Correlates of suicide attempts among self-injurers: A meta-analysis

A systematic review of daily life studies on non-suicidal self-injury based on the four-function model

Non-suicidal self-injury (NSSI) is a prevalent, impairing, and trans-diagnostic behavior that can be comprehensively assessed in daily life studies. We conducted a systematic literature review of 35 Ambulatory Assessment and Daily Diary studies of NSSI, to achieve three aims. First, we reviewed descriptive evidence on NSSI acts. On average, studies observed 1.6 acts per participant, but evidence regarding methods, pain, and context was sparse. Second, we reviewed evidence on NSSI urges. On average, studies reported 4.3 urges per participant. Urges were also associated with increased negative affect and predicted later acts. Third, we reviewed evidence on the Four-function Model of NSSI. Eight studies partially supported negative intrapersonal reinforcement, showing increased negative affect pre NSSI, but, of these, only four studies supported decreased negative affect post NSSI. Additionally, only three studies supported positive intrapersonal reinforcement, showing decreased positive affect pre and increased positive affect post NSSI. Evidence for the interpersonal functions was limited to two studies and inconclusive. We recommend assessing the intensity, frequency, and context of acts and urges, as well as pain and urge duration in future studies. We also recommend follow-up prompts after acts and urges to better track affect trajectories, and a detailed assessment of interpersonal events.

Childhood predictors and moderators of lifetime risk of self-harm in girls with and without attention-deficit/hyperactivity disorder

Attention-deficit/hyperactivity disorder (ADHD) is associated with self-harm during adolescence and young adulthood, especially among females. Yet little is known about the developmental trajectories or childhood predictors/moderators of self-harm in women with and without childhood histories of ADHD. We characterized lifetime risk for nonsuicidal self-injury (NSSI), suicidal ideation (SI), and suicide attempts (SA), comparing female participants with (n = 140) and without (n = 88) childhood ADHD. We examined theory-informed childhood predictors and moderators of lifetime risk via baseline measures from childhood. First, regarding developmental patterns, most females with positive histories of lifetime self-harm engaged in such behaviors in adolescence yet desisted by adulthood. Females with positive histories of self-harm by late adolescence emanated largely from the ADHD-C group. Second, we found that predictors of NSSI were early externalizing symptoms, overall executive functioning, and father's negative parenting; predictors of SI were adverse childhood experiences and low self-esteem; and predictors of SA were early externalizing symptoms, adverse childhood experiences, and low self-esteem. Third, receiver operating characteristics analyses helped to ascertain interactive sets of predictors. Findings indicate that pathways to self-harm are multifaceted for females with ADHD. Understanding early childhood predictors and moderators of self-harm can inform both risk assessment and intervention strategies.

Adapted Dialectical Behavior Therapy for Adolescents with a High Risk of Suicide in a Community Clinic: A Pragmatic Randomized Controlled Trial

OBJECTIVE

This study is a pragmatic randomized controlled trial, which compares the effectiveness of an adapted form of Dialectical Behavior Therapy for Adolescents (DBT-A) and treatment as usual plus group sessions (TAU + GS) to reduce suicidal risk for adolescents in a community health mental clinic.

METHOD

Thirty-five adolescents from a community outpatient clinic, with repetitive NSSI alone or with SA over the last 12 months and with current high suicide risk as assessed by the Columbia-Suicide Severity Rating Scale (C-SSRS), were enrolled. Participants were randomly assigned to undergo either DBT-A (n = 18) or TAU + GT (n = 17) treatments over a 16-week period. Primary outcomes were the difference between NSSI and SA recorded during the first 4 weeks and the final 4 weeks of treatment. Secondary outcomes included changes in Children's Global Assessment Scale (C-GAS), Suicidal Ideation Questionnaire (SIQ-JR), and Beck Depression Inventory-II (BDI-II).

RESULTS

Dialectical Behavior Therapy for Adolescents was more effective than TAU + GS at reducing NSSI, use of antipsychotics, and improving C-GAS. No SAs were reported in the two groups at the end of the treatment. Both treatments were equally effective in decreasing SIQ-JR and BDI-II scores.

CONCLUSIONS

These findings support the feasibility and effectiveness of DBT-A for adolescents at high risk of suicide in community settings.

How do the prevalence and relative risk of non-suicidal self-injury and suicidal thoughts vary across the population distribution of common mental distress (the p factor)? Observational analyses replicated in two independent UK cohorts of young people

OBJECTIVES

To inform suicide prevention policies and responses to youths at risk by investigating whether suicide risk is predicted by a summary measure of common mental distress (CMD (the p factor)) as well as by conventional psychopathological domains; to define the distribution of suicide risks over the population range of CMD; to test whether such distress mediates the medium-term persistence of suicide risks.

DESIGN

Two independent population-based cohorts.

SETTING

Population based in two UK centres.

PARTICIPANTS

Volunteers aged 14-24 years recruited from primary healthcare registers, schools and colleges, with advertisements to complete quotas in age-sex-strata. Cohort 1 is the Neuroscience in Psychiatry Network (n=2403); cohort 2 is the ROOTS sample (n=1074).

PRIMARY OUTCOME MEASURES

Suicidal thoughts (ST) and non-suicidal self-injury (NSSI).

RESULTS

We calculated a CMD score using confirmatory bifactor analysis and then used logistic regressions to determine adjusted associations between risks and CMD; curve fitting was used to examine the relative prevalence of STs and NSSI over the population distribution of CMD. We found a dose-response relationship between levels of CMD and risk of suicide. The majority of all subjects experiencing ST and NSSI (78% and 76% in cohort 1, and 66% and 71% in cohort 2) had CMD scores no more than 2 SDs above the population mean; higher scores indicated the highest risk but were, by definition, infrequent. Pathway mediation models showed that CMD mediated the longitudinal course of both ST and NSSI.

CONCLUSIONS

NSSI and ST in youths reflect CMD that also mediates their persistence. Universal prevention strategies reducing levels of CMD in the whole population without recourse to screening or measurement may prevent more suicides than approaches targeting youths with the most severe distress or with psychiatric disorders.

Self-harm as a predisposition for suicide attempts: A study of adolescents' deliberate self-harm, suicidal ideation, and suicide attempts

The aim of this study was to analyze the predictive risk factors for self-harm in adolescents with and without suicidal ideation. 600 adolescents answered a questionnaire about self-harm and suicidal behaviors. A logistic regression analysis was conducted. Over half of the individuals with deliberate self-harm (DSH) presented significant suicide risk. There was a direct association between DSH and suicide attempts, with almost the totality of the adolescents with suicide attempts also reporting DSH. According to the prediction model, suicidal ideation and diversity of DSH behaviors are significant predictors of suicide attempts, with an augmentation in the diversity of DSH behaviors and suicidal ideation predicting suicide attempts. Depression and anxiety appeared also as significant predictors of suicide attempts in adolescent self-harmers. Considering that the majority of the sample was not from a clinical setting, an alarming finding was that one third of the total sample was at suicide risk. These results place DSH as a key variable for early intervention.

Neural correlates of clinical improvement in response to N-acetylcysteine in adolescents with non-suicidal self-injury

Non-suicidal self-injury (NSSI) is a serious clinical problem that is common in adolescents. Novel, biologically-informed approaches for treating NSSI in adolescents are needed to prevent negative outcomes such as chronic NSSI and future suicide attempts. N-acetylcysteine (NAC) has been used successfully to address other conditions that involve repetitive maladaptive behaviors and may have utility in addressing NSSI. This study explored neural circuit changes following an open-label, 8-week trial of NAC in female adolescents with NSSI. We measured whole-brain resting-state functional connectivity (RSFC) of the amygdala and the nucleus accumbens before and after treatment using resting-state functional neuroimaging. Usable neuroimaging data from both pre- and post-treatment were available for 18 participants. Reduction in NSSI frequency was associated with a decrease in left amygdala RSFC with right supplementary motor area (SMA), but with an increase in right amygdala RSFC with right inferior frontal cortex. For nucleus accumbens, a reduction in NSSI frequency was associated with a decrease in connectivity between right nucleus accumbens and left superior medial frontal cortex. We also report change in similar circuits accompanying clinical improvement in depression and global psychopathology measures. These preliminary findings suggest amygdala and nucleus accumbens-based circuits as potential treatment targets, and set the stage for future research designed to confirm these neural targets using randomized, placebo-controlled designs to confirm clinical efficacy and mechanisms of effect.

