Association between childhood cognitive skills & adult suicidal behavior: A systematic review and meta-analysis.

BACKGROUND: It is unclear whether cognitive skill deficits during childhood carry risk for suicide attempt or mortality later in adulthood at the population level. We conducted a systematic review and meta-analysis of population-based studies examining the association between childhood cognitive skills and adult suicidal behavior, namely attempt and mortality. METHOD: We systematically searched databases for articles then extracted study characteristics and estimates on the association between childhood cognitive skills (i.e., IQ or school performance at age ≤ 18 years) and later suicide attempt and mortality. Random-effect meta-analysis was used to quantify this association across all studies with available data. RESULTS: Twenty-three studies met the inclusion criteria and suggest an association between lower childhood cognitive skills and increased risk of suicidal behavior. Meta-analysis of the adjusted estimates from 11 studies (N = 2,830,191) found the association to be small but statistically significant. Heterogeneity was significant but moderate, and results were unlikely to be influenced by publication bias. In subgroup analyses, associations were significant only for males. No difference in effect size was found between suicide attempt and suicide mortality. LIMITATIONS: Cognitive skills were measured with different cognitive subtests. Heterogeneity in the age of cognitive skills assessment. Meta-regression and subgroup analyses were based on a relatively low number of studies. CONCLUSIONS: Individuals with lower cognitive skills in childhood have a greater risk of suicidal behavior in adulthood, especially males. Although the association was small, interventions improving cognitive skills may yield large effects on suicide prevention at the population level if the association is causal.

Association between hypovitaminosis D and cognitive inhibition impairment during major depression episode.

BACKGROUND: Major depressive episode (MDE) has been associated with cognitive functioning alteration and hypovitaminosis D (hypoVD), but the relationship between hypoVD, depression, and cognition is not well understood. We aimed to compare patient with MDE with or without hypoVD in regard of cognitive functioning. METHODS: 91 patients (38.5 years old, 65.9% female) with MDE were included in a cross-sectional study and were evaluated with a complete cognitive battery. None of the participants were medicated at the time of the inclusion. Serum 25-hydroxyvitamin D was measured using LC-MS/MS method, and hypovitaminosis was defined as 25OHD < 50nmol/L. Covariates were gender, season of dosage, first MDE onset, age, body mass index and depression severity RESULTS: Patients with hypoVD demonstrated a higher stroop intereference index time underscoring that means low cognitive inhibition ability. Mutiple logistic regression confirmed that hypoVD was significantly associated with high stroop interference time index after controlling by gender, season of dosage, first MDE onset, age, body mass index and depression severity. CONCLUSION: Our results suggest that patient with MDE having hypoVD may be more prone to cognitive impairment.

Suicide and assisted dying in dementia: what we know and what we need to know. A narrative literature review.

BACKGROUND: Evidence-based data on prevalence and risk factors of suicidal intentions and behavior in dementia are as scarce as the data on assisted dying. The present literature review aimed on summarizing the current knowledge and provides a critical discussion of the results. METHODS: A systematic narrative literature review was performed using Medline, Cochrane Library, EMBASE, PSYNDEX, PSYCINFO, Sowiport, and Social Sciences Citation Index literature. RESULTS: Dementia as a whole does not appear to be a risk factor for suicide completion. Nonetheless some subgroups of patients with dementia apparently have an increased risk for suicidal behavior, such as patients with psychiatric comorbidities (particularly depression) and of younger age. Furthermore, a recent diagnosis of dementia, semantic dementia, and previous suicide attempts most probably elevate the risk for suicidal intentions and behavior. The impact of other potential risk factors, such as patient's cognitive impairment profile, behavioral disturbances, social isolation, or a biomarker based presymptomatic diagnosis has not yet been investigated. Assisted dying in dementia is rare but numbers seem to increase in regions where it is legally permitted. CONCLUSION: Most studies that had investigated the prevalence and risk factors for suicide in dementia had significant methodological limitations. Large prospective studies need to be conducted in order to evaluate risk factors for suicide and assisted suicide in patients with dementia and persons with very early or presymptomatic diagnoses of dementia. In clinical practice, known risk factors for suicide should be assessed in a standardized way so that appropriate action can be taken when necessary.

Behavioral variant frontotemporal dementia: advanced disease stages and death. A step to palliative care.

