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Background Ketamine is known to rapidly reduce depressive symptoms and suicidal ideation (SI) in patients with major depressive disorder (MDD), but evidence is limited for its acceptability and effectiveness in “real-world” settings. This case series examines serial ketamine infusions in reducing SI and depression scores in adults with MDD admitted to a tertiary care hospital. Methods Five inpatients with MDD and SI admitted to hospital in Toronto, Canada received six infusions of 0.5 mg/kg intravenous (IV) ketamine (n = 5) over approximately 12 days, in addition to treatment-as-usual. Suicide and depression rating scores (Scale for Suicidal Ideation, SSI; Montgomery-Asberg Depression Rating Scale, MADRS) were obtained at baseline, on treatment days, on days 14 and 42 (primary endpoint). Results All patients experienced benefit with ketamine. SSI scores diminished by 84% from 14.0 ± 4.5 at baseline to 2.2 ± 2.5 at study endpoint. MADRS scores diminished by 47% from 42.2 ± 5.3 at baseline to 22.4 ± 8.0. Two patients withdrew from the study, one to initiate electroconvulsive therapy and one due to an adverse event (dissociative effects) during the ketamine infusion. Limitations The major limitation of this study is the small sample size. Discussion These preliminary pilot data are promising with a greater than two-fold reduction in SI following ketamine infusions. They demonstrate that six serial ketamine infusions may be safe and feasible. These findings support the need for large scale randomized controlled trials to confirm the efficacy of serial ketamine for treatment of SI in “real-world” settings.

Background Self-harm (SH) is among the strongest risk factors for eventual suicide death yet there are limited data on which interventions are most effective for treating SH in youth. Methods This single-blind, pilot randomized controlled trial examined brief cognitive behavioral therapy (BCBT) for suicide prevention vs. minimally-directive supportive psychotherapy in youth (aged 16–26) hospitalized following SH. Both therapies included 10 acute sessions over 15 weeks with three booster sessions occurring at three month intervals thereafter. The primary feasibility outcome was ≥70% retention at study endpoint. Efficacy measures, including repeat SH, were secondary outcomes. Results Twenty-four subjects were enrolled (12 per group) with one BCBT subject and two controls dropping out prior to the first therapy session. Five (45%) of the remaining BCBT subjects and seven (70%) control subjects completed all 10 acute therapy sessions. All subjects who completed five sessions went on to complete 10. There were significantly fewer instances of repeat SH in BCBT subjects (7 of 62 weeks of acute follow-up; 11%) compared to control subjects (24 of 79 weeks; 30%)(OR 0.34, 95%CI:0.13–0.92). Three subjects, all in the control condition, made a total of five suicide attempts during the study. Limitations This study had a modest sample size and retention rate. Conclusions This study failed to achieve its primary feasibility retention goal for BCBT. However, it did demonstrate that initial adherence to follow-up predicted study completion. Despite small numbers, it also found a significant reduction in repeat SH in the BCBT group, a finding which requires replication.

Background There is conflicting evidence about the relationship between body mass index (BMI) and suicide death. This study aimed to characterize and compare suicide deaths by weight using BMI weight categories. Methods We examined suicide deaths in adults in the city of Toronto (2009–2015); grouped them by BMI categories (underweight, normal weight, overweight, and obese) and compared groups based on demographics, clinical variables and method of suicide death. Results Suicide decedents’ (n = 1429) mean age was 48.6 years (SD = 17.4) and mean BMI was 25.5 (SD = 5.4). Underweight decedents were more likely to be female and to have cancer while obese decedents were more likely to have diabetes. Underweight decedents were more likely to have an identified history of any medical condition. Obese and overweight decedents were significantly more likely to have an identified history of any psychiatric condition. Non-violent methods (e.g., self-poisoning) were used at a higher proportion by people with obesity and by people who were underweight. Limitations Psychological autopsies were not available and it was not possible to assess for change in or stability of BMI over time. Conclusions These findings add to our understanding of the relationship between suicide and weight. A higher prevalence of females as well as those with a history of cancer and any medical condition in underweight decedents was noteworthy and of potential clinical significance.

Background: Suicide death by gas inhalation has been the subject of global scientific interest due to a rapid increase in the use of helium and charcoal gas for suicide. These may be particularly amenable to means restriction strategies. There has been little scientific attention of this phenomenon in Canada. Methods: A review of coroner records was conducted for all suicide deaths in Toronto (1998–2015). Deaths were categorized as due to inhalational asphyxia by compressed gas (i.e. helium or nitrogen), charcoal burning or motor vehicle exhaust, with suicide deaths by other methods as a comparator. Demographic, clinical and suicide specific differences between decedents in these four categories were compared using chi-squared or ANOVA global test of significance with additional pairwise comparisons where appropriate. Secular trends were also examined. Results: Gas inhalational deaths accounted for 190 (4.7%) of all suicides in Toronto (n = 4062) over the study period and a higher proportion of males used compressed gas or motor vehicle exhaust gases than those who died by other methods (83.3% and 84.0% vs.69.7%, both p = 0.01). Comparing 1998–2003 to 2010–2015 there was a 1075% increase in deaths by helium (4 vs. 43 deaths) and a 533% increase in deaths by charcoal burning (3 vs. 16 deaths) although helium and charcoal burning deaths still accounted for only 4.2% of total suicides 2010–2015. Deaths by helium were more likely to be accompanied by the book “Final Exit” than those by non-inhalational methods (15% vs. 0.7%, p < 0.0001) while 13 of 14 people who died by charcoal burning whose ethnicity could be determined were Asian. Limitations: Ethnicity and specific details of procurement of suicide methods were not systematically available in coroner records. Discussion: Suicide by inhalational asphyxia, particularly by compressed gases, has increased substantially over time in Toronto consistent with observations in other countries. Increased surveillance of these deaths, efforts to restrict access to these methods, and timely interventions including minimizing media reporting are all warranted.