A palliative care approach in psychiatry: clinical implications

Background

Traditionally, palliative care has focused on patients suffering from life-threatening somatic diseases such as cancer or progressive neurological disorders. In contrast, despite the often chronic, severely disabling, and potentially life-threatening nature of psychiatric disorders, there are neither palliative care units nor clinical guidelines on palliative measures for patients in psychiatry.

Main text

This paper contributes to the growing literature on a palliative approach in psychiatry and is based on the assumption that a change of perspective from a curative to a palliative approach could help promote patient-centeredness and increase quality of life for severely ill patients in psychiatry as well as in somatic medicine. To exemplify this, we offer three different clinical scenarios: severe and enduring anorexia nervosa, treatment-refractory schizophrenia, and chronic suicidality and persistent self-injury in borderline personality disorder.

Conclusion

We emphasize that many typical interventions for treatment-refractory psychiatric disorders may indeed be of a palliative nature. Furthermore, introducing traditional features of palliative care, e.g. so-called goals of care conversations, could aid even further in ensuring that caregivers, patients, and families agree on which treatment goals are to be prioritized in order to optimize quality of life in spite of severe, persistent mental disorder.

Investigating the association between bullying victimization and suicidal ideation among adolescents: Evidence from the 2017 Youth Risk Behavior Survey

BACKGROUND

Suicide among adolescents in the United States is the second leading cause of death. Bullying victimization has also been identified as a growing public health concern. Although studies have examined the association between bullying victimization and mental health outcomes, there is a dearth of research investigating the association between bullying victimization and suicidal ideation among adolescents.

OBJECTIVE

The objective of this study is to investigate the association between bullying victimization and suicidal ideation among adolescents.

PARTICIPANTS AND SETTING

Data for this study came from the 2017 National Youth Risk Behavior Survey.

METHODS

An analytic sample of 14,603 adolescents aged 14-18 years (52 % female) was analyzed using binary logistic regression.

RESULTS

About 18 % of adolescents experienced suicidal ideation during the past 12 months. About one in ten adolescents (9.1 %) were victims of both school bullying and cyberbullying. Bullying victimization was associated with suicidal ideation whereby, adolescents who experienced both school bullying and cyberbullying victimization had 3.26 times higher odds of experiencing suicidal ideation (AOR = 3.26, p < .001, 95 % CI=3.10-3.43), adolescents who experienced school bullying victimization had 2.15 times higher odds of experiencing suicidal ideation (AOR = 2.15, p < .001, 95 % CI=2.04-2.27), and adolescents who experienced cyberbullying victimization had twice the odds of experiencing suicidal ideation (AOR = 2.00, p < .001, 95 % CI=1.87-2.14). Other factors significantly associated with suicidal ideation include forced sexual intercourse, depressive symptoms, cigarette smoking, alcohol use, cannabis use, and illicit drug use.

CONCLUSION

Understanding the association between bullying victimization and suicidal ideation could contribute to early identification of adolescents who may be at risk for suicide.

An Exploration of Differences Between Deliberate Self-Harm with and without Suicidal Intent Amongst a Clinical Sample of Young People in Singapore: A Cross-Sectional Study

This study examined differences between young people with mental illness who engage in deliberate self-harm with and without suicidal intent, as well as socio-demographic and clinical factors that are related to the increased likelihood of suicide attempt amongst self-harming young people. A total of 235 outpatients with mental illness who had engaged in deliberate self-harm were recruited from a tertiary psychiatric hospital in Singapore. Participants completed a self-report questionnaire which collected information on their socio-demographic background, self-harm history, diagnosis, depressive symptoms and childhood trauma. A total of 31.1% had reported a history of attempted suicide. Multiple logistic regression conducted found that engaging in self-harm ideation between 1 and 7 days (OR = 4.3, p = 0.30), and more than 1 week (OR = 10.5, p < 0.001) (versus no engagement in any self-harm ideation at all), were significantly associated with greater likelihood of attempted suicide. This study reports a relatively high prevalence rate of reported suicide attempts amongst young people with mental illness who engaged in self-harm. Identifying self-harm behaviors and treating it early could be the first step in managing potential suicidal behaviors among those who engage in self-harm.

Brief admission (BA) for patients with emotional instability and self-harm: nurses' perspectives - person-centred care in clinical practice

Purpose: Emotional instability and self-harm pose major problems for society and health care. There are effective interventions in outpatient care, but when patients need inpatient care, nurses often struggle meeting their patient’s needs. Brief admission (BA) is a newly implemented crisis intervention and novel form of inpatient care. The aim of this study is to describe nurses’ experiences working with BA related to patients with emotional instability and self-harm.

Methods: Eight nurses were interviewed according to a semi-structured interview guide. The data was analysed using qualitative content analysis.

Results: Four main categories emerged regarding nurses’ experiences with BA: provides security and continuity, fosters caring relationships, shifts focus towards patient’s health and empowers the patient. The nurse’s role shifted from “handling problems” to establishing caring relationships with a focus on the person’s health and possibilities for recovering instead of psychiatric symptoms.

Conclusions: Previous studies on patients’ perspective of BA describe positive experiences such as increased autonomy and participation in the healthcare process. This study supports those findings, albeit from the perspective of nurses. Our findings suggest that BA may reduce work-related stress experienced by nurses while caring for persons with emotional instability and self-harm. BA may also support nurses in their ability to provide more meaningful and constructive psychiatric inpatient care.

Links between self-injury and suicidality in autism

BACKGROUND

Autistic individuals without intellectual disability are at heightened risk of self-injury, and appear to engage in it for similar reasons as non-autistic people. A wide divergence of autistic perspectives on self-injury, including those who frame it as a helpful coping mechanism, motivate investigating the link between self-injury, suicide ideation, and attempts which has been reported in typically developing individuals.

METHOD

One hundred three autistic participants completed the Non-Suicidal Self-Injury Assessment Tool (NSSI-AT), the Suicide Behaviors Questionnaire (SBQ-R), and the Interpersonal Social Evaluation List (ISEL-12) across two online studies. Logistic regression was conducted to predict self-harming status via responses to questions on suicidality, and to predict whether certain self-injurious behaviors, including cutting, were especially associated with suicide ideation and attempts. Non-parametric correlation analysis examined relationships between suicide ideation/attempts and other variables that might characterize self-harmers especially at risk of suicidality. These included perceived access to social support, purposes or reasons for self-injury, the number of different self-injurious behaviors engaged in, the duration and lifetime incidence of self-injury, and the individual's feelings about their self-injury.

RESULTS

While self-injuring status was significantly predicted by responses to a question on suicide ideation and attempts, there was no relationship between suicide ideation/attempts and a participant's personal feelings about their self-injury. The method of cutting was also predicted by suicide ideation and attempts, though other methods common in autistic people were at borderline significance. Use of self-injury for the regulation of low-energy emotional states like depression, for self-punishment or deterrence from suicide, and for sensory stimulation, was associated with suicide ideation and attempts, as was the number of self-injurious behaviors engaged in. There was no significant relationship between suicide ideation/attempts and the duration and lifetime incidence of self-injury or social support.

CONCLUSIONS

These preliminary data suggest that while individuals might frame their self-injury as a positive or neutral thing, there remains a concerning relationship between self-injury and suicidality which exists regardless of individual feelings on self-injury. This is consistent with the theoretical perspective that self-injury can be a "gateway" through which individuals acquire capability for lethal suicidal behaviors. The data highlight that particular methods (cutting) and reasons for self-injury may be of significant concern, but this information, which might be of extreme value for clinicians, requires further investigation and validation.

