Functional domains as correlates of suicidality among psychiatric inpatients

Suicide Crisis Syndrome: A systematic review

BACKGROUND

The objective of this systematic review is to describe the scientific evidence for the Suicide Crisis Syndrome (SCS), a presuicidal cognitive and affective state consisting of five symptomatic dimensions: entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The aim of this article is to summarize the emerging literature on the SCS and to assess the extent to which a uniform syndrome can be assumed.

METHODS

A systematic literature search was conducted in three different databases (PubMed, PsycInfo, and Google Scholar) using the search terms "Suicide Crisis Inventory," "Suicide Crisis Syndrome," "Narrative Crisis Model of Suicide," and "Suicide Trigger State."

RESULTS

In total, 37 articles from 2010 to 2022 were identified by search criteria. Twenty-one articles published between 2017 and 2022 were included in the systematic review. All but three studies were conducted in the United States and examined clinical samples of adult high-risk psychiatric in- and outpatients. Sample sizes ranged from N = 170 to 4846. The findings confirm the unidimensional structure of the proposed disorder and support the predictive validity for short-term suicidal behavior above and beyond suicidal ideation.

CONCLUSION

Despite the promising predictive validity of the SCS, a precise prediction of future suicidal behavior remains difficult.

Using the Beck Depression Inventory to Assess Anhedonia: A Scale Validation Study

Anhedonia is central to several psychological disorders and a frequent target of psychosocial and pharmacological treatments. We evaluated the psychometric properties of two widely used anhedonia measures derived from the Beck Depression Inventory: a 3-item (BDI-Anh3) and a 4-item version (BDI-Anh4). We evaluated these measures in a large undergraduate sample, a community sample, and a clinical sample. Both the BDI-Anh3 and the BDI-Anh4 showed adequate internal consistency, with BDI-Anh4 performing somewhat better, across the three samples. Both measures showed good convergent and discriminant validity, even after controlling for shared variance with other items on the BDI. These findings indicate that both measures have sufficient reliability and validity to support their use by researchers and clinicians.

Personality characteristics, not clinical symptoms, are associated with anhedonia in a community sample: A preliminary investigation

Anhedonia is a salient transdiagnostic psychiatric symptom associated with increased illness severity and chronicity. Anhedonia is also present to varying degrees in non-clinical cohorts. Here, we sought to examine factors influencing expression of anhedonia. Participants (N = 335) were recruited through the Nathan Kline Institute-Rockland Sample, an initiative to deeply phenotype a large community sample across the lifespan. Utilizing a data-driven approach, we evaluated associations between anhedonia severity, indexed by Snaith-Hamilton Pleasure Scale (SHAPS), and 20 physical, developmental, and clinical measures, including Structured Clinical Interview for DSM-IV, Beck Depression Inventory, State-Trait Anxiety Inventory, NEO Five-Factor Inventory-3 (NEO-FFI-3), BMI, Hemoglobin A1C, and demography. Using a bootstrapped AIC-based backward selection algorithm, seven variables were retained in the final model: NEO-FFI-3 agreeableness, extraversion, and openness to experience; BMI; sex; ethnicity; and race. Though median SHAPS scores were greater in participants with psychiatric diagnoses (18.5) than those without (17.0) (U = 12238.5, z = 2.473, p = 0.013), diagnosis and symptom measures were not retained as significant predictors in the final robust linear model. Participants scoring higher on agreeableness, extraversion, and openness to experience reported significantly lower anhedonia. These results demonstrate personality as a mild-to-moderate but significant driver of differences in experiencing pleasure in a community sample.

