The association of trait impulsivity and suicidal ideation and its fluctuation in the context of the Interpersonal Theory of Suicide

A systematic review of interpersonal processes and their measurement within experience sampling studies of self-injurious thoughts and behaviours

Self-injurious thoughts and behaviours (SITBs) are a leading cause of death, and interpersonal processes (IPs) appear to play a role in SITBs. This systematic review synthesises the literature on IPs and SITBs in daily life and addresses four critical questions: (1) Which IPs have been assessed and how, (2) How are differences in IPs between individuals associated with SITBs?, (3) How are differences in IPs within individuals associated with SITBs? and (4) Do IPs relate differently to self-injurious thoughts than behaviours? Our review followed PRISMA guidelines and eligible literature was screened until 25 April 2024. We identified 58 Experience Sampling studies (32.76% daily-diary studies) of which most focused on IPs from major SITBs theories (e.g., thwarted belongingness) but largely used inconsistent operationalizations. Results from 39 studies investigating within-person associations were mixed. Based on 26 studies, whether differences in IPs between individuals relate to SITBs remains unclear. Three studies have investigated whether IPs relate to the transition from thoughts to behaviours, but temporal models are needed to draw firm conclusions. Studies investigating IPs and SITBs in daily life are largely inconclusive. Psychometrically validated measures are warranted, and future daily-life studies would benefit from drawing on ideation-to-action frameworks.

Indirect effect of impulsivity on suicide risk through self-esteem and depressive symptoms in a population with treatment-resistant depression: A FACE-DR study

INTRODUCTION

Suicide is a major health issue. Its prevalence is particularly high in subjects presenting major depression disorder (MDD), making this a key suicide-related risk factor. Suicide attempts in severe forms of MDD were assumed to be linked to impulsivity and loss of control. Nevertheless, we failed to find data specifically investigating the link between impulsivity and suicide risk in treatment-resistant depression (TRD). This study seeks to review this relationship.

METHOD

Patients were recruited for a prospective cohort. Suicide risk and impulsivity were assessed using the International Neuropsychiatric Interview and Barratt Impulsiveness Scale, Version 10, respectively, while the severity of depressive symptoms was assessed using the Montgomery-Asberg Depression Rating Scale, anxiety with the State-Trait Anxiety Inventory and childhood maltreatment using the Childhood Trauma Questionnaire.

RESULTS

220 TRD patients were enrolled in the study. The impulsivity score was correlated with self-esteem, marital status, professional status and anxiety. There was no direct link to suicide risk. However, impulsivity was associated with self-esteem (coefficient: -0.24; p value 0.043) and depressive symptom severity (coefficient: 0.; p value 0.045). The suicide risk was significantly correlated with depressive symptom severity (coefficient = 0.38, p < 0.001) and self-esteem (coefficient = -0.34, p = 0.01). Considering these correlations, we postulated that the effect of impulsivity on suicide risk could be mediated by self-esteem in terms of depressive symptom severity and we finally found a relevant mediation model within impulsivity having an indirect effect on suicide risk by impacting self-esteem and depressive symptoms with anxiety also playing a significant role as a covariable.

CONCLUSION

We found that impulsivity could play an indirect role with the involvement of self-esteem and depressive symptoms and the contributing role of anxiety.

The mediating role of impulsivity between sleep quality and suicidal ideation in adolescent population: a multicenter cross-sectional study in the northeastern Sichuan, China

Introduction

Suicidal ideation is a critical early stage in the progression towards suicidal be havior. Prior research has established links between sleep quality, impulsivity, and suicidal tendencies, yet the interaction among these factors has been less explored. This study aims to explore the mediating role of impulsivity in the relationship between sleep quality and suicidal ideation in adolescents.

Methods

Employing a cross-sectional study design, 6,974 questionnaires were distributed,including the Socio-demographic Characteristics Questionnaire, Barratt Impulsiveness Scale, the Positive and Negative Suicide Ideation Inventory,and the Pittsburgh Sleep Quality Index Scale. The participants were high school and middle school students from 33 schools in northeastern Sichuan, China, selected through random cluster sampling.

Results

Of these 6,786 questionnaires were analyzed. The participant distribution included 47.2% male and 52.8% female students, with 68.3% from junior schools and 31.7% from senior schools. The prevalence of suicidal ideation was found to be 13.6%. The analysis, which involved correlation analysis and the construction of a structural equation model, revealed that sleep quality had a significant positive effect on impulsivity (β:0.289,p < 0.05), and impulsivity, in turn, had a positive impact on suicidal ideation (β:0.355,p < 0.05).Moreover, sleep quality was directly linked to suicidal ideation (β:0.208,p < 0.05). Thus, sleep quality affects suicidal ideation both directly and indirectly through impulsivity.

Discussion

The results of this study suggest that both sleep quality and impulsivity are significant direct influencers of suicidal ideation among adolescents in the region studied, with impulsivity also playing an indirect role in the relationship between sleep quality and suicidal ideation.

Neural correlates of automatic emotion regulation and their association with suicidal ideation in adolescents during the first 90-days of residential care

BACKGROUND

Suicide is the second leading cause of death for adolescents in the United States. However, relatively little is known about the forms of atypical neuro-cognitive function that are correlates of suicidal ideation (SI). One form of cognitive/affective function that, when dysfunctional, is associated with SI is emotion regulation. However, very little work has investigated the neural correlates of emotion dysregulation in adolescents with SI.

