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Longer-term outcome and safety data of repeated subcutaneous racemic ketamine for treatment-resistant depression (TRD) is lacking, as is knowledge of the impact of prior ketamine treatment on subsequent response. To evaluate the effectiveness and safety of a 4-week course of subcutaneous racemic ketamine over 6 months and investigate whether prior ketamine treatment influences treatment response. An open label extension (OLE) of a randomised controlled trial (RCT) was conducted at seven mood disorder centres in Australasia, enrolling consenting trial participants who had a Montgomery-Åsberg Depression Rating Scale (MADRS) score of ≥20 at post-trial assessment. Participants initially received twice-weekly 0.5 mg/kg subcutaneous racemic ketamine (fixed regimen) for 4 weeks. Dosing was revised after a Data Safety Monitoring Board recommendation, to a 'flexible regimen' (0.5-0.9 mg/kg with response-guided increments). Depression and safety outcomes were assessed throughout treatment, and 4 weeks and 6 months later. 130 RCT participants entered the OLE phase of whom 32 underwent the fixed OLE regimen and 98 the flexible regimen. At treatment end, 30% (36/116) had responded (MADRS reduction ≥50%), and 4 weeks later 17% (19/110) were 'responders'. Over 50% experienced <25% MADRS reduction. There was no difference in depression response at any time point between regimens. Those treated with ketamine during the RCT showed a transient reduced response after first OLE treatment but at no other assessment point. There were no reports of suicide or suicidal behaviour requiring admission and only expected side-effects observed. In a highly treatment-resistant sample, a 4-week course of subcutaneous racemic ketamine produced short-term clinical benefit in a minority of participants, with response rates declining substantially after treatment cessation, and no unexpected safety concerns. Exploratory subgroup analyses showed no association between prior RCT ketamine exposure and OLE outcomes. ACTRN12616001096448 at www.anzctr.org.au.
To mark the 10th Anniversary of BJPsych Open, we explore the contributions of papers published in BJPsych Open to advance cultural psychiatry practice and policy. In our overview of papers published in BJPsych Open, we found examples of good practice where authors detailed the translation methods and interpretation models in the research. The task facing clinicians and public health practitioners is to evolve applied, locally relevant, culturally competent interventions in which specific adaptations are shaped by the potential beneficiaries, alongside theoretical and practical issues of cultural adaptation. Researchers and clinicians will need to provide evidence of acceptability and effectiveness of adapted interventions, alongside considering financial and implementation realities.
To celebrate the 10th anniversary of BJPsych Open, this Editorial highlights papers published in BJPsych Open over the past decade that have focused on university student mental health. Common mental disorders are increasing in young people and those going on to higher education make up an important and sizeable sector of this population. At the same time, success in university studies is a major determinant of individual and societal health and prosperity. As a field of inquiry, university student mental health research gained momentum through the COVID-19 pandemic and associated campus closures, pivot to remote learning and social restrictions. Although research describing student well-being and mental health burden align globally, not enough is known about determinants that inform sustainable and scalable prevention and early intervention. Furthermore, research evidence should inform university policies, practices and benchmarks to ensure responsive and effective student well-being and mental health support that underpins academic and life success.
Adolescent mental health is a growing public health concern due to the high prevalence of mental disorders, many of which remain unrecognised and untreated. School staff are strategically positioned to promote mental health, recognise mental health problems and support pathways into care, but often lack sufficient mental health literacy (MHL) and confidence to act. This study evaluated the effects of the WhySchool project, a school-based programme to promote MHL among teachers and school health professionals (SHPs). We implemented WhySchool in 72 public middle and high schools across Portugal through a cascade training approach. With a pre-post design, we assessed 788 teachers and 201 SHPs on mental health knowledge (MHK), personal depression stigma, openness to seeking help and confidence in identifying/referring students. Paired-sample t-tests with Cohen's d estimated changes, and generalised linear mixed models (GLMMs) accounted for confounders and within-subject variability. The programme was associated with significant improvements in all outcomes across both professional groups, with moderate-to-large effect sizes (MHK d = 1.12 (95% CI 1.04 to 1.20); stigma d = -1.05 (95% CI -1.12 to -0.97); openness d = 0.44 (95% CI 0.37 to 0.51); confidence d = 0.87 (95%CI 0.79 to 0.94)). GLMMs confirmed these results. Gains varied across professional groups and demographic characteristics, with those having lower baseline scores generally benefiting most. The WhySchool resulted in observable improvements in teachers' and SHPs' MHL, including increased knowledge, reduced stigma, improved help-seeking attitudes and strengthened confidence to support students. The cascade model provides a viable and sustainable strategy for large-scale implementation, empowering educational communities to better support student mental health.
