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The COVID-19 pandemic is expected to increase suicidal behavior. However, data available to date are inconsistent. This study examines suicidal thoughts and behaviors and suicide trends in 2020 relative to 2019 as an approximation to the impact of the pandemic on suicidal behavior and death in the general population of Catalonia, Spain. Data on suicide-related thoughts and behaviors (STBs) and suicidal mortality were obtained from the Catalonia Suicide Risk Code (CSRC) register and the regional police, respectively. We compared the monthly crude incidence of STBs and suicide mortality rates of 2020 with those of 2019. Joinpoint regression analysis was used to assess changes in trends over time during the studied period. In 2020, 4,263 consultations for STBs and 555 suicide deaths were registered in Catalonia (approx. 7.5 million inhabitants). Compared to 2019, in 2020 STBs rates decreased an average of 6.3% (incidence rate ratio, IRR=0.94, 95% CI 0,90-0,98) and overall suicide death rates increased 1.2% (IRR=1.01, 95% CI 0.90-1.13). Joinpoint regression results showed a substantial decrease in STBs rates with a monthly percent change (MPC) of -22.1 (95% CI: -41.1, 2.9) from January-April 2020, followed by a similar increase from April-July 2020 (MPC=24.7, 95% CI: -5.9, 65.2). The most restrictive measures implemented in response to the COVID-19 pandemic reduced consultations for STBs, suggesting that the "stay at home" message may have discouraged people from contacting mental health services. STBs and mortality should continue to be monitored in 2021 and beyond to understand better the mid-to-long term impact of COVID-19 on suicide trends., Competing Interests: Conflict of Interest EV reports personal fees from Abbott, personal fees from Allergan, personal fees from Angelini, grants from Novartis, grants from Ferrer, grants and personal fees from Janssen, personal fees from Lundbeck, personal fees from Sage, personal fees from Sanofi, outside the sub-mitted work. VPS has been a consultant to or has received honoraria or grants from AB-Biotics, AstraZeneca, Bristol-Myers-Squibb, CIBERSAM, FIS- ISCIII, Janssen Cilag, Lundbeck, Otsuka, Servier and Pfizer. DP has received grants and also served as consultant or advisor for Angelini, Janssen, Lundbeck and Servier. FC has served as a speaker or in the advisory board of the following companies: Abott, Sanofi and Sandoz. He has received unrestricted research support from Telefónica Alpha. All other authors reported no conflict of interest., (Copyright © 2021 Elsevier B.V. and ECNP. All rights reserved.)

Background: Suicide prevention is an emerging priority for public health systems. Here, we present the Catalonia Suicide Risk Code (CSRC), a secondary suicide prevention program that provides a systematic approach to follow-up care for patients at risk. We describe the care pathway of the CSRC and characteristics of the patients enrolled in the program., Methods: Observational study based on data extracted from the Catalan health care system between the years 2014 and 2019. The following patient-related data were obtained: sociodemographic and clinical characteristics, characteristics of suicidal behaviour, and pathway of care., Results: A total of 12,596 individuals (64.1% women) were screened for suicide risk and 8,403 (66.7%) were subsequently enrolled in the CSRC. Adherence data show that most patients (81.9%) attended a face-to-face appointment and most (67.1%) were successfully contacted by telephone afterwards. Most face-to-face appointments were performed within 10 days of enrolment for adults and 72 h for minors. Psychiatric disorders were significant risk factors for both men and women. Females were significantly more likely to report stressful life events, while males were more likely to report social problems. Compared to men, women were more likely to use poisoning., Limitations: Adherence to the CSRC care pathway might reflect obstacles to its implementation. Due to the observational study design, it is not possible to determine the effectiveness of the CSRC to reduce suicide re-attempts., Conclusions: Although the CSRC successfully provided follow-up care for many individuals at high risk of suicide, greater adherence to the CSRC care pathway is needed., Competing Interests: Declaration of Competing Interest EV has received grants and served as consultant, advisor or CME speaker for the following entities: AB-Biotics, Abbott, Allergan, Angelini, Dainippon Sumitomo Pharma, Galenica, Janssen, Lundbeck, Novartis, Otsuka, Sage, Sanofi-Aventis, and Takeda. DP has received and also served as consultant or advisor for Angelini, Janssen and Lundbeck. The rest of the authors declare no conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

