Medically serious versus non-serious suicide attempts: relationships of lethality and intent to clinical and interpersonal characteristics

The moderating role of belongingness in the contribution of depression to suicide ideation following the October 7, 2023, terrorist attack in Israel: A nationwide prospective study

INTRODUCTION

With >1300 civilians murdered, the terrorist attack of October 7 is one of the deadliest terrorist attacks in modern history. Previous research documented a sharp increase in depression in the aftermath of the attacks and the military conflict that followed. In this national prospective cohort study, we examined to what extent perceived belongingness (PB) moderates the association between depression and suicide ideation (SI) in the wake of the October 7th terrorist attack.

METHODS

A representative sample of 710 Israeli adults (of them, 362 females, 51.1 %), Jews (557, 79.9 %), and Arabs (153, 20.1 %), aged 18-85 (M = 41.01, SD = 13.72) completed questionnaires assessing depression, current SI, and perceived belongingness at two timepoints: T1 (in August 2023) and T2 (in November 2023).

RESULTS

Perceived belongingness at T1 predicted SI at T2 beyond demographic and trauma-related characteristics. Importantly, we found a significant interaction in which a PB at T1 moderated the link between depression and current SI at T2. Specifically, the level of depression at T2 contributed to current SI-T2 more strongly for individuals with low PB levels than for individuals with high PB levels.

DISCUSSION

Our study highlights the impact of PB on SI following the October 7th terrorist attack. Clinicians treating individuals coping with depression should attend to their patients' sense of belongingness, as low PB comprises a significant risk factor for current SI. Moreover, community and national initiatives that could increase levels of PB among the citizens may help to diminish suicide risk in the aftermath of the attack.

A comprehensive study of medically serious suicide attempts in France: incidence and associated factors

AIMS

People who make medically serious suicide attempts (MSSAs) share a number of features with those who die by suicide, and are at a high risk of suicide themselves. Studies to date have mostly focused on clinical samples of MSSAs. An epidemiological examination at a national level can help to identify risk profiles and pathways of care in this population.

METHODS

We explored the French nationwide hospital discharge database (Programme de Médicalisation des Systèmes d'Information, PMSI) to identify any MSSA taking place between 2012 and 2019. Relevant demographic and medical information was collected about the first MSSA of each attempter. Data from 2010 and 2011 were used to verify the absence of prior attempts.

RESULTS

First occurrences of MSSAs amounted to 81 959 cases over 8 years, with a mean age of 45.8 years, and 53.6% women. Incidence was higher in women (18.1 v. 17.3 per 1 00 000). The most common suicide method was deliberate self-poisoning (64.9% of cases). In comparison, violent methods associated higher mortality and comorbidity and were more frequent in men. The most common mental disorders were mood disorders (55.6%) and substance use disorders (46.2%). A minority of MSSA survivors were hospitalised in psychiatry (32.5%), mostly women.

CONCLUSIONS

MSSAs are frequent and easy to identify. There is a need to reinforce the continuity of psychiatric care for this population given the high risk of subsequent suicide, and the low rates of psychiatric hospitalisation after an MSSA even if violent methods are used. Specific care targeting this population could reduce treatment gaps.

Suicidal intent disclosure among adult suicide decedents: Four age group comparisons

Research on who does/does not disclose suicidal intent (SI) and related factors has important implications for suicide risk management. In this paper based on the 2017-2019 National Violent Death Reporting System, we compared four age groups (18-24, 25-44, 45-64, and 65+ years) of suicide decedents with respect to associations between SI disclosure and (1) suicide contributing/precipitating factors, and (2) suicide means. The results shows that those age 18-44 were more likely to disclose SI than those age> =45, especially among those with relationship problems. Physical health problems and death/suicide of family/friend increased the likelihood of SI disclosure in the 65+ age group.

A comparison of medically serious suicide attempters admitted to intensive care units versus other medically serious suicide attempters

BACKGROUND

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviours very close to deaths by suicide. A simple definition of an MSSA is a suicide attempt with life-threatening consequences, regardless of the severity of the attempter's mental disorder. Few studies have specifically analysed the heterogeneity of MSSA. Therefore, the aim of this study is to describe the profile of individuals who made a highly severe MSSA and to compare those admitted to Intensive Care Units (ICU) - including Burn Units- with other MSSA admitted to other medical and surgical units.

METHODS

The study sample consisted of 168 patients consecutively admitted to non-psychiatric wards from two public hospitals in Barcelona after an MSSA during a 3-year period. In order to select more severe MSSA, the minimum hospital stay was expanded from Beautrais' definition of ≥ 24 h to ≥ 48 h. Mean hospital stay was 23.68 (SD = 41.14) days. Patients needing ICU treatment (n = 99) were compared to other MSSArs (n = 69) that were admitted to other medical and surgical units, not requiring intensive care treatment, with an initial bivariant analysis followed by a logistic regression analysis using conditional entrance.

RESULTS

Medically serious suicide attempters (MSSArs) spent more time hospitalized, more frequently reported recent stressful life events, were more likely to have at least one prior suicide attempt (SA) and their current attempt was more frequently non-planned, compared to the profile of MSSArs reported in previous studies. The most frequent method was medication overdose (67.3%) and jumping from heights (23.2%). Among those who chose more than one method (37.6%), the most frequent combination was medication overdose and drug use. Affective disorders and personality disorders were the most frequent diagnoses. Higher educational level, history of previous mental disorders and prior lifetime suicide attempts were significantly more frequent among those admitted to ICU compared to other MSSArs. Patients needing admission to ICU less frequently used self-poisoning and cuts.

CONCLUSIONS

MSSA needing ICU admission can be regarded clinically as similar to attempts resulting in suicide. More research on this type of highly severe suicide behaviour is needed due to its serious implications both from a clinical and public health perspective.

Potential lethality of suicide attempts in youth

Rates of suicide in youth have increased over the last 50 years, yet our ability to predict suicidal behaviours has not significantly improved during this time. Examining predictors of suicide attempt lethality can enhance our understanding of suicidality in youth, yet research has focused on actual medical lethality (the actual danger to life resulting from a suicide attempt) rather than potential lethality (the potential for death that is associated with a suicide attempt). Thus, the aim of the present study was twofold: first, we quantified the percentage of youth for whom the severity of suicide attempt was misclassified by considering only actual lethality; second, we tested whether key variables that predict the actual lethality of suicide attempts also predict the potential lethality of suicide attempts in youth. We examined these questions in a sample of children and adolescents admitted to a psychiatric inpatient unit following a suicide attempt. Over 70% of youth who made serious suicide attempts would have been misclassified by assessments relying on only actual lethality. Although several variables relevant to the construct of actual lethality significantly predicted potential lethality (e.g., male sex, substance use disorder), others did not. In addition, we found that the subset of youth who would have been misclassified as low risk based on actual lethality had a disproportionately high need for healthcare resources due to future hospital admissions. The present study provides evidence to suggest that considering potential lethality may lead to improved detection and prediction of suicide risk in youth, and in doing so supports recent calls to broaden considerations of the lethality associated with suicide attempts.

Hospital-treated deliberate self-poisoning patients: Drug-induced delirium and clinical outcomes

OBJECTIVE

Drug-induced delirium has been attributed to opioid, benzodiazepine, antipsychotic, antihistaminic and anticholinergic drug groups at therapeutic doses. Delirium also occurs in hospital-treated self-poisoning (at supra-therapeutic doses), although the causative drug classes are not well established and co-ingestion is common. We tested the magnitude and direction of association of five major drug groups with incident cases of delirium.

METHODS

A retrospective longitudinal cohort (n = 5131) study was undertaken of deliberate and recreational/chronic misuse poisoning cases from a regional sentinel toxicology unit. We described ingestion and co-ingestion patterns and estimated the unadjusted and adjusted odds for developing a drug-induced delirium. We also estimated the odds of drug-induced delirium being associated with three outcomes: intensive care unit admission, general hospital length of stay and discharge to home.