A Predictive Coding Framework for Understanding Major Depression

Predictive coding models of brain processing propose that top-down cortical signals promote efficient neural signaling by carrying predictions about incoming sensory information. These "priors" serve to constrain bottom-up signal propagation where prediction errors are carried via feedforward mechanisms. Depression, traditionally viewed as a disorder characterized by negative cognitive biases, is associated with disrupted reward prediction error encoding and signaling. Accumulating evidence also suggests that depression is characterized by impaired local and long-range prediction signaling across multiple sensory domains. This review highlights the electrophysiological and neuroimaging evidence for disrupted predictive processing in depression. The discussion is framed around the manner in which disrupted generative predictions about the sensorium could lead to depressive symptomatology, including anhedonia and negative bias. In particular, the review focuses on studies of sensory deviance detection and reward processing, highlighting research evidence for both disrupted generative predictions and prediction error signaling in depression. The role of the monoaminergic and glutamatergic systems in predictive coding processes is also discussed. This review provides a novel framework for understanding depression using predictive coding principles and establishes a foundational roadmap for potential future research.

Anhedonia and Suicide

Suicide is a leading cause of death, and presently, there is no definitive clinical indicator of future suicide behaviors. Anhedonia, a transdiagnostic symptom reflecting diminished ability to experience pleasure, has recently emerged as a risk factor for suicidal thoughts and behaviors (STBs). This overview, therefore, has the following aims. First, prior research relating anhedonia to STBs will be reviewed, with a particular focus on clarifying whether anhedonia is more closely associated with suicidal thoughts versus behaviors. Second, the National Institute of Mental Health's Research Domain Criteria Positive Valence Systems provide a useful heuristic to probe anhedonia across different units of analysis, including clinical symptoms, behaviors, neural mechanisms, and molecular targets. Accordingly, anhedonia-related constructs linked to STBs will be detailed as well as promising next steps for future research. Third, although anhedonia is not directly addressed in leading suicide theories, this review will provide potential inroads to explore anhedonia within diathesis-stress and interpersonal suicide frameworks. Last, novel approaches to treat anhedonia as a means of reducing STBs will be examined.

Multimodal Investigations of Reward Circuitry and Anhedonia in Adolescent Depression

Depression is a highly prevalent condition with devastating personal and public health consequences that often first manifests during adolescence. Though extensively studied, the pathogenesis of depression remains poorly understood, and efforts to stratify risks and identify optimal interventions have proceeded slowly. A major impediment has been the reliance on an all-or-nothing categorical diagnostic scheme based solely on whether a patient endorses an arbitrary number of common symptoms for a sufficiently long period. This approach masks the well-documented heterogeneity of depression, a disorder that is highly variable in presentation, severity, and course between individuals and is frequently comorbid with other psychiatric conditions. In this targeted review, we outline the limitations of traditional diagnosis-based research and instead advocate an alternative approach centered around symptoms as unique dimensions of clinical dysfunction that span across disorders and more closely reflect underlying neurobiological abnormalities. In particular, we highlight anhedonia-the reduced ability to anticipate and experience pleasure-as a specific, quantifiable index of reward dysfunction and an ideal candidate for dimensional investigation. Anhedonia is a core symptom of depression but also a salient feature of numerous other conditions, and its severity varies widely within clinical and even healthy populations. Similarly, reward dysfunction is a hallmark of depression but is evident across many psychiatric conditions. Reward function is especially relevant in adolescence, a period characterized by exaggerated reward-seeking behaviors and rapid maturation of neural reward circuitry. We detail extensive work by our research group and others to investigate the neural and systemic factors contributing to reward dysfunction in youth, including our cumulative findings using multiple neuroimaging and immunological measures to study depressed adolescents but also trans-diagnostic cohorts with diverse psychiatric symptoms. We describe convergent evidence that reward dysfunction: (a) predicts worse clinical outcomes, (b) is associated with functional and chemical abnormalities within and beyond the neural reward circuitry, (c) is linked to elevated peripheral levels of inflammatory biomarkers, and (d) manifests early in the course of illness. Emphasis is placed on high-resolution neuroimaging techniques, comprehensive immunological assays, and data-driven analyses to fully capture and characterize the complex, interconnected nature of these systems and their contributions to adolescent reward dysfunction.

Physical and social anhedonia are associated with suicidality in major depression, but not in schizophrenia

OBJECTIVE

This cross-sectional study investigated the association of physical and social anhedonia with suicidality in patients with major depressive disorder (MDD), schizophrenia, and in non-psychiatric controls.