OBJECTIVE: The aim of the present study was to gain insight into the living and care situation in advanced behavioral variant frontotemporal dementia (bvFTD), to describe symptoms and findings in advanced bvFTD, and to evaluate somatic comorbidities and circumstances of death. METHODS: Standardized interviews were conducted with family caregivers of 83 patients with bvFTD. Forty-four percent of the patients were already deceased at the time of the interview. RESULTS: At the time of the interview or death, respectively, 47% of the patients lived in a nursing home. The median time between symptom onset and nursing home admission was 5.0 ± 5.5 years. In moderate and severe dementia stages almost all patients suffered from severe disabilities including impairment of language, gait, swallowing, and of the ability to care for themselves. Sixteen percent of the patients had got enteral tube feeding. Comorbid somatic diseases were diagnosed in 46% of the patients. Twenty-three percent of the deceased patients had been admitted into a hospital before death. Cardiovascular disease and respiratory disease, mostly pneumonia, were the most frequent causes of death. CONCLUSIONS: Advanced bvFTD is characterized by severe cognitive impairment and physical disabilities. BvFTD leads to a premature death. Our findings stress the importance of strategies that maximize patient comfort in advanced disease stages and allow for a peaceful death. Copyright © 2016 John Wiley & Sons, Ltd.

[Wernicke encephalopathy: Guiding thiamine prescription]. / Thiamine et encéphalopathie de Gayet-Wernicke : quelles règles de prescription ?

BACKGROUND AND AIM: Wernicke's encephalopathy (WE) is a medical emergency. The objective of this paper is to systematically review the literature published over the past 15 years pertaining to prophylactic and curative treatment of WE with thiamine. METHODS: A systematic literature search was performed using Medline to include all studies published between January 1, 2000 and December 31, 2015. RESULTS: Of the 316 abstracts identified, 20 met the final inclusion criteria. The evidence on the use of prophylactic thiamine was quite heterogeneous. The use of thiamine in this context largely depended on the evaluation of an individual's risk of developing WE. Use of prophylactic thiamine in low-risk patients is not universally indicated. When prescribed in this sub-population, the oral route is suggested but may be insufficient owing to its limited intestinal absorption and the high risk of non-compliance. High-risk patients need parenteral treatment with a recommended posology of 250 mg daily for 3 to 5 days. Intramuscular route is preferred in the outpatient setting, whereas intravenous route is suggested for inpatients. In cases where the diagnosis of WE is suspected or confirmed, a curative treatment with high-dose IV thiamine is justified. The evidence widely accepted in the literature is much clearer in this condition, with treatment regimens consisting of 500 mg IV 3 times daily for 3 to 5 days, followed by 250 mg IV daily for a minimum of 3 to 5 additional days. CONCLUSION: The literature does indicate that thiamine should be prescribed at high dosages, with the parenteral routes indicated in hospital settings and in high-risk patients. Based on the current literature review, we suggest treatment algorithms guiding thiamine prescription for WE.

Neurobiology of Elderly Suicide.

Suicide in the elderly is an underestimated and complex issue that has mainly been explored in sociological, clinical and psychological perspectives. Suicide in non-elderly adults has been associated with diverse neurobiological alterations that may shed light on future predictive markers and more efficient preventative interventions. The aim of this paper was to review studies specifically investigating the neurobiology of elderly suicidal behaviour. We performed a systematic English and French Medline and EMBASE search until 2013. Contrary to literature about the non-elderly, we found a paucity of studies investigating the biomarkers of suicidal risk in elderly adults. Main findings were found in the neurocognitive domain. Studies generally supported the existence of cognitive deficits, notably decision-making impairment and reduced cognitive inhibition, in patients with a history of suicidal act compared to patients without such history. However, replications are needed to confirm findings. Due to several limitations including the small number of available studies, frequent lack of replication and small sample size, no firm conclusions can be drawn. The authors encourage further investigations in this field as insight in the neurobiology of these complex behaviors may limit clichés about end of life and aging, as well as improve future prevention of suicide in the elderly.

Cognitive inhibition in depression and suicidal behavior: a neuroimaging study.

