Background: People with depressive and/or anxiety disorders are at increased risk of suicidal ideation and suicide attempts, but biological correlates signaling such risk remain unclear.... Show moreBackground: People with depressive and/or anxiety disorders are at increased risk of suicidal ideation and suicide attempts, but biological correlates signaling such risk remain unclear. Independent and cumulative dysregulations in physiological stress systems, in particular the hypothalamic-pituitaryadrenal axis (HPA-axis), immune inflammatory system, and autonomous nervous system (ANS), may contribute to this risk. However, findings have either been heterogeneous or absent thus far.Methods: Associations between individual markers and cumulative indices of the HPA-axis (cortisol awakening response and evening cortisol), immune-inflammatory system (C-reactive protein, interleukin-6 (IL-6), and tumor necrosis factor-alpha), and the ANS (heart rate, respiratory sinus arrhythmia, and pre-ejection period) and the outcomes no suicide ideation with suicide attempt (SI-SA+), suicide ideation without suicide attempt (SI+SA-) and suicide ideation with suicide attempt (SI+SA+) were investigated in 1749 persons with depressive and/or anxiety disorders from the Netherlands Study of Depression and Anxiety (NESDA).Results: High levels of CRP and IL-6 were associated with SI-SA+ and SI+SA+ respectively when compared to non-suicidal patients after adjusting for confounders and multiple testing. Also, cumulative immune inflammatory dysregulations were positively associated with SI+SA+, suggesting a dose-response effect. No significant associations were found between HPA-axis or ANS indicators and suicide-outcomes and between immune-inflammatory system markers or cumulative stress system dysregulations and SI+SA-.Conclusion: Although stress system markers could not differentiate between SI+SA-and non-suicidal patients, findings indicate that dysregulations of individual and cumulative immune-inflammatory markers are associated with suicide attempts in depressive and/or anxiety patients. Thus, immune-inflammatory system dysregulation may be involved in the pathophysiology of suicidal behavior, supporting further examination of the effects of anti-inflammatory interventions on suicidality. Show less
The aim of this thesis was to contribute to better care for suicide attempters by studying several aspects of their assessment and management. In the first part of the thesis, the role of... Show moreThe aim of this thesis was to contribute to better care for suicide attempters by studying several aspects of their assessment and management. In the first part of the thesis, the role of guidelines was studied resulting in suggestions for improvement. In the second part, the role of factors is studied that, as experience in clinical practice suggests may hamper proper assessment and management. From the studies in part 1, it was concluded that the available evidence suggests that guidelines for the assessment and management of suicide attempters differ to a large extent with respect to their content, that only a minority can be recommended based on an evaluation of their quality, and that they are probably not implemented properly. This leads to a plea to update the Dutch guideline, made 15 years ago, and to develop procedures that may promote implementation. From the studies of part 2, it was concluded that professionals should be alert on patients forgetting relevant aspects of the assessment. Furthermore, although a systematic assessment in the hospital is comparable to a reassessment at home, for a subgroup of patients there is concern about their condition after discharge, and their tendency to forget the arrangements made for treatment after discharge from the hospital. So, additional strategies to the assessment in the hospital should be developed. In the Appendix, recommendations are given regarding development and implementation of guidelines for assessment and management of suicide attempters. Show less