METHOD

All participants completed the revised Physical Anhedonia Scale (RPAS) and the revised Social Anhedonia Scale (RSAS) and were subdivided according to positive life-time suicide attempt history. MDD patients were evaluated with the Montgomery-Ãsberg Depression Rating Scale (MADRS), healthy respondents with the Patient Health Questionnaire-9 (PHQ-9), and schizophrenia patients with the Calgary Depression Scale for Schizophrenia (CDSS).

RESULTS

In 683 study participants, the prevalence of each anhedonia was the highest in MDD, followed by schizophrenia, and lowest in the control group. Among MDD patients, those with physical and social anhedonia had greater rates of recent suicidal ideation, while a higher frequency of individuals with life-time suicide attempts was detected in those with only social anhedonia. In contrast, no association between either anhedonia and life-time suicide attempts or recent suicidal ideation was found in patients with schizophrenia.

CONCLUSIONS

Assessing social and physical anhedonia might be important in MDD patients, given its association with both life-time suicide attempts and recent suicidal ideation. Suicidality in schizophrenia, while unrelated to anhedonia, might include other risk factors.

Altered anterior cingulate glutamatergic metabolism in depressed adolescents with current suicidal ideation

The anterior cingulate cortex (ACC) is involved in emotion regulation and salience processing. Prior research has implicated ACC dysfunction in suicidal ideation (SI) and suicidal behavior. This study aimed to quantify ACC glutamatergic concentrations and to examine relationships with SI in a sample of healthy and depressed adolescents. Forty adolescents underwent clinical evaluation and proton magnetic resonance spectroscopy (1H-MRS) at 3 T, utilizing a 2-dimensional J-averaged PRESS sequence sampling a medial pregenual ACC voxel. Cerebrospinal fluid-corrected ACC metabolite concentrations were compared between healthy control (HC, n = 16), depressed without SI (Dep/SI-, n = 13), and depressed with SI (Dep/SI+, n = 11) youth using general linear models covarying for age, sex, and psychotropic medication use. Relationships between ACC metabolites and continuous measures of SI were examined using multiple linear regressions. ROC analysis was used to determine the ability of glutamate+glutamine (Glx) and the N-acetylaspartate (NAA)/Glx ratio to discriminate Dep/SI- and Dep/SI+ adolescents. Dep/SI+ adolescents had higher Glx than Dep/SI- participants (padj = 0.012) and had lower NAA/Glx than both Dep/SI- (padj = 0.002) and HC adolescents (padj = 0.039). There were significant relationships between SI intensity and Glx (pFDR = 0.026), SI severity and NAA/Glx (pFDR = 0.012), and SI intensity and NAA/Glx (pFDR = 0.004). ACC Glx and NAA/Glx discriminated Dep/SI- from Dep/SI+ participants. Uncoupled NAA-glutamatergic metabolism in the ACC may play a role in suicidal ideation and behavior. Longitudinal studies are needed to establish whether aberrant glutamatergic metabolism corresponds to acute or chronic suicide risk. Glutamatergic biomarkers may be promising targets for novel risk assessment and interventional strategies for suicidal ideation and behavior.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A validation study of a novel tool for suicide risk assessment

BACKGROUND

Reliable diagnostic tools for the short-term suicide risk assessment are needed. The recently developed multi-informant Modular Assessment of Risk for Imminent Suicide (MARIS) includes four modules: two are patient-rated and two clinician-rated. The patient-rated modules assess a proposed pre-suicidal cognitive/emotional state (Module 1) as well as patients' attitudes towards suicide (Module 2). The clinician-rated modules assess traditional suicide risk factors (Module 3) and clinicians' emotional responses to the patient (Module 4).

METHODS

With the aim of extending our previous preliminary proof of concept findings, the MARIS was administered to 618 psychiatric patients (167 inpatients, 451 outpatients) and their clinicians (N = 115). Patients were assessed with a battery including the Columbia-Suicide Severity Rating Scale. Four outcomes were considered: lifetime and past month suicidal thoughts and behaviors (STB) (0-10 point scale) and suicidal behaviors (SB) (0-5 point scale). Reliability and concurrent, convergent/divergent and incremental validity were assessed.