METHODS

Participants (N = 111 aged 12-18, 32 females, 31 [27.9%] reporting SI) were recruited shortly after their arrival at a residential care facility where they had been referred for behavioral and mental health problems. Daily reports of SI were collected during the participants' first 90-days in residential care. Participants were presented with a task-fMRI measure of emotion regulation - the Affective Number Stroop task shortly after recruitment. Participants were divided into two groups matched for age, sex and IQ based on whether they demonstrated SI.

RESULTS

Participants who demonstrated SI showed increased recruitment of regions including dorsomedial prefrontal cortex/supplemental motor area and parietal cortex during task (congruent and incongruent) relative to view trials in the context of emotional relative to neutral distracters.

CONCLUSIONS

Participants with SI showed increased recruitment of regions implicated in executive control during the performance of a task indexing automatic emotion regulation. Such data might suggest a relative inefficiency in the recruitment of these regions in individuals with SI.

Negative Urgency, (Lack of) Premeditation, and Sensation Seeking: Indirect Relationships with Suicidal Ideation through Thwarted Interpersonal Needs

OBJECTIVE

Differences in how impulsivity is conceptualized, along with a myopic focus on impulsivity's relationship with historical suicidal behaviors, have resulted in limited implications made from prior research regarding impulsivity and suicidal thoughts and behaviors. The current study investigated the indirect effect facets of impulsivity may have on suicidal ideation, specifically, through thwarted interpersonal needs.

METHODS

Participants were N = 424 undergraduate students who completed a cross-sectional survey. Participants completed the Urgency, Premeditation, Perseverance, Sensation Seeking, Impulsive Behavior Scale (UPPS), the Adult Suicide Ideation Questionnaire (ASIQ), and the Interpersonal Needs Questionnaire (INQ). Parallel mediation models were run to examine the relation between facets of impulsivity, perceived burdensomeness, thwarted belongingness, and suicidal ideation.

RESULTS

Thwarted belonginess and perceived burdensomeness significantly accounted for the variance in the relation between negative urgency and suicidal ideation. Neither thwarted belongingness nor perceived burdensomeness significantly explained variance in the relation between (lack of) premeditation and suicidal ideation. Conversely, perceived burdensomeness and thwarted belonginess significantly explained the inverse relation between sensation seeking and suicidal ideation (i.e., greater sensation seeking was related to lower perceived burdensomeness and thwarted belongingness and in turn lower suicidal ideation).

CONCLUSION

Negative urgency, in particular, is related to suicidal ideation through thwarted interpersonal needs. Future research should continue to differentiate between various types of impulsivity and its relationship with both suicidal ideation and behaviors utilizing both cross-sectional and ambulatory assessments of these constructs.HIGHLIGHTSNegative urgency is related to suicidal ideation.Negative urgency is related to thwarted interpersonal needs.Thwarted interpersonal needs partially explain the relation between negative urgency and suicidal ideation.

The relationship between suicidal behavior and perceived stress: The role of cognitive emotional regulation and problematic alcohol use in Spanish adolescents

Suicidal behavior has become an important public health problem, correlating with stress and emotional deficits in recent research. This study examined the relationship between perceived stress and suicidal behavior risk, testing the mediating roles of cognitive emotion regulation and impulsivity, and the moderating role of problematic alcohol use in stress-suicidal behavior association in a sample of 121 Spanish adolescents surveyed online. Results showed positive and significant associations between perceived stress and suicidal behavior risk, as well a mediation role of adaptive cognitive emotion regulation strategies and a moderation role of problematic alcohol use between perceived stress and suicidal behavior risk, supporting stress as an influential factor in suicidal behavior. Our findings emphasize adaptive emotional regulation strategies in stressful situations, as well as the importance of promoting responsible alcohol consumption to decrease suicide risk in adolescents. Additionally, they contribute to effective educational suicide prevention programs for young people.

Impulsivity traits and suicide related outcomes: A systematic review and meta-analysis using the UPPS model

BACKGROUND

The affective, cognitive, and behavioral aspects of impulsivity involved in suicide-related outcomes can be investigated through the UPPS model, which conceptualizes these facets in multidimensional terms related to negative and positive urgency, lack of premeditation and perseverance, and sensation seeking. This systematic review and meta-analysis provided a comprehensive understanding of the role of all facets of impulsivity in the development of suicidal ideation and behaviors.

METHODS

We conducted a systematic search on six databases (PsycINFO, PsycARTICLES, PubMed, MEDLINE, Scopus, and Web of Science) until May 5,2023. Overall, 49 studies met the criteria for systematic review, of which 37 were included in a meta-analysis of data from 17.898 individuals. Additional moderation analyses included age, gender, sample status, country of study conduct, assessment instruments, type of suicide-related outcome, study quality, and research design.

RESULTS

We found significant relationships between aspects of impulsivity and suicide-related outcomes. Specially, affective facets related to impulsivity showed a stronger association with suicidal ideations and attempts than cognitive and behavioral dimensions, recommending the main involvement of emotional aspects-positive and negative-in suicide-related dimensions.

LIMITATIONS

The limited number of studies may have negatively impacted the power of moderation analyses. In addition, for most dimensions of impulsivity, the limited number of longitudinal studies did not allow to test the moderating role of research design.