Does function predict persistence? Nonsuicidal self-injury among adolescents during and after hospitalization

Nonsuicidal self-injury (NSSI) is a prevalent, concerning behavior among adolescents. Importantly, NSSI can serve a variety of functions. Some adolescents engage in NSSI to fulfill automatic or self-oriented functions (e.g., cutting to avoid internal negative states), whereas others engage in NSSI to serve social functions (e.g., cutting to communicate with others). This study tests whether self-reported reasons for engaging in NSSI, hereafter referred to as NSSI functions, predict NSSI thoughts and behaviors during and after hospitalization among adolescent psychiatric inpatients. Endorsement of both automatic and social NSSI functions, as well as positive and negative reinforcement subtypes, was assessed at hospital admission. Results showed that endorsement of overall automatic function predicted which adolescents engaged in NSSI behavior during hospitalization. Moreover, automatic and social functions showed distinct predictive patterns, such that automatic functions corresponded to greater likelihood of NSSI-related thoughts and behaviors whereas social functions mainly corresponded to reduced likelihood of NSSI-related outcomes. Of note, NSSI functions were less predictive of NSSI-related outcomes after hospital discharge. These findings suggest that identifying adolescent inpatients' reasons for NSSI engagement may meaningfully distinguish those at higher risk (and those at lower risk) of NSSI persistence during their hospital stay.

Specific traumatic events elevate the risk of a suicide attempt in a 10-year longitudinal community study on adolescents and young adults

Traumatic events (TEs) have been associated with suicide attempts (SAs). However, the empirical status of some TEs is inconclusive. This also concerns community adolescents and young adults, known to be a high-risk group for SAs. We examined associations between (a) a range of prior TEs (physical attack, rape/sexual abuse, serious accident, and witnessing somebody else experiencing a TE) and a subsequent SA, and (b) the number of prior TEs and an SA, and (c) we estimated attributable proportions of SAs, in relation to each TE. Over a 10-year period, the Early Developmental Stages of Psychopathology (EDSP) study prospectively assessed community members, aged 14-24 years at baseline. Starting with 3021 subjects, each individual was assessed up to four times. Assessment was based on the Munich-Composite International Diagnostic Interview. Temporal associations were estimated using the Cox model with time-dependent covariates. Attributable proportions were based on the results of the Cox models. All four TEs elevated the risk for a subsequent SA, adjusting for confounders. Highest risk was found for the combined TE rape/sexual abuse. Results showed that 56-90% of SAs could be attributed to TEs in the exposed group; on the population level, attributable proportions ranged between 6.9% and 23.5%. Different TEs have been shown to elevate the risk of an SA in a young community sample. Our results suggest that both health professionals and health policy decision-makers consider specific TEs and the number of prior TEs as risk factors for SAs.

Post-traumatic stress burden in a sample of hospitalized patients with Bipolar Disorder: Which impact on clinical correlates and suicidal risk?

BACKGROUND

Increasing evidence suggests Bipolar Disorder (BD) to be frequently associated to a history of traumatic experiences and Post-traumatic Stress Disorder (PTSD), with consequent greater symptoms severity, number of hospitalizations and worsening in quality of life. The aim of the present study was to investigate the lifetime exposure to traumatic events and PTSD rates in-patients with BD and to analyze the relationships between PTSD symptoms, clinical characteristics and severity of the mood disorder.

METHODS

A consecutive sample of 212 in-patients with a DSM-5 diagnosis of BD was enrolled at the psychiatric unit of a major University hospital in Italy and assessed by the SCID-5 and MOOD Spectrum-Self Report lifetime version (MOODS-SR). Socio-demographic characteristics, clinical features, substance or alcohol abuse, history of suicide related behaviors were also collected.

RESULTS

Lifetime trauma exposure emerged in 72.3% subjects, with a DSM-5 PTSD diagnosis reported by 35.6%. Patients with PTSD showed more frequently a (hypo)manic episode at onset, alcohol or substance abuse, psychotic features, suicide behaviors, higher scores in almost all the MOODS-SR domains, compared to those without PTSD.

LIMITATIONS

Cross sectional study. Lack of data about the time since trauma exposure or PTSD onset.

CONCLUSIONS

Our findings show a history of multiple traumatic experiences in hospitalized patients with BD besides high rates of PTSD, with the co-occurrence of these conditions appearing to be related to a more severe BD. Detailed investigation of post-traumatic stress symptoms is recommended for the relevant implications on the choice of a tailored treatment and the prognosis assessment.

Emergency Management in Eating Disorders

Aims and Scope::

Eating disorders commonly present during the adolescent and young adult years, and are complex in that they are a group of psychiatric diagnoses with medical complications.

Methods::

The diagnosis of an eating disorder can often go undetected while a patient is being evaluated for organic causes of weight loss. Anorexia nervosa, in particular, has the highest mortality rate of any psychiatric diagnosis. In the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), there are several diagnoses that are classified as eating or feeding disorders.

Conclusion::

This article will discuss anorexia nervosa and bulimia nervosa, with a focus on medical and psychiatric emergencies that are important for primary care providers to keep in mind when caring for adolescents and young adults.

Using the Body When There Are No Words for Feelings: Alexithymia and Somatization in Self-Harming Adolescents

The present case-control study aimed to investigate the relationship between alexithymia and somatic complaints in the psychopathological setting of non-suicidal self-injury (NSSI). A clinical sample of 134 adolescents (115 females; 85.5%) from 12 to 18 years old engaging in NSSI was compared with a control group of 243 high-school students (157 females; 64.6%) from 13 to 18 years old. Data were collected using two questionnaires: The Youth Self-Report 11-18 and the 20 Toronto Alexithymia Scale. In both cases and controls, the presence of somatization and alexithymia was associated with more severe psychopathological problems. Analyses were conducted to explore the association between somatic disorders and alexithymia. In the clinical group, somatic complaints were reported by 95.9% of alexithymic individuals, whereas only 44.3% of alexithymic adolescents reported somatic complaints. A one-way relationship emerged between somatization and alexithymia: while alexithymia would seem to be a factor associated with self-injury, somatic disorders were strongly associated with alexithymia, but not necessarily with self-injury. Among the self-harming adolescents, those with both alexithymia and somatization had a more severe psychopathological picture than the individuals with alexithymia but no somatization. This would suggest that, in the setting of NSSI, greater difficulty with identifying feelings is associated with somatization, and alexithymia would be an attribute common to self-harming behavior and somatization, both of which are characterized by the body being used to express psychological and emotional problems. Future research could further investigate alexithymia in self-harming individuals, in relation to any presence or absence of somatic disorders, with longitudinal assessments on any differences in their manifestation of self-injury and its psychopathological correlates.

Nonsuicidal Self-Injury: Diagnostic Challenges And Current Perspectives

Nonsuicidal self-injury (NSSI) involves deliberate and intentional injury to body tissue that occurs in the absence of suicidal intent. Typical examples here might include self-cutting, burning, or self-hitting. Behavior of this kind is fundamentally unsettling as well as perplexing. It is also the case that self-harming behavior of any kind runs counter to a fundamental survival instinct. In the past, behaviors such as these were viewed as self-mutilation and considered to be a form of attenuated suicide. Much has changed over time, culminating in the entry of NSSI Disorder into DSM-5 as a condition in need of further study. In this review we describe the evolution of the NSSI construct and consider current issues in its diagnosis and assessment.

Anti-Suicide Function of Nonsuicidal Self-Injury in Female Inpatient Adolescents

BACKGROUND

There have been numerous studies investigating the relationship between nonsuicidal self-injury (NSSI) and suicidality. On the one side, NSSI is an important risk factor for suicidality, including suicidal thoughts and behaviors. On the other side, it has been suggested that one function of NSSI might be as a coping mechanism that can help individuals in the short term avoid suicide. The present study investigated the relationship between suicidality and NSSI in female inpatient adolescents, focusing on NSSI as an anti-suicide strategy.

METHODS

Subjects were 56 female adolescents, aged 12-18 years (M = 15.95 years, SD = 1.27), recruited from different inpatient child and adolescent psychiatric units. All participants fulfilled the DSM-5 research criteria for nonsuicidal self-injury disorder (NSSI-D). To assess suicidality, NSSI-D, and current and past diagnoses, a structured clinical interview was conducted.

RESULTS

NSSI as a short-term coping strategy for avoiding suicide was indicated by one third (32.1%) of the participants. Before participants engaged in NSSI, the anti-suicide function was reported more frequently than reducing interpersonal problems (d = -.59). Getting relief from negative emotions and inducing positive feelings were reported at the same frequency as avoiding suicide before NSSI. Participants engaging in NSSI to avoid suicide and those reporting other functions did not significantly differ regarding other NSSI characteristics, suicidality, or psychopathology. Results indicate that the anti-suicide function significantly predicts the duration of current suicidal ideation (β = .557).

