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Vine V, Victor SE, Mohr H, Byrd AL, Stepp SD. Adolescent suicide risk and experiences of dissociation in daily life. Psychiatry Res 2020; 287:112870. [PMID: 32171125 PMCID: PMC7983062 DOI: 10.1016/j.psychres.2020.112870] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
Dissociation is associated with risk for suicide in adults, but this link is not well studied in adolescents, in spite of their marked suicide risk. This study assessed adolescents' dissociative experiences in daily life and evaluated the association between dissociative experiences and suicide risk, including the independence of this relationship from related affective and clinical states and demographic characteristics. Clinically referred early adolescents (N = 162; aged 11-13) were assessed via multi-informant clinical interview, questionnaires, and 4-day ecological momentary assessment protocol. Adolescents were classified as being at elevated suicide risk using multi-informant, multi-method reports of suicide risk behavior and/or at elevated proximal risk using the 4-day EMA only. Suicide risk was associated with daily dissociative experiences, and this relationship was independent of daily negative and positive affect and co-occurring borderline personality symptoms. Gender differences emerged, such that the relationship between daily dissociative experiences and suicide risk was only significant in adolescent girls. Overall, findings suggest dissociation may be independently relevant to adolescent suicide risk, above and beyond effects of psychopathology and affective disturbance, and especially in girls. Daily dissociative experiences may help understand and detect suicide risk among early adolescents and warrant further research.
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Affiliation(s)
- Vera Vine
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St., Pittsburgh, PA 15213, USA.
| | - Sarah E Victor
- Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA
| | - Harmony Mohr
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St., Pittsburgh, PA 15213, USA
| | - Amy L Byrd
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St., Pittsburgh, PA 15213, USA
| | - Stephanie D Stepp
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O'Hara St., Pittsburgh, PA 15213, USA
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Green J, Berry K, Danquah A, Pratt D. The role of psychological and social factors in the relationship between attachment and suicide: A systematic review. Clin Psychol Psychother 2020; 27:463-488. [PMID: 32167194 DOI: 10.1002/cpp.2445] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/10/2020] [Accepted: 03/10/2020] [Indexed: 11/08/2022]
Abstract
Insecure attachment is widely accepted to be a risk factor for suicidal thoughts and behaviour. To increase our understanding of this distal association, the current systematic review aimed to evaluate empirical evidence that has investigated the role of psychosocial mechanisms within this relationship. Sixteen original research articles were identified, with the majority carrying out mediational analyses to test their hypotheses. Substantial heterogeneity was found across studies with regards to their theoretical approach to assessing attachment, suicide-related outcomes, sample population, statistical analyses, and the psychological factors under investigation. Nevertheless, this emergent evidence base indicates that a range of predisposing, precipitating, and crisis-state factors may mediate the association between attachment security and suicidality. Studies that investigated moderating factors did not report significant findings, and the mediating role for psychiatric diagnoses remains unclear. Furthermore, this emerging research base is limited by an over-reliance on cross-sectional designs and self-reported data. Longitudinal and experimental designs are required to verify causal pathways and to investigate whether trait vulnerabilities interact with acute stressors to increase suicide risk. Finally, disorganized attachment has been overlooked so far and should be given greater consideration going forward.
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Affiliation(s)
- Jessica Green
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Katherine Berry
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Adam Danquah
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Daniel Pratt
- School of Health Sciences, University of Manchester, Manchester, UK
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Barros J, Morales S, García A, Echávarri O, Fischman R, Szmulewicz M, Moya C, Núñez C, Tomicic A. Recognizing states of psychological vulnerability to suicidal behavior: a Bayesian network of artificial intelligence applied to a clinical sample. BMC Psychiatry 2020; 20:138. [PMID: 32228548 PMCID: PMC7106600 DOI: 10.1186/s12888-020-02535-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 03/06/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND This study aimed to determine conditional dependence relationships of variables that contribute to psychological vulnerability associated with suicide risk. A Bayesian network (BN) was developed and applied to establish conditional dependence relationships among variables for each individual subject studied. These conditional dependencies represented the different states that patients could experience in relation to suicidal behavior (SB). The clinical sample included 650 mental health patients with mood and anxiety symptomatology. RESULTS Mainly indicated that variables within the Bayesian network are part of each patient's state of psychological vulnerability and have the potential to impact such states and that these variables coexist and are relatively stable over time. These results have enabled us to offer a tool to detect states of psychological vulnerability associated with suicide risk. CONCLUSION If we accept that suicidal behaviors (vulnerability, ideation, and suicidal attempts) exist in constant change and are unstable, we can investigate what individuals experience at specific moments to become better able to intervene in a timely manner to prevent such behaviors. Future testing of the tool developed in this study is needed, not only in specialized mental health environments but also in other environments with high rates of mental illness, such as primary healthcare facilities and educational institutions.
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Affiliation(s)
- Jorge Barros
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, La Reconquista 498, Las Condes, Santiago, Chile
| | - Susana Morales
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, La Reconquista 498, Las Condes, Santiago, Chile.
