The communication of suicidal intent. A reexamination

Disclosure of suicidal ideation and behaviours: A systematic review and meta-analysis of prevalence

Disclosure of suicidal ideation and behaviours, defined as thoughts, plans, or attempts, to other people provides opportunity for intervention and prevention. This study is the first to meta-analyze all available studies to estimate the prevalence of disclosure, to whom people disclose, and examine factors that influence disclosure. Databases were searched for studies reporting samples of people who had experienced suicidal ideation or behaviours (including those who had died by suicide) and whether they had disclosed this. Almost 100 studies (k = 94, N participants = 1,044,629) were included in the overall prevalance analysis. The results showed less than half of people disclosed suicidal ideation or behaviour: 45.9% (95%CI 41.9-49.9%, PI 12.3-81.8%; k = 94). High heterogeneity, common to prevalence studies, was found (Q[93] = 130,584, p < .001; I² = 99.9%). No publication bias was detected. Removing outliers did not change the prevalence estimate, but provided tighter prediction intervals: 45.6% (95%CI 43.4-47.9%, PI 35.8-55.7%; k = 33). Disclosure was related to higher prevalence of psychiatric disorders, female gender, and a longer timeframe of suicidal ideation or behaviour. Prevalence of disclosure was lower among people who died by suicide, relative to community samples, and lower when reported verbally rather than written online. Disclosure, and proportions of disclosures, to family members, was numerically higher than to friends or professionals, but could not be directly compared. In conclusion, between 50 and 60% of people do not disclose their suicidal ideation and behaviours to other people, and therefore remain unidentified and potentially untreated.

Predictors of Emerging Suicide Death Among Military Personnel on Social Media Networks

Suicide is a leading cause of death in the United States and is the second leading cause of death in the U.S. military. Previous research suggests that data obtained from social media networks may provide important clues for identifying at-risk individuals. To test this possibility, the social media profiles from 315 military personnel who died by suicide (n = 157) or other causes (n = 158) were coded for the presence of stressful life situations (i.e., triggers), somatic complaints or health issues (i.e., physical), maladaptive or avoidant coping strategies (i.e., behaviors), negative mood states (i.e., emotion), and/or negative cognitive appraisals (cognition). Content codes were subsequently analyzed using multilevel models from a dynamical systems perspective to identify temporal change processes characteristic of suicide death. Results identified temporal sequences unique to suicide, notably social media posts about triggers followed by more posts about cognitions, posts about cognitions followed by more posts about triggers, and posts about behaviors followed by fewer posts about cognitions. Results suggest that certain sequences in social media content may predict cause of death and provide an estimate of when a social media user is likely to die by suicide.

Dying online: live broadcasts of Chinese emerging adult suicides and crisis response behaviors

BACKGROUND

Social media and online environments are becoming increasingly popular and integral to modern lives. The online presentation of suicidal behaviors is an example of the importance of communication technologies, and the need for professionals to respond to a changing world. These types of behaviors, however, have rarely been scientifically analyzed. This study aimed to examine the behaviors of both suicide broadcasters and their audience, with attention on prevention/crisis opportunities.

METHODS

Multiple case studies were employed to explore live-broadcast suicide by Chinese emerging adults (aged 18-25 years). Six cases were selected (four males, two females; aged 19-24, M = 21.60, SD = 2.25), retrieved from 190 public documents (case range = 5 to 32; M = 11.50, SD = 10.37). A qualitative study based on grounded theory was adopted. Information on case background, stages, participants and their behaviors were collected.

RESULTS

(1) Five stages of blogcast suicide incidents were revealed, including: Signaling, Initial reactions, Live blogcast of suicide attempts, Crisis responses, and Final outcomes. (2) Common behavioral trends (e.g., comforting, verbal abuse) were identified from the blogcast participants (e.g., active audience, peers, parents and police). (3) Suicide blogcasters exhibited tendencies to communicated signs of pain and cries for help.

CONCLUSIONS

This multi-case study found live presentations of suicidal behaviors offered unique opportunities to respond to suicidal crises, and also to learn more about the relationships between suicidal people and potential help sources. Findings showed many audience members wanted to be helpful but lacked appropriate skills or knowledge. Others engaged in suicide cyberbullying. The social media is an environment in the making. This study revealed that increasing knowledge and skills for crisis response and suicide prevention is needed. Such efforts could lead to empowered netizens and a more hospitable online world.

Predicting Risk of Suicide Attempt Using History of Physical Illnesses From Electronic Medical Records

BACKGROUND

Although physical illnesses, routinely documented in electronic medical records (EMR), have been found to be a contributing factor to suicides, no automated systems use this information to predict suicide risk.

