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The debates on euthanasia and assisted suicide (EAS) are topical in Europe. The extension of EAS for psychiatric reasons, already legalized in some countries, raises ethical and clinical issues, given the proximity between suicidal patients and patients who request or have accessed EAS. How can ESA be reconciled with the promotion of suicide prevention, which kills nearly 10,000 people per year in France? We will raise here several key questions that deserve a clear answer before considering going further in the social debates: how to ensure the irreversibility of psychological suffering? how to ensure that patients requesting EAS have full decision-making capacity? how to judge therapeutic futility? It seems crucial to protect the most vulnerable patients by ensuring that psychiatry benefits from scientific progress and can offer new solutions to suffering patients.Thes issues will be discussed viewing the proposed law on EAS in France, which is supposed to come in February 2024…Disclosure of InterestNone Declared

Suicidal behavior is a public health challenge that resists the various efforts made toward its prevention and treatment. Indeed, suicide rate have not significantly changed in the past decades. Then one may wonder if precision psychiatry could be the solution?Advances towards precision suicidology will be detailed from detection to oportunities for treatment.First, current suicide risk assessment methods are unable to detect suicidal risk with sufficient accuracy and while thousand of risk factors for suicide have been identified, they are no more accurate in predicting suicidal behavior than flipping a coin. Second, we are lacking specific and effective evidence based strategies for suicide prevention.The aim of precision psychiatry is tailoring efficient preventive and therapeutic approaches to the unique characteristics of each patient. It assumes that the determination of a reliable medical diagnosis is unfeasible if based on symptomology alone and it must integrate genomics data, clinical dimensions, biomarkers, and environmental and lifestyle factors and this amount of data analysed by artificial intelligence would give us “biosignatures” that would yield a more appropriate diagnosis, treatment and prognosis.We will cover advances in genomics, imaging, inflammatory markers and digital health that witness the realistic possibility to change the field of suicide prevention.Disclosure of InterestNone Declared

Suicide prevention remains very difficult to achieve for many reasons, notably because we do not have any indicator of risk prediction, short-term risk factors being little explored, and evaluations being retrospective they are biased. Furthermore, patients at risk are not followed up, because of their lack of confidence in care, stigma, shame. On the other hand, the gap observed during the covid19 pandemic between distress and less occurrence of suicides could be linked to more virtual contacts. Then, the smartphone might be a good tool to stay connected to a protective network. We will discuss the opportunity offered by the smartphone to monitor patients with ecological momentary assessment, allowing to better characterize their acute states and detect an increased risk in real time, and thanks to the ecological momentary intervention 24/7 availability, improve access to care and better coordinate resources, and encourage self-care. These tools while offering new solutions for an efficient real time suicide prevention, may also raise some ethical issues that should be addressed.

Despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not decreased substantially. Specifically, the most commonly used strategy, which is the use of antidepressant treatments, is clearly nonsufficient to attain the goal of a substantial reduction of suicides. Then, we will discuss the hypothesis that people who are more sensitive to experiences of social disconnection may activate a pathophysiological process which lead to a greater risk of suicide, and by such its study may offer new avenues for assessing the suicide risk as well as in providing new therapeutic targets. It is well demonstrated that both the objective condition of being alone and loneliness are strongly associated with suicide. From a series of cognitive imaging studies, it appears that suicidal patients are more sensitive to social exclusion, relying on a neural network implicated in the pain matrix, and individuals experiencing more psychological pain in daily life would be less prone to activate orbitofrontal cortex in social contexts which would facilitate disadvantageous decision-making, leading to choose options (i.e. suicidal act) with short-term reward (i.e. relief from pain) in spite of the risks (i.e. death). As psychological pain predicts suicidal behaviour, suggesting the need in assessing it in clinical practice, in using alleviating drugs i.e. opiates or ketamine, and in implementing evidence-based psychosocial strategies, based on caring contacts and social prescription. In conclusion, there are many innovations available to help tackle social vulnerability, which should be a priority in suicide prevention.

Until 2016, only few interventions were supposed to work in suicide prevention: restriction of access to lethal means, school-based universal prevention, treatment of depression and ensuring chain of care. Then, despite the multiplication of the therapeutic strategies for psychiatric disorders during the last decades, the incidence of suicide has not substantially decreased. Among several hypotheses, we proposed that suicidal depression is a specific form of depression, less responsive to antidepressants, carrying a high suicide risk, which deserves specific interventions. During the last decade, few controlled studies have been performed in at risk patients with short term reduction of the risk of suicide as a main objective, and the interest for old drugs such as lithium and clozapine remains. Recent data allow to propose that a new era is coming with evidence-based strategies of suicide prevention that should lead to change the way we deal with suicidal patients. Importantly, most efforts to develop interventions have moved to a perspective that suicide- specific treatments are necessary in addition to interventions for primary psychiatric disorders. By formulating the hypothesis that suicidal patients present a dysregulated response to social adversity based on specific brain areas associated with psychological pain, relying to opioidergic, immune and glutamatergic systems. Last, due to the difficult management of suicidal patients, innovative psychosocial interventions should be implemented for patients in suicidal crises and including safety planning, coordination of care, brief contact using phone calls. We have probably more solutions than ever to prevent suicide.