Glucocorticoids are widely prescribed for autoimmune and inflammatory conditions, but their long-term use carries serious risks. Patients with psychiatric disorders have a high burden of medical comorbidities, which may be associated with higher odds of receiving sustained glucocorticoid therapy. We examined whether psychiatric patients were more likely to receive sustained oral glucocorticoid therapy compared with controls, and assessed variation across psychiatric subgroups. This retrospective, nationwide cohort study used South Korea's National Health Insurance Service database. Adults diagnosed with a major psychiatric disorder in 2021 (n = 331 020) were compared with a sample without psychiatric disorders (n = 668 980). Propensity score matching generated 283 942 participants per group. The outcome was sustained oral glucocorticoid use in 2022, defined as ≥90 cumulative days with continuous therapy ≥90 days and prescription gaps ≤30 days. Before propensity score matching, glucocorticoid use in 2022 was more frequent in psychiatric patients (13.8%) than controls (10.8%; odds ratio 1.32, 95% CI 1.31-1.34; P < 0.001). After matching, the difference persisted (14.7 v. 12.5%; odds ratio 1.18, 95% CI 1.16-1.19; P < 0.001). Multivariable analyses confirmed higher odds of glucocorticoid use (odds ratio 1.05, 95% CI 1.03-1.06; P < 0.001). Increased risk was observed for anxiety disorders (odds ratio 1.06) and obsessive-compulsive disorder (odds ratio 1.07), whereas major depressive disorder showed no significant association. Psychiatric patients are more likely to receive sustained glucocorticoid therapy, underscoring the need for cautious prescribing and monitoring in this vulnerable population.
Healthcare personnel exhibit higher levels of anxiety and depression, with differences in the use of coping strategies to manage stressful situations. To assess which coping strategies, sociodemographic factors and job-related variables predict anxiety and/or depression among healthcare professionals. A total of 744 participants, including physicians, nurses and nursing assistants were involved in a cross-sectional study. The ordinary least squares estimator was used to estimate the parameters. The results identified negative self-focus (β = 0.42, β = 0.45, p < 0.001), positive reappraisal (β = -0.20, β = -0.30, p < 0.001) and open emotional expression (β = 0.12, p < 0.001; β = 0.08, p < 0.01), as coping strategies significantly associated with anxiety and depression. Additionally, seeking social support was related to depressive symptoms (β = -0.02, p < 0.01), but not of anxiety. Interestingly, avoidant coping was associated with lower levels of both anxiety and depression (β = -0.14, p < 0.001). The absence of family responsibilities was associated with lower levels of anxiety and depression (β = -0.11, β = -0.10, p < 0.001). Being male was linked to lower anxiety levels (β = -0.11, p < 0.001), while being female was associated with greater depressive symptoms (β = 0.09, p < 0.01). Holding the position of nursing assistant was identified as a variable associated with anxiety and depression (β = 0.08, p < 0.05; β = 0.06, p < 0.05). These results are essential for tailoring interventions aimed at occupational health.
Questions have been raised whether the patient organisations assessments of coercion - often critical - captures the breadth of patient experiences of coercion. Existing systematic reviews have not captured the full scope of reported experiences, necessitating a more comprehensive approach. To identify the existing body of qualitative studies reporting patients' experiences of coercion; map study distribution over time, regions, and type of coercion; and synthesise broad categories of reported experiences. The review protocol was preregistered (PROSPERO identifier CRD42021248744). We searched 12 databases (MEDLINE, Embase, APA PsycINFO, CINAHL, Web of Science, Sociological Abstracts, Scopus, ASSIA, Norart, SveMed+, OpenGrey.eu and Google Scholar) for qualitative studies published from 1 January 1991 to 3 June 2025. Peer-reviewed studies and approved doctoral theses were included. We used EPPI-Reviewer for screening, data extraction and coding. Study quality was assessed with a modified Critical Appraisal Skills Programme tool. We included 291 studies, 18 of them from low-and middle-income countries. The most studied coercive practices were involuntary admissions, coercive measures and community treatment orders. Quality concerns included limited author reflexivity and lack of involvement of experts by experience. At least one negative experience was reported in 279 of the studies, while mixed and positive experiences appeared in 166 and 167, respectively. A large body of qualitative research reporting patient experiences of coercion exists, with a near-universal presence of negative experiences. Improved patient involvement in research, and more studies from low-and middle-income countries and on involuntary medication are needed.