BACKGROUND: Cognitive inhibition deficits have previously been found in suicide attempters. This study examined the neural basis for these deficits in depressed patients with and without a history of suicidal behavior. METHOD: Functional magnetic resonance imaging was used to measure brain activation during the Go/No-Go response inhibition task in 25 unmedicated and depressed middle-aged suicide attempters, 22 unmedicated depressed patient controls with no personal or family history of suicidal behavior, and 27 healthy controls. Whole-brain analyses were conducted with SPM12. RESULTS: Suicide attempters exhibited an elevated number of commission errors relative to both control groups. However, suicide attempters did not differ from patient controls in terms of brain activation for any contrast. Analyses showed a significant association between depression and brain activation in the left inferior frontal gyrus and medial thalamus during Go v. No-Go, and in the bilateral parietal cortex and left orbitofrontal cortex during No-Go v. baseline. These regions were correlated with psychological pain, suicidal ideation and global functioning. There was no association between brain activation and personal histories of suicidal act. CONCLUSIONS: Our study suggests that deficits in cognitive inhibition, in relation to the inferior frontal gyrus, thalamus, orbitofrontal cortex and parietal cortex, are related to the depressive state and not specifically to suicide vulnerability. We hypothesize that state-related deficits may add to trait-like cognitive impairments to facilitate suicidal acts. These different types of cognitive impairments may necessitate different therapeutic strategies for the prevention of suicide.

Impaired decision-making in symptomatic anorexia and bulimia nervosa patients: a meta-analysis.

BACKGROUND: Impaired decision-making is a potential neurocognitive phenotype of eating disorders. It is therefore important to disentangle the decision-making deficits associated with the eating disorder subtypes and determine whether this putative impairment is a state or trait marker of the disease or more related to starvation. We systematically reviewed the literature on decision-making in eating disorders and conducted a meta-analysis to explore its role in anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). METHOD: A search of the Medline and EMBASE databases and article references was performed. A total of 23 studies (2044 participants) met the selection criteria. When the Iowa gambling task (IGT) was used in at least three of the studies, a meta-analysis was run. RESULTS: IGT performance was significantly worse in patients with an eating disorder diagnosis (AN, BN or BED) compared with healthy controls, indicating that eating disorders have a negative effect on decision-making. Hedges' g effect sizes were moderate to large (-0.72 in AN, -0.62 in BN, and -1.26 in BED). Recovered AN patients had IGT scores similar to those of healthy controls. Restrictive AN patients had significantly lower IGT net scores than purging AN patients, and both AN subtypes had worse performances than healthy controls. Age and body mass index did not explain results. CONCLUSIONS: Decision-making was significantly altered in patients with eating disorders. Poor decision-making was more pronounced during the acute phase than in the recovered state of AN. Nutritional status during the acute phase of the disease did not seem to influence decision-making skills.

First-degree relatives of suicide completers may have impaired decision-making but functional cognitive control.

BACKGROUND: The heritability of suicide is well established. Transmission of risk appears to follow traits more than disorders like depression. In the present project, we aimed at investigating the potential for transmission of cognitive deficits previously observed in suicide attempters, specifically impaired decision-making and cognitive control. METHODS: Seventeen healthy first-degree relatives of suicide completers with no personal history of suicidal act were compared to 18 first-degree relatives of individuals with major depressive disorder but no family history of suicidal act, and 19 healthy controls. Decision-making was assessed with the Iowa Gambling Task, and cognitive control with the Stroop Task, the Hayling Sentence Completion Test, and the Trail-Making Test. RESULTS: Both suicide and depressed relatives showed lower gambling task net scores than healthy controls. However, there were trends toward lower learning abilities in suicide than depressed relatives (interaction: p = 0.07), with more risky choices at the end of the test. Suicide relatives also showed a higher number of self-corrected errors relative to the total number of errors in the Stroop colour test compared to both control groups, with no difference in interference scores. There was no group-difference for any other cognitive tests. CONCLUSION: Our findings suggest that decision-making impairment may be found in healthy relatives of suicides and represent a cognitive endophenotype of suicidal behaviour. Normal cognitive control (or self-corrected deficits) may protect relatives against suicidal acts. Impairments in value-based and control processes may, therefore, be part of the suicide vulnerability and represent potential targets of preventative interventions.

[Court-ordered treatment: Analysing a complex practise through a literature review]. / Les soins pénalement ordonnés : analyse d'une pratique complexe à travers une revue de la littérature.

