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      Suicidality in Patients with Brain Tumors: A Brief Literature Review with Clinical Exemplar

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          Abstract

          Background: Suicidality and brain tumors are two life-threatening conditions and, somewhat unexpectedly, the associations between them have scarcely been reported. Objective: In this study, we aimed to provide a brief literature review of epidemiological studies on suicidal ideation (SI) and suicidal behavior (SB) in patients with brain tumors. To illustrate various aspects of brain tumors that potentially underlie the emergence of suicidality, the review is supplemented with a clinical exemplar of a long-term survivor of brain tumor (glioblastoma) who experienced persistent SI. Furthermore, we discuss putative both neurobiological (including anatomical and immunological) and psychosocial mechanisms that might be accountable for the development of SI and SB in patients with brain tumors. Conclusions: While the etiology of this phenomenon appears to be multifactorial and still remains a subject of much debate, it is of critical importance to identify patients for which a psychiatric evaluation could recognize, in a timely manner, a possible suicide risk and alleviate the deep related suffering, by appropriate psychopharmacological and supportive and psychotherapeutic interventions.

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          Most cited references82

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          The interpersonal theory of suicide.

          Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness (and hopelessness about these states)-and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory's hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory's hypotheses. PsycINFO Database Record (c) 2010 APA, all rights reserved.
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            Suicide and suicidal behaviour.

            Suicide is a complex public health problem of global importance. Suicidal behaviour differs between sexes, age groups, geographic regions, and sociopolitical settings, and variably associates with different risk factors, suggesting aetiological heterogeneity. Although there is no effective algorithm to predict suicide in clinical practice, improved recognition and understanding of clinical, psychological, sociological, and biological factors might help the detection of high-risk individuals and assist in treatment selection. Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behaviour; additionally, regular follow-up of people who attempt suicide by mental health services is key to prevent future suicidal behaviour.
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              Interleukin-6 is elevated in the cerebrospinal fluid of suicide attempters and related to symptom severity.

              Depressive disorders are associated with immune system alterations that can be detected in the blood. Cytokine concentrations in cerebrospinal fluid (CSF) and their relationship to aspects of suicidality have previously not been investigated. We measured interleukin-1beta, interleukin-6 (IL-6), interleukin-8, and tumor necrosis factor-alpha (TNF-alpha) in CSF and plasma of suicide attempters (n = 63) and healthy control subjects (n = 47). Patients were classified according to diagnosis and violent or nonviolent suicide attempt. We evaluated suicidal ideation and depressive symptoms using the Suicide Assessment Scale and the Montgomery-Asberg Depression Rating Scale (MADRS). We also analyzed the relation between cytokines and monoamine metabolites 5-hydroxyindoleacetic acid (5-HIAA), homovanillic acid (HVA), and 3-methoxy-4-hydroxyphenylglycol (MHPG) in CSF, as well as the integrity of the blood-brain barrier as reflected by the CSF:serum albumin ratio. IL-6 in CSF was significantly higher in suicide attempters than in healthy control subjects. Patients who performed violent suicide attempts displayed the highest IL-6. Furthermore, there was a significant positive correlation between MADRS scores and CSF IL-6 levels in all patients. IL-6 and TNF-alpha correlated significantly with 5-HIAA and HVA in CSF, but not with MHPG. Cytokine levels in plasma and CSF were not associated, and patients with increased blood-brain barrier permeability did not exhibit elevated cytokine levels. We propose a role for CSF IL-6 in the symptomatology of suicidal behavior, possibly through mechanisms involving alterations of dopamine and serotonin metabolism.
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                Author and article information

                Journal
                Medicina (Kaunas)
                medicina
                Medicina
                MDPI
                1010-660X
                1648-9144
                21 December 2020
                December 2020
                : 56
                : 12
                : 725
                Affiliations
                [1 ]Department of Psychiatry, Faculty of Medicine, University of Geneva (UNIGE), 1211 Geneva, Switzerland; guido.bondolfi@ 123456hcuge.ch
                [2 ]Department of Psychiatry, ASO Santi Antonio e Biagio e Cesare Arrigo Hospital, 15121 Alessandria, Italy
                [3 ]Department of Neurosurgery, University and City of Health and Science Hospital, 10126 Torino, Italy; zengafra@ 123456hotmail.com
                [4 ]Department of Neuro-Oncology, University and City of Health and Science Hospital, 10126 Torino, Italy; rudarob@ 123456hotmail.com
                [5 ]Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Section of Psychiatry, University of Genoa, 16133 Genoa, Italy; andrea.amerio@ 123456unige.it (A.A.); andrea.aguglia@ 123456unige.it (A.A.); gianluca.serafini@ 123456unige.it (G.S.); mario.amore@ 123456unige.it (M.A.)
                [6 ]IRCCS Ospedale Policlinico San Martino, 16133 Genoa, Italy
                [7 ]Department of Psychiatry, Tufts University, Boston, MA 02111, USA
                [8 ]Department of Psychiatry, Service of Liaison Psychiatry and Crisis Intervention, Geneva University Hospitals, 1211 Geneva, Switzerland
                [9 ]Department of Neuroscience, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital, Sapienza University of Rome, 00185 Rome, Italy; isabella.berardelli@ 123456uniroma1.it
                [10 ]Department of Microbiology and Immunology, Stanford University, Palo Alto, CA 94305, USA; khoa.d.nguyen@ 123456gmail.com
                [11 ]Tranquis Therapeutics, Palo Alto, CA 94305, USA
                [12 ]Hong Kong University of Science and Technology, Hong Kong, China
                Author notes
                Author information
                https://orcid.org/0000-0001-6387-6462
                https://orcid.org/0000-0001-5440-3276
                https://orcid.org/0000-0002-3439-340X
                https://orcid.org/0000-0002-2003-2101
                https://orcid.org/0000-0002-6631-856X
                https://orcid.org/0000-0003-0602-871X
                Article
                medicina-56-00725
                10.3390/medicina56120725
                7767493
                33371470
                fe865ab6-119d-4b04-876e-158c50790ae1
                © 2020 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 03 October 2020
                : 19 December 2020
                Categories
                Review

                brain tumor,glioblastoma,glioma,suicide,suicidal ideation,suicide attempt,suicidal behavior,demoralization,meaning in life

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