The Satispsy-22 scale is an instrument created for the specific evaluation of psychiatric inpatient satisfaction. Therefore, the study aims to carry out the Satispsy-22 scientific translation to Spanish and to learn its psychometric properties. The Satipsy-22-E was administered to discharged patients from four units of acute psychiatric admission, a unit of dual pathology and two units of subacute psychiatric admission (N = 268). Cronbach's alpha was 0.886, which can be interpreted as good internal reliability. All the dimensions showed a good internal consistency with scores from 0.722 to 0.919. Test-retest offered scores of 0.752-0.951 showing good stability. Confirmatory factor analysis showed that all elements load in the estimated dimensions of the original scale and these were significant and the adjustment measures showed, in general, a rather good adjustment, Root Mean Square Error (RMSE) showed that the error between observations and actual data is small and acceptable. Satispsy-22-E is a specific scale in Spanish language for the assessment of psychiatric inpatient satisfaction. It is an easy to use tool that offers good psychometric properties. The availability of a validated survey in Spanish may help to improve the care provided by psychiatric wards in Spanish-speaking countries., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: The purpose of this study was to analyze differences in clinical and socio-demographic characteristics between older and younger bipolar outpatients paying special attention to depressive symptoms in a large, naturalistic cohort., Method: Five hundred and ninety-three DSM-IV-TR bipolar outpatients were enrolled. Clinical characteristics were assessed according to DSM-IV-TR (SCID-I). Subjects were categorized into two groups according to current age (older OBD: age > 65 years; younger-YBD: age < 65 years)., Results: About 80% of patients were younger (N = 470), and a fifth were older (N = 123), with a mean age of 77.30 years in OBD. Older patients were more likely to be married, not qualified, bipolar II, with depressive polarity of first episode, higher age at illness onset, higher age at first hospitalization. They were more likely to present with depressive predominant polarity, with lifetime history of catatonic, psychotic and melancholic features, age at illness onset >40 years, as well as suffering from more medical comorbidities when compared to younger bipolars., Conclusion: The clinical presentation of bipolar disorder in late life would be defined more frequently by melancholic depressive features and a predominantly depressive polarity. These results suggest that treatment strategies for elderly bipolar patients should focus in the prevention of depressive episodes., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Psychological interventions on top of pharmacological treatment can improve the outcome of bipolar disorder. However, there is a paucity of data on the aspects that may influence the effectiveness of psychological approaches to bipolar disorders. The staging models suggest a progression from prodromal to more severe and treatment-resistant presentations. The aim of this study was to assess whether a staging model in bipolar disorder was related to patients' response to psychoeducation delivered to caregivers., Methods: Post-hoc analysis from a 15-month randomized controlled trial showing the efficacy of group psychoeducation for caregivers in the prophylaxis of recurrences. The sample was composed of 113 medicated euthymic bipolar outpatients who lived with their caregivers. For the purpose of this study the patients were subdivided into two groups according to staging. The prophylactic efficacy of caregiver psychoeducation was studied based on staging., Results: Patients on Stage I benefited from caregiver psychoeducation by having longer time to recurrence (Log-rank chi-square: 6.26; p=0.012). No significant benefits from caregiver psychoeducation were found in patients on advanced stages., Limitations: The present post-hoc analysis was not properly powered to compare each one of the four stages with each other, instead staging was divided into Stage I and advanced stages (II, III or IV)., Conclusions: Psychoeducation for caregivers of bipolar patients on Stage I may improve long-term outcome in terms of time to recurrence. This study highlights the need to introduce psychological interventions early in the course of the illness as some treatments may be more useful in patients at earlier stages of bipolar disorder., (Copyright 2009 Elsevier B.V. All rights reserved.)