RESULTS

Drug-induced delirium occurred in 3.9% of cases (n = 200). The unadjusted odds ratios for development of delirium were increased for anticholinergics 10.79 (5.43-21.48), antihistamines 6.10 (4.20-8.84) and antipsychotics 2.99 (2.20-4.06); non-significant for opioids 1.31 (95% confidence interval = [0.81, 2.13]); and reduced for benzodiazepines 0.37 (0.24-0.58); with little change after adjustment for age, gender and co-ingestion. Delirium was associated with intensive care unit admission, longer length of stay and discharge destination.

CONCLUSION

Drug-induced delirium was uncommon in this population. Co-ingestion was common but did not alter the risk. In contrast to drug-induced delirium at therapeutic doses in older populations, opioids were not associated with delirium and benzodiazepines were protective. Drug-induced delirium required increased clinical services. Clinical services should be funded and prepared to provide additional supportive care for these deliriogenic drug group ingestions.

Demographic and Clinical Correlates of High-lethality Suicide Attempts: A Retrospective Study in Psychiatric Inpatients

Assessment of the lethality of suicide attempts is a neglected topic in the literature in this area. Based on the hypothesis that suicide attempters who choose a highly lethal method differ from those who use less lethal methods, we analyzed the characteristics of suicide attempters who used different suicide methods to determine demographic and clinical risk factors for the lethality of suicide methods. For this purpose, we used the Risk-Rescue Rating Scale to assess the lethality of the suicide method in a consecutive sample of 107 psychiatric inpatients with a recent suicide attempt (in 6 mo before hospitalization). The results demonstrated that patients who used a highly lethal method were younger and more frequently single. A novel finding of this study was that earlier age of onset of psychiatric symptoms and a higher number of previous hospitalizations were associated with the use of more lethal methods. In conclusion, patients who used more lethal methods differed from those who used less lethal methods. Identification of these differences may be necessary to implement specific suicide prevention strategies in patients with psychiatric conditions.

Were suicide deceased more determined to die than attempters? A comparison study based on two psychological autopsy studies

The reason that some victims of suicide behaviors survived while the others died is unknown, and few studies have been conducted for Chinese populations. We aimed to analyze the effect of suicide intent on outcomes of suicide behaviors, and to explore the impact of psychological strain on suicide intent. Data for this study was derived from two psychological autopsy research projects conducted in China. The same interview procedure and instruments were used in the two projects. Suicide intent was measured by Beck's Suicidal Intention Scale. Information on psychological strain was obtained. A total of 274 suicide deaths and 507 suicide attempters were included in the study. After controlling for socio-demographic variables, suicide intent was significantly associated with suicide death among people having suicide behaviors. Aspiration strain and coping strain were significantly associated with suicide intent. Significant intent-death association and psychological strain-suicide intent association were found in this study. Suicide intent might be an intermediate variable in the pathway from psychological strain to suicide death. Therefore, suicides might be more determined or motivated to die than those attempters who did not die of the act. Future research should continue to explore the mechanism of the psychological strain-suicide intent association, and more efforts on suicide prevention should be made from the perspective of psychological strain.

Medically Serious Suicide Attempts in Personality Disorders

Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviors very close to suicides. Personality disorders (PD) are highly prevalent among them, together with affective and substance use disorders. However, few studies have specifically analyzed the role of PD in MSSA. These suicide attempts (SA) are usually followed by longer hospitalization periods and may result in severe physical and psychological consequences. The aim of this study is to compare the profile of MSSA patients with and without PD. MSSA were defined according to Beautrais 'criteria, but had to remain hospitalized ≥48 h. Overall, 168 patients from two public hospitals in Barcelona were evaluated during a three-year period. Mean hospital stay was 23.68 (standard deviation (SD) = 41.14) days. Patients with PD (n = 69) were more likely to be younger, female, make the first and the most serious SA at a younger age, reported recent stressful life-events and more frequently had previous suicide attempts compared to those without PD. However, no differences were found with regards to comorbid diagnoses, current clinical status, features of the attempt, or their impulsivity and hopelessness scores. Therefore, focusing on the subjective, qualitative experiences related to MSSA among PD patients may increase understanding of the reasons contributing to these attempts in order to improve prevention strategies in the future.

Ultra-brief crisis interpersonal psychotherapy based intervention for suicidal children and adolescents

Suicidal behaviors in adolescence are a major public health concern. The dramatic rise in self-injurious behaviors among adolescents has led to an overwhelming increase in the number of those presenting to the emergency rooms. The intervention described below was constructed on the basis of brief and focused interventions that were found to be effective among suicidal adults using an adaptation of interpersonal psychotherapy for adolescents. The intervention has four main objectives: first, a focused treatment for reducing suicide risk; second, a short and immediate response; third, building a treatment plan based on understanding the emotional distress and interpersonal aspects underlying suicidal behavior; and lastly, to generate hope among adolescents and their parents. The intervention includes intensive five weekly sessions, followed by 3 mo of email follow-up.

The Mediating Roles of Psychological Pain and Dream Anxiety in the Relationship between Sleep Disturbance and Suicide

ABSRTACTSuicide is a significant public health problem worldwide, and sleep disturbances have negative effects on mental health and suicidality. Several psychological concepts may mediate the relationship between sleep disturbances and suicide. We aimed to investigate the mediating roles of psychological pain and dream anxiety in this relationship. This cross-sectional study included 150 depressive patients with or without recent suicide attempts and 91 healthy controls. The Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Psychache Scale (PS), and Van Dream Anxiety Scale (VDAS) were used to assess sleep quality, depression severity, psychological pain, and dream anxiety, respectively. Depression group's mean depression, dream anxiety, psychache, and median sleep quality scores were higher than those of the control group. The ROC analyses indicated no relationship between the violence status of the suicides and the mean dream anxiety, sleep quality or psychache scores. Multivariate regression analysis demonstrated that only the depression score predicted suicide attempts. Mediation analyses revealed that both psychache and dream anxiety have full mediator roles in the relationship between sleep disturbance and suicide attempts. Psychotherapeutic approaches to relieve dream anxiety and psychache may help prevent suicide attempts of at-risk individuals.

Pulling Together - The Protective Role of Belongingness for Depression, Suicidal Ideation and Behavior Among Suicide-Bereaved Individuals

Background: While belongingness has frequently been investigated in the general population as an antidote to experiencing depression, suicidal thoughts, and suicidal behavior, it has rarely been evaluated as a protective factor among individuals bereaved by suicide. Aims: We examined whether perceived belongingness could moderate the differences between suicide-bereaved, suicide-exposed, and nonexposed respondents regarding depression, suicide ideation, and suicide attempts. Method: We conducted an online survey of the adult Israeli population (N = 806), with 203 suicide-bereaved, 266 suicide-exposed, and 377 nonexposed respondents. Participants completed several questionnaires tapping depression and suicidality as well as perceived belongingness levels. Results: Individuals bereaved by suicide reported the highest levels of depression, suicide ideation, and suicide attempts in comparison with suicide-exposed and nonexposed individuals. However, belongingness was found to moderate these distinctions concerning suicide ideation and suicide attempts. Limitations: Belongingness was assessed by only a single question, and the online survey suffered from a relatively high nonresponse rate. Conclusion: Our results suggest that belongingness may act as a potent antidote to the adverse mental health consequences among individuals bereaved by suicide. Clinicians should accord adequate attention to fostering social connectedness among their clients bereaved by suicide.

The comparison of psychological scales as hospitalization predictors between adult and elderly suicide attempters

BACKGROUND

During the process of managing suicide attempters in the emergency department (ED), the importance of hospitalization has been emphasized. Lethality and intent have been suggested as hospitalization determinants of suicide attempters, but their predictive values remain limited in adult and elderly populations.