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile.
| | - Arnol García
- Independent mathematical engineer, Santiago, Chile
| | - Orietta Echávarri
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, La Reconquista 498, Las Condes, Santiago, Chile
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile
| | - Ronit Fischman
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile
| | - Marta Szmulewicz
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, La Reconquista 498, Las Condes, Santiago, Chile
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile
| | - Claudia Moya
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile
- School of Nursing, San Sebastian University, Santiago, Chile
| | - Catalina Núñez
- Psychiatry Department, School of Medicine, Pontificia Universidad Católica de Chile, La Reconquista 498, Las Condes, Santiago, Chile
| | - Alemka Tomicic
- Millennium Institute for Research in Depression and Personality MIDAP, Santiago, Chile
- School of Psychology, Diego Portales University, Santiago, Chile
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Guzmán EM, Tezanos KM, Chang BP, Cha CB. Examining the impact of emergency care settings on suicidal patients: A call to action. Gen Hosp Psychiatry 2020; 63:9-13. [PMID: 30077397 DOI: 10.1016/j.genhosppsych.2018.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/15/2018] [Accepted: 07/19/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The emergency department (ED) offers a critical and unique opportunity to assess and intervene on suicide risk. Despite its potential benefits, the ED setting presents several potential sources of stress. The present paper calls attention to how suicidal patients may be especially vulnerable to stressful ED experiences. METHOD This research synthesis cites the growing literature on ED-related stressors, as they have been shown to affect both psychiatric and nonpsychiatric patient populations. RESULTS We identified specific interpersonal, physical, and temporal features of the ED that have been shown to affect multiple patient populations, including suicidal individuals. Beyond this, there appears to be broad underutilization of therapeutic care in ED settings. CONCLUSIONS It is important to consider how the ED setting may be both helpful and harmful toward suicidal patients. We conclude with recommended domains of study and methodological considerations when pursuing these future directions. The proposed research agenda would help address this known high risk period around hospitalization and discharge, and ultimately optimize suicide prevention efforts.
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Affiliation(s)
- Eleonora M Guzmán
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America
| | - Katherine M Tezanos
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America
| | - Bernard P Chang
- Department of Emergency Medicine, Columbia University Medical Center, United States of America
| | - Christine B Cha
- Department of Counseling and Clinical Psychology, Teachers College, Columbia University, United States of America.
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Pia T, Galynker I, Schuck A, Sinclair C, Ying G, Calati R. Perfectionism and Prospective Near-Term Suicidal Thoughts and Behaviors: The Mediation of Fear of Humiliation and Suicide Crisis Syndrome. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041424. [PMID: 32098414 PMCID: PMC7068323 DOI: 10.3390/ijerph17041424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 02/07/2020] [Accepted: 02/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Perfectionism has been linked to suicide. According to the Narrative-Crisis Model of suicide, individuals with trait vulnerabilities are prone to develop a certain mindset, known as a Suicidal Narrative, which may precipitate the Suicide Crisis Syndrome (SCS), culminating in suicide. The purpose of this study was to investigate the association between perfectionism (trait vulnerability), fear of humiliation (component of the Suicidal Narrative), SCS, and prospective near-term suicidal thoughts and behaviors (STB). METHODS Adult psychiatric outpatient participants (N = 336) were assessed at baseline with the Suicidal Narrative Inventory for perfectionism and fear of humiliation. The questions used to assess perfectionism were adapted from the Multidimensional Perfectionism Scale. The severity of the SCS was calculated using the Suicide Crisis Inventory. STB were assessed at baseline and after one month using the Columbia Suicide Severity Rating Scale. Serial mediation analyses were conducted using PROCESS version 3.3 in SPSS. RESULTS While the direct effect of perfectionism on prospective STB was not significant (b = 0.01, p = 0.19), the indirect effect of perfectionism on STB, through serial mediation by fear of humiliation and the SCS, was significant (indirect effect p = 0.007, 95% CI [0.003,0.013]). The indirect effect was not significant for models that did not include both mediators. LIMITATIONS Variables were assessed at one time only. CONCLUSION Perfectionism did not directly modulate STB. Perfectionism may be related to suicidal behavior through fear of humiliation, leading to the SCS. These results support the Narrative-Crisis Model of suicide and clarify the role of perfectionism in the etiology of suicide.
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Affiliation(s)
- Tyler Pia
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
- Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA
| | - Allison Schuck
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
| | - Courtney Sinclair
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
| | - Gelan Ying
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
| | - Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY 10003, USA; (T.P.); (I.G.); (A.S.); (C.S.); (G.Y.)
- Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574, USA
- Department of Psychology, University of Milan-Bicocca, 20126 Milan, Italy
- Department of Adult Psychiatry, Nîmes University Hospital, 30029 Nîmes, France
- Correspondence:
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Calati R, Cohen LJ, Schuck A, Levy D, Bloch-Elkouby S, Barzilay S, Rosenfield PJ, Galynker I. The Modular Assessment of Risk for Imminent Suicide (MARIS): A validation study of a novel tool for suicide risk assessment. J Affect Disord 2020; 263:121-128. [PMID: 31818767 DOI: 10.1016/j.jad.2019.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/16/2019] [Accepted: 12/01/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Reliable diagnostic tools for the short-term suicide risk assessment are needed. The recently developed multi-informant Modular Assessment of Risk for Imminent Suicide (MARIS) includes four modules: two are patient-rated and two clinician-rated. The patient-rated modules assess a proposed pre-suicidal cognitive/emotional state (Module 1) as well as patients' attitudes towards suicide (Module 2). The clinician-rated modules assess traditional suicide risk factors (Module 3) and clinicians' emotional responses to the patient (Module 4). METHODS With the aim of extending our previous preliminary proof of concept findings, the MARIS was administered to 618 psychiatric patients (167 inpatients, 451 outpatients) and their clinicians (N = 115). Patients were assessed with a battery including the Columbia-Suicide Severity Rating Scale. Four outcomes were considered: lifetime and past month suicidal thoughts and behaviors (STB) (0-10 point scale) and suicidal behaviors (SB) (0-5 point scale). Reliability and concurrent, convergent/divergent and incremental validity were assessed. RESULTS Good internal consistency was found for modules 1 and 4 (Cronbach's α: 0.87 and 0.86, respectively) but not for the others. Module 1's total score positively correlated with lifetime STB/SB and past month STB (all p ≤ 0.003). Module 4's total score positively correlated with all four outcomes (all p < 0.001). Modules 1 and 4 showed additional capacity to detect patients' lifetime and past month STB/SB beyond other associated factors. LIMITATIONS Lack of prospective assessment. Inpatients were evaluated at discharge, whereas outpatients at intake. CONCLUSIONS These findings supported the utility of multiple data sources to identify patients at imminent suicide risk, and in particular clinicians' emotional responses.
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Affiliation(s)
- Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Psychology, University of Milan-Bicocca, Milan, Italy; Department of Adult Psychiatry, Nîmes University Hospital, Nîmes, France.
| | - Lisa J Cohen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Allison Schuck
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Dorin Levy
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Department of Psychiatry, Mount Sinai St. Luke's and Mount Sinai West, USA
| | - Sarah Bloch-Elkouby
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shira Barzilay
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul J Rosenfield
- Department of Psychiatry, Mount Sinai St. Luke's and Mount Sinai West, USA
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA; Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Pompili M. Intranasal Esketamine and Current Suicidal Ideation With Intent in Major Depression Disorder: Beat the Clock, Save a Life, Start a Strategy. Front Psychiatry 2020; 11:325. [PMID: 32425826 PMCID: PMC7203410 DOI: 10.3389/fpsyt.2020.00325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 04/01/2020] [Indexed: 01/08/2023] Open
Affiliation(s)
- Maurizio Pompili
- Department of Neuroscience, Mental Health and Sensory Organs, Suicide Prevention Center, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
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Cramer RJ, Rasmussen S, Tucker RP. An examination of the Entrapment Scale: Factor structure, correlates, and implications for suicide prevention. Psychiatry Res 2019; 282:112550. [PMID: 31522892 DOI: 10.1016/j.psychres.2019.112550] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/21/2019] [Accepted: 08/31/2019] [Indexed: 02/08/2023]
Abstract
Entrapment is an emerging theoretical and empirical factor associated with suicide. The current study expanded our understanding of entrapment by examining the Entrapment Scale factor structure, demographic correlates, and association with suicidal thoughts and behaviors (STBs). Data from an online cross-national study of suicide were analyzed from two samples of young adults aged 18-34 (United Kingdom [U.K.] sample N = 418; United States [U.S.] N = 414). Primary findings included: (1) factor-analytic support for a two factor (i.e., internal and external) Entrapment Scale structure; (2) variation in external entrapment subscale factor loadings by sample; (3) significant demographic correlates of elevated entrapment of younger age, female gender, and U.S. sample; (4) significant convergent positive associations for both entrapment types with cognitive (e.g., perceived burdensomeness), mental health (e.g., anxiety), and STB correlates; and (5) significant, robust associations of internal entrapment and perceived burdensomeness with STBs in the U.K. sample. Implications are reviewed for suicide prevention theory, research and practice.
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Affiliation(s)
- Robert J Cramer
- Department of Public Health Sciences, University of North Carolina at Charlotte, CHHS Building 354, 9201 University City Blvd., Charlotte, NC 28223, USA.
| | - Susan Rasmussen
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Raymond P Tucker
- Department of Psychology, Louisiana State University, Baton Rouge, LA, USA
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Calati R, Nemeroff CB, Lopez-Castroman J, Cohen LJ, Galynker I. Candidate Biomarkers of Suicide Crisis Syndrome: What to Test Next? A Concept Paper. Int J Neuropsychopharmacol 2019; 23:192-205. [PMID: 31781761 PMCID: PMC7171927 DOI: 10.1093/ijnp/pyz063] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/25/2019] [Accepted: 11/27/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND There has been increasing interest in both suicide-specific diagnoses within the psychiatric nomenclature and related biomarkers. Because the Suicide Crisis Syndrome-an emotional crescendo of several interrelated symptoms-seems to be promising for the identification of individuals at risk of suicide, the aim of the present paper is to review the putative biological underpinnings of the Suicide Crisis Syndrome symptoms (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal). METHODS A PubMed literature search was performed to identify studies reporting a link between each of the 5 Suicide Crisis Syndrome symptoms and biomarkers previously reported to be associated with suicidal outcomes. RESULTS Disturbances in the hypothalamic-pituitary-adrenal axis, with dysregulated corticotropin-releasing hormone and cortisol levels, may be linked to a sense of entrapment. Affective disturbance is likely mediated by alterations in dopaminergic circuits involved in reward and antireward systems as well as endogenous opioids. Loss of cognitive control is linked to altered neurocognitive function in the areas of executive function, attention, and decision-making. Hyperarousal is linked to autonomic dysregulation, which may be characterized by a reduction in both heart rate variability and electrodermal activity. Social withdrawal has been associated with oxytocin availability. There is also evidence that inflammatory processes may contribute to individual Suicide Crisis Syndrome symptoms. CONCLUSION The Suicide Crisis Syndrome is a complex syndrome that is likely the consequence of distinct changes in interconnected neural, neuroendocrine, and autonomic systems. Available clinical and research data allow for development of empirically testable hypotheses and experimental paradigms to scrutinize the biological substrates of the Suicide Crisis Syndrome.