CONCLUSIONS

This study supports the role of impulsivity in suicidal ideation and behavior, identifying the affective component of impulsivity as the most involved, providing a significant contribution from a clinical and diagnostic point of view.

The impact of social connection on near-term suicidal ideation

While predominant suicide theories emphasize the role of social connectedness in suicidal thinking, there is a need to better understand (a) how specific aspects of social connection relate to suicidal ideation and (b) the timeframe over which these relationships persist. The current study examined ecological momentary assessment data over a 30-day period from 35 participants with past-year suicidal thoughts or behaviors (mean age = 25.88; 62.9% women; 68.6% White) to address these questions. Results demonstrated that absence of social contact was associated with next timepoint suicidal ideation, even after considering the suicidal ideation autoregressive effect (i.e., concurrent), with effects strongest in the short-term. Findings provide preliminary evidence of the need to assess for the presence of social contact, and for assessments to occur in close proximity (i.e., a few hours), to capture the true dynamics of risk for suicidal ideation. Although needing replication, results suggest importance of just-in-time interventions targeting suicidal ideation.

The use of advanced technology and statistical methods to predict and prevent suicide

In the past decade, two themes have emerged across suicide research. First, according to meta-analyses, the ability to predict and prevent suicidal thoughts and behaviours is weaker than would be expected for the size of the field. Second, review and commentary papers propose that technological and statistical methods (such as smartphones, wearables, digital phenotyping and machine learning) might become solutions to this problem. In this Review, we aim to strike a balance between the pessimistic picture presented by these meta-analyses and the optimistic picture presented by review and commentary papers about the promise of advanced technological and statistical methods to improve the ability to understand, predict and prevent suicide. We divide our discussion into two broad categories. First, we discuss the research aimed at assessment, with the goal of better understanding or more accurately predicting suicidal thoughts and behaviours. Second, we discuss the literature that focuses on prevention of suicidal thoughts and behaviours. Ecological momentary assessment, wearables and other technological and statistical advances hold great promise for predicting and preventing suicide, but there is much yet to do.

Suicidal urges and attempted suicide at multiple time scales in borderline personality disorder

BACKGROUND

There is strong evidence for an enduring suicidal diathesis among individuals with a history of suicide attempts, particularly among people diagnosed with borderline personality disorder (BPD). However, the progression of suicidal crises among people predisposed to suicidal behavior remains poorly understood.

METHODS

Via multilevel structural equation modeling we tested the hypothesis that a history of attempted suicide predicts a stronger dynamic link between affect and impulsivity with suicidal ideation (i.e., suicidal urges) - both moment-to-moment and day-to-day. 153 patients diagnosed with BPD, 105 of whom had a history of medically serious suicide attempts completed a 21-day ecological momentary assessment protocol (17,926 total assessments).

RESULTS

Individuals with higher average levels of negative affect reported more suicidal thoughts. Moments characterized by more negative affect, hostility, impulsivity, and less positive affect were also characterized by elevated suicidal ideation. For hostility and positive affect, these significant links generalized to the daily level. At the same time, for negative affect and hostility the within-person coupling was stronger among attempters in comparison to non-attempters, and these effects did not significantly differ across timescales.

LIMITATIONS

Follow-up studies replicating our findings of the dysregulation-suicidality nexus in clinically more diverse samples are needed.

CONCLUSIONS

The diathesis for suicidal behavior manifests in tighter dynamic links between negative affect or hostility and suicidal ideation. Because these within-person links were amplified in attempters compared to non-attempters, differential coupling patterns may index potentially lethal processes that generalize beyond BPD reflecting distinct diathesis components.

Impulsivity in Depression: Its Relation to Suicidality

OBJECTIVE

Impulsivity is an important risk for suicidality, which is common in patients with major depressive disorder (MDD). The goal of this study was to examine multiple facets of impulsivity in depressed patients compared with healthy controls and to assess their relationship to suicidality.

METHOD

Outpatients diagnosed with MDD using the Structured Clinical Interview for DSM-IV were recruited. Two groups were constituted as "MDD in remission" (n=32) and "MDD" (n=71). The "healthy control" group (n=30) consisted of individuals who had never been diagnosed with any psychiatric disorder. Impulsivity was assessed with the Barratt Impulsivity Scale (BIS), a self-rating measure, and with the following behavioral tasks: Go/No-go Task, Iowa Gambling Task, and Balloon Analogue Risk Task. The scores of the 3 groups (n=133) were compared to evaluate the effect of MDD. The scores were also analyzed and compared in the patients in the 2 MDD groups (n=103) with respect to their current and lifetime suicidality.

RESULTS

There was no difference in the 3 groups in task scores, but nonplanning BIS was correlated with the severity of depressive symptoms. Patients with suicidal ideation (SI) had higher BIS total and attention impulsivity scores and more commission errors on the Go/No-go Task, reflecting failure in response inhibition, compared with the patients without SI.

CONCLUSIONS

Failure to show differences in impulsivity-related tasks suggests that there might be no relationship between the state of depression and impulsivity. However, these findings confirm that there is an association between SI and response inhibition and the attention facet of impulsivity in depression.