METHODS

Using prospectively collected the ED-based Suicide Registry, data from suicide attempters over 18 years old was retrospectively studied (2010-2020). The enrolled participants were divided into adult (N = 832) and elderly (>65 years, N = 378) groups. Suicide lethality and intent were assessed by the Risk-Rescue Rating Scale (RRRS) and Suicide Intent Scale (SIS), respectively. The moderating effects of age on the relationship between the psychological scales and hospitalization were examined by entering the interaction terms into a multivariable regression model. The predictive ability of each scale for hospitalization was evaluated in terms of performance and goodness-of-fit.

RESULTS

Both scales' scores in both age groups were significantly higher in hospitalized patients than non-hospitalized patients. Interaction result indicated that only the odds of RRRS for hospitalization significantly differed by age group. Moreover, the predictive performance for hospitalization significantly differed by age group in RRRS but not SIS. In predicting hospitalization, the AUC of the RRRS was significantly higher than that of the SIS in the elderly group but not in the adult group. Comparing the two groups, the RRRS of the elderly group tended to have higher AUC than the adult group, whereas the AUC of the SIS was similar. The RRRS in both groups had a better overall fit compared to the SIS for hospitalization, but its best overall fit and strength with greater power were observed in the elderly group.

CONCLUSIONS

The age-by-RRRS interaction is significantly associated with hospitalization, and the RRRS implementation as a hospitalization determinant is more useful and suitable for elderly suicide attempters than for adult suicide attempters in an emergency setting.

The Serious Suicide Attempts Approach for Understanding Suicide: Review of the Psychological Evidence

The study of survivors of a serious suicide attempt (SSA)--an attempt that would have been fatal had it not been for the provision of rapid and effective emergency treatment--can help researchers understand the suicidal mind. Serious suicide attempters are epidemiologically very similar to those who died by suicide, and thus can serve as valid proxies for studying suicides. In this paper, our objective was to briefly review the main risk factors that may facilitate more dangerous suicide behavior with high levels of intent. Our review highlights several dimensions of risk factors for SSAs, including psychopathology, mental pain, communication difficulties, decision-making impulsivity, and aggression. Several studies have indicated that the interaction between some of these dimensions, especially between mental pain and interpersonal difficulties, may serve as major catalysts for SSAs. Suicidal risk assessment should incorporate a designated evaluation of these risk factors as part of suicide prevention models.

Contemporary Characteristics and Lethality Correlates of Serious Suicide Attempts in Children and Adolescents

OBJECTIVE

Adolescent suicide rates have increased in the past decade. Few studies have examined contemporary pediatric suicide attempters with medically serious suicide attempts, particularly among younger pediatric suicide attempters.

METHOD

This preliminary chart review study examined 200 adolescents with medically serious suicide attempts and sought to identify general cohort characteristics, differences in cohort characteristics based on age, correlates of lethality, and correlates of rescue (likelihood of prompt medical attention).

RESULTS

Our study found that younger adolescents specifically endorsed increased cyberbullying (β = 1.1, p = .046) and less hopelessness (β = -0.83, p = .02) compared to older adolescents. Suicide attempt lethality was negatively associated with female gender (β = -0.59, p = .041), rescue (β = -0.19, p = .005), an anxiety diagnosis (β = -0.81, p = .0003), and history of consensual sexual activity (β = -0.79, p = .002). Rescue was positively associated with an ADHD diagnosis (β = 0.73, p = .018) and less attempt planning (β = 0.96, p = .01), while a history of previous suicide attempt (β = -0.54, p = .04) and more proximal suicide attempt (β = -0.045, p = .008) were associated with a lower rescue score.

CONCLUSION

Our preliminary findings suggest clinicians and future researchers may need to assess certain social and diagnostic factors in children and adolescents at particularly high risk for death by suicide.

Alexithymia and self-harm: A review of nonsuicidal self-injury, suicidal ideation, and suicide attempts

INTRODUCTION

Suicide attempts are a significant global public health concern. Research into non-traditional factors, such as the presence of alexithymia, may shed light on the prediction of suicidal behaviours, which can aid intervention and prevention strategies. To ascertain whether alexithymia is a unique risk factor for suicide attempts, this article reviews the evidence on alexithymia related to suicidal ideation, attempts, and non-suicidal self-injury (NSSI).

METHODS

A literature search was conducted for original articles examining the general and psychiatric populations.

RESULTS

There is consistent evidence linking alexithymia with suicidal ideation and NSSI, but inconsistent evidence linking it to suicide attempts.

CONCLUSION

The relationship between alexithymia and suicidality seems to differ based on whether the research focuses on suicidal ideation, suicide attempts, or NSSI. The relationship between alexithymia and suicidality can be understood within the context of multiple code theory and childhood trauma. Future research should explore the whether alexithymia can reliably distinguish between those with a single attempt and those with multiple suicide attempts as well as alexithymia levels pre- and post-intervention with suicide-related behavior as outcomes in treatment studies.

Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach

Background: Moral Injury (MI) is one of the adverse consequences of combat. Following exposure to potentially morally injurious events (PMIEs)--events perceived as violations of deep moral beliefs by oneself or trusted individuals--a significant minority of veterans could develop posttraumatic stress disorder (PTSD) and depression. Objective: The current study represents the first attempt to apply a network analysis model to examine an exploratory empirical conceptualization of a network of PMIEs during military service, post-traumatic stress disorder (PTSD) symptom clusters, depression, and combat exposure among Israel Defence Forces veterans. Method: A volunteer sample of 191 Israeli combat veterans were recruited during 2017, and completed validated self-report questionnaires tapping PMIEs, PTSD, and depression in a cross-sectional design study. A regularized Gaussian graphical model was estimated. Results: Network analysis revealed strong bridge associations between the PTSD nodes and most of the PMIEs nodes. The nodes of PMIE-betrayal and PTSD negative alterations in cognitions and mood (NACM) symptom cluster were found to have a bridging function between other PMIEs and PTSD. Depression was found to be connected to most of the PMIEs and PTSD nodes. Conclusions: The study's findings offer an overview of the complex relationships between PMIEs and PTSD clusters among Israeli veterans. PMIEs--notably, betrayal-based experiences--are related to PTSD clusters directly and through depressive symptoms. Some possible mechanisms for the links between PMIEs and PTSD and the clinical implications related to specific interventions are discussed.

Ultra-Brief Crisis IPT-A Based Intervention for Suicidal Children and Adolescents (IPT-A-SCI) Pilot Study Results

In recent years, suicidal behaviors have shown substantial increase worldwide. This trend is also prominent in Israel and has led to a dramatic increase in mental health treatment demand resulting in long wait times and low treatment acceptance rate. To address the critical need in crisis intervention for children and adolescents at suicidal risk we developed an ultra-brief acute crisis intervention, based on Interpersonal Psychotherapy (IPT). IPT is an evidence-based intervention for various psychopathologies among different age groups. The current adaptation of IPT-A is comprised of five weekly sessions, followed by monthly follow-up caring email contacts to the patients and their parents, over a period of 3 months. This paper aims to review the theoretical foundation of this intervention, describe the research design, and present preliminary results of a pilot study. Preliminary Results from our samples of 26 adolescents indicate meaningful trends for both the suicidal ideation (SIQ) and depression (MFQ) outcome measures. Significant interaction was found concerning suicidal ideation but not for depression. Main limitations include small sample size and stratified controls. The treatment appears to be safe, feasible and acceptable and initial results show promising trends to support further study of the approach.

Differences between medically treated and untreated non-fatal self-harm reported by hotline callers in China

Background

Many self-harmers do not present in hospitals due to the self-harm. It is still unclear on the differences between medically treated and untreated self-harm in China. This study described the differences of the two groups of self-harmers using the largest psychological aid hotline data.

Methods

The present observational study recruited 3,403 hotline callers who reported episodes of self-harm before the call. In routine assessment, information about the most recent episode of self-harm was collected, including the method of self-harm, the wish to die, goals of the self-harm, and any medical treatment (irrespective of psychological services) in the hospital. The callers were divided into two groups: those who received hospital-based medical treatment due to the most recent self-harm (treated self-harm callers) and those who did not (untreated self-harm callers).