CONCLUSION

This study provides preliminary support for the idea that NSSI is frequently used by female adolescents with NSSI-D to avoid suicide. Given the high co-occurrence of NSSI and suicidality, our results underline the importance of clinical assessment of suicidality and several NSSI functions, including the anti-suicide function, in adolescents with NSSI.

Nonsuicidal Self-Injury: Management on the Inpatient Psychiatric Unit[Formula: see text]

BACKGROUND. Between 4% to 70% of inpatients engage in self-harming behaviors and effective interventions are needed to address this population. AIM. This article reviews literature from 2007 to 2017 to address treatment and management strategies specific for the treatment of nonsuicidal self-injury in the inpatient psychiatric setting. METHODS. Cochrane, PsycINFO, PubMed, and CINAHL were searched for relevant articles with 34 studies reviewed for applicability to the question, and 9 parsed into a summary of Findings table. RESULTS. Therapeutic approaches that show promise include cognitive behavioral therapy, dialectical behavior therapy, and mentalization as well as medications that act on the serotonergic, dopaminergic, and opioid systems. Effective models of care aim toward enhancing therapeutic relationships with staff, providers, and most important, encouraging the internal shift toward recovery within the patient. CONCLUSIONS. More research with controlled designs in the inpatient setting is needed, however, regardless of which approach is used, the impact of the individual caregiver on the patient's recovery is key.

Interoceptive deficits, non-suicidal self-injury, and suicide risk: a multi-sample study of indirect effects

BACKGROUND

Interoceptive deficits (ID) have been associated with non-suicidal self-injury (NSSI) and suicidal behavior in multiple studies. Many of these studies are limited in scope, and have not fully examined possible mechanisms explaining how ID affect suicidal behavior.

METHODS

This study assesses how self-reported ID relate to suicide ideation and attempts in six distinct and geographically diverse samples of adults (n = 2706) and one sample of adolescents (n = 436). Participants responded to a variety of self-report questionnaires and interviews.

RESULTS

Contrary to our hypothesis, self-reported ID were only associated with suicidal ideation in two samples, one of which was the adolescent sample. Largely consistent with our predictions, self-reported ID exhibited an indirect effect on suicide attempts through versatility of NSSI in four of the five adult samples tested. Finally, the indirect effects of self-reported ID on suicide attempts through NSSI versatility did not act indirectly through behaviorally assessed pain tolerance.

CONCLUSIONS

We found that, in adults, self-reported ID are not associated with suicidal ideation, but are connected with a history of suicide attempts, through an indirect effect via NSSI. Our findings also indicate that the mechanism of action leading from self-reported ID to suicidal behavior may differ between adolescents and adults, and relate to suicidal behavior independent of pain tolerance. Clinical implications and future directions are discussed.

Social media, internet use and suicide attempts in adolescents

PURPOSE OF REVIEW

Suicide is the second leading cause of death in youth aged 10-24 years old globally, but detecting those at risk is challenging. Novel preventive strategies with wide influence across populations are required. Interest in the potential for both detrimental and supportive influences of social media/internet use on suicidal behaviour has been growing; however, the relationship remains unclear.

RECENT FINDINGS

A systematic search of articles from database inception up to 25 January 2019 across five databases: Medline, PsycINFO, EMBASE, HMIC and CINAHL revealed nine independent studies investigating social media/internet use and suicide attempts in young people less than 19 years old (n = 346 416). An independent direct association was found between heavy social media/internet use and increased suicide attempts in seven studies (adjusted ORs ranged from 1.03 to 5.10), although adjusting for cyberbullying victimization and sleep disturbance reduced the strength of this association. Two studies found that some social media/internet use, versus no use, may be associated with fewer suicide attempts. There were no studies investigating the relationship between social media/internet use and completed suicide.

SUMMARY

There is an independent association between problematic use of social media/internet and suicide attempts in young people. However, the direction of causality, if any, remains unclear. Further evaluation through longitudinal studies is needed.

Daily patterns in nonsuicidal self-injury and coping among recently hospitalized youth at risk for suicide

Among adolescents at high suicide risk, using a daily diary design, this study examined: (1) the co-occurrence between nonsuicidal self-injury (NSSI) and suicidal ideation, (2) the link between NSSI and coping, and (3) endorsement of using NSSI to cope with suicidal ideation (anti-suicide function). Thirty-four adolescents hospitalized due to suicide risk (76% female; ages 13-17) responded to daily surveys for four weeks after discharge (n = 650 observations). NSSI was positively associated with suicidal ideation at the between- (i.e. relative to others) and within-person (relative to adolescents' own average) levels of analysis. When NSSI and suicidal thoughts co-occurred, adolescents used NSSI to cope with thoughts of suicide on nearly all occasions. While adolescents did not use less adaptive coping when they engaged in NSSI (i.e. within-person), youth who utilized more coping strategies in general (i.e. between-person) had lower probability of NSSI. The probability of NSSI also decreased when adolescents perceived coping to be helpful and for youth who generally tended to perceive coping as helpful. Findings offer fine-grained insights about the intersection of NSSI, suicidal thoughts, and coping among high-risk adolescents, adding to the body of research highlighting the benefit of broadening adolescents' coping strategies as well as assessing their perceived utility.

Function and progression of non-suicidal self-injury and relationship with suicide attempts: A qualitative investigation with an adolescent clinical sample

AIM

To investigate the function and progression of non-suicidal self-injury (NSSI) and its relationship with suicide attempts.

METHOD

Qualitative in-depth interviews were conducted with 15 adolescents psychiatrically hospitalized following a suicide attempt who reported NSSI. Applied thematic analysis was used to identify and examine themes from the interview data.

RESULTS

Thematic analysis revealed that the primary function of NSSI was relief from emotional pain, though the function often changed over time. NSSI was often not directly related to patients' suicide attempts, yet risk of suicidal behavior seemed to increase once NSSI lost its effectiveness, and suicide became the only option.

CONCLUSION

Clinicians need to understand and monitor the functions of NSSI, and its relationship with suicidality, to prevent suicide attempts among adolescents.

Non-suicidal Self-injury Differentiates Suicide Ideators and Attempters and Predicts Future Suicide Attempts in Patients with Eating Disorders

OBJECTIVE

We aimed first to identificate psychopathological variables differentiating between suicide ideators, suicide attempters and patients without suicide ideation or attempts, and second to identificate better predictors of suicide attempts longitudinally.

METHOD

We compared suicide ideation, hopelessness, borderline symptoms, frequency, types, number of different non-suicidal self-injury (NSSI) methods, intrapersonal and interpersonal functionality of NSSI in a sample of 238 patients with Eating Disorders (1) with no history of suicide ideation or suicide attempts (n = 150); (2) with recent suicide ideation (n = 65); and (3) with suicide attempts in the previous year (n = 23). In addition, we analyzed the predictive power of the mentioned variables over the number of suicide attempts 7 months after the first assessment.

RESULTS

The group of suicide attempters showed a major number of different methods of NSSI, higher frequency of NSSI, cutting, and more NSSI intra and interpersonal functions than the group of ideators. Unlike in previous studies, hopelessness did not differentiate between patients with ideation and suicide attempts. In addition, the best predictor of suicide attempts 7 months later was frequency of NSSI at T1 (N = 123).

CONCLUSIONS

Cutting, frequency and different methods of NSSI, intra and interpersonal functions were risk factors that differentiated ideators from attempters, being frequency of NSSI the best predictor of suicide attempts longitudinally. Thus, patients with ED with NSSI should be the focus of preventive interventions for suicidal behavior.