INTRODUCTION: In France, there are two main types of court-ordered treatment (COT) as far as mental health is concerned: obligations of treatment and injunctions of treatment. Obligations of treatment date back from 1958 whereas the law implementing injunctions of treatment is fairly recent as it was passed in 1998. Obligations and injunctions of treatment are two different types of COT that differ in terms of proceedings (obligations of treatment require no preliminary forensic psychiatric assessment; as for injunctions of treatment, they require the appointment of a coordinating medical doctor) and that are applied for different offences. However, both are psychiatric commitment procedures connecting the judicial, medical and social fields and their overall numbers have been on the rise. These common psychiatric practices have seldom been assessed and no review of the literature on the subject has ever been published. Better knowledge of such forensic practices is essential to their improvement and even to adjust the legal framework of these measures that are enjoying a boom. The purpose of this literature review is to define the prevalence of COT as well as the sociodemographic, criminal and psychiatric characteristics of those concerned by such measures. MATERIAL AND METHODS: A review of the French medical literature on COT was carried out using Science Direct up to December 2013. The results of seven studies were included and analysed. This was completed with a review of the articles listed in social sciences and law databases (Cairn and Dalloz). RESULTS: It has become increasingly frequent to rely on psychiatric teams to implement COT while at the same time public mental health services have to face a surge in activity with restricted financial means. Obligations of treatment are far more common (about 20,000 court orders a year) than injunctions of treatment (about 4000 measures are currently being enforced). However the latter have showed an increase of 506% over the 2000 decade. Both measures mainly concern men (83-99%) who are rather low on the social scale. In about half of these men, no mental disorder was found, however the prevalence of personality disorders ranged from 22 to 65% while that of psychotic disorders was low. Injunctions of treatment concerned sex offenders (90% of cases) whereas obligations of treatment concern non-sexual abusers (40-70%) rather than sex offenders (20-30%). DISCUSSION: Psychiatric research on COT is still thin on the ground and its methodology does not allow rigorous evaluation though the use of such measures is growing. When confronted with people who have not sought any care or treatment, healthcare professionals are at a loss. In France, training in forensic psychiatry is inadequate and specialised healthcare (particularly for sex offenders) need improving to reach the level of those found in many other European countries. The purpose of psychiatric treatment differs from that of lawmakers whose aim is to prevent recidivism. However, better treatment consistency requires setting up partnerships between justice, health and social services. To improve connections, there are various avenues of work such as, for instance, the creation of coordinating medical doctors for injunctions of treatment in France or European experiments using a multidisciplinary approach to prevent recidivism in sex offenders. The framework of such a partnership remains to be created as it is part and parcel of COT but has not been provided for in the law. Healthcare jurisdictions as defined in the 2009 French National Health Law might provide an appropriate framework for mental health and law professionals to collaborate.

Psychomotor retardation is a scar of past depressive episodes, revealed by simple cognitive tests.

The cumulative duration of depressive episodes, and their repetition, has a detrimental effect on depression recurrence rates and the chances of antidepressant response, and even increases the risk of dementia, raising the possibility that depressive episodes could be neurotoxic. Psychomotor retardation could constitute a marker of this negative burden of past depressive episodes, with conflicting findings according to the use of clinical versus cognitive assessments. We assessed the role of the Retardation Depressive Scale (filled in by the clinician) and the time required to perform the neurocognitive d2 attention test and the Trail Making Test (performed by patients) in a sample of 2048 depressed outpatients, before and after 6 to 8 weeks of treatment with agomelatine. From this sample, 1140 patients performed the TMT-A and -B, and 508 performed the d2 test, at baseline and after treatment. At baseline, we found that with more past depressive episodes patients had more severe clinical level of psychomotor retardation, and that they needed more time to perform both d2 and TMT. When the analyses were performed again after treatment, and especially when the analyses were restricted to patients with clinical remission, the cognitive tests were the only ones correlated with past depressive episodes. Psychomotor retardation tested at a cognitive level was therefore systematically revealing the burden of past depressive episodes, with an increased weight for patients with less remaining symptoms. If prospectively confirmed, interventions such as cognitive remediation therapy could benefit from a more specific focus on neurocognitive retardation.

A meta-analysis of neuropsychological markers of vulnerability to suicidal behavior in mood disorders.