Multidimensional variability in ecological assessments predicts two clusters of suicidal patients

The variability of suicidal thoughts and other clinical factors during follow-up has emerged as a promising phenotype to identify vulnerable patients through Ecological Momentary Assessment (EMA). In this study, we aimed to (1) identify clusters of clinical variability, and (2) examine the features associated with high variability. We studied a set of 275 adult patients treated for a suicidal crisis in the outpatient and emergency psychiatric departments of five clinical centers across Spain and France. Data included a total of 48,489 answers to 32 EMA questions, as well as baseline and follow-up validated data from clinical assessments. A Gaussian Mixture Model (GMM) was used to cluster the patients according to EMA variability during follow-up along six clinical domains. We then used a random forest algorithm to identify the clinical features that can be used to predict the level of variability. The GMM confirmed that suicidal patients are best clustered in two groups with EMA data: low- and high-variability. The high-variability group showed more instability in all dimensions, particularly in social withdrawal, sleep measures, wish to live, and social support. Both clusters were separated by ten clinical features (AUC = 0.74), including depressive symptoms, cognitive instability, the intensity and frequency of passive suicidal ideation, and the occurrence of clinical events, such as suicide attempts or emergency visits during follow-up. Initiatives to follow up suicidal patients with ecological measures should take into account the existence of a high variability cluster, which could be identified before the follow-up begins.

Impulsivity and aggression in suicide ideators and suicide attempters of high and low lethality

BACKGROUND

Impulsivity and aggression have been associated with all forms of suicidal behaviour and linked to theories of suicide capability. There is a need to clarify the role of impulsivity and aggression in the progression from suicidal thoughts to suicide attempts and suicide.

METHOD

In this naturalistic cross-sectional study, suicide ideators (35), low lethal suicide attempters (37), and high lethal suicide attempters (26) were compared with the Columbia-suicide severity rating scale (C-SSRS), Barratt impulsiveness scale (BIS-11), and the Buss & Perry aggression questionnaire (AQ).

RESULTS

Physical aggression score (p = 0.032) contributed to the difference between predicted low lethal suicide attempt and predicted high lethal suicide attempt. This model predicting physical aggression showed a fairly weak positive relationship (OR = 1.1) to high lethal attempt and explained 13% of the variance so there is a need for further replications to verify these results. Impulsive behaviour scores in females were significantly higher in the low lethal suicide attempt group compared to suicide ideators (F(2.51) = 3.47, p = 0.039, η²= 0.12). Hostility aggression in females was significantly higher in the high lethal suicide attempters compared to suicide ideators (F(2.52) = 3.53, p = 0.037, η² = 0.12). Physical aggression scores in females were significantly higher in the high lethal attempters compared to suicide ideators (F(2.52) = 6.79, p = 0.002, η²= 0.21). When these analyses were conducted without the participants who died in suicide, men in the high lethal attempt group scored significantly higher than men in the low lethal attempt group (F(2.37) = 3.8, p = 0.031, η² = 0.17), but men did not differ in aggression and impulsivity scores in other comparisons.

CONCLUSION

Suicide prevention should address physical aggression, as high levels can be associated with high lethal attempts. Assessment of suicidal patients should address impulsive behaviour with the insight that it can be more prominent in female low lethal suicide attempters. It could be that assessment and treatment of suicidal patients should be tailored differently for men and women. Aggression as a feature of suicide capability could be the link that makes suicide possible.

Suicidality and relief of depressive symptoms with intermittent theta burst stimulation in a sham-controlled randomized clinical trial

OBJECTIVES

Suicidality is a serious public health problem and is closely associated with the severity of depression. In this work, we examined the effects of accelerated intermittent theta burst stimulation (iTBS) on suicidal status, risk factors for suicide, and severity of depressive symptoms in subjects with major depressive disorder (MDD).

METHODS

We present data from a quadruple-blind (patient, care provider, investigator, rater) sham-controlled crossover randomized clinical trial. During a 6-week observation period, each participant underwent 2 weeks of stimulation - each week with 20 sessions of active or sham iTBS. A suicide score was created using a composite of individual items from Montgomery-Åsberg Depression Scale (MADRS), Hamilton Depression Scale, and Beck Depression Inventory. The severity of depression was determined by MADRS total scores. In addition, we used demographic and Columbia Suicidality Rating Scale information to assess suicide risk.

RESULTS

Among 81 participants, we observed a significant reduction in suicidality and this change was positively correlated with a change in depressive symptoms. A significant difference between active and sham iTBS provided evidence for antidepressant effects. Higher changes in levels of anxiety and impulsiviness also correlated with larger changes in suicidality.

CONCLUSIONS

As neither suicide nor other serious adverse events were evidenced, this intervention was a safe and viable procedure to reduce suicidality and severity of depressive symptoms. Moreover, we identified more pronounced anti-suicidal effects in those with higher risk profiles. Unlike MADRS, composite suicidal scores did not provide evidence of an effect between stimulation conditions in this crossover design study. Even so, based on our promising results, parallel and larger studies could contribute to a better characterization of the anti-suicidal placebo effect and the benefit of using iTBS against suicidal symptoms.

Momentary interpersonal processes of suicidal surges in borderline personality disorder

BACKGROUND

Suicide rates are high in borderline personality disorder (BPD) where interpersonal problems trigger intense affective dysregulation and impulses to act on suicidal thoughts. To date, however, no study has examined how interpersonal stressors contribute to momentary within-person links among affect and impulsivity with suicidal ideation (SI), and how those links vary over time in people's daily lives.