Self-injury Age of Onset: A Risk Factor for NSSI Severity and Suicidal Behavior

This study replicates and extends prior work by examining how age of Non Suicidal Self-Injury (NSSI) onset relates to NSSI severity, suicidal behavior, perceived recovery from NSSI, and protective factors of life satisfaction, resilience, and subjective happiness. University students who reported engaging in NSSI within the past year (n = 644) completed on-line questionnaires assessing NSSI characteristics, suicidal behavior, and protective factors. Participants who began self-injuring at or before age 12 reported significantly more lifetime acts of NSSI, greater method versatility, and medically severe NSSI than those who began NSSI at older ages (17 years). Those with a typical age of onset (13-16 years) did not differ from the younger age group on method versatility, medical severity, past year frequency, or perceived recovery but did differ from those with an older age of onset. The proportion of individuals reporting suicide attempts significantly increased as the age of onset became younger. No age of onset group differences were observed on the protective factors. The age at which one begins NSSI appears to be a risk factor for increasingly severe NSSI and potential suicidal behavior. Early detection and intervention is important for reducing the negative consequences of engaging in NSSI.

Effects of Self-Esteem on the Association between Negative Life Events and Suicidal Ideation in Adolescents

Negative life events (NLEs) increase the risk of suicidal ideation (SI) in adolescents. However, it is not known whether the association between NLEs and SI can be moderated by self-esteem and varies with gender. The aim of the current paper was to examine gender differences in the association of SI with NLEs in adolescents, and assess the effects of self-esteem on the association and their gender variations. We conducted a school-based health survey in 15 schools in China between November 2013 and January 2014. A total of 9704 participants aged 11–19 years had sociodemographic data reported and self-esteem (Rosenberg self-esteem scale), NLEs, and SI measured. Multivariate-adjusted logistic regression was used to calculate the odds ratio (OR) of having SI in relation to NLEs. Increased risk of SI was significantly associated with NLEs (adjusted OR 2.19, 95%CI 1.94–2.47), showing no gender differences (in females 2.38, 2.02–2.80, in males 1.96, 1.64–2.36, respectively). The association was stronger in adolescents with high esteem (2.93, 2.34–3.68) than those with low esteem (2.00, 1.65–2.42) (ORs ratio 1.47, p = 0.012). The matched figures in females were 3.66 (2.69–4.99) and 2.08 (1.61–2.70) (1.76, p = 0.006), while in males these figures were 2.27(1.62–3.19) and 1.89 (1.41–2.53) (1.20, p = 0.422), respectively. Self-esteem had moderate effects on the association between NLEs and SI in adolescents, mainly in females. NLEs, self-esteem, and gender need to be incorporated into future intervention programs to prevent SI in adolescents.

Childhood adversity predicts persistence of suicidal thoughts differently in females and males at clinical high-risk patients of psychosis. Results of the EPOS project

AIM

Depression and suicidal ideation (SUI) and behaviour are more prevalent in females than males, and common in clinical high-risk (CHR) patients. Childhood adversities and trauma (CAT) are associated with adult depression and SUI. The role of gender as a moderator and depression as a mediator for the effect of CAT on SUI has not been explored in CHR patients.

METHODS

In all, 245 young help-seeking CHR patients were assessed for SUI (thoughts of killing themselves) with the Beck Depression Inventory at baseline, 9-month and 18-month follow-ups. At baseline, clinical depression was assessed by the Structured Clinical Interview for DSM-IV (SCID-I), and CAT by the Trauma and Distress Scale (TADS) which includes the five domains of emotional, physical and sexual abuse, emotional and physical neglect.

RESULTS

CAT total and all domains except physical neglect predicted SUI over the study period. The effect of CAT on SUI was mediated via clinical depression and concurrent depression symptoms differently for females and males. In females, the effect of emotional abuse and neglect on SUI was mediated via baseline depression. In males, emotional and physical abuse had a direct effect on SUI, and the effect of sexual abuse and emotional neglect was partly mediated via concurrent depression symptoms.

CONCLUSIONS

For CHR females, the effect of CAT on adult SUI is mediated via depression, while for males, CAT and its domains have mainly direct effects in maintaining SUI. These gender differences should be taken into account when treating CHR patients with SUI.

I Want You to Want Me: Interpersonal Stress and Affective Experiences as Within-Person Predictors of Nonsuicidal Self-Injury and Suicide Urges in Daily Life

OBJECTIVE

To investigate near-term risk for self-injurious urges, we evaluated how within-person changes in internalizing and externalizing negative affect, as well as interpersonal rejection and criticism, impact subsequent nonsuicidal self-injury (NSSI) and suicide urges in daily life.

METHOD

Young adult women (N = 62) from an ongoing community cohort study with past-year self-injurious thoughts completed a 21-day ecological momentary assessment protocol. We used multilevel path analyses to model within-person effects of negative affect and interpersonal stress on subsequent suicide and NSSI urges within several hours.

RESULTS

When modeled simultaneously, within-person changes in internalizing, but not externalizing, negative affect predicted later self-injurious urges. Rejection and criticism predicted later self-injurious urges, with rejection showing a unique relationship to NSSI urges specifically. Effects of rejection and criticism on later NSSI and suicide urges were mediated by internalizing negative affect; rejection also retained a significant direct effect on NSSI urges.

CONCLUSION

Interpersonal stressors may be potent near-term risk factors for self-injurious urges by increasing internalizing negative affect among vulnerable individuals. The direct role of rejection and criticism on self-injurious urges is less clear, particularly for suicide. These findings have implications for understanding processes underlying self-injurious urges, as well as designing real-time interventions for these experiences in daily life.

An examination of individual forms of nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) is a growing public health concern, and there is an increasing need to better characterize and identify severe NSSI behavior. One readily accessible, yet understudied, avenue for improving the assessment of NSSI severity is through the examination of individual forms, or methods, of the behavior. The present study aimed to address this gap in the literature by investigating the relationship between 12 different NSSI methods with three NSSI severity indicators and three distinct suicidal thoughts and behaviors among 1,436 undergraduate students with a history of NSSI (70.90% female, M age = 20.69, SD = 3.32). Results across six decision tree analyses highlighted the use self-hitting / punching, in addition to cutting oneself, as the most informative NSSI methods for differentiating outcome severity. Gender differences were only found for the outcome of suicidal ideation. The present study provides preliminary evidence that the examination of individual NSSI methods may be useful in identifying individuals at risk for negative correlates of NSSI, including NSSI-related hospital visits, unintended serious injury, and suicidal behavior. Upon replication in longitudinal work, findings have important clinical utility by providing a potential marker of prognosis and the need for higher levels of care.

Factors Associated With Suicidal Attempt Among School-Going Adolescents in Malaysia

Various factors contribute to suicidal attempt. This study aims to determine the relationship between suicidal attempt and its associated factors among school-going adolescents in Malaysia. Data from the National Health and Morbidity 2017 survey were analyzed. This survey was implemented as a nationwide school-based survey targeting adolescents 13 to 17 years old. Descriptive and multiple logistic regression analysis was done using SPSS version 20. A total of 27 399 adolescents participated in this survey. The prevalence of suicidal attempt was 6.9% (95% confidence interval = 6.2-7.7). Multivariate analysis found that the odds of suicidal attempt among adolescent with depression is 4.3 (adjusted odds ratio = 4.3; 95% confidence interval = 3.9-4.8). Other significant factors are young adolescent, non-Malay ethnicities especially Indian, adolescent with parents living apart, and those without peer support and parental connectedness. A holistic approach for the planning of preventative strategies and public health policies should be made according to these risk factors.

Suicide attempts in eating disorder subtypes: a meta-analysis of the literature employing DSM-IV, DSM-5, or ICD-10 diagnostic criteria

BACKGROUND

Quantification of suicidal risk in specific populations is important for the adoption of targeted prevention and harm reduction measures. Though there remains little systematic evidence, risk of suicide attempts for bulimia nervosa (BN) and binge-purging anorexia nervosa (AN-bp) appears higher than restrictive AN (AN-r); risk in binge eating disorder (BED) is still unclear. The aim of this meta-analysis was to compare proportions of suicide attempts in eating disorder (ED) subgroups.

METHODS

A literature search using combinations of key-words for ED and suicide attempts was performed. Studies reporting proportions of suicide attempters in at least two ED groups, diagnosed according to DSM-IV or -5 and ICD-10 diagnostic criteria were considered. ED subgroups were analyzed in pairs using a binary random effect model for proportions. Publication bias, meta-regression, and sensitivity analyses were performed.

RESULTS

In BN, attempted suicide was more frequent (21%) than in AN (12.5%), but the difference was statistically significant only when BN was compared with AN-r (9-10%). In BED, the proportion of suicide attempts was as high as in AN (10-12%).

