Risk Factors, Warning Signs, and Drivers of Suicide: What Are They, How Do They Differ, and Why Does It Matter?

Research investigating suicide attempts and deaths by suicide has yielded many specific risk factors and warning signs for future suicidal behaviors. Yet, even though these variables are each valuable for suicide prevention efforts, they may be limited in their applicability to clinical practice. The differences among risk factors, warning signs, and "drivers," which are person-specific variables that lead individuals to desire death by suicide, are highlighted. The scarce evidence on drivers is described and specific recommendations for conducting future drivers-focused research and targeting them in clinical practice are suggested.

Barriers and facilitators of suicide risk assessment in emergency departments: a qualitative study of provider perspectives

OBJECTIVE

To understand emergency department (ED) providers' perspectives regarding the barriers and facilitators of suicide risk assessment and to use these perspectives to inform recommendations for best practices in ED suicide risk assessment.

METHODS

Ninety-two ED providers from two hospital systems in a Midwestern state responded to open-ended questions via an online survey that assessed their perspectives on the barriers and facilitators to assess suicide risk as well as their preferred assessment methods. Responses were analyzed using an inductive thematic analysis approach.

RESULTS

Qualitative analysis yielded six themes that impact suicide risk assessment. Time, privacy, collaboration and consultation with other professionals and integration of a standard screening protocol in routine care exemplified environmental and systemic themes. Patient engagement/participation in assessment and providers' approach to communicating with patients and other providers also impacted the effectiveness of suicide risk assessment efforts.

CONCLUSION

The findings inform feasible suicide risk assessment practices in EDs. Appropriately utilizing a collaborative, multidisciplinary approach to assess suicide-related concerns appears to be a promising approach to ameliorate the burden placed on ED providers and facilitate optimal patient care. Recommendations for clinical care, education, quality improvement and research are offered.

Response to commentary on "The modal suicide decedent did not consume alcohol just prior to the time of death: An analysis with implications for understanding suicidal behavior"

A commentary on our article, "The Modal Suicide Decedent Did Not Consume Alcohol Just Prior to the Time of Death: An Analysis with Implications for Understanding Suicidal Behavior," published in this issue, was reviewed. We agree with the authors of that commentary regarding a coding error that has now been corrected. While we disagree with several of the points raised by the authors, the majority of our disagreements lie in how the results of our original study are being interpreted. We provide a point-by-point response to that commentary and thank the authors for advancing scientific debate on what we view as a very important issue in understanding the role of alcohol as a risk factor for suicide.

Suicide Attempt Characteristics Among Veterans and Active-Duty Service Members Receiving Mental Health Services: A Pooled Data Analysis

Past suicidal behaviors are among the strongest and most consistent predictors of eventual suicide and may be particularly salient in military suicide. The current study compared characteristics of suicide attempts in veterans (N = 746) and active-duty service members (N = 1,013) receiving treatment for acute suicide risk. Baseline data from six randomized controlled trials were pooled and analyzed using robust regression. Service members had greater odds of having attempted suicide relative to veterans, though there were no differences in number of attempts made. Service members also had higher rates of premilitary suicide attempts and nonsuicidal self-injury (NSSI). Veterans disproportionately attempted suicide by means of overdose. In veterans, combat deployment was associated with lower odds of lifetime suicide attempt, while history of NSSI was associated with greater attempt odds. Neither was significantly associated with lifetime suicide attempt in service members. Implications for suicide assessment and treatment are discussed.

An investigation of the interactive effects of the capability for suicide and acute agitation on suicidality in a military sample

BACKGROUND

According to the interpersonal theory of suicide (1, 2), the difficulties inherently associated with death by suicide deter many individuals from engaging in suicidal behavior. Consistent with the notion that suicide is fearsome, acute states of heightened arousal are commonly observed in individuals immediately prior to lethal and near-lethal suicidal behavior. We suggest that among individuals who possess elevated levels of the capability for suicide, the heightened state of arousal experienced during periods of acute agitation may facilitate suicidal behavior in part because it would provide the necessary energy to approach a potentially lethal stimulus. Among individuals who are low on capability, the arousal experienced during agitation may result in further avoidance.

METHODS

In the present project we examine how acute agitation may interact with the capability for suicide to predict suicidality in a large military sample (n = 1,208) using hierarchical multiple regression.

RESULTS

Results were in line with a priori hypotheses: among individuals high on capability, as agitation increases, suicidality increases whereas as agitation increases among individuals low on capability, suicidality decreases. Results held beyond the effects of thwarted belongingness, perceived burdensomeness, and suicidal cognitions.

CONCLUSIONS

Beyond further substantiating the link between agitation and suicide, findings of the present study provide evidence for the construct validity of the acquired capability as well as offer initial evidence for moderating role of capability on the effect of agitation on suicide. Limitations of the current study highlight a need for future research that improves upon the techniques used in the present study. Implications for science and practice are discussed.

Reconsidering the link between impulsivity and suicidal behavior

It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon.

Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: what does the literature tell us?

Research suggests that both the military and veteran and the lesbian, gay, bisexual, and transgender (LGBT) populations may be at increased risk for suicide. A literature review was conducted to identify research related to suicide risk in the LGBT military and veteran populations. Despite the paucity of research directly addressing this issue, themes are discussed evident in the literature on LGBT identity and suicide risk as well as LGBT military service members and veterans. Factors such as social support and victimization appear to be particularly relevant. Suggestions are made with respect to future research that is needed on this very important and timely topic.