Post-migration stressors can exacerbate post-traumatic stress disorder (PTSD) and reduce treatment effectiveness among refugees. Evidence for integrated care models in high-income settings remains limited. To compare treatment as usual (TAU) with an add-on integrated care intervention for unemployed refugees with PTSD. We conducted a two-arm, parallel-group superiority trial with 1:1 randomisation to TAU or TAU with an add-on integrated care intervention, delivered at a specialised out-patient clinic in Denmark (ClinicalTrials.gov NCT04244864). TAU included sessions with a psychologist and physician over 8-12 months. The integrated care intervention also included structured collaboration with employment services. The primary outcome was functioning, using the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS) interview. Secondary outcomes included symptoms, quality of life and post-migration stressors. Analyses followed the intention-to-treat principle, using analysis of covariance and linear regression with multiple imputations. The study included 195 patients in treatment from 2020 to 2025. No difference was observed in WHODAS score between groups pre- to post-treatment (mean difference 0.30, 95% CI -2.40 to 3.00; P = 0.825). Similarly, no differences were found for secondary or exploratory outcomes, and overall change was limited. However, the integrated care group had a lower rate of early dropout (P = 0.042) and higher level of treatment satisfaction (P = 0.035). Integrated care was feasible but not superior to TAU in improving outcomes for refugees with longstanding symptoms and unemployment. Future research should examine how the timing and intensity of integrated care interventions influence outcomes, including earlier implementation and adequate support for refugees with longstanding and complex needs.
Neuroimaging research in autism often excludes individuals with co-occurring intellectual impairment or minimally verbal status, limiting the generalisability of findings. Understanding magnetic resonance imaging (MRI) scan success predictors in a representative autistic sample is crucial for equitable research. This study identified factors predicting successful brain MRI acquisition and data quality in diverse autistic individuals, focusing on including those with intellectual impairment or minimally verbal status. A total of 122 participants (83 autistic individuals (27 with intellectual impairment, 19 with minimally verbal status) and 39 typically developing controls) received multi-modal brain MRI scans (including structural, resting-state functional and diffusion MRI). Scan success, assessed using both binary criteria and quantitative data-quality metrics, was related to participant characteristics. Although overall scan success was high, specific factors differentiated success within subgroups. Key factors contributing to scan success included age, non-verbal intelligence and attention-deficit hyperactivity disorder (ADHD) symptoms. Older participants, those with fewer ADHD symptoms and those with higher non-verbal intelligence were more likely to achieve successful scans, regardless of autism diagnosis. Higher data quality, particularly in structural and functional MRI, was associated with higher intelligence, better adaptive functioning, fewer autistic and ADHD symptoms, and fewer behavioural problems. Identifying these factors is key to designing more inclusive and effective neuroimaging protocols. This work paves the way for more comprehensive research into the neurobiology of the full autism spectrum, and offers insights for improving the clinical MRI experience for autistic individuals with diverse support needs. Individualised strategies may also be useful in clinical settings, helping to improve the experience of MRI scanning for autistic individuals.
Nitrous oxide is being investigated as a treatment for therapy-resistant depression, yet its environmental implications as a potent greenhouse gas are largely unaddressed. A single 1 h treatment generates ∼150 kg CO2-equivalents, rising to ∼7.8 t per patient-year, highlighting the need to incorporate environmental externalities into evaluation.