Results

In the most recent episode of self-harm, 65% (n = 2,217) of callers were untreated and 55% (1,226/2,217) of the untreated self-harm callers reported a wish to die. A total of 67% of the callers reported that their main goal of self-harm was to relieve suffering. The most common self-harm methods were using instruments (knife or rope) and overdosing on medicines. Compared with treated self-harm callers, the untreated self-harm callers were less likely to have a wish to die (OR = 0.57), engage in self-harm outside the home (OR = 0.71 and 0.78), and attribute their self-harm to romantic relationship problems (OR = 0.76); however, they were more likely to use instruments, to jump, or to choose other methods (OR = 3.73, 3.83, and 7.71, respectively).

Conclusions

Among hotline callers, many episodes of self-harm did not receive medical treatment, despite over half reporting a wish to die. Characteristics of self-harm behaviors were different between treated and untreated self-harm callers. Our findings suggest that more strategies should improve access to hospital-based medical treatment and coverage for post-intervention for self-harmers who are not presented in hospitals.

Correlates of Near-Fatal Deliberate Self-Harm in Qatar

Background: There are few research studies from Arab countries on suicide since many cultural and religious factors influence reporting. Aims: The purpose of this study was to explore the correlates of near-fatal deliberate self-harm in Qatar. Method: The study comprised a retrospective review of documented data of all patients with a suicide attempt admitted to the only Psychiatry Hospital in Qatar over a 12-month period. Logistic regression analysis was used to evaluate the contributors to near-fatal deliberate self-harm. Results: Out of 165 admissions with self-harm, 47 fulfilled criteria for near-fatal deliberate self-harm. The commonest methods were hanging followed by jumping from a height. Limitations: The retrospective nature of the study meant a lot of valuable data was missing. Also, lethality scales were not used and thus could not be measured. Conclusion: Men over the age of 25 years, widowed or divorced, and/or with psychotic disorder were more likely to engage in near-fatal deliberate self-harm.

Self-Disclosure Here and Now: Combining Retrospective Perceived Assessment With Dynamic Behavioral Measures

Most previous research on self-disclosure (SD) focused on its perceived retrospective aspects using self-report questionnaires. Few studies investigated actual SD as reflected in interpersonal interaction. We propose a comprehensive approach that combines new objective and dynamic measures of SD that evaluate situated SD with the traditional measures that evaluate stable SD properties. As SD is essentially verbal, we build on linguistic parameters for assessing actual SD, including acoustic features such as intonation and fluency, and verbal features such as the particular choice of words. Critically, the new measures highlight SD here and now and may reveal transient situational factors that affect it, such as the dynamics of interpersonal interaction. Based on these measures, we propose a three-dimensional evaluation that can portray different profiles of SD and offer a better prediction of SD behavior in different situations. The theoretical and clinical implications of the proposed approach are discussed.

The role of seasonality and photoperiod on the lethality of suicide attempts: A case-control study

BACKGROUND

The risk factors related to suicidal behaviors are complex and not yet fully known. Several studies underline how suicide results from the combination of psycho-social, biological, cultural, and environmental factors. The aim of this study was to investigate the potential role of seasonality and photoperiod on high-lethality suicide attempts (HLSA) compared with low-lethality suicide attempts (LLSA) in a sample of psychiatric inpatients.

METHODS

After attempting suicide, subjects were admitted in the emergency/psychiatric ward of the IRCCS Ospedale Policlinico San Martino from 1st August 2013 to 31st July 2018. Socio-demographic and clinical characteristics were collected.

RESULTS

The sample consisted of four hundred thirty-two individuals admitted for suicide attempt. One hundred thirty-three subjects (30.8%) of the sample committed a HLSA. The HLSA group peaked in the months with a higher sunlight exposure (June and July). Bivariate correlation analyses between seasonality/photoperiod in the whole sample and HLSA were positively associated with summer and highest solar intensity period.

LIMITATIONS

Data were limited to a single hospital, patients' seasonal environment, meteorological variables and psychological factors. In addition, the presence of acute life-events fostering the suicidal crisis has not been investigated.

CONCLUSIONS

The current study provides a novel perspective on the questions surrounding the impact of seasonality and daylight exposure on lethality of suicide attempts. further studies are needed to provide deeper understandings on the delicate molecular network that links suicide behaviors, seasonality and daylight in order to develop more effective prevention and treatment strategies in the future.

Impulsive suicide attempts among young people-A prospective multicentre cohort study in Sweden

BACKGROUND

We aimed to compare the prevalence of impulsive suicide attempts (ISA) among young adults and those over 25 who present at hospital in connection with attempted suicide. We also aimed to identify factors associated with ISA in young adults and to assess medical severity as well as the probability of repeated suicide attempts in this age group.

METHOD

A prospective multicentre cohort study included hospital known cases of suicide attempt (N = 666). The prevalence of ISA was compared between young adults (18-25) and adults aged > 26. We used logistic regression models to identify factors associated with ISA, associations of ISA with high medical severity and prediction of new fatal or non-fatal suicide attempts within 6 months.

RESULTS

43.7% of the young patients had made an ISA, and 30.2% among those aged > 26 (p = 0.001). Among the young, substance use disorder was associated with ISA; crude odds ratio (OR) 2.0 (1.0-4.2), and adjusted OR 2.1 (0.99-4.4). Affective disorder and unemployment/ sickness absence implied lower odds of ISA. ISA resulted in injuries of high medical severity as often as more planned attempts and non-fatal or fatal repetition within 6 months was equally common (30%) in both groups.

LIMITATIONS

The study was set in psychiatric emergency services, which limits the generalizability.

CONCLUSIONS

Clinicians should acknowledge that suicide attempts among youth often occur without previous planning and may result in medically severe injuries. The probability of new fatal or non-fatal suicide attempts should be kept in mind also after an impulsive suicide attempt.

The Association Between Dyslipidemia and Lethality of Suicide Attempts: A Case-Control Study

Evidence supports the existence of an association between dyslipidemia, psychiatric disorders, and suicide risk due to the effects of altered lipid profiles on serotoninergic neuron membranes. The aim of this study was to investigate the differences in c-reactive protein (CRP), thyroid functioning, total cholesterol, high lipoprotein density cholesterol (HDL-c), low-lipoprotein density cholesterol (LDL-c), and triglycerides (TG) serum levels in low lethality (LLSA) vs. high lethality suicide attempters (HLSA) within 24 h from the suicide attempt and inpatients who never attempted suicide (NAS). After attempting suicide, subjects were admitted to the emergency ward of the IRCCS Ospedale Policlinico San Martino and later to the section of Psychiatry from 1st August 2013 to 31st July 2018. Socio-demographic and clinical characteristics, serum lipids profile, CRP, and thyroid functioning were collected. The sample consisted of 133 individuals with a HLSA, 299 subjects with LLSA, and 200 patients NAS. HLSA subjects were more likely to be males and diagnosed as having a bipolar disorder. Furthermore, HLSA subgroup showed significantly lower total cholesterol and LDL-c levels and higher CRP serum levels compared to LLSA and control group, respectively. LLSA subgroup showed higher HDL-c levels compared to HLSA subgroup (no differences between HLSA and control group were observed). Additionally, the control group reported higher triglycerides levels compared to patients admitted to psychiatric ward for a suicide attempt. Only male gender, having a diagnosis of bipolar disorder, lower total cholesterol, and higher CRP serum levels predicted HLSA. Investigating the relation between dyslipidemia and the severity of suicide attempts may contribute to reveal the complex determinants underlying at-risk behaviors such as suicide, thus playing a relevant role in the possible prevention of this disabling phenomenon.