Background: Rapid-cycling (RC) is a course modifier of bipolar disorder which often implicates a poor prognosis. However, the relationship of RC with suicidal features as a marker of impairment has been understudied., Methods: Three hundred and five patients (n=305) were included in a naturalistic, systematic prospective study in a single site setting. Patients with rapid-cycling (RC) were defined as having four or more manic, mixed or depressive episodes in the year prior to baseline assessment. The two groups were compared regarding clinical and sociodemographic variables, paying special attention to suicidal features. Statistical methods consisted of chi-square statistic for the comparison of categorical data, and Student's t test for dimensional variables normally distributed. Also, a General Linear Model was used to study the main effect of different sociodemographic and clinical variables on suicidality. All statistics were two-tailed, and significance was set at p less than 0.05., Results: Fifty-five patients (18%) were classified as RC, whilst 250 (82%) were considered as nonrapid-cycling (NRC). No significative difference was found in the prevalence of RC amongst bipolar I and II patients. RC was associated with depressive onset of bipolar disorder. The number of suicide attempts was significantly higher amongst RC (RC mean 0.82 [SD 1.85] vs. NRC 0.44[SD 0.94] t=2.09, p=0.37). Nonetheless, no significative differences were found between RC and NRC regarding the percentage of suicide attempters. On the other hand patients that presented RC showed a marked increase of lifetime history of suicidal ideation (Chi(2)=4.363, p=0.039). Finally, there were not any differences between RC patients and NRC in family history of suicide., Discussion: Bipolar patients with RC are more likely to attempt suicide. Intensive treatment of this marker should be considered.

Objective: Despite the additional complications associated with alcohol misuse in bipolar populations, it is generally the case that studies exploring neurocognitive aspects of bipolar disorder specifically exclude patients with alcohol abuse or dependence. Given the role of cognitive dysfunctions in overall illness outcome, this study addressed the neurocognitive functioning of patients with a history of alcohol abuse or dependence as compared to bipolar patients without such a history and healthy controls., Method: The study sample included 100 subjects: 65 bipolar patients, 30 of whom with a history of alcohol abuse or dependence and 35 without a previous history of alcohol abuse or dependence, based on DSM-IV criteria, and a control group of 35 healthy subjects. Comprehensive neuropsychological tests were carried out during strictly defined clinical remission. Differences between groups were analyzed and a linear regression analysis was undertaken to establish predictors of psychosocial functioning as measured using the Global Assessment of Functioning. Data were collected from September 2006 to July 2007., Results: Bipolar patients with a history of alcohol abuse or dependence obtained lower scores in the interference task of the Stroop test compared to the control group. Both patient groups showed a poorer performance in some verbal memory and executive function measures than healthy controls. Verbal learning impairment was significantly associated with poor psychosocial functioning., Conclusions: Cognitive dysfunctions appeared to be more strongly associated with bipolar disorder than with the "history of alcohol abuse or dependence" factor. Bipolar patients with history of alcohol misuse may have greater difficulties of inhibitory control, probably due to higher impulsivity., (©Copyright 2009 Physicians Postgraduate Press, Inc.)

Objective: There is a dearth of research focusing on factors associated with suicide attempts. High rates of atypical depression have been reported in studies including unipolar and bipolar II patients. In this study, the association between suicide attempt and atypical depression, in addition to other major risk factors, was evaluated in 390 bipolar I and II out-patients., Method: Variables were defined according to DSM-IV criteria, and assessed with a Structured Interview for DSM-IV (axis I and II). History of suicide attempt was obtained through interviews with patients and relatives. Attempters and non-attempters were compared using univariate and multivariate analysis., Results: Attempters showed significantly higher rates of atypical depression, family history of completed suicide, depression at index episode and cluster B personality disorder., Conclusion: Our results highlight the relevance of atypical depression in bipolar disorder. A more accurate identification of potential attempters may contribute to the development of effective preventive treatment strategies.