BACKGROUND: Suicidal behavior results from a complex interplay between stressful events and vulnerability factors, including cognitive deficits. However, it is not clear which cognitive tests may best reveal this vulnerability. The objective was to identify neuropsychological tests of vulnerability to suicidal acts in patients with mood disorders. METHOD: A search was made of Medline, EMBASE and PsycINFO databases, and article references. A total of 25 studies (2323 participants) met the selection criteria. A total of seven neuropsychological tests [Iowa gambling task (IGT), Stroop test, trail making test part B, Wisconsin card sorting test, category and semantic verbal fluencies, and continuous performance test] were used in at least three studies to be analysed. RESULTS: IGT and category verbal fluency performances were lower in suicide attempters than in patient controls [respectively, g = -0.47, 95% confidence interval (CI) -0.65 to -0.29 and g = -0.32, 95% CI -0.60 to -0.04] and healthy controls, with no difference between the last two groups. Stroop performance was lower in suicide attempters than in patient controls (g = 0.37, 95% CI 0.10-0.63) and healthy controls, with patient controls scoring lower than healthy controls. The four other tests were altered in both patient groups versus healthy controls but did not differ between patient groups. CONCLUSIONS: Deficits in decision-making, category verbal fluency and the Stroop interference test were associated with histories of suicidal behavior in patients with mood disorders. Altered value-based and cognitive control processes may be important factors of suicidal vulnerability. These tests may also have the potential of guiding therapeutic interventions and becoming part of future systematic assessment of suicide risk.

[Homicide, schizophrenia and substance abuse: a complex interaction]. / Homicide, schizophrénie et abus de substances : des liaisons dangereuses ?

BACKGROUND AND AIM: The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia. METHODS: A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively. RESULTS: Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not. CONCLUSION: Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.

[Female intimate partner homicide: clinical and criminological issues]. / Singularités cliniques et criminologiques de l'uxoricide: éléments de compréhension du meurtre conjugal.

BACKGROUND: Female intimate partner homicide (FIPH) is a fatal complication of domestic violence. The aim of this study was to describe the socio-demographic, clinical and criminological characteristics of male perpetrators of FIPH and to compare them to the perpetrators of extrafamilial homicide and the perpetrators of intrafamilial homicide other than FIPH. METHODS: Between 1975 and 2005, 32 FIPH were perpetrated in the region of Angers (France), and these were compared to 26 intrafamilial homicides other than FIPH and to 97 extrafamilial homicides perpetrated in the same period, in the same region. The socio-demographic, clinical and criminological data were collected from psychiatric expert reports and medical files. RESULTS: The mean age of the FIPH perpetrators was 37.8years. They were professionally active, in majority as manual workers. They had a psychiatric record (69%), a previous criminal record (31%), and a history of violence against others (47%). Half of these perpetrators also had experienced a traumatic event before the age of 18. Compared to extrafamilial homicide perpetrators, FIPH perpetrators occupied more frequently a manual job and had prior criminal records less frequently. In the majority of cases of FIPH and intrafamilial homicide, the murder occurred in the evening, at the victim's home, and while the perpetrator was intoxicated. FIPH was mostly premeditated and was accompanied four times less frequently by another criminal behaviour compared to extrafamilial homicide. The FIPH perpetrators had more depressive symptoms and suicidal ideations when committing the crime and remained on the crime scene more often than extrafamilial homicide perpetrators who mostly attempted to flee the crime scene. FIPH perpetrators and extra- and intrafamilial homicide perpetrators were found criminally responsible in half of the cases. The socio-demographic, clinical and criminological characteristics of FIPH perpetrators were not statistically different from those of perpetrators of another intrafamilial homicide except that conflict preceded FIPH more frequently. CONCLUSION: Identification of specific features of FIPH could contribute to the early identification of domestic violence at risk of becoming lethal and to the elaboration of preventive strategies.

Influence of gender and age on cognitive inhibition in late-onset depression: a case-control study.

OBJECTIVE: To compare cognitive inhibition performance between people with early-onset (EOD) or late-onset depression (LOD) and controls, and between women and men with LOD. METHODS: On the basis of a case-control design, global executive performance (Frontal Assessment Battery); verbal (Hayling), attention (Stroop), and motor (Go/No-Go) components of cognitive inhibition; mental shifting (Trail Making Test parts A and B); and updating in working memory (Wechsler Adult Intelligence Scale) were assessed in 40 participants (10 depressed women with LOD (i.e., ≥60 years old), 10 depressed women with EOD (i.e., <60 years old), 10 healthy women and 10 depressed men with LOD (i.e., ≥60 years old)). RESULTS: Older depressed women, irrespective of age of depression onset, had greater cognitive inhibition impairments (attention and verbal component) compared with healthy women. LOD was significantly associated with the attention component of cognitive inhibition impairment, unlike EOD (p = 0.026). No executive differences were found regarding age of first-onset depression in older depressed women, and between women and men with LOD. CONCLUSION: Cognitive inhibition impairment, and more specifically its attention component, was the main characteristic of depression in the studied sample of older adults, independently of gender and age of depression onset. It is essential to perform similar studies in both genders in view of future tailor-made therapeutic modalities.