Risk-taking behaviors and stressors differentially predict suicidal preparation, non-fatal suicide attempts, and suicide deaths

Negative life events are elevated in suicidal populations. Diathesis-stress and kindling effects models suggest different mechanisms by which negative life events increase suicide risk. Different forms of negative life events - risk-taking behaviors and stressors - may have different effects on non-fatal suicide attempts and suicide. We assessed the effects of risk-taking behaviors and stressors on suicide, history of non-fatal suicide attempts, and active preparation for suicide in a sample of adults who died by suicide or other causes (N = 377). Psychological autopsy procedures using family member interviews and collateral record review were used to complete a risk-taking behaviors composite measure from the Structured Interview for DSM-IV Personality Disorders, the Modified Life Experiences Scale, and the planning subscale of the Suicide Intent Scale. Stressors were significantly associated with death by suicide, even when accounting for demographic and diagnostic characteristics. Risk-taking behaviors were significantly associated with non-fatal suicide attempts, even when accounting for demographic and diagnostic characteristics. Suicide decedents who did not actively prepare for suicide showed significantly higher risk-taking scores than suicide decedents who actively planned for suicide. Our results suggest that risk-taking behaviors and stressors impact suicide risk through separate mechanisms. Risk-taking behaviors may represent a longstanding vulnerability to act impulsively on suicidal thoughts. Stressors may impact risk for fatal suicidal behaviors in mood disordered populations.

Correlates of Suicidal Ideation During Pregnancy and Postpartum Among Women Living with HIV in Rural South Africa

In developing countries, up to 20% of maternal deaths during pregnancy are due to suicide, and being HIV-infected confers additional risk. This manuscript sought to identify perinatal correlates of suicidal ideation among women living with HIV (WLHIV) in rural South Africa. Pregnant WLHIV (N = 681) were recruited and re-assessed at 12-months postpartum. Mean age was 28.3 (SD = 5.7) years and 68% were below the poverty line. Prenatal suicidal ideation was 39%; suicidal ideation continued for 7% at 12 months, 13% experienced incident suicidal ideation, and for 19% suicidal ideation had stopped postnatally. Intimate partner violence (AOR = 1.17) and depression (AOR = 1.14) predicted sustained suicidal ideation. Increased income (AOR = 2.25) and greater stigma (AOR = 1.33) predicted incident suicidal ideation. Younger age (AOR = 0.94), disclosure of HIV status to partner (AOR = 0.60), and greater stigma (AOR = 1.24) predicted postnatal cessation of suicidal ideation. Perinatal care may provide windows of opportunity for identification and treatment of suicidal ideation.

When the Pain Becomes Unbearable: Case-Control Study of Mental Pain Characteristics Among Medically Serious Suicide Attempters

The unbearable mental pain experience is recognized as a key antecedent of suicidal behavior. We aimed to examine the precise nature of the mental pain among medically serious suicide attempters (MSSAs), a population closely resembling those who died by suicide. We evaluated various factors of mental pain from the Orbach and Mikulincer Mental Pain Scale, as well as medical lethality and suicide intent. MSSAs were higher than non-MSSAs and psychiatric controls for Irreversibility of pain. Moreover, Emptiness predicted medical lethality, while Cognitive Confusion negatively predicted suicide intent level, controlling for hopelessness and depression. high sense of Irreversibility of pain as well as high Emptiness and low Cognitive Confusion are important risk factors for more severe suicidal behavior. Implications for identification of at-risk groups for suicide as well as for suicide prevention and treatment of suicidal individuals are discussed.

The Function of Personality in Suicidal Ideation from the Perspective of the Interpersonal-Psychological Theory of Suicide

The Interpersonal-Psychological Theory of Suicide (IPTS) has been increasingly studied over the last years, responding to the demand for a valid framework addressing suicidality. Yet, only a few studies have explored the function of personality in the IPTS and none with clinical patients. We aimed to contribute to fill this gap in investigating the relationship between personality as conceptualized by the Five-Factor Model, the IPTS constructs, and a dimensional measure of current suicidal ideation. We conducted correlation, multiple linear regression, and path analyses based on a trait-interpersonal framework in a sample of 201 individuals visiting the psychiatric emergency room of a general hospital with current suicidal ideation. Neuroticism (positively) and openness (negatively) predicted perceived burdensomeness, while neuroticism (positively) and extraversion (negatively) predicted thwarted belongingness. Higher conscientiousness and lower extraversion were both predictors of the acquired capability for suicide. However, none of the models involving path analyses with IPTS variables as mediators of the relationship between personality traits and suicidal ideation was adequately adjusted to the data. Thus, it appears that personality plays a significant albeit modest role in suicidality when considered from an IPTS perspective. As personality is frequently assessed in the clinical routine, health professionals should consider it as complementary to detect individuals at risk of or presenting suicidal ideation.

Serious Suicide Attempts: Systematic Review of Psychological Risk Factors

BACKGROUND

One of the main obstacles in studying suicide risk factors is the difference between cases in which the individual died by suicide and those in which the individual engaged in suicidal behavior. A promising strategy that overcomes this obstacle is the study of survivors of serious suicide attempt (SSA), i.e., an attempt that would have been lethal had it not been for the provision of rapid and effective emergency treatment. Serious suicide attempters are epidemiologically very much like those who died by suicide, and thus may serve as valid proxies for studying suicides. This paper aims to define the specific risk factors for SSAs by conducting a qualitative data synthesis of existing studies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search of the literature in PubMed, ProQuest, and Psychlit electronic research-literature databases. Search terms were "serious" "OR" "near lethal," combined with the Boolean "AND" operator with "suicide*." In addition, we performed a manual search on Google Scholar for further studies not yet identified.

RESULTS

The preliminary search identified 683 citations. A total of 39 research reports that met the predefined criteria were analyzed. Mental pain, communication difficulties, decision-making impulsivity, and aggression, as well as several demographic variables, were found to be major risk factors for SSAs.

LIMITATIONS

We found a variability of definitions for SSA that hamper the ability to draw a model for the risk factors and processes that facilitate it. Moreover, the role of suicide intent and planning in SSA is still unclear. Further studies should aim to clarify and refine the concepts and measures of SSA, thereby enabling more specific and concrete modeling of the psychological element in its formation.

CONCLUSION

SSA is a distinguishable phenomenon that needs to be addressed specifically within the scope of suicidal behavior. Interpersonal problems, as well as impulsivity and aggression, seem to facilitate SSA when mental pain serves as a secondary factor. Healthcare professionals should be aware of SSA, and familiar with its specific risk factors. Moreover, psychological and suicidal risk assessment should include a designated evaluation of these risk factors as part of intervention and prevention models for SSA.

Factors Affecting Suicide Method Lethality Among Suicide Attempters in the Korea National Suicide Survey

This is the first national survey study in South Korea investigating the relationship between suicide lethality and the clinical information of suicide attempters. An interview questionnaire was used to assess their sociodemographic factors, medical and psychiatric information, and two suicide scales, the Columbia-Suicide Severity Rating Scale and the Suicide Intent Scale. Suicide methods were categorized as low and high lethality; low lethality covered drug overdose or self-cutting behavior, and high lethality covered all other methods. High and low lethality suicide method groups were significantly different in demographic, medical, and psychiatric factors. The two scale score distributions differed significantly across two groups, and the difference was also valid for the subcategory analyses of the Suicide Intent Scale. Multiple factors such as older age, male sex, no previous psychiatric history, and previous suicide attempt, as well as high suicide intent by means of suicide scale, affect selection of suicide method of high lethality.

Psychological scales as predictors of emergency department hospitalizations in suicide attempters

BACKGROUND

The purpose of this study was to evaluate the psychological scales reflecting lethality and intent as predictors of suicide attempter's hospitalization.

METHODS

Data of suicide attempters aged over 15years, who visited the ED from January 2013 to June 2016, were retrospectively collected and they were divided into the hospitalization and discharge groups. We evaluated the Risk-Rescue Rating Scale (RRRS) and Self-Inflicted Injury Severity Form (SIISF) for lethality and Suicide Intent Scale (SIS) for intent, respectively. The predictive abilities of these scales for hospitalization were compared in terms of performance (AUCs) and goodness-of-fit (the Bayesian information criterion [BIC]).