OBJECTIVE

The aim of this study is to quantify the impact of physical illnesses on suicide risk, and develop a predictive model that captures this relationship using EMR data.

METHODS

We used history of physical illnesses (except chapter V: Mental and behavioral disorders) from EMR data over different time-periods to build a lookup table that contains the probability of suicide risk for each chapter of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes. The lookup table was then used to predict the probability of suicide risk for any new assessment. Based on the different lengths of history of physical illnesses, we developed six different models to predict suicide risk. We tested the performance of developed models to predict 90-day risk using historical data over differing time-periods ranging from 3 to 48 months. A total of 16,858 assessments from 7399 mental health patients with at least one risk assessment was used for the validation of the developed model. The performance was measured using area under the receiver operating characteristic curve (AUC).

RESULTS

The best predictive results were derived (AUC=0.71) using combined data across all time-periods, which significantly outperformed the clinical baseline derived from routine risk assessment (AUC=0.56). The proposed approach thus shows potential to be incorporated in the broader risk assessment processes used by clinicians.

CONCLUSIONS

This study provides a novel approach to exploit the history of physical illnesses extracted from EMR (ICD-10 codes without chapter V-mental and behavioral disorders) to predict suicide risk, and this model outperforms existing clinical assessments of suicide risk.

The ABC's of Suicide Risk Assessment: Applying a Tripartite Approach to Individual Evaluations

There is considerable need for accurate suicide risk assessment for clinical, screening, and research purposes. This study applied the tripartite affect-behavior-cognition theory, the suicidal barometer model, classical test theory, and item response theory (IRT), to develop a brief self-report measure of suicide risk that is theoretically-grounded, reliable and valid. An initial survey (n = 359) employed an iterative process to an item pool, resulting in the six-item Suicidal Affect-Behavior-Cognition Scale (SABCS). Three additional studies tested the SABCS and a highly endorsed comparison measure. Studies included two online surveys (Ns = 1007, and 713), and one prospective clinical survey (n = 72; Time 2, n = 54). Factor analyses demonstrated SABCS construct validity through unidimensionality. Internal reliability was high (α = .86-.93, split-half = .90-.94)). The scale was predictive of future suicidal behaviors and suicidality (r = .68, .73, respectively), showed convergent validity, and the SABCS-4 demonstrated clinically relevant sensitivity to change. IRT analyses revealed the SABCS captured more information than the comparison measure, and better defined participants at low, moderate, and high risk. The SABCS is the first suicide risk measure to demonstrate no differential item functioning by sex, age, or ethnicity. In all comparisons, the SABCS showed incremental improvements over a highly endorsed scale through stronger predictive ability, reliability, and other properties. The SABCS is in the public domain, with this publication, and is suitable for clinical evaluations, public screening, and research.

Predicting the risk of suicide by analyzing the text of clinical notes

We developed linguistics-driven prediction models to estimate the risk of suicide. These models were generated from unstructured clinical notes taken from a national sample of U.S. Veterans Administration (VA) medical records. We created three matched cohorts: veterans who committed suicide, veterans who used mental health services and did not commit suicide, and veterans who did not use mental health services and did not commit suicide during the observation period (n = 70 in each group). From the clinical notes, we generated datasets of single keywords and multi-word phrases, and constructed prediction models using a machine-learning algorithm based on a genetic programming framework. The resulting inference accuracy was consistently 65% or more. Our data therefore suggests that computerized text analytics can be applied to unstructured medical records to estimate the risk of suicide. The resulting system could allow clinicians to potentially screen seemingly healthy patients at the primary care level, and to continuously evaluate the suicide risk among psychiatric patients.

Suicidal communication signifies suicidal intent in Chinese completed suicides

BACKGROUND

Recognizing suicidal communication from the distressful catharsis in a high-risk group with suicidal tendencies is essential for suicide prevention. This study analyzes whether suicidal communication can indicate the severity of suicidal intent. Various types of suicidal communication are defined, and their clinical significance is further explored.

METHOD

A comprehensive analysis of the psychological autopsy data of 200 victims of completed suicide, including their general socio-demographic status, suicidal communication methods, previous suicide attempts, mental disorders, and psychosocial situation.