METHODS

A total of 153 individuals diagnosed with BPD and 52 healthy controls completed a 21-day ecological momentary assessment protocol. Of these 153 individuals with BPD, 105 had a history of suicide attempts. Multilevel structural equation modeling was used to examine dynamic links among interpersonal perceptions, affect, state impulsivity, and suicidal intent.

RESULTS

Aggregated across interactions, lower perceived warmth in others was associated with SI. This direct relationship, however, did not extend to momentary within-person associations. Instead, interpersonal conflicts were linked to SI indirectly via greater negative affect and lower positive affect. While a robust within-person link between interpersonal perceptions and impulsivity emerged, impulsivity did not account for the relationship between interpersonal perceptions and SI.

CONCLUSION

This intensive longitudinal study illustrates momentary interpersonal signatures of an emerging suicidal crisis. Among people with BPD at high risk for suicide, interpersonal triggers initiate a cascade of affective dysregulation, which in turn gives rise to SI.

The Use of Intensive Longitudinal Methods in Research on Suicidal Thoughts and Behaviors: A Systematic Review

OBJECTIVE

Intensive longitudinal methods (ILM), such as ecological momentary assessment (EMA) and daily diary, involve repeatedly assessing individuals over short periods of time and have been increasingly used to study suicidal thoughts and behaviors (STBs). Suicidal thoughts have been shown to vary over short periods of time and reports of STBs are subject to negative biases. Therefore, ILM are important methodological tools for studying STBs, ones that capture enhanced precision and realism of data compared to traditional survey methods. The present systematic review aims to provide a comprehensive overview of ILM used to study STBs, including the various EMA and daily diary methodologies used, the feasibility of those methodologies, and the ethical considerations in this line of research. This review also summarizes the characteristics of descriptive STB outcomes specific to the ILM data collection period.

METHODS

A thorough search of PubMed and PsycINFO was conducted up to May 2020, resulting in twenty-eight papers reviewed.

RESULTS AND CONCLUSIONS

The review of the studies showed that ILM are largely feasible and do not have a negative impact on participants. In addition, the reviewed studies revealed unique aspects of STBs, such as the variability of suicidal thoughts, that suggest that ILM are important methodologies to use when studying STBs. Gaps in the research and recommendations for future research are discussed.HighlightsIt is feasible to use ILM to study suicidality.ILM do not have a negative impact on participants with suicidality.Few studies have used ILM to study suicidality in diverse samples.

Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research

Suicide and suicide-related behaviors are prevalent yet notoriously difficult to predict. Specifically, short-term predictors and correlates of suicide risk remain largely unknown. Ecological momentary assessment (EMA) may be used to assess how suicidal thoughts and behaviors (STBs) unfold in real-world contexts. We conducted a systematic literature review of EMA studies in suicide research to assess (1) how EMA has been utilized in the study of STBs (i.e., methodology, findings), and (2) the feasibility, validity and safety of EMA in the study of STBs. We identified 45 articles, detailing 23 studies. Studies mainly focused on examining how known longitudinal predictors of suicidal ideation perform within shorter (hourly, daily) time frames. Recent studies have explored the prospects of digital phenotyping of individuals with suicidal ideation. The results indicate that suicidal ideation fluctuates substantially over time (hours, days), and that individuals with higher mean ideation also have more fluctuations. Higher suicidal ideation instability may represent a phenotypic indicator for increased suicide risk. Few studies succeeded in establishing prospective predictors of suicidal ideation beyond prior ideation itself. Some studies show negative affect, hopelessness and burdensomeness to predict increased ideation within-day, and sleep characteristics to impact next-day ideation. The feasibility of EMA is encouraging: agreement to participate in EMA research was moderate to high (median = 77%), and compliance rates similar to those in other clinical samples (median response rate = 70%). More individuals reported suicidal ideation through EMA than traditional (retrospective) self-report measures. Regarding safety, no evidence was found of systematic reactivity of mood or suicidal ideation to repeated assessments of STBs. In conclusion, suicidal ideation can fluctuate substantially over short periods of time, and EMA is a suitable method for capturing these fluctuations. Some specific predictors of subsequent ideation have been identified, but these findings warrant further replication. While repeated EMA assessments do not appear to result in systematic reactivity in STBs, participant burden and safety remains a consideration when studying high-risk populations. Considerations for designing and reporting on EMA studies in suicide research are discussed.

Analysis of a national response to a White House directive for ending veteran suicide

OBJECTIVE

Analyze responses to a national request for information (RFI) to uncover gaps in policy, practice, and understanding of veteran suicide to inform federal research strategy.

DATA SOURCE

An RFI with 21 open-ended questions generated from Presidential Executive Order #1386, administered nationally from July 3 to August 5, 2019.

STUDY DESIGN

Semi-structured, open-ended responses analyzed using a collaborative qualitative and text-mining data process.

DATA EXTRACTION METHODS

We aligned traditional qualitative methods with natural language processing (NLP) text-mining techniques to analyze 9040 open-ended question responses from 722 respondents to provide results within 3 months. Narrative inquiry and the medical explanatory model guided the data extraction and analytic process.

RESULTS

Five major themes were identified: risk factors, risk assessment, prevention and intervention, barriers to care, and data/research. Individuals and organizations mentioned different concepts within the same themes. In responses about risk factors, individuals frequently mentioned generic terms like "illness" while organizations mentioned specific terms like "traumatic brain injury." Organizations and individuals described unique barriers to care and emphasized ways to integrate data and research to improve points of care. Organizations often identified lack of funding as barriers while individuals often identified key moments for prevention such as military transitions and ensuring care providers have military cultural understanding.