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Affiliation(s)
- Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, New York,Icahn School of Medicine at Mount Sinai, New York, New York,Department of Psychology, University of Milan-Bicocca, Milan, Italy,Department of Adult Psychiatry, Nîmes University Hospital, Nîmes, France,Correspondence: Raffaella Calati, PsyD, PhD, Department of Psychology, University of Milan-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126, Milan, Italy ()
| | - Charles B Nemeroff
- Department of Psychiatry, University of Texas Dell Medical School, Austin, Texas
| | - Jorge Lopez-Castroman
- Department of Adult Psychiatry, Nîmes University Hospital, Nîmes, France,INSERM, University of Montpellier, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France
| | - Lisa J Cohen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, New York,Icahn School of Medicine at Mount Sinai, New York, New York
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, New York,Icahn School of Medicine at Mount Sinai, New York, New York
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Bauer BW, Capron DW. How Behavioral Economics and Nudges Could Help Diminish Irrationality in Suicide-Related Decisions. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2019; 15:44-61. [PMID: 31697611 DOI: 10.1177/1745691619866463] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
People regularly make decisions that are not aligned with their own self-interests. These irrational decisions often stem from humans having bounded rationality (e.g., limited computational power), which produces reliable cognitive biases that occur outside of people's awareness and influences the decisions people make. There are many important decisions leading up to a suicide attempt, and it is likely that these same biases exist within suicide-related decisions. This article presents an argument for the likely existence of cognitive biases within suicide-related decision making and how they may influence people to make irrational decisions. In addition, this article provides new evidence for using a behavioral economic intervention-nudges-as a potential way to combat rising suicide rates. We explore how nudges can help increase means safety, disseminate suicide prevention skills/materials, diminish well-known biases (e.g., confirmation bias), and uncover biases that may be occurring when making suicide-related decisions.
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Affiliation(s)
- Brian W Bauer
- Department of Psychology, University of Southern Mississippi
| | - Daniel W Capron
- Department of Psychology, University of Southern Mississippi
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Abstract
BACKGROUND Psychotic disorders, as well as psychotic symptoms, are associated with a greater lifetime risk of suicidal behavior (SB). It is not known, however, whether psychotic symptoms are independent predictors for short-term SB. METHODS Data were collected from 201 psychiatric inpatients at Mount Sinai Beth Israel Hospital. Self-reported psychotic symptoms were assessed using the Brief Symptom Inventory (BSI). Postdischarge SB defined as an aborted, interrupted, or actual suicide attempt was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), during the 4 to 8 weeks following discharge from an inpatient psychiatric unit (n=127, 63% retention). Logistic regressions were performed to assess the relationships between psychotic symptoms and SB, controlling for primary psychiatric disorders. RESULTS Self-reported psychotic symptoms were associated with subsequent postdischarge SB. There was no significant difference between the SB versus no SB groups on the basis of primary psychiatric disorder. Self-reported psychotic symptoms remained an independent and significant predictor of postdischarge SB when the analysis controlled for primary psychiatric disorder. CONCLUSIONS These results suggest that psychotic symptoms are a dimensional predictor of near-term postdischarge SB and are a necessary component of suicide risk assessment during inpatient hospitalization, independent of psychiatric diagnosis.
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Jobes DA, Chalker SA. One Size Does Not Fit All: A Comprehensive Clinical Approach to Reducing Suicidal Ideation, Attempts, and Deaths. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193606. [PMID: 31561488 PMCID: PMC6801408 DOI: 10.3390/ijerph16193606] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/14/2019] [Accepted: 09/25/2019] [Indexed: 01/24/2023]
Abstract
While the existence of mental illness has been documented for centuries, the understanding and treatment of such illnesses has evolved considerably over time. Ritual exorcisms and locking mentally ill patients in asylums have been fundamentally replaced by the use of psychotropic medications and evidence-based psychological practices. Yet the historic roots of mental health management and care has left a certain legacy. With regard to suicidal risk, the authors argue that suicidal patients are by definition seen as mentally ill and out of control, which demands hospitalization and the treatment of the mental disorder (often using a medication-only approach). Notably, however, the evidence for inpatient care and a medication-only approach for suicidal risk is either limited or totally lacking. Thus, the "one-size-fits-all" approach to treating suicidal risk needs to be re-considered in lieu of the evolving evidence base. To this end, the authors highlight a series of evidence-based considerations for suicide-focused clinical care, culminating in a stepped care public health model for optimal clinical of suicidal risk that is cost-effective, least-restrictive, and evidence-based.
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Affiliation(s)
- David A Jobes
- Department of Psychology, The Catholic University of America, Washington, DC 20064, USA.
| | - Samantha A Chalker
- Department of Psychology, The Catholic University of America, Washington, DC 20064, USA.