RESULTS

Our results showed that 39.5% of all the subjects were suicidal communicators, 23.0% had previously attempted suicide, and 14.0% left suicide notes; 32.4% of 142 subjects free of physical disease suffered from mental disorders. Suicidal communication included verbal communication, behavioral communication, and suicidal notes. Younger people with a higher level of education were more inclined to communicate their suicidal intent by leaving a suicide note. Suicide notes, but not previous suicide attempts or psychosocial situation, were significantly correlated with suicidal intent. Suicidal communicators showed higher depression scores than non-communicators. Those who suffered from mood disorders with higher levels of both depression and suicidal intent were more likely to expose their intent through behavioral communication.

CONCLUSIONS

The present study provides strong evidence that suicidal communication can indicate the severity of suicidal intent. Current findings help interpret high-risk, self-destructive behavior and consequently provide the theoretical basis for a feasible suicide prevention program.

An empirically supported program to prevent suicide in a college student population

In the fall of 1984, the University of Illinois instituted a formal program to reduce the rate of suicide among its enrolled students. At the core of the program is a policy that requires any student who threatens or attempts suicide to attend four sessions of professional assessment. The consequences for failing to comply with the program include withdrawal from the university. In the 21 years that the program has been in effect, reports on 2,017 suicide incidents have been submitted to the Suicide Prevention Team. The rate of suicide at locations within Champaign County (where the university is located) have decreased from a rate of 6.91 per 100,000 enrolled students during the 8 years prior to the program's start to a rate of 3.78 during the first 21 years of the program. This represents a reduction of 45.3 percent. This reduction occurred against a backdrop of stable rates of suicide both nationally and among 11 peer institutions within the Big Ten. The implications for programs and policies at institutions of higher education are discussed.

Emergency department assessment of suicidal patients

Despite advances in the treatment of depression and increasing awareness of mental illness, suicide remains a significant public health problem. Individuals presenting to the emergency department with suicidal ideation are uniquely challenging to assess and treat because prediction of this lethal act is not yet possible. Clinicians need to take careful histories along with their direct exam in order to identify patients with true suicidal intent. Safety issues and medico-legal concerns are addressed as well as critical aspects of the suicidal ideation.

The meaning of suicidal psychiatric in-patients' experiences of being cared for by mental health nurses

Twenty-one psychiatric in-patients who had thought about, expressed the wish or even attempted to commit suicide narrated their experiences of receiving care from mental health nurses. The interview texts were transcribed and interpreted using a phenomenological-hermeneutic method, inspired by Ricoeur's philosophy. Two main themes with subthemes were found: Confirming: attending to patients' basic needs; seeing patient; having time for patient; being with patient; listening to patient without prejudice; being open to patient; accepting patient's feelings; communicating hope to patient; and Lack of confirming: overlooking patient's basic needs; not seeing patient; not having time for patient; leaving patient to herself or himself; listening to patient with prejudice; not being open to patient; denying patient her or his feelings; communicating hopelessness to patient. These findings were interpreted in the light of Hegel's philosophy of mutual recognition and confirmation. When relating episodes of good or bad nursing care suicidal patients emphasized their need for confirmation during their interaction with nurses when in hospital after suicide attempts.

Adolescent suicide: endpoint of long-term difficulties

Characteristics of adolescent suicide victims (N = 53) were investigated in a nationwide study of suicides in Finland. The data were collected through interviews with the victims' parents and attending health care personnel and from official records. Four victims in 10 had shown antisocial behavior. One-third of the adolescents had previous suicide attempts, and 6 in 10 were known to have verbalized their suicidal thoughts. One-third of the victims had been in contact with a psychiatric care system. The results suggest that most adolescent suicides are an endpoint of long-term difficulties, and all suicidal tendencies among adolescents should be taken seriously.

Suicide: a conceptual model for an avoidable death

Suicide as a premature exit from life is confusing not only for family and friends of the individual who shows suicidal behavior but also for many professionals. This article defines the concept of suicide, clarifies terms associated with suicide, reviews current clinical and research literature on suicide, and proposes a conceptual model that describes suicide as both an event and a process.

A psychiatric study of suicide among urban Swedish women

A total of 104 suicides among women were investigated by means of a modified psychological autopsy, including interviews with survivors and a review of somatic and psychiatric records. Diagnosis according to Research Diagnostic Criteria (RDC) showed that 35% were suffering from a major depressive disorder during their final month and another 24% were also depressed; 12% were substance abusers and 14% had adjustment disorders. Two thirds had attempted suicide and another 23% had communicated suicidality in other ways. Slightly more than half of the women had been psychiatric inpatients and another 19% had at some time been outpatients. Fifty-seven percent had been psychiatric inpatients or outpatients during the final year of life. An increasing number of life events occurred during the final 6 months. In most cases the depressed women had been treated ineffectively with antidepressant drugs.

