structures of the human specimen during flexion showed a strong correlation with anterior/posterior position on the ligaments (R > 0.91). CONCLUSION: Adjusting ultrasound speckle tracking algorithms using an optimization routine based on repeatability led to robust and reliable results with low RMSE for the medial ligamentous structures of the knee. This tool may be equally beneficial in other soft-tissue displacement or strain measurement applications and can assist in the development of novel ultrasonic diagnostic tools to assess soft tissue biomechanics.

The Relationship of Anxious Arousal With Treatment of Dysphoria Using Virtual Reality Mindfulness and 2 Accelerated Transcranial Magnetic Stimulation Protocols.

Objective: This secondary analysis investigated the relationship of anxious arousal, as measured by the Tension Anxiety subscale of the Profile of Mood States (TA-POMS), to treatment outcome across diagnoses for each phase of the study. Sequential treatment phases of virtual reality (VR) mindfulness followed by left dorsolateral prefrontal cortex (dlPFC) accelerated transcranial magnetic stimulation (accel-TMS) and then dorsomedial prefrontal cortex (dmPFC) accel-TMS were used to treat dysphoria across diagnoses in an open trial from September 2021 to August 2023.Methods: The change in the TA-POMS subscale was compared to the percent change in primary clinician scale scores using a bivariate analysis. Baseline TA-POMS subscales were compared to treatment response using linear regression models to assess anxious arousal's impact on treatment outcome for the 3 phases. Significance was defined as P < .05, 2-tailed.Results: Twenty-three participants were enrolled in VR mindfulness, 19 in left dlPFC accel-TMS, and 12 in dmPFC accel TMS. Although the change in TA-POMS scores did not significantly correlate with the percent change in primary clinician scale ratings for the VR phase, they did for both the dlPFC (P = .041) and the dmPFC (P = .003) accel-TMS treatment phases. Importantly, baseline anxious arousal levels as measured by TA-POMS were not predictive of treatment outcome in any treatment phase.Conclusion: The outcome of accel-TMS treatment was not adversely affected by anxious arousal and similarly improved along with primary rating scales.Trial Registration: ClinicalTrials.gov identifier: NCT05061745.

Validation of the Quality Analysis of Medical Artificial Intelligence (QAMAI) tool: a new tool to assess the quality of health information provided by AI platforms.

BACKGROUND: The widespread diffusion of Artificial Intelligence (AI) platforms is revolutionizing how health-related information is disseminated, thereby highlighting the need for tools to evaluate the quality of such information. This study aimed to propose and validate the Quality Assessment of Medical Artificial Intelligence (QAMAI), a tool specifically designed to assess the quality of health information provided by AI platforms. METHODS: The QAMAI tool has been developed by a panel of experts following guidelines for the development of new questionnaires. A total of 30 responses from ChatGPT4, addressing patient queries, theoretical questions, and clinical head and neck surgery scenarios were assessed by 27 reviewers from 25 academic centers worldwide. Construct validity, internal consistency, inter-rater and test-retest reliability were assessed to validate the tool. RESULTS: The validation was conducted on the basis of 792 assessments for the 30 responses given by ChatGPT4. The results of the exploratory factor analysis revealed a unidimensional structure of the QAMAI with a single factor comprising all the items that explained 51.1% of the variance with factor loadings ranging from 0.449 to 0.856. Overall internal consistency was high (Cronbach's alpha = 0.837). The Interclass Correlation Coefficient was 0.983 (95% CI 0.973-0.991; F (29,542) = 68.3; p < 0.001), indicating excellent reliability. Test-retest reliability analysis revealed a moderate-to-strong correlation with a Pearson's coefficient of 0.876 (95% CI 0.859-0.891; p < 0.001). CONCLUSIONS: The QAMAI tool demonstrated significant reliability and validity in assessing the quality of health information provided by AI platforms. Such a tool might become particularly important/useful for physicians as patients increasingly seek medical information on AI platforms.

