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Objective: The aim of this study was to summarize results of a blinded review of potential suicidal events and analyses comparing incidence rates between paroxetine- and placebotreated pediatric patients. Method: One thousand one hundred ninety-one (1191) children and adolescents received paroxetine (n = 642) or placebo (n = 549) during placebo-controlled portions of all acute double-blind trials of paroxetine (n = 5). An expert panel blindly reviewed and categorized all identified cases detected by electronic and manual search of adverse events (AEs), serious AEs, and selected cases as suicidal or nonsuicidal behavior. Incidence rates were calculated for suicide-related events and for rating scale items assessing suicidality. Results: Suicide-related events occurred more often in paroxetine (22 of 642, 3.4%) than placebo groups (5 of 549, 0.9%); odds ratio (OR) 3.86 (95% CI 1.45, 10.26; p = 0.003). All suiciderelated events occurred in adolescents of at least 12 years, except for 1 of 156 paroxetinetreated children. All suicide attempts occurred in major depressive disorder (MDD); few suicide-related events occurred in patients with a primary anxiety disorder. Suicide item analyses did not reveal significant differences between paroxetine and placebo. Conclusions: Adolescents treated with paroxetine showed an increased risk of suiciderelated events. Suicidality rating scales did not show this risk difference. The presence of uncontrolled suicide risk factors, the relatively low incidence of these events, and their predominance in adolescents with MDD make it difficult to identify a single cause for suicidality in these pediatric patients.

The aims of this work were to assess the efficacy and tolerability of controlled-release paroxetine (paroxetine CR) in the treatment of outpatients with severe major depressive disorder (MDD). This was a retrospective analysis ofpooled data from 4 previously published, double-blind, randomized, placebo-controlled, 8- to 12-week outpatient studies of paroxetine CR (12.5–62.5 mg) in MDD. However, the studies were designed to assess the efficacy of paroxetine CR overall, rather than specifically in those with severe MDD. Subjects were categorized according to their baseline mean 17-item Hamilton Depression Rating Scale (HAMD-17) total score as having severe (≥25) or nonsevere (<25) depression. Changes in depressive symptomatology were assessed, based on the mean change from baseline in HAMD-17 total scores and the proportion of responders (≥50% reduction from baseline in HAMD-17 total scores or Clinical Global Impression [CGI] of Improvement scores of 1 or 2), for each study and pooled across the studies. The pooled analysis of data also assessed the proportion of patients achieving remission (HAMD-17 total score ≤7 or CGI-Improvement score of 1) at last-observation-carried-forward end point. A total of 1083 subjects participated in the4 studies; 303 had severe MDD (paroxetine CR, n = 174; placebo, n = 129). Among the patients with severe MDD, most were women, had a mean HAMD-17 score between 26.3 and 27.7, and had a mean CGI of Severity score between 4.5 and 4.9. In 3 studies, the mean age of such participants was between 35 and 43 years. However, the fourth study was an evaluation in late-life depression in which the mean age was 71.3 years in the paroxetine CR group and 70.0 years in the placebo group. In the overall pooled sample, significantly greater improvements in depressive symptoms were observed among those with severe MDD who were treated with paroxetine CR compared with those who received placebo (HAMD-17 total treatment difference, −4.37 [95% CI, −6.31 to −2.42; P < 0.001]). The odds of CGI-Improvement response were also significantly higher for patients receiving paroxetine CR than those receiving placebo, regardless of baseline depressive symptomatology (severe MDD: odds ratio [OR], 2.42 [95% CI, 1.50–3.91; P < 0.001]; nonsevere MDD: OR, 1.63 [95% CI, 1.21–2.19; P < 0.002] ). Withdrawal rates due to adverse events were 9.8% versus 5.4% (severe) and 5.2% versus 4.5% (nonsevere), paroxetine CR versus placebo, respectively. This post hoc analysis of pooled data suggests that paroxetine CR was effective and well tolerated in these outpatients with severe MDD.

Objective: A high percentage of suicide victims have seen a primary care physician in the months before committing suicide. Thus, primary care physicians may play an important role in suicide prevention. Method: The authors mailed a survey to directors of training programs in family practice, internal medicine, and pediatrics, and 50.5% responded. Data obtained were analyzed with WebStat. Results: Training directors reported deficiencies in training in suicide and depression. Notably, less than half of the internal medicine and pediatrics training directors who replied reported that teaching about suicide was adequate. The majority of them indicated a need for standardized curricular materials on suicide and depression. Conclusions: Experts could provide standardized curricula to primary care residencies in the recognition and management of suicide and depression. More robust training about these vital mental health concerns in primary care could reduce morbidity and mortality.

Data from therapists who were treating patients when they killed themselves were used to provide information about precipitating events that was missing from accounts obtained from suicide victims' relatives and friends. Among 26 patient suicides studied, the therapists identified a precipitating event in 25 cases; in 19 of these, supporting evidence linked the identified event to the suicide. A schema was developed that identifies nine types of evidence provided by therapists in determining that an event precipitated the suicide. Use of the schema is likely to improve accurate identification of events that precipitate patient suicides, and distinguish them from unrelated coterminous events or suicide risk factors.

The rate of suicide in young adults has more than doubled since 1950. This paper presents some explanations for this rise and analyzes the diagnoses and population groups whose high rates of suicide contribute most of this increase. The factors leading to suicide are presented for each group, and preventative interventions are developed from the analyses. Groups that can be readily affected by suicide reduction measures are discussed, and methods for reducing their suicide rates are proposed.

Plasma ferritin is a secretory component of intracellular ferritin synthesis. In normal persons its amount reflects the size of iron stores. A decrease to less than 12 μg per liter indicates iron deficiency. Increased iron stores are associated with an increased plasma ferritin level. Various other conditions, however, can increase the plasma ferritin concentration including increased metabolism, inflammation, tissue damage and neoplastic disease. The use of the plasma ferritin determination in diagnosing iron overload depends on excluding these other causes, leaving storage iron as the only explanation for the increased plasma ferritin. It is then necessary to establish the parenchymal nature of the iron overload by showing an elevated transferrin saturation and, if elevated, the more definitive liver biopsy should be done. Images

Data from therapists who were treating 26 patients when they committed suicide were utilized to identify signs that warned of a suicide crisis. Three factors were identified as markers of the suicide crisis: a precipitating event; one or more intense affective states other than depression; and at least one of three behavioral patterns: speech or actions suggesting suicide, deterioration in social or occupational functioning, and increased substance abuse. Problems in communication between patient and therapist were identified as factors interfering with crisis recognition. Evaluation of the identified affects and behaviors may help therapists recognize a suicide crisis.