Intropunitiveness and parasuicide: prediction of interview response

A recently proposed relationship between intropunitiveness and depressive states was examined in interview intervention with parasuicidal in-patients. To test the prediction that highly intropunitive parasuicidal individuals would be most responsive to cognitive intervention, a sample of 48 parasuicidal in-patients were administered a battery of individual difference measures, including the Hostility Questionnaire. Subjects were randomly assigned to one of three interview procedures, namely a cognitive interview, an affective interview or a waiting period (control). Highly intropunitive individuals in the cognitive interview group showed the most improvements on a self-report depressive symptom change measure. In addition to supporting theoretical models of depressive state changes, the study has important clinical implications because of the need to identify parasuicidal individuals who are most likely to benefit from brief interventions.

Eventual suicide in interrupted and uninterrupted attempters: a challenge to the cry-for-help hypothesis

A total of 499 patients hospitalized for suicide attempts (attempters) between 1970 and 1975 were followed until 1982; of this group, 28 (5.6%) eventually committed suicide. Six (14.6%) of the 41 patients who had been interrupted during their initial attempts eventually committed suicide, whereas only 22 (4.8%) of the 458 patients who had not been interrupted eventually committed suicide. The interrupted attempters were approximately three times more likely to commit suicide than the uninterrupted attempters.

Contacts of suicidal neurotic and prepsychotic/psychotic patients and their significant others with public care institutions before the suicide attempt

Interviews were conducted with 21 patients classified as neurotic or prepsychotic/psychotic, consecutively admitted to an intensive care unit (ICU) owing to suicide attempts by means of drug intoxication, with their 37 significant others and with care personnel concerning the patients' contacts with psychiatric, somatic or social care institutions before their suicide attempts. Nineteen patients came into contact with public care institutions between 1 and 6 months before attempting suicide; of these, 11 had contacts with psychiatric departments. Nine patients--chiefly those who were prepsychotic/psychotic--were in contact with public care institutions during the last 7 days before attempting suicide; of these, six had contacts with psychiatric departments. The neurotic patients' suicidal thoughts were seldom expressed in the contacts with care personnel, who consequently seldom noticed their suicidal tendencies. Contacts served to alleviate and lend structure to the patients' anxiety, promoted the mobilisation of their defences and temporarily concealed their hopelessness, depression and suicidal impulses. The personnel misinterpreted the patients' defences and considered the patients to be non-suicidal, capable and even strong. The prepsychotic/psychotic patients usually expressed suicidal thoughts in the form of indirect, non-verbal suicidal communication which was difficult to understand: it was recognised as such by their regular therapists, but seldom by staff who were unfamiliar with the patients. Consequently, suicidal risks were usually not recognised in emergency situations. The reasons why none of the significant others sought contact with public care institutions are discussed.

Suicidal communication of persons attempting suicide and responses of significant others

Forty consecutively admitted suicide attempt patients in an intensive care unit, their therapists, and 70 significant others of 37 of the patients, were investigated by means of 300 semi-structured interviews. The patients belonged to three diagnostic groups: neurosis, alcohol and drug abuse, and prepsychosis/psychosis. Thirty-seven of the patients had communicated their suicidal intentions to people around them. All patients used protracted indirect verbal communication. Immediately before the suicide attempt, most of the neurotics continued often to indirect verbal communication, amplified by demanding behaviour. Drug and alcohol abusers, moreover, also employed direct verbal communication, and prepsychosis/psychosis patients indirect non-verbal communication. The majority of significant others understood the patients' suicidal communication and responded with near-total silence. Ambivalence about continuing the relationship characterised most partners of patients in all diagnostic groups, and also persons other than partners in the abuse group. Ambivalence about helping the patient, and aggression expressed by significant others were most prevalent in the abuse group.

Norms, reliability, and item analysis of the Hopelessness Scale in general psychiatric, forensic psychiatric, and college populations

Administered the Hopelessness Scale to 99 criminal psychiatric inpatients, 118 general psychiatric inpatients, and 197 upper-level college students. Normative data were reported for each group. Both of the psychiatric groups endorsed significantly more items in the hopeless direction than did the college student sample. The scale was found to be more reliable with the psychiatric patients than with the college students. The difference in reliability may reflect the restriction of range of hopelessness scores among college students. An item analysis of the Hopelessness Scale for each of the three groups was presented. These data suggest that three items (4, 5, 13) were not measuring hopelessness as reflected in the other items. Suggestions for further research with the Hopelessness Scale to clarify the components of hopelessness in nonpsychiatric populations were presented.