CONCLUSIONS

This study provides an example of a rapid, adaptive analysis of a large body of qualitative, public response data about veteran suicide to support a federal strategy for an important public health topic. Combining qualitative and text-mining methods allowed a representation of voices and perspectives including the lived experiences of individuals who described stories of military transition, treatments that worked or did not, and the perspective of organizations treating veterans for suicide. The results supported the development of a national strategy to reduce suicide risks for veterans as well as civilians.

Using intensive time sampling methods to capture daily suicidal ideation: A systematic review

INTRODUCTION

There has been an increased emphasis on understanding suicidal thoughts and behaviors as they occur in real-time, resulting in a proliferation of studies utilizing intensive time sampling methods. Given the continued growth in this area, there is a need to synthesize the feasibility of these methods in capturing suicidal ideation at the daily level, in addition to an examination of study factors that may impact suicidal ideation detection, to guide future research.

METHOD

Online databases (i.e., PsychINFO, ERIC, PubMed, MEDLINE) were systematically searched for articles published through December 2020 that assessed suicidal ideation at the daily level.

RESULTS

Twenty-six articles presenting data from sixteen independent datasets met inclusion criteria. Across included articles, suicidal ideation detection ranged from approximately 1-92% of participant-completed surveys, with 18-100% of unique study participants reporting suicidal ideation during the study period. Assessment-based factors (i.e., number of daily assessments, duration of daily assessment period) did not appear to be meaningfully associated with suicidal ideation detection rates. Rather, participant characteristics (i.e., baseline suicide risk history, inclusion criteria) were better indicators of a study's ability to capture suicidal ideation at the daily level.

CONCLUSIONS

Findings highlights the impact of targeting participants with elevated suicide risk at study enrollment.

The Association Between Cyberbullying Victimization and Suicidal Ideation Among Chinese College Students: The Parallel Mediating Roles of Core Self-Evaluation and Depression

With the rapid development of science and technology, the Internet has formed a new form of aggression, which is called cyberbullying. Many studies have demonstrated that cyberbullying can cause serious damage to the physical and mental health of Chinese college students, such as depression and suicide. The main purpose of this study was to investigate the relationship between cyberbullying victimization and suicidal ideation and the parallel mediating roles of core self-evaluation and depression. A questionnaire was used to measure the research variables in this study among 1,509 college students. The results indicated that: After controlling for participants' gender, age, family structure, and family economic status, cyberbullying victimization significantly and positively related to suicidal ideation. Core self-evaluation and depression separately mediated the relationship between cyberbullying victimization and suicidal ideation. The mediating effect of depression was stronger than that of core self-evaluation. The findings support a parallel mediation model of the relationship between cyberbullying victimization and suicidal ideation. Our study may help to develop interventions and prevention measures for college students who experienced cyberbullying victimization.

Electrophysiological Changes Between Patients With Suicidal Ideation and Suicide Attempts: An Event-Related Potential Study

INTRODUCTION

Inhibitory control is regarded as an important ability related to the transition from suicidal ideation to suicide attempts. In event-related potential, patients with dysfunction of inhibitory control demonstrate a reduction in the no-go amplitude. This study aimed to determine the association between the no-go event-related potential component and suicidal behaviors among suicide attempters and ideators who never attempted suicide.

METHODS

Overall, 150 patients who visited the emergency room by suicide attempts or patients who visited the psychiatric department with suicidal ideation were recruited and instructed to perform a go/no-go task during electroencephalography recording. The Beck Depression Inventory, Beck Anxiety Inventory, Barratt Impulsivity Scale, Difficulties in Emotional Regulation Scale, and Acquired Capability for Suicide Scale were used. Individuals were divided into two groups: those with suicide attempt group) and with suicidal ideation (SI group) without SA. The psychological characteristics and event-related potentials of the two groups were compared. Correlation analyses were conducted to test the association between the clinical characteristics and event-related potentials.

RESULTS

The SA group had significantly decreased no-go P3 amplitudes at all electrodes compared to the SI group. In the correlation analysis between the clinical measurements and event-related potentials in all the participants, no-go P3 amplitudes in whole electrode sites were negatively correlated with the scores of the acquired capability for the suicide scale.

CONCLUSIONS

This study revealed that suicide attempters have dysfunction in controlling inhibition compared to suicide ideators reflected in the no-go P3. Our findings suggested that no-go P3 can be a biomarker associated suicide attempts in suicide ideators.

Utilising the Integrated Motivational Volitional (IMV) model to guide CBT practitioners in the use of their core skills to assess, formulate and reduce suicide risk factors

Cognitive behavioural therapists based in primary care are not usually expected to provide therapy to acutely suicidal individuals or work directly on suicidal thoughts. However, all practitioners should be vigilant about suicide risk and potentially help to reduce vulnerabilities to future suicide risk as part of their routine work. Many of the risk factors and processes hypothesised to play a role in the development of suicidal thinking and behaviours are likely to be evident within the usual content of standard evidence-based protocols for depression or anxiety disorders. In this paper we are suggesting that even within the current primary care remit, (i) an increased awareness of suicide risk vulnerability factors and (ii) using knowledge of a psychological model of suicidal behaviour to inform clinical care are likely to be extremely helpful in structuring clinical formulation and informing interventions.