Cognitive inhibition and quality of life in schizophrenia: a pilot study.

AIM: To compare cognitive inhibition and quality of life in patients with schizophrenia and healthy controls. METHODS: Ten patients with schizophrenia were compared to 10 healthy controls, matched for age, sex, and educational level. Cognitive inhibition was examined by: 1) access to relevant information (Reading with distraction task), 2) suppression of no longer relevant information (Trail Making Test), and 3) restraint of cognitive resources to relevant information (Stroop Test, Hayling Sentence Completion Test, Go/No-Go Test). Montgomery Asberg Depression Rating Scale, Positive and Negative Syndrome Scale, and Schizophrenia-Quality of Life scale (S-QoL) were also used. RESULTS: Patients with schizophrenia showed a significant impairment in the suppression function of cognitive inhibition only, in comparison to the control group. Their access and restraint functions of cognitive inhibition were preserved. No relationship between quality of life and cognitive inhibition was found in patients with schizophrenia. CONCLUSIONS: During the stabilization phase of schizophrenia, the ability to inhibit neutral information access to working memory, and to restrain and suppress irrelevant information may not impair the patient's capacity to respond adequately to stressful situations, and thus would do not impact their quality of life.

Deficit of cognitive inhibition in depressed elderly: a neurocognitive marker of suicidal risk.

BACKGROUND: Cognitive deficits, in relation to ventral and dorsal prefrontal cortex dysfunctions, have been associated with a higher risk of suicidal acts in young adult patients. Although a public health concern, much less is known about the neurocognitive basis of suicidal behavior in elderly. Here, we aimed at assessing alterations in cognitive inhibition, a suspected major mechanism of the suicidal vulnerability, in suicidal depressed elderly. METHODS: We compared 20 currently depressed patients, aged 65 and older who recently attempted suicide to 20 elderly subjects with a current depression but no personal history of suicide attempt and 20 elderly controls. Using an extensive neuropsychological battery, we particularly examined different aspects of cognitive inhibition: access to relevant information (using the Reading with distraction task), suppression of no longer relevant information (Trail Making Test, Rule Shift Cards), and restraint of cognitive resources to relevant information (Stroop test, Hayling Sentence Completion test, Go/No-Go). RESULTS: After adjustment for age, intensity of depression, Mini-Mental State Examination score and speed of information processing, suicidal depressed elderly showed significant impairments in all 3 domains of cognitive inhibition in comparison to both control groups. LIMITATIONS: Our results need replication in a larger sample size. CONCLUSIONS: Our study suggests that the inability to inhibit neutral information access to working memory, restrain and delete irrelevant information may impair the patient's capacity to respond adequately to stressful situations subsequently leading to an increased risk of suicidal behavior during late-life depression. Interventions may be developed to specifically target cognitive impairment in the prevention of suicide in depressed elderly.

[Risk of homicide and major mental disorders: a critical review]. / Risque d'homicide et troubles mentaux graves: revue critique de la littérature.

