Emergency Psychiatry

Article information
Title: Suicide and Self-Harm in Intellectual Disability: A Systematic Review and Meta-Analysis
PubMed ID: 41045179
First Author Last Name: Lindstedt

Abstract:

Background:
Individuals with intellectual disabilities (ID) are disproportionately exposed to several risk factors for suicidality. However, no meta-analysis has yet quantified the relative risk of suicide and self-harm, including suicide attempts, within this population. The aim of this project was to bring together and synthesise the research on suicidality among individuals with ID.

Methods:
A systematic review and meta-analysis was carried out. Medline, Embase, Web of Science and PsycInfo were searched from inception through 4 August 2025. Observational studies with a quantitative design, evaluating the relative risk of suicide or self-harm, including suicide attempts, in individuals with and without ID, were included. Risk of bias was assessed using a shortened version of the Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) checklist. A random effects model was used to synthesise the results.

Results:
Eleven primary studies were included in the review (n = 241 438). The level of ID severity was only presented in two articles. Compared to the general population, the pooled relative risk for death by suicide was 0.54 (95% CI 0.33 to 0.89, k = 6, I2 = 77%) and the relative risk for self-harm was 3.16, (95% CI 2.3 to 4.35, k = 6, I2 = 89%).

Conclusion:
The findings suggest that individuals with ID have an elevated risk of self-harm but a lower risk of dying by suicide compared to the general population. However, these results should be interpreted with caution due to the limited number of primary studies and substantial between-study heterogeneity. Further, separate analyses of mild versus moderate-to-profound ID are warranted.

Annotation

The finding:
The neurodevelopmental disorder Intellectual Disability (ID) is characterized by difficulties in reasoning, problem solving, planning, abstract thinking, judgment, study skills, and learning from experience. Many of these individuals suffer medical, genetic, neurologic, and psychiatric disorders and comorbidities; resultantly, individuals with ID may be subject to numerous social determinants of suicide and self-harm (low employment, isolation, interpersonal violence). This PRISMA metanalysis of 11, internationally-based studies found that individuals with ID had a lower relative risk of suicide compared with the general population, with a pooled estimate of approximately 0.54 (0.33–0.89). Contrastingly, individuals with ID had a substantially higher risk of self-harm, with a pooled relative risk of approximately 3.16 (2.3–4.35).

Strength and weaknesses:
This article is one of the first to highlight self-harm, alongside suicide, as critical considerations in the care of individuals with ID. Given the dearth of previous research, this metanalysis was relatively small, heterogenous, and did not allow for subgroup analyses or assessment of publication bias.

Relevance:
For emergency and consultation-liaison psychiatrists, this study challenges assumptions about suicide risk in individuals with ID. While completed suicide risk may be lower, the markedly elevated rate of self-harm signals substantial psychological distress and unmet mental health needs. These findings highlight the importance of careful assessment of intent, avoidance of diagnostic overshadowing, and recognition that self-injurious behaviors may expand beyond suicidality. Clinically, patients with ID presenting with self-harm require nuanced risk assessment and individualized treatment plan strategies, particularly if communication challenges or other behavioral patterns are present.

Article information
Title: Pharmacological management of agitation in dementia: An evidence-based review with expert consensus
PubMed ID: 41527161
First Author Last Name: Cheng

Abstract:
Agitation is a frequently occurring and challenging neuropsychiatric symptom of Alzheimer's disease (AD) that substantially affects quality of life, caregiver burden, and healthcare utilization. Nonpharmacological interventions, especially trigger identification, environmental adjustments, and supportive activities, remain the first-line approach for treating agitation. Pharmacological treatment should be considered only when nondrug measures are insufficient or when agitation causes severe distress or safety risks. This consensus integrates evidence up to June 2025, the Taiwan Ministry of Health and Welfare approval status, and expert opinion from Taipei Veterans General Hospital. Among the approved agents, brexpiprazole demonstrated the strongest evidence and most favorable safety profile. Risperidone and aripiprazole are effective, but require careful monitoring for cerebrovascular and extrapyramidal risks. Selected antidepressants, particularly citalopram and agomelatine, should be considered when safety is prioritized. Anticonvulsants, acetylcholinesterase inhibitors, and memantine have limited efficacy and should be reserved for refractory cases. Long-term or routine pharmacological use is not supported by current evidence. Future research should focus on identifying responsive patient subgroups, optimizing dosing strategies, and integrating medications into individualized, multidisciplinary care plans.

Annotation
The finding:
Informed by a literature review and expert consensus, this article discusses the pharmacological treatment of agitation in Alzheimer’s Disease (AD). Taking into consideration clinical evidence, acceptability, Taiwan's Ministry of Health and Welfare regulatory status, and expert clinical experience, pharmacological options were graded. Brexpiprazole and aripiprazole, followed by risperidone, received the most favorable grades, followed by SSRIs. Antiepileptics consistently received grades indicative of a poor risk-benefit ratio and unacceptable levels of evidence. SSRIs were noted to have a high number needed to harm (NNH), a very modest benefit in AD agitation, but a potential niche in treatment of Frontotemporal Dementia agitation. The authors make a distinction between “baseline” (chronic) agitation and acute agitation, suggesting that acetylcholinesterase inhibitors and NMDA antagonists may offer more long-term, global benefits but constitute less effective acute interventions.

Strengths and weaknesses:
These guidelines offer the perspective of an interdisciplinary team of clinical experts caring for a cohort that is quite complex and often treatment resistant. All practitioners were based in Taiwan; regional differences in support for individuals suffering from AD and incorporation of non-pharmacological interventions for agitation may impact the applicability of these grades in unforeseen ways.

Relevance:
This review reinforces the importance of evidence-based prescribing practices for this complex and medically-vulnerable population. Medications used for agitation in AD carry significant risks of mortality and severe side effects, making the risk-benefit consideration critical. Brexpiprazole, with its FDA-approval for “agitation associated with dementia due to Alzheimer’s disease” remains a first-line option when agitation is severe and/or dangerous, with aripiprazole and risperidone as reasonable second-line options. Memantine and donepezil remain useful options for chronic agitation and for addressing more global symptoms of cognitive decline. While frequently utilized, quetiapine and olanzapine are flagged due to mixed evidence and a variety of adverse effects: orthostasis, anticholinergic properties, oversedation, and metabolic syndrome. Finally, in line with previous studies, recent evidence suggests against the use of valproic acid for agitation in AD.