CONCLUSIONS

Though limited by heterogeneity across the studies in terms of methodology and aims, inability to control for relevant confounding variables, exclusion of ED not otherwise specified, this study supports suicide attempts as a major issue in EDs, especially in binge-purging subtypes, i.e. BN and AN-bp. Similar suicidal proportions were observed in AN and BED. The reasons for a greater proportion of attempted suicide in binge/purging subtypes need to be explored in future studies.

Non-suicidal self-injury and co-occurring suicide attempt in male prisoners

High rates of non-suicidal self-injury (NSSI) and suicide attempts (SA) are well documented in prisoners, however, few studies examined their co-occurrence in this high-risk population. Study participants were 1203 adult men randomly selected from 15 Belgian prisons, representing 12% of the national male prison population. Lifetime prevalence rates for NSSI and SA are 17% and 20% respectively, with half (55%) of self-injurers reporting a SA history. Bivariate analyses show that NSSI and SA are significantly related to one another, and many risk factors are common to both. Multivariate analysis comparing prisoners who engaged in NSSI with (n = 109) and without (n = 90) co-occurring SA indicates that suicidal ideation is the strongest independent correlate of SA among self-injurers. Additionally, relative to those with a history of NSSI only, prisoners with co-occurring NSSI and SA are significantly more likely to be violent offenders, being prescribed psychotropic medication, and report a psychiatric diagnosis; suggesting that they constitute a more clinically severe subgroup. Collectively, these findings highlight the marked overlap between NSSI and SA in prisoners, both in terms of prevalence and correlates, with suicidal ideation being an important predictor of suicide risk among self-injurers.

Understanding the Pathways from Depression to Suicidal Risk from the Perspective of the Interpersonal-Psychological Theory of Suicide

Suicide is a major public health concern, especially in adolescence. Identifying risk factors for suicide is important to effectively prevent such behavior. Depression is one of the most widely examined risk factors for suicidal risk. How depression and suicidal risk are related, however, is still not clear. This study tested a model with three key constructs of the interpersonal-psychological theory of suicidal behavior (IPTS)-perceived burdensomeness, thwarted belongingness, and nonsuicidal self-injury (NSSI)-as mediators in the relationship between depression and suicidal risk among Chinese adolescents. Chinese high school students (N = 1,074; 54.2% male; M_age  = 13.87 years, SD = 1.48) completed questionnaires assessing all study variables. Results suggested that perceived burdensomeness and NSSI partially mediated the relationship between depression and suicidal risk. Findings of this study emphasize the importance of the IPTS framework in understanding the possible mechanisms underlying the relationship between depression and suicidal risk, and suggest a possible avenue for suicide interventions.

The time course of responding to aversiveness in females with a history of non-suicidal self-injury

Non-suicidal self-injury is a risk factor for suicidal behavior, particularly in females. Two prominent theories of suicide suggest that habituation to the psychophysiological aversiveness of NSSI is a mechanism by which NSSI exposure may lead to increased risk for suicide. Several laboratory studies examining the relationship between physiological habituation and suicide attempt history have yielded mixed results, potentially due to their use of broad measures of physiological arousal and/or focus on specific psychopathologies. However, no studies have examined the association between the time course (e.g., habituation, initial reactivity) of responding to aversiveness and NSSI, which may help to elucidate psychophysiological mechanisms of NSSI. Therefore, we examined habituation and initial reactivity to aversiveness (indexed by the time course of acoustic startle reflex, a well-validated measure of defensive responding) in three groups of young adult females - those with a history of NSSI, psychiatric controls matched on potential confounds (e.g., psychopathology, trauma history, demographics), and healthy controls. Results indicated that individuals with a history of NSSI exhibited blunted initial reactivity and marginally slower habituation to aversiveness relative to the two control groups. The NSSI group's insensitivity to aversiveness may reflect prior psychophysiological habituation, and may be a mechanism through which prior NSSI exposure leads to increased risk for suicidal behavior.

Perfectionism and Social Problem Solving as Predictors of Nonsuicidal Self-Injury in Ethnoracially Diverse College Students: Findings Controlling for Concomitant Suicide Risk

The present study was designed to examine the extent to which perfectionism and social problem solving add to the prediction model of nonsuicidal self-injury (NSSI), independent of suicide risk, in a sample of 386 ethnoracially diverse college students. Moreover, the authors were interested in whether social problem solving, beyond perfectionism, would account for additional variance in their prediction model. Results indicated that social problem solving did account for significant variance in the prediction model of NSSI, above and beyond perfectionism. Moreover, on controlling for suicide risk, a possible confound for NSSI behaviors, social problem solving was found to account for an additional 4.0 percent of unique variance in the prediction of NSSI, beyond that accounted for by perfectionism. The present findings have theoretical implications for the literature on perfectionism and social problem solving, specifically in relation to NSSI. In addition, the present findings have practical implications for social workers who work with college students engaging in NSSI behaviors.

Tinnitus, Depression, Anxiety, and Suicide in Recent Veterans: A Retrospective Analysis

OBJECTIVES

The purpose of this project was to investigate whether there is an association between tinnitus diagnosis and suicide and whether depression and anxiety strengthen that association. Given that tinnitus is the top service-connected disability among U.S. Veterans () and that suicide among Veterans has been occurring at a higher frequency as compared with community suicide rates (), the possible associations between tinnitus and suicide will be explored. Co-occurring physical conditions also will be examined to determine if they increase the risk of suicide in the context of tinnitus.

DESIGN

Administrative health care data related to Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) were used to identify Veterans who accessed the Veterans Administration (VA) health care system from January 1, 2002, to December 31, 2011. Veterans who were deceased as of December 2011 were identified using the National Death Index (NDI) files. Tinnitus cases were followed until either they were deceased or to the end of the study period. The International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) codes were used to identify all conditions and diseases. As per mortality research standards, International Classification of Diseases 10th Revision (ICD-10) codes were used to identify cause of death.

RESULTS

Of 769,934 OEF/OIF/OND Veterans receiving VA care January 2002 to December 2011, 15% (n =116,358) were diagnosed with tinnitus. Of these Veterans diagnosed with tinnitus, 21% were also diagnosed with depression, another 8% with anxiety, and another 17% with both depression and anxiety. Fifty-four percentage were identified as having tinnitus without depression or anxiety. Among individuals with tinnitus, 41.9% had co-occurring hearing loss. Suicide rates were lower among Veterans with tinnitus than Veterans without tinnitus. Co-occurring diagnoses of mental-health conditions did not significantly increase the risk of suicide.

CONCLUSIONS

The study results do not confirm clinical and anecdotal reports that tinnitus could be related to suicide among Veterans. However, tenets from rehabilitation psychology suggest that the onset of chronic impairment or disability does not predict an individual's subsequent psychological states; other personal attributes may be more influential. Health care professionals, such as audiologists and psychologists, should be cognizant of the associations between tinnitus and mental health issues and be prepared to address the psychological needs of individuals who have tinnitus.

Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study

BACKGROUND

Suicidal thoughts and non-suicidal self-harm are common in adolescents and are strongly associated with suicide attempts. We aimed to identify predictors of future suicide attempts in these high-risk groups.

METHODS

Participants were from the Avon Longitudinal Study of Parents and Children, a population-based birth cohort study in the UK. The sample included 456 adolescents who reported suicidal thoughts and 569 who reported non-suicidal self-harm at 16 years of age. Logistic regression analyses were used to explore associations between a wide range of prospectively recorded risk factors and future suicide attempts, assessed at the age of 21 years.

FINDINGS

38 (12%) of 310 participants with suicidal thoughts and 46 (12%) of 380 participants who had engaged in non-suicidal self-harm reported having attempted suicide for the first time by the follow-up at 21 years of age. Among participants with suicidal thoughts, the strongest predictors of transition to attempts were non-suicidal self-harm (odds ratio [OR] 2·78, 95% CI 1·35-5·74; p=0·0059), cannabis use (2·61, 1·11-6·14; p=0·029), other illicit drug use (2·47, 1·02-5·96; p=0·045), exposure to self-harm (family 2·03, 0·93-4·44, p=0·076; friend 1·85, 0·93-3·69, p=0·081), and higher levels of the personality type intellect/openness (1·62, 1·06-2·46; p=0·025). Among participants with non-suicidal self-harm at baseline, the strongest predictors were cannabis use (OR 2·14, 95% CI 1·04-4·41; p=0·038), other illicit drug use (2·17, 1·10-4·27; p=0·025), sleep problems (waking in the night 1·91, 0·95-3·84, p=0·069; insufficient sleep 1·97, 1·02-3·81, p=0·043), and lower levels of the personality type extraversion (0·71, 0·49-1·03; p=0·068).