Behavioural activation is effective for depression, but its effectiveness in treating adults with depression when delivered by lay workers remains unclear. To examine the effectiveness of behavioural activation delivered by lay workers, compared with any control group, in reducing depressive symptoms in adults. This systematic review searched six databases from inception to January 2025, for randomised controlled trials (RCTs) comparing behavioural activation and any control conditions for individuals with depression when delivered by lay workers. Additional searches were conducted in the international trial registries and reference lists (PROSPERO registration CRD42024625620). Risk of bias was assessed using the Cochrane Collaboration's Risk-of-Bias 2 tool. Random effects meta-analysis was conducted using the Metafor package in R. Of 9614 initial studies, six RCTs met the inclusion criteria and were included. A total of 1118 participants in the intervention groups and 1596 in the control groups. The findings demonstrated a small but statistically significant effect in reducing depressive symptoms in favour of the intervention group (standardised mean difference: -0.28, 95% CI -0.46 to -0.09; p = 0.0029). However, the risk of bias was high across all studies, with substantial heterogeneity (I2 = 76%). Evidence from this review and meta-analysis suggests that behavioural activation, when delivered by trained lay workers, may offer an effective approach for reducing depressive symptoms in adults, particularly in settings with limited access to specialist mental healthcare professionals. However, high risk of bias and heterogeneity of the included studies means that these findings should be interpreted with caution.
Psychedelics were used for centuries in healing and spiritual rituals, long before the mid-20th century when they became subjects of biomedical research. Although initial trials generated optimism, these were quickly overshadowed by sensationalist media coverage and political backlash. Following decades of inactivity, research on compounds including 3,4-methylenedioxymethamphetamine (MDMA) has resurged, along with the media attention. Investigating this growing interest, Bender et al employed a large-language model, validated against human raters, to analyse 25 years of media articles (2000-2025), quantifying trends in sentiment towards psychedelic therapies. Findings showed a dramatic increase in coverage, with positive sentiment peaking in 2020 followed by a significant decline from 2024, coinciding with the U.S. Food and Drug Administration's decision not to approve MDMA-assisted therapy for post-traumatic stress disorder, and echoing the dynamics of the 1960s. The authors emphasise that sustained progress in the field will require reliance on scientific evidence to advance therapeutic applications.
In-patient mental health rehabilitation services provide specialist care to adults with complex psychosis. In England, there are more than 350 such services, half provided by the National Health Service (NHS) and half by the independent sector. To investigate whether NHS and independent sector in-patient mental health rehabilitation services differ. We recruited a random sample of NHS and independent sector services across England. We collected cross-sectional data regarding service and patient characteristics through interviews with patients, clinicians and managers, and from healthcare record reviews. We recruited 411 patients from 48 NHS services and 172 patients from 20 independent sector services. Service characteristics, including standardised quality scores, were similar. Most patients had a diagnosis of schizophrenia (NHS n = 237, 57.7%; independent sector n = 99, 57.6%) or schizoaffective disorder (NHS n = 88, 21.4%; independent sector n = 32, 18.6%). More than half had at least one comorbid condition, but more independent sector patients had at least two (NHS 131 of 411, 31.9%; independent sector 80 of 172, 46.5%; P = 0.001). Current admissions were twice as long for independent sector patients (NHS mean 1.2 years [s.d. 1.5]; independent sector mean 2.4 years [s.d. 2.8]). Standardised ratings of patients' quality of life, autonomy, time use, satisfaction with care, social and everyday functioning, and challenging behaviours were similar. However, independent sector patients had more needs (NHS mean 6.5 [s.d. 3.2]; independent sector mean 7.9 [s.d. 3.9]; P < 0.001) and more had a history of fire setting (NHS 32, 7.9%; independent sector 28, 17.2%; P = 0.001). Both NHS and independent sector in-patient rehabilitation services support people with complex psychosis, but independent sector patients may have more complex conditions, which could explain their longer admissions.