INTRODUCTION: Tragic and high profile killings by people with mental illness have been used to suggest that the community care model for mental health services has failed. It is also generally thought that schizophrenia predisposes subjects to homicidal behaviour. OBJECTIVE: The aim of the present paper was to estimate the rate of mental disorder in people convicted of homicide and to examine the relationship between definitions. We investigated the links between homicide and major mental disorders. METHODS: This paper reviews studies on the epidemiology of homicide committed by mentally disordered people, taken from recent international academic literature. The studies included were identified as part of a wider systematic review of the epidemiology of offending combined with mental disorder. The main databases searched were Medline. A comprehensive search was made for studies published since 1990. RESULTS: There is an association of homicide with mental disorder, most particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. However, it is not clear why some patients behave violently and others do not. Studies of people convicted of homicide have used different definitions of mental disorder. According to the definition of Hodgins, only 15% of murderers have a major mental disorder (schizophrenia, paranoia, melancholia). Mental disorder increases the risk of homicidal violence by two-fold in men and six-fold in women. Schizophrenia increases the risk of violence by six to 10-fold in men and eight to 10-fold in women. Schizophrenia without alcoholism increased the odds ratio more than seven-fold; schizophrenia with coexisting alcoholism more than 17-fold in men. We wish to emphasize that all patients with schizophrenia should not be considered to be violent, although there are minor subgroups of schizophrenic patients in whom the risk of violence may be remarkably high. According to studies, we estimated that this increase in risk could be associated with a paranoid form of schizophrenia and coexisting substance abuse. The prevalence of schizophrenia in the homicide offenders is around 6%. Despite this, the prevalence of personality disorder or of alcohol abuse/dependence is higher: 10% to 38% respectively. The disorders with the most substantially higher odds ratios were alcohol abuse/dependence and antisocial personality disorder. Antisocial personality disorder increases the risk over 10-fold in men and over 50-fold in women. Affective disorders, anxiety disorders, dysthymia and mental retardation do not elevate the risk. Hence, according to the DMS-IV, 30 to 70% of murderers have a mental disorder of grade I or a personality disorder of grade II. However, many studies have suffered from methodological weaknesses notably since obtaining comprehensive study groups of homicide offenders has been difficult. CONCLUSIONS: There is an association of homicide with mental disorder, particularly with certain manifestations of schizophrenia, antisocial personality disorder and drug or alcohol abuse. Most perpetrators with a history of mental disorder were not acutely ill or under mental healthcare at the time of the offence. Homicidal behaviour in a country with a relatively low crime rate appears to be statistically associated with some specific mental disorders, classified according to the DSM-IV-TR classifications.

[Homicide and major mental disorder: what are the social, clinical, and forensic differences between murderers with a major mental disorder and murderers without any mental disorder?]. / Homicide et maladie mentale grave: quelles sont les différences sociodémographiques, cliniques et criminologiques entre des meurtriers malades mentaux graves et ceux indemnes de troubles psychiatriques?

OBJECTIVES: To establish the social, clinical, and forensic differences between murderers suffering from a major mental disorder and murderers without any psychiatric disorder and, in particular, to compare their respective records of psychiatric symptoms and their respective relationship with their victims. METHOD: We studied 210 forensic examinations of murderers, the offences related to the murders, and the social and clinical information collected from psychiatric court reports on persons convicted of homicide. Firstly, we identified the socio-demographic, clinical and criminological profiles of 210 murderers from which were distinguished murderers with major mental disorder. Then, we compared the profiles of murderers suffering from a major mental disorder with those of murderers without any mental disease. In other words, we compared 37 persons affected with major mental disorder (schizophrenia, paranoiac delusional disorder, and affective disorder) with 73 persons without any mental disorder. We deliberately excluded subjects with personality disorder or abuse of/dependency on drugs, mental retardation or dementia. RESULTS: With the exception of certain variables, murderers with major mental disorder have the same characteristics as others murderers: young man, living alone, with psychiatric and offence records and substance abuse. Murderers with major mental disorder are older (37.8 versus 31.7 years old) than perpretators without any mental disorder, and the former have a psychiatric record more often than the latter (81 versus 32.9%). In addition, contrary to the latter, the former show clinical symptoms of a psychopathological process. Depression, delusional and suicidal ideas are frequent among murderers with a major mental disorder, whereas the persons without mental disorder quarrel or have a row with their victim just before their crime. The victim was known to the perpetrator significantly more often in the major mental disorder group than in the no mental disorder group (94,6 versus 76,7%, p=0,008). The most major mental disorders' homicide was more likely to be against intimates than strangers. The application of the former article 64 or the present article 122-1 of the French Criminal Code are envisaged more often in the major mental disorder group than in the no mental disorder group. CONCLUSION: The main difference between murderers with a major mental disorder and murderers without any mental disorder is the psychopathology of the morbid process which underlies the homicide. Impairment of judgment at the time of the crime should be taken into account. As a clinician, we should focus our attention on general risk factors of violence and homicide (male, young, underprivileged class, abuse of alcohol) and on more specific factors (mental disorder co-morbidities...). To these factors should be added the dynamic characteristics of the meeting of the protagonists.