Randomized controlled clinical trial on the efficacy of a novel antimicrobial chewing gum in reducing plaque and gingivitis in adolescent orthodontic patients.

OBJECTIVES: Chewing gums containing antiseptics or other antimicrobial substances may be effective in reducing plaque and gingivitis. Therefore, the aim of this randomized placebo-controlled clinical trial was to investigate the efficacy of a novel antimicrobial chewing gum containing essential oils (cinnamon, lemon, peppermint) and extracts on reduction of dental plaque and gingivitis as well as on oral health-related quality of life (OHRQoL) in adolescent orthodontic patients. MATERIALS: 52 patients (11-22 years of age) were randomly assigned to use a test chewing gum (COVIDGUM, Clevergum) or a commercially available control chewing gum over a period of 10 days. Approximal plaque index (API), papillary bleeding index (PBI) and an OHRQoL questionnaire for children (COHIP-G19) were assessed at baseline (BL), after 10 days (10d) and 30 days (30d). In addition, oral health and oral hygiene related questions of the COHIP-G19 questionnaire were evaluated separately in subscales at each timepoint. Data were analyzed using non-parametrical statistical procedures (α = 0.05). RESULTS: API and PBI decreased significantly over time from BL to 10d and from BL to 30d in both groups, without significant differences between the groups. In both groups, the COHIP-G19 score, oral health subscale and oral hygiene subscale decreased significantly over time. Regarding the oral hygiene subscale, the test group showed significantly better scores at 30d (p = 0.011). CONCLUSION: Both chewing gums performed similarly effective in terms of reducing plaque accumulation and gingival inflammation and improving OHRQoL. CLINICAL RELEVANCE: Chewing gums without antimicrobial ingredients may be sufficient to decrease plaque accumulation and gingival inflammation.

Contemporary dental student professionalism: moving towards a macro-level perspective.

Defining professionalism and developing educational interventions that foster and assess student professionalism are integral to dental education. Nevertheless, conceptual, methodological and pedagogic differences define the academic field, leaving students, educators and the profession itself struggling to make meaningful progress on how best to elicit and monitor dental student professionalism. This article proposes that more progress can be made on this important issue when a contextualised, sociological assessment of dentistry and dental professionalism is undertaken. We contend that identifying some of the socio-cultural demands in UK dental students' lives, and acknowledging how these pressures shape their interactions with the UK dental education system, provides a nuanced and contemporaneous understanding of what it means to be an oral health care professional at a time of social and health care upheaval. Dental educators can use this insight to work towards being more understanding of and responsive to dental student professional development.

Substance use and self-poisoning in schizophrenia: 11-year findings from a national clinical survey of suicide in mental health patients in the UK.

Suicide is the leading cause of unnatural death among people with schizophrenia. Substance use is a highly prevalent comorbid feature of schizophrenia and a modifiable risk factor for suicide. However, no studies have examined changes in the frequency of substance use or self-poisoning in those who died by suicide over time. Knowing this could support more tailored approaches to reducing specific risk factors and access to means in those with schizophrenia who are at risk of suicide. We conducted an 11-year observational study on a clinical survey of people with schizophrenia in the UK who died by suicide within 12 months of contact with mental health services between 2010 and 2020 (n = 2718). Overall, alcohol, cannabis and stimulants were the most frequently reported substances. The odds of lifetime use significantly increased over time for cannabis, stimulants, heroin, and benzodiazepines. There were differences in socio-demographic, behavioural and clinical factors between those with recent and historical alcohol and drug use before death. Deaths by hanging, jumping and self-poisoning were the most common suicide methods. Though deaths by hanging significantly increased over time, deaths by self-poisoning significantly decreased, especially by means of psychotropic medication and opioids. To improve risk management, clinical efforts should focus on identifying and treating people with schizophrenia using specific substances. Nationwide initiatives for improving safety in prescribing could be contributing to reduced risks of suicide via self-poisoning in this group.