RESULTS

Good internal consistency was found for modules 1 and 4 (Cronbach's α: 0.87 and 0.86, respectively) but not for the others. Module 1's total score positively correlated with lifetime STB/SB and past month STB (all p ≤ 0.003). Module 4's total score positively correlated with all four outcomes (all p < 0.001). Modules 1 and 4 showed additional capacity to detect patients' lifetime and past month STB/SB beyond other associated factors.

LIMITATIONS

Lack of prospective assessment. Inpatients were evaluated at discharge, whereas outpatients at intake.

CONCLUSIONS

These findings supported the utility of multiple data sources to identify patients at imminent suicide risk, and in particular clinicians' emotional responses.

Differential effects of state and trait social anhedonia on suicidal ideation at 3-months follow up

BACKGROUND

Recent work suggests that the social component of anhedonia is more associated with suicide ideation than the other component of pleasure. The present study investigated the differential effects of state and trait social anhedonia on suicidal ideation across two undergraduate samples based on the Interpersonal Theory and Three-Step Theory of Suicide.

METHODS

State social anhedonia was assessed with a single item (Loss of Interest in People) extracted from the Beck Depression Inventory, while trait social anhedonia was assessed using the Anticipatory and Consummatory Interpersonal Pleasure Scale. Suicidal ideation was re-administered at a 3-month follow-up.

RESULTS

In Study 1, higher state social anhedonia was associated with greater levels of suicidal ideation, while trait social anhedonia moderated the relationship between thwarted belongingness, perceived burdensomeness and suicidal ideation. In Study 2, state social anhedonia was margin significant predictor of suicidal ideation, while trait social anhedonia moderated the relationship between psychological pain and suicidal ideation.

CONCLUSIONS

These findings confirmed the presence of two different effects on suicidal ideation in state and trait social anhedonia: state social anhedonia directly was associated with suicidal ideation, while trait social anhedonia was indirectly related through their effects on other risk factors of suicidality.

Candidate Biomarkers of Suicide Crisis Syndrome: What to Test Next? A Concept Paper

BACKGROUND

There has been increasing interest in both suicide-specific diagnoses within the psychiatric nomenclature and related biomarkers. Because the Suicide Crisis Syndrome-an emotional crescendo of several interrelated symptoms-seems to be promising for the identification of individuals at risk of suicide, the aim of the present paper is to review the putative biological underpinnings of the Suicide Crisis Syndrome symptoms (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal).

METHODS

A PubMed literature search was performed to identify studies reporting a link between each of the 5 Suicide Crisis Syndrome symptoms and biomarkers previously reported to be associated with suicidal outcomes.

RESULTS

Disturbances in the hypothalamic-pituitary-adrenal axis, with dysregulated corticotropin-releasing hormone and cortisol levels, may be linked to a sense of entrapment. Affective disturbance is likely mediated by alterations in dopaminergic circuits involved in reward and antireward systems as well as endogenous opioids. Loss of cognitive control is linked to altered neurocognitive function in the areas of executive function, attention, and decision-making. Hyperarousal is linked to autonomic dysregulation, which may be characterized by a reduction in both heart rate variability and electrodermal activity. Social withdrawal has been associated with oxytocin availability. There is also evidence that inflammatory processes may contribute to individual Suicide Crisis Syndrome symptoms.

CONCLUSION

The Suicide Crisis Syndrome is a complex syndrome that is likely the consequence of distinct changes in interconnected neural, neuroendocrine, and autonomic systems. Available clinical and research data allow for development of empirically testable hypotheses and experimental paradigms to scrutinize the biological substrates of the Suicide Crisis Syndrome.