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Yaseen ZS, Hawes M, Barzilay S, Galynker I. Predictive Validity of Proposed Diagnostic Criteria for the Suicide Crisis Syndrome: An Acute Presuicidal State. Suicide Life Threat Behav 2019; 49:1124-1135. [PMID: 30073686 DOI: 10.1111/sltb.12495] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Determining imminent risk of suicide continues to challenge psychiatrists. To this end, we test the clinical utility of a proposed set of diagnostic criteria for the suicide crisis syndrome (SCS) for prediction of imminent suicidal thoughts and behaviors prospectively. METHOD One hundred and seventy individuals hospitalized for suicidal thoughts and behaviors (STB) were evaluated within 72 hr of admission with measures assessing symptoms of the proposed SCS, history of STB, current ideation, and depression severity. Four-eight weeks following discharge, STB were reassessed. Associations between SCS and postdischarge attempts were examined using chi-square and logistic regression analyses. The receiver operator characteristic analysis was used to test the optimal number of symptoms required to meet proposed SCS criteria. RESULTS The syndrome was maximally informative about short-term risk of postdischarge suicide behavior when all criteria were met. The syndrome conferred a sevenfold increase in risk of postdischarge suicide attempt, and significantly improved prediction by standard risk factors, which was null to limited. CONCLUSIONS The SCS diagnostic criteria are supported and appear to describe a clinically meaningful syndrome in a high-risk population. Assessment of SCS may meaningfully improve clinical assessment of imminent suicide risk. Further study is needed to better understand the syndrome and its applicability in low-risk populations.
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Affiliation(s)
- Zimri S Yaseen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Mariah Hawes
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Shira Barzilay
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
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Rogers ML, Hom MA, Joiner TE. Differentiating acute suicidal affective disturbance (ASAD) from anxiety and depression Symptoms: A network analysis. J Affect Disord 2019; 250:333-340. [PMID: 30875677 DOI: 10.1016/j.jad.2019.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/11/2019] [Accepted: 03/03/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND A growing body of literature supports the potential existence of a new clinical entity, Acute suicidal affective disturbance (ASAD), which is characterized by rapid-onset, acute suicidality. This study aimed to evaluate whether current ASAD symptoms (i.e., suicidal intent, thwarted belongingness, perceived burdensomeness, disgust with others and oneself, agitation, irritability, insomnia, and nightmares) comprise a psychopathological network distinct from anxiety and depression symptoms. METHODS A sample of 167 psychiatric inpatients completed self-report measures of current ASAD, anxiety, and depression symptoms. RESULTS Network analyses revealed three distinct clusters of symptoms corresponding to ASAD, anxiety, and depression symptom self-report measure items. Namely, ASAD symptoms not only demonstrated strong associations with each other, but they also exhibited weak associations with symptoms of anxiety and depression. LIMITATIONS This study utilized a cross-sectional design and distinct self-report measures to assess all constructs, which may have led to methodological confounds that influenced the observed network structure. CONCLUSIONS Overall, our findings provide further evidence for ASAD as a syndrome with strongly interrelated symptoms. Furthermore, results indicate that ASAD may represent a construct distinct from anxiety and depression, underscoring its potential diagnostic value. Additional research is needed to replicate these findings across other high-risk populations, as well as to examine how ASAD symptoms may relate to other psychiatric symptoms.
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Affiliation(s)
- Megan L Rogers
- Department of Psychology, Florida State University, Tallahassee, FL, USA.
| | - Melanie A Hom
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Thomas E Joiner
- Department of Psychology, Florida State University, Tallahassee, FL, USA
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65
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Schuck A, Calati R, Barzilay S, Bloch-Elkouby S, Galynker I. Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis. BEHAVIORAL SCIENCES & THE LAW 2019; 37:223-239. [PMID: 30900347 DOI: 10.1002/bsl.2397] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 12/21/2018] [Accepted: 12/22/2018] [Indexed: 06/09/2023]
Abstract
Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.
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Affiliation(s)
- Allison Schuck
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Shira Barzilay
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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66
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Cohen LJ, Gorman B, Briggs J, Jeon ME, Ginsburg T, Galynker I. The Suicidal Narrative and Its Relationship to the Suicide Crisis Syndrome and Recent Suicidal Behavior. Suicide Life Threat Behav 2019; 49:413-422. [PMID: 29397571 DOI: 10.1111/sltb.12439] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/30/2017] [Indexed: 11/28/2022]
Abstract
In this study, we introduce the construct of the suicidal narrative, a hypothetical personal narrative linked to imminent suicide, and explore its relationship to near-term suicidal risk and the suicide crisis syndrome (SCS). Psychiatric outpatients (N = 289) were administered the Columbia Suicide-Severity Rating Scale (C-SSRS), Suicide Crisis Inventory (SCI), and Suicide Narrative Inventory (SNI), a novel instrument combining the documented risk factors of Thwarted Belongingness, Perceived Burdensomeness, Humiliation, Social Defeat, Goal Disengagement, and Goal Reengagement. Dimensional measures of past month, lifetime, and past suicidal phenomena, incorporating ideation and behavior, were calculated from the C-SSRS. Structural equation modeling was used to explore the interaction among variables. Factor analysis of the SNI yielded two orthogonal factors, termed Interpersonal and Goal Orientation. The former factor was comprised of Perceived Burdensomeness, Social Defeat, Humiliation, and Thwarted Belongingness, the latter of Goal Disengagement and Goal Reengagement. The Interpersonal factor correlated with both SCS severity and suicidal phenomena in each time frame and the Goal Orientation factor with no other variable. As hypothesized, the proposed model was significant for the past month only. Our findings support the construct of the suicidal narrative and its function as a near-term suicidal risk factor.