The multidimensional scale of perceived social support: analyses of internal reliability, measurement invariance, and correlates across gender

In this study, we examined estimates of internal consistency reliability, measurement invariance, and differential correlates of the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) in samples of undergraduate men (n = 270) and women (n = 340). The MSPSS is designed to assess 3 sources of perceived social support: family, friends, and significant others. The participants ranged in age from 18 to 24 years (M(age) = 19.60, SD = 1.4 years). First, composite scale reliability and coefficient omega methods provided adequate estimates of internal consistency reliability for the original MSPSS total and subscale scores. Second, results of multiple-groups invariance confirmatory factor analysis provided support for configural and metric invariance. Partial measurement invariance was attained for scalar and strict measurement invariance across men and women. Additionally, given the high correlations among the first-order factors, we conducted multiple-groups bifactor item response theory (bifactor-IRT) analysis to evaluate further the performances of the individual MSPSS items across gender. Support for the bifactor model was strong. Third, we conducted a series of simultaneous regression analyses to identify potential correlates of the social support construct for women and men.

The Depression Anxiety Stress Scales-21 (DASS-21): further examination of dimensions, scale reliability, and correlates

OBJECTIVES

We conducted two studies to examine the dimensions, internal consistency reliability estimates, and potential correlates of the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995).

METHOD

Participants in Study 1 included 887 undergraduate students (363 men and 524 women, aged 18 to 35 years; mean [M] age = 19.46, standard deviation [SD] = 2.17) recruited from two public universities to assess the specificity of the individual DASS-21 items and to evaluate estimates of internal consistency reliability. Participants in a follow-up study (Study 2) included 410 students (168 men and 242 women, aged 18 to 47 years; M age = 19.65, SD = 2.88) recruited from the same universities to further assess factorial validity and to evaluate potential correlates of the original DASS-21 total and scale scores.

RESULTS

Item bifactor and confirmatory factor analyses revealed that a general factor accounted for the greatest proportion of common variance in the DASS-21 item scores (Study 1). In Study 2, the fit statistics showed good fit for the bifactor model. In addition, the DASS-21 total scale score correlated more highly with scores on a measure of mixed depression and anxiety than with scores on the proposed specific scales of depression or anxiety. Coefficient omega estimates for the DASS-21 scale scores were good.

CONCLUSIONS

Further investigations of the bifactor structure and psychometric properties of the DASS-21, specifically its incremental and discriminant validity, using known clinical groups are needed.

The Colorado Violent Death Reporting System (COVDRS): validity and utility of the Veteran status variable

OBJECTIVE

Using the Veterans Affairs Beneficiary Identification Record Locator Subsystem (BIRLS) as the criterion database, we evaluated the sensitivity and specificity of the death certificate information in the Colorado Violent Death Reporting System (COVDRS) to determine Veteran status for those who died by suicide.

METHODS

The study sample consisted of 3,820 individuals aged 18 years and older who died by suicide in Colorado from January 1, 2004, through December 31, 2008. To determine agreement on Veteran status, COVDRS data were submitted to the Veterans Benefits Administration for linkage to the BIRLS using Social Security numbers.

RESULTS

Sensitivity and specificity of the Veteran status information on the death certificate were 93.1% (95% confidence interval [CI] 90.7, 95.2) and 91.7% (95% CI 90.5, 92.8), respectively. The overall agreement between the death certificate and the BIRLS on Veteran status was very good (kappa = 0.76; 95% CI 0.74, 0.79).

CONCLUSIONS

This study of 3,820 suicide deaths in Colorado demonstrated a high level of agreement between the COVDRS Veteran status variable and the BIRLS. Such findings offer support for using the COVDRS in studying factors associated with suicide in the Veteran population.

Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military

BACKGROUND

Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.

METHODS

Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).

RESULTS

In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.

LIMITATIONS

The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk.

CONCLUSIONS

These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Development and evaluation of the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory

We describe the development of a new self-report instrument, the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory. We initially retained 30 content specific items for the instrument (Study 1). In Study 2 (N = 438), we established a 2-factor solution, Social Anxiety Life Interference-12 (SALI-12) and Depression Life Interference-12 (DLI-12). We also examined estimates of known-groups and concurrent validity. Confirmatory factor analysis in Study 3 (N = 430) provided support for the oblique two-factor structure. In Study 4 (N = 179), we provided additional support for estimates of known-groups validity. In Study 5 (N = 63), we evaluated estimates of test-retest reliability. Both SADLI-24 scale scores showed good estimates of internal consistency.

Surrogate endpoints in suicide research

Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.

Neuropsychological test performance in soldiers with blast-related mild TBI

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.

Psychometric evaluation of the body investment scale for use with adolescents

We conducted two studies to examine the psychometric properties of the Body Investment Scale (BIS; Orbach & Mikulincer, 1998) in U.S. adolescent samples. The BIS was designed to assess bodily experiences that are associated with suicide-related behaviors. In Study 1, confirmatory factor analysis (CFA) with data from a combined sample of 204 high school adolescents (83 boys, 121 girls) and 197 psychiatric inpatient (101 boys, 96 girls) adolescents provided moderate support for the oblique four-factor solution: Body Feelings (rho=.86, 95% CI=.83-.89), Body Touch (rho=.71, 95% CI=.65-.76), Body Care (rho=.78, 95% CI=.71-.81), and Body Protection (rho=.78, 95% CI=.73-.82); robust comparative fit index=.88 and the robust Tucker Lewis Index=.83. The second-order factor model also provided moderate fit to the data. In Study 2, results of the CFA with data from adolescent psychiatric inpatients (N=205; 101 boys, 104 girls) provided additional support for the four-factor solution. In addition, results of the receiver operating characteristic and logistic regression analyses showed that scores on the Body Feelings and Body Protection scales were most useful in differentiating the responses of suicidal and nonsuicidal adolescents, all Cohen's d values >.30. The study also examined associations between scores on the BIS scales and the validation self-report measures of hopelessness, suicide-related behavior, and reasons for living.