Key learning aims

(1)

Suicide ideation and psychosocial distress among refugee adolescents in Bidibidi settlement in West Nile, Uganda

This study investigated the factors associated with suicidal ideation and psychological distress among Sudanese refugees (aged 10–19 years) in Bidibidi refugee settlement, Yumbe district, Uganda. The analysis is based on cross-sectional data collected as part of the implementation of a project on sexual and reproductive health in Bidibidi refugee settlement. Data were collected from 284 South Sudanese adolescents in July 2020. We estimated the prevalence of psychological distress and suicidal ideation, and their associated profiles. Odds ratios and their 95% Confidence Intervals based on a logistic regression model were used to assess the effect of different potential factors on the risk profiles for suicidal ideation and psychological distress. The prevalence of psychological distress (on KS-6 scale) was estimated to be 12.3% (95%CI: 8.7, 16.7%). The risk for psychological distress is low among male adolescents (AOR = 0.51; 95%CI: 0.23, 1.02), older adolescents, (AOR = 0.12; 95%CI: 0.04, 0.40), and adolescents with a friend or family members they can confide in (AOR = 0.33; 95%CI: 0.11, 0.96). Both suicidal ideation and psychological distress are very high among the female adolescents. Familial and individual interventions can be potentially useful for female adolescents who have a high risk of suicide and psychological distress.

Impulsivity Scale-12 and its utilization in alcohol use disorder

INTRODUCTION

One of the core symptoms of alcohol use disorder (AUD) is impulsivity. The recently published study on the Impulsivity Scale 12 (IS-12) offers a promising tool to use in clinics working with clients with AUD due to its simplicity. IS-12 includes subscales related tocognitive impulsivity and behavioral impulsivity, which are related to different aspects of AUD symptomatology. The aim of the study was to adapt IS-12 to polish and test its utility in a sample of patients diagnosed with AUD.

METHODS

Using a Confirmatory Factor Analysis, we compared the two-factor model of the Polish adaptation of the BIS-11 and the IS-12 on a sample of 615 patients diagnosed with AUD. Additionally, we explored the association between the IS-12's cognitive impulsivity and behavioral impulsivity subscales and depressive symptoms, AUD severity, and suicidal ideation using Structural Equation Modeling on a subsample of 450 patients with AUD.

RESULTS

The IS-12 demonstrated a better model fit and good reliability compared to the BIS-11. Moreover, cognitive impulsivity predicted suicidal ideation, but not AUD severity, while behavioral impulsivity predicted AUD severity, but not suicidal ideation. Both subscales of IS-12 predicted depressive symptoms.

CONCLUSION

Consistent with prior work, findings indicate that the second-order factor model of the BIS-11 had reliability issues and evidenced poor model fit. In contrast, the IS-12 demonstrated a satisfactory model fit and was predictive of clinical symptomatology. Thus, utilizing an easy tool, such as IS-12, might be beneficial for researchers and clinicians working with patients with AUD.

Prediction of suicidal ideation and attempt in 9 and 10 year-old children using transdiagnostic risk features

The objective of the current study was to build predictive models for suicidal ideation in a sample of children aged 9–10 using features previously implicated in risk among older adolescent and adult populations. This case-control analysis utilized baseline data from the Adolescent Brain and Cognitive Development (ABCD) Study, collected from 21 research sites across the United States (N = 11,369). Several regression and ensemble learning models were compared on their ability to classify individuals with suicidal ideation and/or attempt from healthy controls, as assessed by the Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Version. When comparing control participants (mean age: 9.92±0.62 years; 4944 girls [49%]) to participants with suicidal ideation (mean age: 9.89±0.63 years; 451 girls [40%]), both logistic regression with feature selection and elastic net without feature selection predicted suicidal ideation with an AUC of 0.70 (CI 95%: 0.70–0.71). The random forest with feature selection trained to predict suicidal ideation predicted a holdout set of children with a history of suicidal ideation and attempt (mean age: 9.96±0.62 years; 79 girls [41%]) from controls with an AUC of 0.77 (CI 95%: 0.76–0.77). Important features from these models included feelings of loneliness and worthlessness, impulsivity, prodromal psychosis symptoms, and behavioral problems. This investigation provided an unprecedented opportunity to identify suicide risk in youth. The use of machine learning to examine a large number of predictors spanning a variety of domains provides novel insight into transdiagnostic factors important for risk classification.

Use of Ecological Momentary Assessment to Study Suicidal Thoughts and Behavior: a Systematic Review

PURPOSE OF REVIEW

Ecological momentary assessment (EMA) is a recently introduced approach to patient evaluation that consists of asking patients questions in real time and in their usual habitat. This method seeks to contribute to suicide prevention by providing psychiatrists with detailed information about suicidal thoughts and behavior, how these fluctuate over short periods of time, and the short-term risk factors presented by patients. We conducted a systematic review of published research using EMA to study suicidal thoughts and behavior.