Can Anhedonia Be Considered a Suicide Risk Factor? A Review of the Literature

Background and Objectives: At present, data collected from the literature about suicide and anhedonia are controversial. Some studies have shown that low levels of anhedonia are associated with serious suicide attempts and death by suicide, while other studies have shown that high levels of anhedonia are associated with suicide. Materials and Methods: For this review, we searched PubMed, Medline, and ScienceDirect for clinical studies published from 1 January 1990 to 31 December 2018 with the following search terms used in the title or in the abstract: “anhedonia AND suicid*.” We obtained a total of 155 articles; 133 items were excluded using specific exclusion criteria, the remaining 22 articles included were divided into six groups based on the psychiatric diagnosis: mood disorders, schizophrenia spectrum disorders, post-traumatic stress disorder (PTSD), other diagnoses, attempted suicides, and others (healthy subjects). Results: The results of this review reveal inconsistencies. Some studies reported that high anhedonia scores were associated with suicidal behavior (regardless of the diagnosis), while other studies found that low anhedonia scores were associated with suicidal behavior, and a few studies reported no association. The most consistent association between anhedonia and suicidal behavior was found for affective disorders (7 of 7 studies reported a significant positive association) and for PTSD (3 of 3 studies reported a positive association). In the two studies of patients with schizophrenia, one found no association, and one found a negative association. For patients who attempted suicide (undiagnosed), one study found a positive association, one a positive association only for depressed attempters, and one a negative association. Conclusions: We found the most consistent positive association for patients with affective disorders and PTSD, indicating that the assessment of anhedonia may be useful in the evaluation of suicidal risk.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

Emotional Pain Mediates the Link Between Preoccupied Attachment and Non-suicidal Self-Injury in High Suicide Risk Psychiatric Inpatients

Background: Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts (SA). Both attachment disturbances and cognitive and emotional problems (e.g., emotional pain) have been associated with SA history. This study sought to determine differential contributions of attachment styles and cognitive and emotional states associated with SA to lifetime NSSI occurrence among adults hospitalized for suicide risk.

Sampling and Methods: Adult psychiatric inpatients (n = 200) were assessed for attachment style, cognitive and emotional states, and lifetime NSSI within 72 h of hospitalization. Binary logistic regression and mediation analyses were performed.

Results: Preoccupied attachment and emotional pain at admission were independently associated with lifetime NSSI. Emotional pain partially mediated the relationship between preoccupied attachment and lifetime NSSI.

Limitations: The cross-sectional nature of the study and the use of a dichotomous (yes/no) measure of NSSI, not specifically designed for its assessment.

Conclusions: Preoccupied attachment and emotional pain are associated with NSSI and may be useful targets for assessing risk of NSSI.

Anhedonia and suicidal thoughts and behaviors in psychiatric outpatients: The role of acuity

BACKGROUND

Anhedonia-impairment related to the experience of pleasure-has been identified as a potential risk factor for suicide, with some mixed findings. The current study sought to clarify the role of acuity of anhedonia in the relationship between anhedonia and suicidal thoughts and behaviors by comparing acutely and chronically anhedonic subjects on severity of suicidal ideation (SI) and suicide attempt (SA) history.

METHODS

Psychiatric outpatients (N = 395) were administered the Columbia Suicide Severity Rating Scale, the Beck Scale for Suicidal Ideation and a modified version of the Snaith-Hamilton Pleasure Scale (SHPS); SI measures were readministered at a 1-month follow-up (N = 289, 73%). Participants were classified as acutely anhedonic, chronically anhedonic and nonanhedonic based on their responses to the SHPS at initial assessment.

RESULTS

Controlling for symptoms of anxiety and depression, acute anhedonia was cross-sectionally and prospectively associated with greater severity of SI compared to the nonanhedonic group; no differences in severity of SI were found between the chronically anhedonic and nonanhedonic group at either time point. Anhedonia grouping was not associated with SA history.

CONCLUSION

Changes in capacity to experience pleasure may be more informative of near-term SI than typically low pleasure levels. Future investigation should focus on the relationship between acute anhedonia and imminent suicidal behavior.

Young children with psychotic symptoms and risk for suicidal thoughts and behaviors: a research note

Objective

Suicidal thoughts and behaviors (STBs) are prevalent among youth with psychotic disorders (PD) relative to the general population. Recent research now suggests that STBs may present during the prodromal phase of the disease, or the clinical high risk (CHR) state. While this knowledge is important for the development of suicide prevention strategies in adolescent and adult populations, it remains unclear whether risk for suicide extends to children with or at risk for psychosis. The current study is an extension of previous work assessing STBs in youth across the psychosis continuum. We examine STBs in 37 CHR and PD children ages 7–13 years old, and further explore the prodromal symptom correlates of STB severity among CHR children.