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Affiliation(s)
- Lisa Janet Cohen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Bernard Gorman
- Department of Psychology, Adelphi University, Garden City, NY, USA
| | - Jessica Briggs
- Touro College of Osteopathic Medicine, New York, NY, USA
| | - Min Eun Jeon
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Tal Ginsburg
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
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67
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Barzilay S, Yaseen ZS, Hawes M, Kopeykina I, Ardalan F, Rosenfield P, Murrough J, Galynker I. Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk. Suicide Life Threat Behav 2019; 49:614-626. [PMID: 29665120 DOI: 10.1111/sltb.12462] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/16/2018] [Indexed: 12/11/2022]
Abstract
We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.
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Affiliation(s)
- Shira Barzilay
- Mount Sinai Beth Israel, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zimri S Yaseen
- Mount Sinai Beth Israel, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - James Murrough
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Igor Galynker
- Mount Sinai Beth Israel, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, New York, NY, USA
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68
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Molaie AM, Chiu CY, Habib Z, Galynker I, Briggs J, Rosenfield PJ, Calati R, Yaseen ZS. Emotional Pain Mediates the Link Between Preoccupied Attachment and Non-suicidal Self-Injury in High Suicide Risk Psychiatric Inpatients. Front Psychol 2019; 10:289. [PMID: 30846949 PMCID: PMC6393353 DOI: 10.3389/fpsyg.2019.00289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/29/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts (SA). Both attachment disturbances and cognitive and emotional problems (e.g., emotional pain) have been associated with SA history. This study sought to determine differential contributions of attachment styles and cognitive and emotional states associated with SA to lifetime NSSI occurrence among adults hospitalized for suicide risk. Sampling and Methods: Adult psychiatric inpatients (n = 200) were assessed for attachment style, cognitive and emotional states, and lifetime NSSI within 72 h of hospitalization. Binary logistic regression and mediation analyses were performed. Results: Preoccupied attachment and emotional pain at admission were independently associated with lifetime NSSI. Emotional pain partially mediated the relationship between preoccupied attachment and lifetime NSSI. Limitations: The cross-sectional nature of the study and the use of a dichotomous (yes/no) measure of NSSI, not specifically designed for its assessment. Conclusions: Preoccupied attachment and emotional pain are associated with NSSI and may be useful targets for assessing risk of NSSI.
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Affiliation(s)
- Ali M Molaie
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Chih-Yun Chiu
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Zara Habib
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Jessica Briggs
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Paul J Rosenfield
- Department of Psychiatry, Mount Sinai St. Luke's and Mount Sinai West, New York, NY, United States
| | - Raffaella Calati
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
| | - Zimri S Yaseen
- Department of Psychiatry, Mount Sinai Beth Israel, New York, NY, United States
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69
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Rogers ML, Chu C, Joiner T. The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance. J Clin Psychol 2019; 75:999-1010. [PMID: 30632615 DOI: 10.1002/jclp.22743] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/31/2018] [Accepted: 12/04/2018] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Here we argue for the necessity, validity, and clinical utility of a new diagnostic entity, acute suicidal affective disturbance (ASAD). METHOD We expand on the conceptual, clinical, and practical rationale for ASAD, propose its defining features, describe research results to date, and suggest avenues for future research. RESULTS There is accruing evidence for the existence of a previously unclassified, rapid-onset mood disturbance that geometrically escalates and regularly results in life-threatening behavior. CONCLUSIONS ASAD research may not only improve the field's understanding of suicidal behavior but also enhance clinical effectiveness and save lives.
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Affiliation(s)
- Megan L Rogers
- Department of Psychology, Florida State University, Tallahassee, Florida
| | - Carol Chu
- Department of Psychology, Harvard University, Cambridge, Massachusetts
| | - Thomas Joiner
- Department of Psychology, Florida State University, Tallahassee, Florida
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70
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Hawes M, Galynker I, Barzilay S, Yaseen ZS. Anhedonia and suicidal thoughts and behaviors in psychiatric outpatients: The role of acuity. Depress Anxiety 2018; 35:1218-1227. [PMID: 30107636 DOI: 10.1002/da.22814] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/16/2018] [Accepted: 07/01/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Anhedonia-impairment related to the experience of pleasure-has been identified as a potential risk factor for suicide, with some mixed findings. The current study sought to clarify the role of acuity of anhedonia in the relationship between anhedonia and suicidal thoughts and behaviors by comparing acutely and chronically anhedonic subjects on severity of suicidal ideation (SI) and suicide attempt (SA) history. METHODS Psychiatric outpatients (N = 395) were administered the Columbia Suicide Severity Rating Scale, the Beck Scale for Suicidal Ideation and a modified version of the Snaith-Hamilton Pleasure Scale (SHPS); SI measures were readministered at a 1-month follow-up (N = 289, 73%). Participants were classified as acutely anhedonic, chronically anhedonic and nonanhedonic based on their responses to the SHPS at initial assessment. RESULTS Controlling for symptoms of anxiety and depression, acute anhedonia was cross-sectionally and prospectively associated with greater severity of SI compared to the nonanhedonic group; no differences in severity of SI were found between the chronically anhedonic and nonanhedonic group at either time point. Anhedonia grouping was not associated with SA history. CONCLUSION Changes in capacity to experience pleasure may be more informative of near-term SI than typically low pleasure levels. Future investigation should focus on the relationship between acute anhedonia and imminent suicidal behavior.