RECENT FINDINGS

Several systematic reviews of EMA in mental health have been conducted to date, and the literature contains numerous theoretical papers and compilations on EMA and suicide phenomena. To date, however, no systematic reviews have explored the use of this tool to study suicidal thoughts and behavior. We performed a systematic review of five databases (i.e., PubMed, Embase, Scopus, Web of Science, and PsycINFO) to identify studies on EMA and suicidal thoughts and behavior. An initial search revealed 544 articles. Following the study selection process, 35 studies were included in the review. Almost three-quarters of the studies were published in the last 4 years. The studies reviewed concluded that EMA was generally feasible and well accepted. EMA findings correlated well with the results of a retrospective assessment, though tended to over-represent symptom severity. Our review points to important aspects of suicidal thoughts and behavior, such as its wide fluctuation over short periods of time. Negative affect and disturbed sleep, among others, emerged as short-term predictors of suicidal thoughts and behavior. Therefore, EMA is a potentially useful tool in clinical practice, although not without drawbacks, such as participant fatigue with questionnaires and ethical concerns.

Disturbed sleep as a clinical marker of wish to die: A smartphone monitoring study over three months of observation

BACKGROUND

Smartphone monitoring could contribute to the elucidation of the correlates of suicidal thoughts and behaviors (STB). In this study, we employ smartphone monitoring and machine learning techniques to explore the association of wish to die (passive suicidal ideation) with disturbed sleep, altered appetite and negative feelings.

METHODS

This is a prospective cohort study carried out among adult psychiatric outpatients with a history of STB. A daily questionnaire was administered through the MEmind smartphone application. Participants were followed-up for a median of 89.8 days, resulting in 9,878 person-days. Data analysis employed a machine learning technique called Indian Buffet Process.

RESULTS

165 patients were recruited, 139 had the MEmind mobile application installed on their smartphone, and 110 answered questions regularly enough to be included in the final analysis. We found that the combination of wish to die and sleep problems was one of the most relevant latent features found across the sample, showing that these variables tend to be present during the same time frame (96 hours).

CONCLUSIONS

Disturbed sleep emerges as a potential clinical marker for passive suicidal ideation. Our findings stress the importance of evaluating sleep as part of the screening for suicidal behavior. Compared to previous smartphone monitoring studies on suicidal behavior, this study includes a long follow-up period and a large sample.

The acute antisuicidal effects of single-dose intravenous ketamine and intranasal esketamine in individuals with major depression and bipolar disorders: A systematic review and meta-analysis

The efficacy of ketamine in reducing suicidal ideation (SI) has been previously reported. We aimed to evaluate acute anti-SI effects of single-dose ketamine in different formulations/routes of administration by pooling results from randomized controlled trials (RCTs). A systematic search was conducted on Cochrane, Embase, Medline, and PubMed from inception to July 1st, 2020. Studies were selected based on pre-determined eligibility criteria. Effect sizes of different formulations/routes at various time points were computed using random-effects models. With data from nine eligible RCTs (n = 197), the pooled effect size for anti-SI effects at the 24-h time point was 1.035 (N = 6, CI: 0.793 to 1.277, p < 0.001) for intravenous (IV) racemic ketamine and 1.309 (N = 1, CI: 0.857 to 1.761, p < 0.001) for intranasal (IN) esketamine. An additional five RCTs were available for qualitative analysis. RCTs were identified for oral/sublingual ketamine for depression, however, none of these trials reported anti-SI effects preventing quantitative analysis for these routes of delivery. No RCTs for intramuscular (IM) ketamine were identified. The findings suggest that single-dose IV ketamine/IN esketamine is associated with robust reductions in suicidal thoughts at 2-h, 4-h, and 24-h post-intervention. In addition, future studies on IM/oral/sublingual ketamine and comparative studies are warranted to evaluate the anti-SI efficacy of distinct formulations and routes of administration.

Mental Pain Surrounding Suicidal Behaviour: A Review of What Has Been Described and Clinical Recommendations for Help

OBJECTIVE

To conduct a comprehensive review of scientific publications related to mental pain and suicide risk in order to deepen relevant aspects to guide clinical interventions.

METHOD

Using a text analysis tool, we collected the terms most frequently linked with that situation in published results of research using various tools to evaluate mental pain or psychache.

DISCUSSION

We propose clinical interventions for the clinical conditions most commonly associated with mental pain.

Suicidal thoughts, suicidal behaviours and self-harm in daily life: A systematic review of ecological momentary assessment studies

Background

Ecological Momentary Assessments (EMA) offer an approach to understand the daily risk factors of suicide and self-harm of individuals through the use of self-monitoring techniques using mobile technologies.

Objectives

This systematic review aimed to examine the results of studies on suicidality risk factors and self-harm that used Ecological Momentary Assessments.

Methods

Pubmed and PsycINFO databases were searched up to April 2020. Bibliographies of eligible studies were hand-searched, and 744 abstracts were screened and double-coded for inclusion.

Results

The 49 studies using EMA included in the review found associations between daily affect, rumination and interpersonal interactions and daily non-suicidal self-injury (NSSI). Studies also found associations between daily negative affect and positive affect, social support, sleep, and emotions and a person's history of suicide and self-harm. Associations between daily suicide thoughts and self-harm, and psychopathology factors measured at baseline were also observed.

Conclusions

Research using EMA has the potential to offer clinicians the ability to understand the daily predictors, or risk factors, of suicide and self-harm. However, there are no clear reporting standards for EMA studies on risk factors for suicide. Further research should utilise longitudinal study designs, harmonise datasets and use machine learning techniques to identify patterns of proximal risk factors for suicide behaviours.