RESULTS

A total of 382 suicide attempters were enrolled, of which 233 (61%) were hospitalized. The scores of all psychological scales were significantly higher in the hospitalization group and all scales were identified as independent predictors of hospitalization. The AUC of the RRRS tended to be higher than those of the SIS and SIISF; similarly, the RRRS demonstrated the best overall fit (the lowest BIC). The AUC of combined the RRRS and SIS was superior to that of any of the individual scales alone. While the AUC of combined the SIISF and SIS was superior to that of either individual scale, it was comparable to that of the RRRS.

CONCLUSIONS

The psychological scales can be helpful for predicting suicide attempter's hospitalization in emergency settings. Especially, the RRRS seemed to have a superior predictive ability. Moreover, combining the scales had significantly better predictive performance than use of the individual scale alone did.

Suicide attempters with high and low suicide intent: Different populations in rural China

This paired case-control study aimed to compare characteristics between suicide attempters with high and low suicide intent in rural China. We evaluated 409 suicide attempters and their paired controls who were matched with the same gender, age (a difference of no more than 3 years), and similar residence. Compared to paired control, suicide attempt with high and low suicide intent shared the 3 common risk factors of negative life event, high depression score, and low social support score. In addition, mental disorder was an independent risk factor of suicide attempt with high intent. Having a low education level and occupation as a farmer were risk factors of suicide attempt with low intent. Mental disorder and depression were associated with a significantly increased risk of suicide attempt with high intent compared to low intent. Depression was found to be related to suicide attempt with high intent compared to low intent in the subgroups of male or female aged 35-54 or 55-70 years. Distinct characteristics were found in the suicide attempters with different intent. These findings are important and the aim is to transform them into concrete ideas for the prevention of suicide attempt in rural China.

Is There a Relationship between Suicidal Intent and Lethality in Deliberate Self-Poisoning?

The relationship between suicidal intent and lethality of deliberate self-poisoning (DSP) episodes and their associations with suicide have yielded contradictory findings. The aims of this study were to investigate the association between patients' suicidal intent and independently rated lethality of DSP episodes, and whether the association changes over time. Eighty-nine DSP patients were investigated longitudinally. Self-reported suicidal intent, including perceived likelihood of dying, wish to die, and whether or not the DSP was considered a suicide attempt, was measured at the time of the index episode (t1), 3 months (t2), and 12 months (t3) later. Lethality was assessed independently by three clinical toxicologists. Lethality was significantly associated with patients' reported wish to die (p = .01) and perceived likelihood of dying (p = .04) at t1, but not at t2 and t3. No association was found between whether the episode was considered a suicide attempt or not and lethality at t1, t2, or t3. Lethality and suicidal intent should be considered as largely separate dimensions of self-harm. Clinicians should bear this in mind during clinical assessment, especially regarding historical information.

Life satisfaction and degree of suicide intent: A test of the strain theory of suicide

BACKGROUND

Various factors contribute to suicide. Psychological strains are hypothesized to precede suicidal thought and attempt. Life satisfaction can be a measure of relative deprivation strain and aspiration-reality strain.

AIMS

This study was to compare the suicide attempters with various levels of life satisfaction and find out how life satisfaction affects the degree of suicide intent among medically serious suicide attempters.

METHODS

Subjects for study were recruited in some rural counties in China. Interview data were from hospital emergency rooms with medically serious attempters of suicide (n=791). The subjects were aged between 15 and 54years and 293 males and 498 females. Face to face interview was conducted for each suicide attempter with a semi-structural protocol including life satisfaction, physical health, demographic, sociological, and psychological measures, as well as psychological strains.

FINDINGS

The multiple linear regression analysis showed that mental disorder, aspiration strain and relative deprivation strain were significant risk factors for high intent of suicide among suicide attempters. The interaction between the two psychological strains also indicated that both failed aspiration and self-perceived low economic status in village play an important role in suicidal intent.

CONCLUSION

Low level of life satisfaction is associated with strong intent for suicide. Lack of life satisfaction is exemplified by relative deprivation perceived by the individuals and the discrepancy between an individual's aspiration for life and his/her reality. The findings from the suicide attempt data in rural China support the Strain Theory of Suicide.

The Promise and the Challenge of Technology-Facilitated Methods for Assessing Behavioral and Cognitive Markers of Risk for Suicide among U.S. Army National Guard Personnel

Suicide was the 10th leading cause of death for Americans in 2015 and rates have been steadily climbing over the last 25 years. Rates are particularly high amongst U.S. military personnel. Suicide prevention efforts in the military are significantly hampered by the lack of: (1) assessment tools for measuring baseline risk and (2) methods to detect periods of particularly heightened risk. Two specific barriers to assessing suicide risk in military personnel that call for innovation are: (1) the geographic dispersion of military personnel from healthcare settings, particularly amongst components like the Reserves; and (2) professional and social disincentives to acknowledging psychological distress. The primary aim of this paper is to describe recent technological developments that could contribute to risk assessment tools that are not subject to the limitations mentioned above. More specifically, Behavioral Signal Processing can be used to assess behaviors during interaction and conversation that likely indicate increased risk for suicide, and computer-administered, cognitive performance tasks can be used to assess activation of the suicidal mode. These novel methods can be used remotely and do not require direct disclosure or endorsement of psychological distress, solving two challenges to suicide risk assessment in military and other sensitive settings. We present an introduction to these technologies, describe how they can specifically be applied to assessing behavioral and cognitive risk for suicide, and close with recommendations for future research.

Suicide Ideation Is Related to Therapeutic Alliance in a Brief Therapy for Attempted Suicide

The objective of this study was to investigate the role of therapeutic alliance on suicide ideation as outcome measure in a brief therapy for patients who attempted suicide. Sixty patients received the 3-session therapy supplemented by follow-up contact through regular letters. Therapeutic alliance was measured with the Helping Alliance Questionnaire (HAQ). Outcome at 6 and 12 months was measured with the Beck Scale for Suicide Ideation (BSS). Therapeutic alliance increased from session 1 to session 3. Higher alliance measures correlated with lower suicidal ideation at 12 months follow-up. A history of previous attempts and depression had a negative affect on therapeutic alliance. The results suggest that in the treatment of suicidal patients therapeutic alliance may be a moderating factor for reducing suicide ideation.

Comparison of the characteristics of suicide attempters with major depressive disorder and those with no psychiatric diagnosis in emergency departments of general hospitals in China

BACKGROUND

Major depressive disorder (MDD) is a known major risk factor for suicide due to the high suicide mortality. However, studies comparing the characteristics of suicide attempters with major depressive disorder and those with no psychiatric diagnosis in China are very limited. This study examined and compared the sociodemographic and psychological characteristics of suicide attempters with MDD and those with no psychiatric diagnosis in emergency departments of general hospitals to better understand the risk factors for suicide attempts in China.

METHODS

All subjects were enrolled in the study between June 2007 and January 2008. A total of 127 suicide attempters-54 with MDD and 73 with no psychiatric diagnosis-were enrolled. The sociodemographic and clinical characteristics were compared between two groups using the statistical analysis performed using frequency distribution, Student's t test, Chi-square test, and Fisher's exact test and a logistic regression model.

RESULTS

Suicide attempters with MDD were more likely to be more depressive, older, divorced or separated, unemployed, and living alone, and more likely to write a suicide note, have suicide ideation, and be motivated by reducing pain and burden. Suicide attempters with no psychiatric diagnosis were more likely to be younger and more impulsive, have self-rescue, and be motivated by threatening or taking revenge on others. Multivariate logistic regression analysis identified the following independent predictors of suicide attempts in individuals with MDD: a lower score on the quality of life scale, more years of education, and suicide ideation.