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Affiliation(s)
- Mariah Hawes
- Department of Psychiatry, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Igor Galynker
- Department of Psychiatry, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Shira Barzilay
- Department of Psychiatry, Mount Sinai Beth Israel Medical Center, New York, New York
| | - Zimri S Yaseen
- Department of Psychiatry, Mount Sinai Beth Israel Medical Center, New York, New York
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71
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Cohen LJ, Ardalan F, Yaseen Z, Galynker I. Suicide Crisis Syndrome Mediates the Relationship Between Long-term Risk Factors and Lifetime Suicidal Phenomena. Suicide Life Threat Behav 2018; 48:613-623. [PMID: 28833408 DOI: 10.1111/sltb.12387] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 05/19/2017] [Indexed: 11/27/2022]
Abstract
In recent years, there has been growing attention to the distinction between acute and long-term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS), as a marker of near-term suicidal risk. Here, we test whether documented long-term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS. A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS-3) as a measure of the SCS. While both STS-3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS-3 was related to pre-admission suicide attempts. The STS-3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long-term risk factors increase suicidal risk.
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Affiliation(s)
| | | | - Zimri Yaseen
- Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
| | - Igor Galynker
- Psychiatry, Mount Sinai Beth Israel, New York, NY, USA
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72
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Abstract
Background: It is a peculiar fact that the deadliest psychiatric disturbance - suicidality - cannot be formally diagnosed. Suicidal behavior disorder (SBD), a condition for further study in the DSM-5, is the field's first attempt to capture suicidality in a diagnosis. Aims: To provoke discussion about the standing of suicidality as a diagnosable psychiatric condition. Method: I present pragmatic and conceptual rationales for why a diagnosis of suicidality is clinically useful but conclude that SBD does little to aid clinicians in assessing suicidality's symptoms, planning treatment, or monitoring progress. Results: To improve the clinical utility of SBD, I re-conceptualize it from the vantage point of descriptive psychiatry. I hypothesize that this revised SBD is an independent, episodic, and frequently co-occurring condition and propose new cognitive, affective, and behavioral criteria that more completely capture the phenomenology of suicidality. Conclusion: The revised SBD is a starting place for dialogue about whether a clinically significant presentation of suicidality is a mental illness and, if it is, what its defining features should be.
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Affiliation(s)
- Joseph H Obegi
- 1 California Department of Corrections and Rehabilitation, California State Prison, Solano, Vacaville, CA, USA
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73
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Whether Called Acute Suicidal Affective Disturbance or Suicide Crisis Syndrome, a Suicide-specific Diagnosis Would Enhance Clinical Care, Increase Patient Safety, and Mitigate Clinician Liability. J Psychiatr Pract 2018; 24:274-278. [PMID: 30427811 DOI: 10.1097/pra.0000000000000315] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Separate research groups have independently argued the need for a suicide-specific diagnosis within the psychiatric diagnostic nomenclature. Although a suicide-specific diagnosis could possibly enhance clinical care and improve patient safety, some clinicians have expressed concerns regarding the legal risk of utilizing a suicide-specific diagnosis. In this column, the first of a 2-part series exploring the potential risks and benefits of a suicide-specific diagnosis, the authors draw from their decades of experience in clinical work, legal consulting, as well as the litigation of suicide and wrongful death lawsuits and contend that the bona fide use of a suicide-specific diagnosis would mitigate legal liability to clinicians.
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74
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Li S, Yaseen ZS, Kim HJ, Briggs J, Duffy M, Frechette-Hagan A, Cohen LJ, Galynker II. Entrapment as a mediator of suicide crises. BMC Psychiatry 2018; 18:4. [PMID: 29310622 PMCID: PMC5759206 DOI: 10.1186/s12888-018-1587-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 01/01/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients. METHODS The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated. RESULTS Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI. CONCLUSION Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior.
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Affiliation(s)
- Shuang Li
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Zimri S. Yaseen
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Hae-Joon Kim
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Jessica Briggs
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Molly Duffy
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Anna Frechette-Hagan
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Lisa J. Cohen
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
| | - Igor I. Galynker
- Department of Psychiatry, Beth Israel Medical Center NY, 1st Avenue and 15th Street, New York, NY 10003 USA
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75
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Barzilay S, Yaseen ZS, Hawes M, Gorman B, Altman R, Foster A, Apter A, Rosenfield P, Galynker I. Emotional Responses to Suicidal Patients: Factor Structure, Construct, and Predictive Validity of the Therapist Response Questionnaire-Suicide Form. Front Psychiatry 2018; 9:104. [PMID: 29674979 PMCID: PMC5895710 DOI: 10.3389/fpsyt.2018.00104] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/15/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of near-term suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting. METHODS Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes. RESULTS Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state- and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses. CONCLUSION The TRQ-SF is a brief and reliable measure with a 3-factor structure. It demonstrates construct validity for assessing distinct suicide-related countertransference to psychiatric outpatients. Mental health professionals' emotional responses to their patients are concurrently indicative and prospectively predictive of suicidal thoughts and behaviors. Thus, the TRQ-SF is a useful tool for the study of countertransference in the treatment of suicidal patients and may help clinicians make diagnostic and therapeutic use of their own responses to improve assessment and intervention for individual suicidal patients.