Dementia affects approximately 6-13% of adults aged 65 years and older, with Alzheimer's disease accounting for most cases. Established symptomatic therapies, including acetylcholinesterase inhibitors and memantine, provide limited benefit and do not modify disease progression. Multiple monoclonal antibodies (mABs) targeting different amyloid-β species have been developed as potential disease-modifying therapies; because some agents have entered clinical use whereas others remain investigational, a continuously updated synthesis of their efficacy and safety is needed. To evaluate the efficacy and safety of all anti-amyloid mABs for adults with Alzheimer's disease, using a living systematic review and meta-analysis. We will conduct a living systematic review and meta-analysis in accordance with the Cochrane Handbook, Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 and the PRISMA extension for living systematic reviews. Randomised controlled trials comparing any approved or investigational anti-amyloid mAB with placebo, standard care or active comparators will be included. Searches of Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and WHO International Clinical Trials Registry Platform will be updated every 6 months. Meta-analyses will be conducted separately for each antibody molecule using random-effects models. Critical outcomes include global clinical change and disease severity, cognitive abilities, functional ability and dependency, and safety (serious adverse events, treatment discontinuation and amyloid-related imaging abnormalities). Important outcomes include neuropsychiatric symptoms, quality of life and health system outcomes. Certainty of evidence will be assessed using the methodology Grading of Recommendations, Assessment, Development and Evaluation. This article describes a protocol; therefore, no review findings are available at this stage. This living systematic review will provide an up-to-date synthesis of the benefits and harms of anti-amyloid monoclonal antibodies to inform clinical decision-making and health-system planning in Alzheimer's disease.
Evidence shows that advance care planning has the potential to reduce involuntary admissions and empower service users. The perinatal period is a time of heightened risk of relapse of mental illness, and, in this context, many perinatal mental health services routinely offer pre-birth mental health care planning meetings. We aimed to explore the experience of perinatal mental health service users and their partners following a pre-birth planning meeting and the writing of a perinatal care plan that included advance care plans for birth, postpartum and in case of crisis. We interviewed pregnant perinatal mental health service users and their partners at two large, urban maternity hospitals in Dublin, Ireland. We used thematic analysis to identify key themes relevant to their experiences of pre-birth planning meetings and written perinatal mental health care plans. Ten service users and three partners were interviewed. We identified five themes: theme 1, Hoping for change; theme 2, A wish to be heard; theme 3, Individualised care; theme 4, Security of 'a plan in place' and theme 5, Role of the support network. Women and their partners value pre-birth planning meetings and these should routinely be offered within services, with consideration as to the size and timing of the meeting, and who is in attendance. These findings are relevant to general adult and liaison psychiatrists who should also incorporate advance care planning into routine practice.
Community treatment orders (CTOs) permit compulsory mental healthcare outside hospital. Such orders have become part of an increasing number of mental health laws, even if there is a lack of consensus on their effects, negative personal experiences, diverging ethical positions and expectations that governments should reduce or abandon coercive practices. It is therefore surprising that there is limited research describing the availability and restrictiveness of CTO legislation, and we found no comprehensive European study. Such studies could contribute to clarification of differing positions and, through that, informing further research and discussions of how to promote voluntary options in clinical practice. To establish the availability of CTO legislation across Europe, and how regimes in different ways restrict the person. Data were collected from 33 European countries through a network of researchers and practitioners, and links to relevant legislation were provided. We found 13 CTO regimes across the 33 countries: two-thirds therefore managed without them. Despite some variation, most law texts specified restrictions related to legal criteria, enforcement mechanisms and safeguards. Restrictions on the person were often specified in separate tailored plans, and most regimes permitted indefinite renewals, which means that the duration of restrictions can be ascertained only in retrospect. CTO law texts preclude scrutiny of overall restrictiveness, which might add to current uncertainties regarding the proportionality of CTOs and their role in balancing individuals' rights to both autonomy and care. The current policy drive towards community care should not automatically lead to new CTO regimes until their effectiveness and de facto restrictiveness are established.
As generative artificial intelligence chatbots become embedded in everyday life, concerns about their psychological risks are growing. Emerging reports describe cases of artificial intelligence-induced or -associated psychosis (hereafter artificial intelligence (AI) psychosis) in which intensive chatbot use is associated with delusional thinking patterns. This paper proposes a provisional mechanism wherein baseline user vulnerabilities and engagement patterns interact with generative artificial intelligence characteristics, such as sycophancy and hallucination, contributing to delusional ideation. It subsequently outlines clinical, design and regulatory strategies that may help mitigate risks.