CONCLUSIONS

The present study found both similarities and differences in the sociodemographic and clinical characteristics of suicide attempters with MDD and those with no psychiatric diagnosis in the emergency departments of general hospitals in China. These findings will help us to recognize the characteristics of suicide attempters in both groups and develop specific interventions for the two types of suicide attempters to prevent future suicide in China. For example, the suicide attempters with MDD in the emergency departments must be advised to the psychological clinic.

Comorbid intermittent explosive disorder and posttraumatic stress disorder: Clinical correlates and relationship to suicidal behavior

OBJECTIVE

Posttraumatic stress disorder (PTSD) is associated with both aggressive and suicidal behavior. Recent research suggests that the diagnosis of intermittent explosive disorder (IED), an impulse-control disorder characterized by repeated impulsive aggressive behavior, may help to identify individuals at risk for attempting suicide. Given the relationship between anger and PTSD, there is likely to be an increased prevalence of IED among individuals with PTSD; however, little is known about the overlap in these two disorders, including how individuals with comorbid IED and PTSD may differ from those with either disorder alone. The purpose of this study is to examine the clinical correlates of comorbid IED and PTSD and the contribution of these two disorders (among others) to lifetime suicide attempt and characteristics of suicidal behavior.

METHOD

In a large sample of community research volunteers (N=1460), we compared individuals with PTSD, IED, and comorbid PTSD and IED on measures of current mood, trait aggression, and trait impulsivity. We also examined the contributions of PTSD, IED, and other syndromal and personality disorders to the prediction of lifetime aggression and lifetime suicide attempt, and their relationship to characteristics of suicide attempts, including level of intent, use of violent versus non-violent means, and the medical seriousness of the attempt.

RESULTS

Comorbid PTSD and IED was associated with significantly elevated levels of depression, anxiety, anger, aggression, and impulsivity, as well as with high rates of comorbidity with other psychiatric disorders. IED (β=.56, p<.001), but not PTSD, significantly and uniquely predicted lifetime aggressive behavior. Both IED and PTSD were associated with lifetime suicide attempt in multivariate analysis (ORs: 1.6 and 1.6, ps<.05). The results show that IED, when comorbid with PTSD, identifies a subgroup of individuals with particularly high levels of aggressive behavior and a high rate of suicide attempt (41.4% in this sample).

CONCLUSION

These findings add support to the notion that the diagnosis of IED may aid in identifying individuals at risk for aggressive and suicidal behavior.

Medically Serious and Non-Serious Suicide Attempts in Persons Aged 70 and Above

High rates of suicide are observed among older adults in many countries worldwide. In clinical settings, those who make a medically serious suicide attempt are generally considered to be at higher risk of subsequent suicide than those who make less serious attempts. Medically serious attempts in older clinical cohorts are, however, relatively understudied. The aim was to compare older adult suicide attempters (70+) who did or did not make medically serious attempts. We hypothesized, in line with the Interpersonal Model of suicide, that social problems and feelings of being a burden would be associated with medical seriousness. Participants (n = 101) were recruited in hospitals in the aftermath of a suicide attempt; they took part in an interview with a research psychologist. Attempters with (n = 28) and without (n = 73) medically serious attempts were compared. Major depression was common in both groups, and scores on the Geriatric Depression Scale did not differ. However, older adults who made medically serious attempts scored higher on the Brief Scale of Anxiety and lower on the Mini Mental State Examination than their peers who made less serious attempts. Medically serious attempters more often attributed the attempt to social problems as well as problems with functioning and autonomy, but perceived burdensomeness was not associated with seriousness. Findings may help to inform clinicians who meet and treat older suicidal persons.

Predictive value of psychological characteristics and suicide history on medical lethality of suicide attempts: A follow-up study of hospitalized patients

BACKGROUND

This study examined the role of mental pain, communication difficulties, and suicide history in predicting the medical severity of follow-up suicide attempts.

METHODS

The cohort included 153 consecutive psychiatric in-patients who participated in earlier studies 1-9 years previously. Fifty-three had a history of a medically serious suicide attempt (MSSA), 64 had a history of a medically non-serious suicide attempt (MNSSA), and 36 had no history of suicide. A MSSA was defined as a suicide attempt that warranted hospitalization for at least 24h and extensive medical treatment. Participants completed a battery of instruments measuring mental pain and communication difficulties. Findings were analyzed in relation to follow-up suicide attempts and their severity.

RESULTS

Fifty-three patients (35.5%) had attempted suicide: 15 (9.9%) a MSSA (including 5 fatalities) and 38 (25%) a MNSSA. The medical severity of the index attempt and level of hopelessness at the index attempt were significantly correlated with medical severity of the follow-up attempt. In younger patients, high levels of depression and self-disclosure predicted the medical severity of the follow-up attempt. In patients with relatively low hopelessness, the medical severity of the attempt increased with the level of self-disclosure.

LIMITATIONS

(i) Possibly incomplete patient information, as some of the patients who participated in the index studies could not be located. (ii) Relatively small group of patients with an index MSSA.

CONCLUSIONS

Patients who have made a suicide attempt should be assessed for medical severity of the attempt, hopelessness, and communication difficulties, which are important factors in follow-up attempts.

Serious Suicide Attempts

BACKGROUND

Suicidal behavior comprises a diverse set of behaviors with significant differences among several behavioral categories. One noteworthy category includes individuals who have made serious suicide attempts, epidemiologically very similar to those completing suicide. This behavioral category is important, since interviewing survivors of a potentially lethal incident of self-harm enables a detailed investigation of the psychological process leading to the suicidal act.

AIM

To achieve a consensus definition and operational criteria of serious suicide attempts.

METHOD

We reviewed studies that included the term serious suicide attempt or related terms (e.g., highly lethal), with a focus on the variety of operational criteria employed across studies.

RESULTS

More than 60 papers addressing various types of serious suicide attempt were explored. We found a large variety of operational definitions, reflecting the lack of consensus regarding terminology and criteria related to the term.

CONCLUSION

We undertook the challenge of developing an integrative and comprehensive set of criteria of serious suicide attempt and suggest a definition comprising three key dimensions: medical lethality, potential lethality of the method used, and severity of the objective circumstances of the suicide intent. Clinicians and researchers are strongly encouraged to consider using the term serious suicide attempt with its attendant components.

Psychotic spectrum symptoms across the lifespan are related to lifetime suicidality among 147 patients with bipolar I or major depressive disorder

BACKGROUND

Conflicting evidence exists about the relationship between psychotic symptoms and suicidality in mood disorders. We aimed to investigate the lifetime suicidality and its relationship with dimensions of the psychotic spectrum over the lifespan among subjects with bipolar I (BD I) or major depressive disorder (MDD).

METHODS

147 Consecutive out- and inpatients with BD I or MDD presenting for treatment at 11 Italian Departments of Psychiatry were administered the Structured Clinical Interview for DSM-IV Axis I Disorders, the Structured Clinical Interview for the Psychotic Spectrum (SCI-PSY, lifetime version) and the Mood Spectrum Self-Report (MOODS-SR, lifetime version).

RESULTS

Subjects with psychotic features did not differ from those without for MOODS-SR suicidality score. Controlling for age, gender and diagnosis (MDD/BD I), the SCI-PSY total score (p = .007) and Paranoid (p = .042), Schizoid (p = .007) and Interpersonal Sensitivity (p < .001) domain scores independently predicted lifetime MOODS-SR suicidality score in the overall sample.

CONCLUSIONS

Psychotic features, as evaluated upon the presence of delusions or hallucinations, are not associated with suicidality among subjects with BD I or MDD. However, more subtle dimensions of the psychotic spectrum, such as Interpersonal Sensitivity, Paranoid and Schizoid symptoms, show a significant relationship with lifetime suicidality. Our findings highlight the potential usefulness of a spectrum approach in the assessment of psychotic symptoms and suicide risk among subjects with BD I or MDD.