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Affiliation(s)
- Shira Barzilay
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY, United States
| | - Zimri S Yaseen
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY, United States.,Department of Psychiatry and Behavioral Health, Mount Sinai Beth Israel Medical Center, New York City, NY, United States
| | - Mariah Hawes
- Department of Psychiatry and Behavioral Health, Mount Sinai Beth Israel Medical Center, New York City, NY, United States
| | - Bernard Gorman
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, United States
| | - Rachel Altman
- Department of Psychiatry and Behavioral Health, Mount Sinai Beth Israel Medical Center, New York City, NY, United States
| | - Adriana Foster
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
| | - Alan Apter
- Feinberg Child Study Center, Schneider Children's Medical Center, Petach Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Paul Rosenfield
- Department of Psychiatry, Mount Sinai St. Luke's, New York City, NY, United States
| | - Igor Galynker
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York City, NY, United States.,Department of Psychiatry and Behavioral Health, Mount Sinai Beth Israel Medical Center, New York City, NY, United States
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76
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Attachment style and suicide behaviors in high risk psychiatric inpatients following hospital discharge: The mediating role of entrapment. Psychiatry Res 2017; 257:309-314. [PMID: 28797954 DOI: 10.1016/j.psychres.2017.07.072] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/27/2017] [Accepted: 07/30/2017] [Indexed: 01/06/2023]
Abstract
Insecure attachment is associated with suicidal behavior. This relationship and its possible mediators have not been examined in high-risk psychiatric inpatients with respect to the critical high-risk period following hospital discharge. Attachment styles and perception of entrapment were assessed in 200 high-risk adult psychiatric inpatients hospitalized following suicidal ideation or suicide attempt. Suicidal behaviors were evaluated with the Columbia Suicide Severity Rating Scale at 1-2 months post-discharge. Associations between different attachment styles and suicidal behaviors were assessed and mediation of attachment effects by entrapment was modeled. Fearful attachment was associated with post-discharge suicidal behavior and there was a trend-level negative association for secure attachment. In addition, entrapment mediated the relationship between fearful attachment and suicidal behavior. The current study highlights the mediating role of perceptions of entrapment in the contribution of fearful attachment to suicidal behavior in high-risk patients, suggesting entrapment as potential therapeutic target to prevent suicidal behavior in these individuals. Further research is warranted to establish the mechanisms by which entrapment experiences emerge in patients with insecure attachment styles.
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77
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Rogers ML, Galynker I, Yaseen Z, DeFazio K, Joiner TE. An Overview and Comparison of Two Proposed Suicide-Specific Diagnoses: Acute Suicidal Affective Disturbance and Suicide Crisis Syndrome. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20170630-01] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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78
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Yaseen ZS, Galynker II, Cohen LJ, Briggs J. Clinicians' conflicting emotional responses to high suicide-risk patients-Association with short-term suicide behaviors: A prospective pilot study. Compr Psychiatry 2017; 76:69-78. [PMID: 28431270 DOI: 10.1016/j.comppsych.2017.03.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/18/2017] [Accepted: 03/29/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Clinician's emotional responses to patients have been recognized as potentially relating to treatment outcome, however they have received little attention in the literature on suicide risk. We examine the relationship between a novel targeted measure of clinicians' emotional responses to high-risk psychiatric inpatients and their short-term post-discharge suicide behavior. METHODS First-year psychiatry residents' emotional responses to their patients were assessed anonymously with the novel self-report 'Therapist Response Questionnaire-Suicide Form' (TRQ-SF). Patient outcomes were assessed at 1-2months post-discharge, and post-discharge suicide outcomes were assessed with the Columbia Suicide Severity Rating Scale. Following exploratory factor analysis of the TRQ-SF, scores on the resultant factors were examined for relationships with clinical and demographic measures and post-discharge suicide behavior. RESULTS A two-factor model fit the data, with factors reflecting dimensions of affiliation/rejection and distress/non-distress. Two items that did not load robustly on either factor had face validity for hopefulness and hopelessness and were combined as a measure along a hopefulness/hopelessness dimension. The interaction Distress×Hopefulness, reflecting a conflicting emotional response pattern, significantly predicted post-discharge suicide outcomes even after covarying for depression, entrapment, and suicidal ideation severity. CONCLUSION Clinicians' conflicting emotional responses to high-risk patients predicted subsequent suicidal behavior, independent of traditional risk factors. Our findings demonstrate the potential clinical value of assessing such responses.
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Affiliation(s)
- Zimri S Yaseen
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E. 17th St., New York, NY 10003.
| | - Igor I Galynker
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E. 17th St., New York, NY 10003
| | - Lisa J Cohen
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E. 17th St., New York, NY 10003
| | - Jessica Briggs
- Mount Sinai Beth Israel, Department of Psychiatry, 317 E. 17th St., New York, NY 10003
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