INTERPRETATION

Most adolescents who think about suicide or engage in non-suicidal self-harm will not make an attempt on their life. Many commonly cited risk factors were not associated with transition to suicide attempt among these high-risk groups. Our findings suggest that asking about substance use, non-suicidal self-harm, sleep, personality traits, and exposure to self-harm could inform risk assessments, and might help clinicians to identify which adolescents are at greatest risk of attempting suicide in the future.

FUNDING

American Foundation for Suicide Prevention, National Institute for Health Research Biomedical Research Centre at the University Hospitals Bristol National Health Service Foundation Trust, and the University of Bristol.

Does nonsuicidal self-injury prospectively predict change in depression and self-criticism?

Few studies have investigated nonsuicidal self-injury (NSSI) as a predictor of outcomes other than suicidal self-injury, severely limiting our understanding of this behavior's full range of consequences. Three independent studies were used to examine the prospective association between NSSI and two outcomes: depressive symptoms and self-criticism. Data were collected from samples of (1) adults with past-month NSSI, (2) adults with lifetime NSSI, and (3) adults with past-year NSSI. Studies included one-month and six-month follow-up periods. Results were tested in an internal meta-analysis. Results suggested that NSSI did not prospectively predict changes in self-criticism. No changes in depressive symptoms were seen over shorter follow-up periods; however, NSSI predicted increases in depressive symptoms at six-month follow-up in one sample. The internal meta-analysis indicated a null relationship between NSSI and prospective internalizing symptoms. Future research should replicate these findings and examine a broader range of outcomes of NSSI to better understand its complex relationship to psychopathology.

Environmental Stressors May Drive Inflammation and Alter Neurocircuitry to Promote Suicidal Behavior

Suicide morbidity and mortality are serious public health problems, accounting for over 40,000 deaths annually and over $10 billion in combined medical and work loss costs. Suicidal behavior is the outcome of a complex causal web of distal and proximal risk processes that includes a range of interacting environmental and biological determinants. We review current understanding of risk and protective factors, including recent findings on inflammatory processes, discuss recent research on environmental risks for suicidal behaviors with a focus on economic stress, and examine potential mechanisms by which external factors and internal processes such as inflammation might contribute to pathways leading to suicidal behavior. We propose a model that links changes in the default network or resting state of brain activity with corresponding changes in brain structure and function, which in turn may be influenced by diverse inflammatory mediators, and suggest a potential framework that highlights multidisciplinary opportunities for further research.

Non-Suicidal self-injury and suicide in depressed Adolescents: Impact of peer victimization and bullying

BACKGROUND

While prior research has demonstrated that peer victimization and bully perpetration contribute to non-suicidal self-injury (NSSI) and suicidal thoughts and behaviors (STBs), it remains unclear whether these interpersonal processes differentiate self-injuring adolescent suicide ideators and attempters.

METHODS

The study included adolescents aged 13-18 years (n = 223; M = 15.31, SD = 1.34) recruited from an acute inpatient program. Participants were divided into two groups: (1) NSSI_SI (n = 106): endorsed past year NSSI, current suicide ideation, and no lifetime suicide attempts and (2) NSSI_SI+SA (n = 117): endorsed past year NSSI, current suicide ideation, and lifetime suicide attempts. Adolescents completed clinical interviews (i.e., mental disorders, NSSI, and STBs) and self-report measures assessing peer victimization, bully perpetration, and depression severity.

RESULTS

NSSI_SI+SA youth reported higher levels of peer victimization and bully perpetration than NSSI_SI youth (ps < 0.01, ds = 0.36-0.37). Among the NSSI_SI+SA youth, bully perpetration was associated with a greater number of past month suicide attempts (p = 0.02, RR = 1.07). Only peer victimization was associated with greater NSSI behaviors in the past month (p = 0.04, RR = 1.01).

LIMITATIONS

The study is cross-sectional, and reports of peer victimization and bully perpetration rely on self-report assessment.

CONCLUSIONS

Peer victimization and bully perpetration differentiated adolescent suicide ideators and attempters, highlighting the need to address bully perpetration in addition to peer victimization in suicide interventions and research.

Protective factors do not moderate risk for past-year suicide attempts conferred by recent NSSI

BACKGROUND

NSSI is a robust predictor of suicide attempts but little is known about what factors may serve protective functions in this relationship.

METHODS

This study used a subsample of 828 young adults with past year NSSI. Participants were recruited from two universities to complete an on-line survey that included assessments of past year NSSI frequency and total NSSI methods used (versatility), past year suicide attempts, life satisfaction, subjective happiness, and resilience.

RESULTS

Bootstrapping logistic regression models were used to test the protective factors as moderators between NSSI frequency, versatility and past year suicide attempts. Greater NSSI versatility and past year frequency were significantly associated with greater likelihood of past year suicide attempts in all models. Life satisfaction and subjective happiness were associated with decreased likelihood of past year suicide attempts in all models. Resilience was not associated with past year suicide attempts, and all moderation analyses were non-significant.

LIMITATIONS

Our sample had limited heterogeneity, focused on a college-age population with lower severity relative to clinical samples, and all data were collected on-line.

CONCLUSIONS

NSSI emerged as a robust predictor of recent suicide attempts as the strength of the relationship did not change in the presence of protective factors. Our results highlight the strong relationship between NSSI and suicide attempts that occur within the same time frame (past year in this study), and the need for future research to identify factors that do serve protective functions between NSSI and suicide attempts.

Parent and peer relationships as longitudinal predictors of adolescent non-suicidal self-injury onset

BACKGROUND

Adolescence is characterized by developmental changes in social relationships, which may contribute to, or protect against, psychopathology and risky behaviors. Non-suicidal self-injury (NSSI) is one type of risky behavior that typically begins during adolescence and is associated with problems in relationships with family members and peers. Prior research on social factors in adolescent NSSI has been limited, however, by a narrow focus on specific interpersonal domains, cross-sectional methods, retrospective self-report of childhood experiences, and a failure to predict NSSI onset among as-yet-unaffected youth.

METHODS

We investigated these relationships in 2127 urban-living adolescent girls with no NSSI history at age 13, who were participating in a longitudinal cohort study (Pittsburgh Girls Study). We used discrete-time survival analyses to examine the contribution of time-varying interpersonal risk factors, assessed yearly at ages 13-16, to NSSI onset assessed in the following year (ages 14-17), controlling for relevant covariates, such as depression and race. We considered both behavioral indicators (parental discipline, positive parenting, parental monitoring, peer victimization), and cognitive/affective indicators (quality of attachment to parent, perceptions of peers, and perceptions of one's own social competence and worth in relation to peers) of interpersonal difficulties.

RESULTS

Parental harsh punishment, low parental monitoring, and poor quality of attachment to parent predicted increased odds of subsequent adolescent NSSI onset, whereas positive parenting behaviors reduced the odds of next year NSSI onset. Youth who reported more frequent peer victimization, poorer social self-worth and self-competence, and more negative perceptions of peers were also at increased risk of NSSI onset in the following year. When tested simultaneously, no single parenting variable showed a unique association with later NSSI onset; in contrast, peer victimization and poor social self-worth each predicted increased odds of later NSSI onset in an omnibus model of peer and parent relationship characteristics.

CONCLUSIONS

In this urban sample of adolescent girls, both peer and parent factors predicted new onset NSSI, although only peer factors were associated with subsequent NSSI in combined multivariate models. Results further suggest that both behavioral and cognitive/affective indicators of interpersonal problems predict NSSI onset. These findings highlight the relevance of family and peer relationships to NSSI onset, with implications for prevention of NSSI onset among at-risk youth.