Cognitive impairment is common in bipolar disorder (BD), but the underlying pathophysiology remains unclear. This systematic review aimed to (1) summarize all literature describing relationships of biofluid biomarkers and cognition in BD and (2) identify which biofluid biomarkers correlate most consistently with cognition in BD. This systematic review followed procedures of the PRISMA statement. PubMed, EMBASE, and PsycINFO were searched from inception until July 2023. Original studies assessing the relationships between biofluid biomarkers and cognitive functioning in adults with BD were included. Studies on neuroimaging markers and genetic biomarkers were excluded. We identified 60 studies, together describing 184 biofluid biomarkers that were measured in relation to cognitive functioning in BD. Biomarkers were organized into ten categories: oxidative stress markers (n = 14); growth factors (n = 13); neurotransmitters (n = 14); neuropeptides and hormones (n = 14); neurodegenerative markers (n = 11); inflammatory/immune markers (n = 59); serostatus to infectious agents (n = 11); amino acids, vitamins, and minerals (n = 7); metabolic factors (n = 23); hemogram, coagulation, and fibrinolysis markers (n = 18). Preliminary evidence for a significant relationship with cognition appeared for HSV-1 IgG, CRP, and homocysteine (Hcy); higher biomarker levels were associated with worse cognition. Included studies were heterogeneous and many were deemed to be of low quality following risk of bias assessment. The identified three biofluid biomarkers represent history of previous infections, current inflammation, and/or physical or psychological stress. Poor physical health, possibly represented by a broad range of biomarker aberrations, may play a role in the pathophysiology of cognitive impairment in BD. PROSPERO registration number: CRD42021224226.
The increasing demand for adolescent eating disorder services during and following the COVID-19 pandemic necessitated alternative treatment approaches. Traditional in-patient and daycare settings faced challenges, including resource limitations and geographical accessibility. To describe and evaluate the outcomes of the Hospital at Home (H@H) service, an innovative, virtual, intensive treatment programme designed to prevent in-patient admissions or shorten length of in-patient stay. A prospective cohort of 71 consecutive admissions from October 2021 to December 2024 was established. Data included percentage median body mass index (%mBMI), Eating Disorders Examination Questionnaire (EDE-Q), Children's Global Assessment Scale (CGAS) and any readmissions for in-patient treatment within the following 6 months. Qualitative feedback was also sought from staff and a sample of patients and family members. Of the 71 admissions to H@H, only 9 (13%) required hospitalisation. Mean %mBMI increased significantly, from 82.4% (s.d. 8.17) on admission to 90.07% (s.d. 9.44) on discharge (p < 0.001, 95% CI 5.67 to 9.61). Global EDE-Q score improved significantly, from 3.75 (s.d. 1.32) on admission to 2.62 (s.d. 1.45) on discharge (p < 0.001, 95% CI -1.47 to -0.78). Average CGAS improved significantly, from 38.7 (s.d. 7.4) on admission to 51.8 (s.d. 14.2) on discharge (p < 0.001, 95% CI 10.06 to 16.11). Families and patients reported high satisfaction with the virtual care model. This innovative model prevented hospital admissions, demonstrating clinical benefits and high user satisfaction. Expansion and further research are recommended to explore the long-term clinical outcomes and cost-effectiveness.
Although all patient deaths affect clinicians, it remains unclear how the impact of suicides differs from other deaths. Is the trauma of losing a patient by suicide qualitatively distinct, or are the emotional, professional and organisational consequences of suicidal and non-suicidal deaths more similar than assumed? To investigate the impact of patient suicide compared with other patient deaths on clinicians' psychological well-being, clinical practice and career. To explore clinicians' perspectives on how current support systems do, or do not, meet their needs. A mixed-methods approach was used. An online survey with two subsets of questions (one for suicidal and one for non-suicidal patient deaths) was circulated to clinicians across South London and Maudsley NHS Foundation Trust. A total of 122 responses were collected: two-thirds of respondents had experienced a patient suicide, with 53% reporting moderate and 12% reporting severe impact versus 36.6% reporting moderate and 4.2% severe for non-suicidal deaths. Non-suicidal death was associated with significantly lower impact (odds ratio 0.14, 95% CI [0.05, 0.41], p < 0.001) and less disruption to clinical practice. Blame emerged as a key factor shaping clinicians' responses: 98% of respondents rated suicide as <60% predictable in secondary care, and 69% rated the 'zero-suicide' policy as unachievable. Patient suicide has a heavier impact on clinicians, qualitatively distinct from other patient deaths. Blame shapes defensive responses in suicides, and internal questioning in non-suicidal deaths. The low-risk paradox and perceived unachievability of zero-suicide policies call for re-evaluation. Acknowledging predictability limits and clinicians' support needs can help systems navigate the complex impact of patient suicides.