Mental Pain and Suicide: A Systematic Review of the Literature

BACKGROUND

Mental pain, defined as a subjective experience characterized by perception of strong negative feelings and changes in the self and its function, is no less real than other types of grief. Mental pain has been considered to be a distinct entity from depression. We have performed a systematic review analyzing the relationship between mental pain and suicide by providing a qualitative data synthesis of the studies.

METHODS

We have conducted, in accordance with PRISMA guidelines, a systematic search for the literature in PubMed, Web Of Science, and Scopus. Search terms were "mental pain" "OR" "psychological pain" OR "psychache" combined with the Boolean "AND" operator with "suicid*." In addition, a manual search of the literature, only including the term "psychache," was performed on Google Scholar for further studies not yet identified.

RESULTS

Initial search identified 1450 citations. A total of 42 research reports met the predefined inclusion criteria and were analyzed. Mental pain was found to be a significant predictive factor of suicide risk, even in the absence of a diagnosed mental disorder. Specifically, mental pain is a stronger factor of vulnerability of suicidal ideation than depression.

CONCLUSION

Mental pain is a core clinical factor for understanding suicide, both in the context of mood disorders and independently from depression. Health care professionals need to be aware of the higher suicidal risk in patients reporting mental pain. In this regard, psychological assessment should include a clinimetric evaluation of mental pain in order to further detect its contribution to suicidal tendency.

Suicidal Intent and Method of Self-Harm: A Large-scale Study of Self-Harm Patients Presenting to a General Hospital

Data from the Oxford Monitoring System for Attempted Suicide (2004-2011) were used to study hospital presentations for self-harm in which Suicidal Intent Scale (SIS) scores were obtained (N = 4,840). Regression of medians was used to control for the confounding effect of age and gender. Higher estimated median SIS scores were associated with increasing age, male gender, self-poisoning versus self-injury, multiple methods of self-harm versus self-injury alone, use of gas (mainly carbon monoxide), dangerous methods of self-injury (including hanging, gunshot), and use of alcohol as part of the act. For self-poisoning patients, there was a correlation between the number of tablets taken and the total SIS score. Compared with self-poisoning with paracetamol and paracetamol-containing compounds, self-poisoning with antipsychotics was associated with a lower median SIS score while antidepressants had the same estimated median as paracetamol. Use of alcohol within 6 hours of self-harm was associated with lower SIS scores. In conclusion, certain methods of self-harm, particularly dangerous methods of self-injury and self-poisoning with gas, were associated with high intent and should alert clinicians to potential higher risk of suicide. However, apart from use of gas, suicidal intent cannot be inferred from type of drugs used for self-poisoning.

Reasons for attempted suicide in later life

OBJECTIVE

Using the Interpersonal Theory of Suicide as a guiding framework, we investigated older adults' causal attributions for suicidal behavior. We hypothesized that older adults who attributed their suicidal behavior to thwarted belongingness or perceived burdensomeness would be more likely to use more immediately lethal means and to re-attempt suicide during the 12-month follow-up.

DESIGN

Prospective cohort study in western Sweden.

PARTICIPANTS

A total of 101 older adults who presented to medical emergency rooms for suicide attempts.

MEASUREMENTS

Participants were asked why they attempted suicide.

RESULTS

Attributions included: a desire to escape (N = 29), reduced functioning and autonomy (N = 24), psychological problems, including depression (N = 24), somatic problems and physical pain (N = 16), perceived burdensomeness (N = 13), social problems that reflected either thwarted belongingness or family conflict (N = 13), and lack of meaning in life (N = 8); 41 participants provided more than one reason. No specific reason was given by 28 participants, 15 of whom reported not understanding or remembering why they attempted suicide and 13 reported simply wanting to die (or go to sleep and not wake up). As hypothesized, patients who attributed the attempt to thwarted belongingness were more likely to use more immediately lethal means for their index attempt and were more likely to re-attempt during follow-up. This was not the case for those reporting burdensomeness.

CONCLUSION

People who attribute suicide attempts to thwarted belongingness use more lethal methods and have a poorer prognosis. Replications across diverse cultural settings are needed to determine whether attributing suicide attempts to thwarted belongingness may warrant increased monitoring.

Examining the Importance of Mental Pain and Physical Dissociation and the Fluid Nature of Suicidality in Young Suicide Attempters

This study evaluated the importance of distress (i.e., mental pain, tolerance of mental pain, and depression) and physical dissociation factors for a group of young suicide attempters. Analyses indicated that those with higher current suicidality also evidenced higher current levels of depression and mental pain, lower mental pain tolerance, and higher physical dissociation. However, no correlations between suicidality and distress or physical dissociation were found when the level of suicidality was based on the time of the suicide attempt. The results demonstrate the importance of mental pain and its tolerance as well as physical dissociation in assessing severity of suicidality. However, analyses suggest there might be a decline in suffering after a suicide attempt and highlight the importance of assessing current suicidality when evaluating relevant variables for suicide. Findings are interpreted with regard to theories relating to the fluctuating nature of suicidality.

Positron emission tomography quantification of serotonin(1A) receptor binding in suicide attempters with major depressive disorder

IMPORTANCE

Serotonergic system dysfunction has been associated with increased lethal suicide attempts and suicide. Dysfunction includes higher binding of serotonin(1A) autoreceptor in the brainstem raphe of individuals who die by suicide.

OBJECTIVES

To determine the relationships between brain serotonin(1A) binding and suicidal behavior in vivo in major depressive disorder (MDD) using positron emission tomography and the serotonin(1A) antagonist radiotracer carbon C 11 [11C]-labeled WAY-100635.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional positron emission tomography study at an academic medical center from 1999 through 2009. We compared serotonin(1A) binding between individuals with MDD who did not attempt suicide (nonattempters) (n = 62) and those who attempted suicide (attempters) (n = 29). We subdivided the attempters into those with lower (n = 16) and higher (n = 13) levels of lethality.

MAIN OUTCOMES AND MEASURES

The binding potential (BPF) of [11C]WAY-100635 (calculated as the number of receptors available divided by affinity) in the prefrontal cortex (PFC) and brainstem, estimated by kinetic modeling with an arterial input function; the severity of suicidal behaviors, including lethality and intent of suicide attempts; and suicidal ideation.

RESULTS

Using a linear mixed-effects model, we found no difference between attempters and nonattempters with MDD in serotonin(1A) BPF in the PFC regions (F1,88 = 0.03; P = .87) or in the raphe nuclei (F1,88 = 0.29; P = .59). Raphe nuclei serotonin(1A) BPF was 45.1% greater in higher-lethality attempters compared with lower-lethality attempters (F1,25 = 7.33; P = .01), whereas no difference was observed in the PFC regions (F1,25 = 0.12; P = .73). Serotonin(1A )BPF in the raphe nuclei of suicide attempters was positively correlated with the lethality rating (F1,25 = 10.56; P = .003) and the subjective lethal intent factor (F1,25 = 10.63; P = .003; R2 = 0.32) based on the most recent suicide attempt. Suicide ideation in participants with MDD was positively correlated with serotonin(1A) BPF in the PFC regions (F1,88 = 5.19; P = .03) and in the raphe nuclei (F1,87 = 7.38; P = .008; R2 = 0.12).

CONCLUSIONS AND RELEVANCE

Higher brainstem raphe serotonin(1A)BPF observed in higher-lethality suicide attempters with MDD is in agreement with findings in suicide studies and also with the finding of low cerebrospinal fluid levels of 5-hydroxyindoleacetic acid in higher-lethality suicide attempters. Higher brainstem raphe serotonin(1A) BPF would be consistent with lower levels of serotonin neuron firing and release and supports a model of impaired serotonin signaling in suicide and higher-lethality suicidal behavior. Severity of suicidal ideation in MDD is related to brainstem and prefrontal serotonin(1A) BPF, suggesting a role for both regions in suicidal ideation. Lower levels of serotonin release at key brain projection sites, such as the prefrontal regions, may favor more severe suicidal ideation and higher-lethality suicide attempts.