BackgroundInflammatory biomarkers are reportedly increased in depressed patients. Several studies have been conducted using neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and monocyte/lymphocyte ratio (MLR). The objective of this systematic review was to study the relationship between these peripheral biomarkers and suicidality in depressed patients with/without suicidal behavior, including suicide attempts and ideation, and healthy controls.MethodsWe searched the following relevant terms in the PubMed, Web of Science, and Scopus databases published in the last 5 years. We assessed the methodological quality of included studies using the Oxford criteria and reviewed the evidence following PRISMA guidelines.ResultsEleven studies were retained for the data synthesis, with a total sample of 1,701 participants, of which the majority (819) were patients with depression and suicidal behavior, 494 were depressed patients without suicidal behavior, and only 388 were healthy participants. Our results reinforce the idea that NLR could be an attractive, convenient, and cost-effective trait marker of suicidal vulnerability in patients with major depressive disorder (MDD).ConclusionFuture large-scale replication studies are needed to examine the apparently understudied role of PLR and MLR in depressed patients in greater depth.

ObjectiveBipolar disorder is one of the most frequent psychiatric disorders among suicidal patients. A large part of patients with bipolar disorder (30–50%) will attempt suicide. Suicidal ideation being a major risk factor of suicidal act, it is crucial to better characterize patients with suicidal bipolar depression (i.e. depression with current suicidal ideation). The aim of this study was to characterize suicidal bipolar depressed patients in comparison with non-suicidal depressed patients in terms of clinical characteristics, evolution of depression and suicidal ideation course over time, and risk of suicide attempt during follow-up.MethodsAmong patients with bipolar disorder recruited from the network of FondaMental expert centres for bipolar disorder between 2009 and 2017, we selected patients with at least mild depression and without current manic symptomatology at baseline (N = 938). Suicidal depression was defined by a baseline score ⩾2 for item 12 of the QIDS-SR (28.9%). A subsample of about 300 patients (w/ or w/o suicidal ideation at baseline) was followed up for 2 years.ResultsBaseline clinical features (e.g. depression severity, childhood trauma, global functioning) were more severe in patients with without suicidal depression. Suicidal patients tended to remain more suicidal throughout the followup (3.4-fold higher risk of persistent suicidal ideation at the 2-year visit despite an improvement in depressive symptomatology).ConclusionsDepressed bipolar disorder patients reporting suicidal ideation had more severe clinical features and were more prone to report persistent suicidal ideation during the follow-up, independently of thymic state. Clinicians should closely monitor this subgroup of patientsDisclosureNo significant relationships.

Childhood trauma and affective disorders are known risk factors for adult suicidal behavior. Studies have shown a mediating effect of insecure attachment on the effect of childhood trauma and suicidal behavior but so far it is not clear whether this effect is related to an attachment dimension (anxiety, avoidance). The present study sought to examine the mediating effect of attachment anxiety and avoidance on suicidal behavior. We analyzed data on childhood trauma, attachment style, depression severity, presence of prior suicide attempts and current suicide ideation from 96 patients diagnosed with an affective disorder. Two mediation analyses were conducted to assess the effect of childhood trauma on 1) prior suicide attempts and 2) current suicidal ideation through its effect on attachment. We found that childhood trauma had a complete mediated effect on the presence of prior suicide attempts through its effect on avoidant attachment (a1b1 = 0.0120, 95%-CI [0.0031, 0.0276]). However, only emotional abuse had a direct influence on suicidal ideation (c’ = 0.0273, p < 0.01) without any indirect effect of anxious or avoidant attachment. Variables were not assessed in a prospective way and sample size was small. Our findings suggest that individuals with avoidant attachment and childhood trauma are likely to present a high suicide risk. Since avoidant attachment is associated with altered perceptions and eventual rejection of social support, we recommend to screen for attachment early and to engage patients in therapeutical approaches focusing on the client-therapist alliance. •Neurodevelopmental profile of suicide attempters.•Profile characterized through avoidant attachment and childhood trauma.•Childhood trauma influences suicide attempts in adulthood through avoidant attachment.•Only emotional abuse found to influence suicidal ideation.

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). 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. 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. 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.

At the time of writing (December 2020), coronavirus disease 2019 (COVID-19) has already caused more than one million deaths worldwide, and therefore, it is imperative to find effective treatments. The “cytokine storm” induced by Severe Acute Respiratory Syndrome-Coronavirus type 2 (SARS-CoV-2) is a good target to prevent disease worsening, as indicated by the results obtained with tocilizumab and dexamethasone. SARS-CoV-2 can also invade the brain and cause neuro-inflammation with dramatic neurological manifestations, such as viral encephalitis. This could lead to potentially incapacitating long-term consequences, such as the development of psychiatric disorders, as previously observed with SARS-CoV. Several pathways/mechanisms could explain the link between viral infection and development of psychiatric diseases, especially neuro-inflammation induced by SARS-CoV-2. Therefore, it is important to find molecules with anti-inflammatory properties that penetrate easily into the brain. For instance, some antidepressants have anti-inflammatory action and pass easily through the blood brain barrier. Among them, clomipramine has shown very strong anti-inflammatory properties in vitro , in vivo (animal models) and human studies, especially in the brain. The aim of this review is to discuss the potential application of clomipramine to prevent post-infectious mental complications. Repositioning and testing antidepressants for COVID-19 management could help to reduce peripheral and especially central inflammation and to prevent the acute and particularly the long-term consequences of SARS-CoV-2 infection.