Differentiating Suicide Attempters from Suicide Ideators: The Role of Capability for Suicide

This study examined whether different components of capability for suicide (i.e., fearlessness about death, pain tolerance, pain insensitivity, preparation for suicide, suicide plan, and courage), as well as painful and provocative events, nonsuicidal self-injury, depressive symptoms, and hopelessness, could distinguish between suicide attempters, suicide ideators, and non-suicidal controls. A total of 930 Chinese adolescents completed questionnaires, and a multinomial logistic regression was conducted to identify factors that could distinguish among the 3 groups. We found that higher levels of pain tolerance, more detailed suicide plans, more positive attitudes towards suicide, as well as more painful and provocative experiences and more severe depressive symptoms were positively associated with increased likelihood of the engagement in both suicide ideation and suicide attempts. Only nonsuicidal self-injury increased the likelihood of falling in the suicide attempt group as compared to the suicide ideation group. Findings of this study emphasize the role of nonsuicidal self-injury in intervening suicidality.

White Matter Microstructure in Adolescents and Young Adults With Non-Suicidal Self-Injury

BACKGROUND

Non-suicidal self-injury (NSSI) is a growing public health concern that commonly begins in adolescence, and can persist into young adulthood. A promising approach for advancing our understanding of NSSI in youth is to examine white matter microstructure using diffusion magnetic resonance imaging (dMRI).

METHOD

The present study examined whole-brain group differences in structural connectivity (as measured by generalized fractional anisotropy [GFA]) between 28 female adolescents and young adults ages 13-21 years with NSSI and 22 age-matched healthy controls (HC). We also explored the association between clinical characteristics including NSSI severity and duration, impulsivity, emotion regulation and personality traits within the NSSI group and GFA of the uncinate fasciculus and cingulum.

RESULTS

Compared to the HC group, participants with NSSI had lower GFA in several white matter tracts, including the uncinate fasciculus, cingulum, bilateral superior and inferior longitudinal fasciculi, anterior thalamic radiation, callosal body, and corticospinal tract. When controlling for depressive symptoms, the NSSI group showed an association between NSSI duration (time since initiating NSSI behavior) and lower GFA in the left cingulum. Higher levels of attentional impulsivity were related to lower GFA in the left uncinate fasciculus within the NSSI group.

CONCLUSIONS

We found evidence suggesting widespread white matter microstructure deficits in adolescents and young adults with NSSI versus HC. We also report inverse associations between white matter integrity and clinical characteristics (duration of NSSI and attentional impulsivity). These white matter microstructural deficits may represent a possible neurobiologically-based vulnerability to developing maladaptive coping mechanisms, such as NSSI. Additionally, results suggest that this white matter disorganization may either worsen with prolonged engagement in NSSI or predict persistent NSSI; thereby highlighting the importance of early intervention targeting this behavior.

Referral of patients to plastic surgeons following self-harm: Opportunities for suicide prevention

Self-harm is a common source of referral to plastic and hand surgery services. Appropriate management of these patients is complex and includes the need for close liaison with mental health services. Self-harm is the single biggest risk factor for completed suicide, thereby increasing the risk by a factor of 66.¹ This study aimed to analyse the clinical pathway and demographics of patients referred to plastic surgeons following self-harm. This 6-year retrospective series included patients referred to plastic surgeons following self-harm within the Galway University Hospital group. Patients were identified through the Hospital inpatient enquiry system, cross-referenced with data from the National Suicide Research Foundation. Data collected included demographics, psychiatric history, details of self-harm injury, admission pathway and operative intervention. Forty-nine patients were referred to plastic surgery services during the study period, accounting for 61 individual presentations. The male-to-female ratio was 26 (53%) to 23 (47%). Mean age was 40 years (range 21-95 years). Alcohol or illicit substance use was recorded in 17 of 61 (28%) presentations. Mortality from suicide occurred in 4 patients (8%). Mental health assessment was not carried out in 9 presentations (15%). Documentation of need for close or one-to-one observation was made in 11 cases (20%) and was not referred to in 43 cases (83%) following mental health assessment. This study demonstrates significant diversity in the management of this vulnerable patient group and may inform development of referral pathways to improve the safety of transfer, surgical admission and discharge of patients following self-harm, in consultation with mental health services.

The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors

BACKGROUND

Theoretical and empirical literature suggests that non-suicidal self-injury (NSSI) is an important correlate of suicide risk. The present study was designed to evaluate: (a) whether NSSI is associated with increased odds of subsequent onsets of suicidal thoughts and behaviors (STB) independent of common mental disorders, (b) whether NSSI is associated with increased risk of transitioning from suicide ideation to attempt, and (c) which NSSI characteristics are associated with STB after NSSI.

METHOD

Using discrete-time survival models, based on retrospective age of onset reports from college students (n = 6,393, 56.8% female), we examined associations of temporally prior NSSI with subsequent STB (i.e., suicide ideation, plan, and attempt) controlling mental disorders (i.e., MDD, Broad Mania, GAD, Panic Disorder, and risk for Alcohol Dependence). NSSI characteristics associated with subsequent STB were examined using logistic regressions.

RESULTS

NSSI was associated with increased odds of subsequent suicide ideation (OR = 2.8), plan (OR = 3.0), and attempt (OR = 5.5) in models that controlled for the distribution of mental disorders. Further analyses revealed that NSSI was associated with increased risk of transitioning to a plan among those with ideation, as well as attempt among those with a plan (ORs = 1.7-2.1). Several NSSI characteristics (e.g., automatic positive reinforcement, earlier onset NSSI) were associated with increased odds of experiencing STB.

LIMITATIONS

Surveys relied on self-report, and thus, there is the potential for recall bias.

CONCLUSIONS

This study provides support for the conceptualization of NSSI as a risk factor for STB. Investigation of the underlying pathways accounting for these time-ordered associations is an important avenue for future research.

Exploratory analysis of mediators of the relationship between childhood maltreatment and suicidal behavior

INTRODUCTION

Suicide is a major public health concern. One consistently cited risk factor for suicide is childhood maltreatment, which also may play a role in the transition from suicidal ideation to suicidal behavior.

METHOD

The current study aimed to examine the relationship between childhood maltreatment and suicide attempts during adolescence (N = 4834; 52.1% female; 67.5% Caucasian). Data from the U.S. National Longitudinal Study of Adolescent Health were utilized. Forty-six theoretically-relevant risk factors were explored as potential mediators of this relationship using an exploratory mediation data analytic method.

RESULTS

Results demonstrated a significant childhood maltreatment - suicide attempt relationship only among females. After considering demographics and suicidal ideation, having received counseling in the previous 12 months was the most influential mediator, followed by having a friend attempt suicide in the previous 12 months.

CONCLUSIONS

These findings highlight potential gender differences in the relationship between childhood maltreatment and later suicide attempts, and, moreover, the importance of assessing for recent exposure to peer suicidal behavior in suicide risk assessments.

Prefrontal cortex activation during cognitive interference in nonsuicidal self-injury

Nonsuicidal self-injury (NSSI), deliberate behavior resulting in self-inflicted damage to oneself, is common, particularly among female adolescents, and may be a form of maladaptive emotion regulation. Cognitive interference, a specific type of processing associated with inhibiting prepotent responses in favor of less automatic ones, is utilized in treatment strategies to shift patients' thoughts and behaviors away from maladaptive responses and replace them with more adaptive ones. We examined cognitive interference processing using the Multi-Source Interference Task (MSIT) in females with NSSI behavior (n=15) and healthy control females (n=15). Functional magnetic resonance imaging (fMRI) data were collected concurrently. Results revealed similar between-group performance on the MSIT; however, women with NSSI behavior exhibited altered patterns of neural activation during the MSIT. Specifically, the NSSI group demonstrated increased cingulate cortex (CC) and decreased dorsolateral prefrontal cortex (DLPFC) activation compared to the control group. Further, within the NSSI group, DLPFC activation inversely correlated with emotional reactivity and self-reported impulsivity, suggesting that decreased DLPFC activation is associated with poorer emotional control and increased impulsivity. Taken together, these results indicate that women with NSSI behavior utilize different cortical areas during cognitive interference processing, which may have broader implications regarding the treatment efficacy of cognitive-based therapies.