Background: The co-occurrence of bipolar disorder and substance use is frequent. The question whether substance use precedes, induces or follows bipolar disorder is still unresolved. Substance use has been typically represented as a negative prognostic factor for the clinical course of bipolar illness and it has been associated with decreased compliance and treatment resistance. To extend these previous findings we examined the clinical course and outcome of patients with bipolar disorder I or II whose bipolar onset was preceded by substance/alcohol use., Methods: The impact of substance use as a predisposing or precipitating factor of a bipolar episode was evaluated by comparing a group of bipolar subjects whose mood symptomatology onset was preceded by substance/alcohol use (N=145) (SUBP) with a similar sized representative sample of bipolar patients (either substance users/abusers or not using substances) whose first mood episode was unrelated to substance use (N=144) (NSUBP). RESULTS; The analysis of clinical and socio-demographic variables revealed that patients in the SUBP group showed less severe psychopathology, as indicated by fewer total hypomanic and depressive episodes during the course of their illness. Depressive onset was less frequent amongst the SUBP group. SUBP patients, compared to NSUBP, were poorly compliant to treatment., Conclusions: Bipolar disorder preceded by substance misuse may represent a clinically milder subtype of bipolar illness. This subtype would be less "primary" and might be more early targeted by primary prevention with programmes focused on substance misuse.

Objective: To determine the clinical and long-term implications of mood polarity at illness onset., Methods: During a 10-year follow-up prospective study, systematic clinical and outcome data were collected from 300 bipolar I and II patients. The sample was split into 2 groups according to the polarity of the onset episode (depressive onset [DO] vs manic/hypomanic onset [MO]). Clinical features and social functioning were compared between the 2 groups of patients., Results: In our sample, 67% of the patients experienced a depressive onset. Depressive onset patients were more chronic than MO patients, with a higher number of total episodes and a longer duration of illness. Depressive onset patients experienced a higher number of depressive episodes than MO patients, who in turn had more manic episodes. Depressive onset patients made more suicide attempts, had a later illness onset, were less often hospitalized, and were less likely to develop psychotic symptoms. Depressive onset was more prevalent among bipolar II patients. Bipolar I patients with DO had more axis II comorbidity and were more susceptible to have a history of psychotic symptoms than bipolar II patients with DO., Conclusion: The polarity at onset is a good predictor of the polarity of subsequent episodes over time. A depressive onset is twice as frequent as MO and carries more chronicity and cyclicity.

Background: Identifying and modifying burdensome aspects might reduce the level of burden and their negative effects both on caregivers and patients' outcome. Most studies evaluate acutely ill patients, whereas the most relevant problems may be related to subthreshold symptoms and long-term outcome. The aims of the present study were to assess caregiver's subjective burden, to analyse which were the most burdensome aspects for caregivers and to study which variables could explain the caregiver's subjective burden., Methods: Caregivers of 86 euthymic bipolar patients completed the subjective burden subscale from an adapted version of the Social Behaviour Assessment Schedule., Results: Caregivers showed a moderate level of subjective burden. The highest levels of distress were reported regarding the patient's behaviour; the most distressing behaviours were hyperactivity, irritability, sadness and withdrawal. Regarding the patient's role performance, the most worrying aspects were those associated with the patient's work or study and social relationships. Regarding adverse effects on others, caregivers were especially distressed by the way the illness had affected their emotional health and their life in general. Poorer social and occupational functioning, an episode in the last 2 years, history of rapid cycling and the caregiver being responsible for medication intake explained a quarter of the variance of the caregiver's subjective burden., Limitations: This was a cross-sectional study focused only on primary caregivers, there was no control group of non-bipolar patients., Conclusions: This study provides relevant data concerning the burden of caregivers of stable bipolar patients, pointing at potential targets for psychosocial interventions.