Results

CHR and PD children endorsed STBs with a frequency and severity similar to what is observed in older CHR and PD populations. A number of children had never previously vocalized their suicidal plans or intent. Among CHR children, Social Anhedonia and Odd Behavior or Appearance were significantly correlated with STB severity. These findings underscore the importance of screening for STBs even in young children presenting with psychotic symptoms.

Modes of Resting Functional Brain Organization Differentiate Suicidal Thoughts and Actions: A Preliminary Study

OBJECTIVE

A major target in suicide prevention is interrupting the progression from suicidal thoughts to action. Use of complex algorithms in large samples has identified individuals at very high risk for suicide. We tested the ability of data-driven pattern classification analysis of brain functional connectivity to differentiate recent suicide attempters from patients with suicidal ideation.

METHODS

We performed a cross-sectional study using resting-state functional magnetic resonance imaging in depressed inpatients and outpatients of both sexes recruited from a university hospital between March 2014 and June 2016: recent suicide Attempters within 3 days of an attempt (n = 10), Suicidal Ideators (n = 9), Depressed Non-Suicidal Controls (n = 17), and Healthy Controls (n = 18). All depressed patients fulfilled DSM-IV-TR criteria for major depressive episode and either major depressive disorder, bipolar disorder, or depression not otherwise specified. A subset of suicide attempters (n = 7) were rescanned within 7 days. We used a support vector machine data-driven neural pattern classification analysis of resting-state functional connectivity to characterize recent suicide attempters and then tested the classifier's specificity.

RESULTS

A binary classifier trained to discriminate patterns of resting-state functional connectivity robustly differentiated Suicide Attempters from Suicidal Ideators (mean accuracy = 0.788, signed rank test: P = .002; null hypothesis: area under the curve = 0.5), with distinct functional connectivity between the default mode and the limbic, salience, and central executive networks. The classifier did not discriminate stable Suicide Attempters from Suicidal Ideators (mean accuracy = 0.58, P = .33) or presence from absence of lifetime suicidal behavior (mean accuracy = 0.543, P = .348) and was not improved by modeling clinical variables (mean accuracy = 0.736, P = .002).

CONCLUSIONS

Measures of intrinsic brain organization may have practical value as objective measures of suicide risk and its underlying mechanisms. Further incorporation of serum or cognitive markers and use of a prospective study design are needed to validate and refine the clinical relevance of this candidate biomarker of suicide risk.

Relationships between anhedonia, suicidal ideation and suicide attempts in a large sample of physicians

BACKGROUND

The relationships between anhedonia and suicidal ideation or suicide attempts were explored in a large sample of physicians using the interpersonal psychological theory of suicide. We tested two hypotheses: firstly, that there is a significant relationship between anhedonia and suicidality and, secondly, that anhedonia could mediate the relationships between suicidal ideation or suicide attempts and thwarted belongingness or perceived burdensomeness.

METHODS

In a cross-sectional study, 557 physicians filled out several questionnaires measuring suicide risk, depression, using the abridged version of the Beck Depression Inventory (BDI-13), and demographic and job-related information. Ratings of anhedonia, perceived burdensomeness and thwarted belongingness were then extracted from the BDI-13 and the other questionnaires.

RESULTS

Significant relationships were found between anhedonia and suicidal ideation or suicide attempts, even when significant variables or covariates were taken into account and, in particular, depressive symptoms. Mediation analyses showed significant partial or complete mediations, where anhedonia mediated the relationships between suicidal ideation (lifetime or recent) and perceived burdensomeness or thwarted belongingness. For suicide attempts, complete mediation was found only between anhedonia and thwarted belongingness. When the different components of anhedonia were taken into account, dissatisfaction-not the loss of interest or work inhibition-had significant relationships with suicidal ideation, whereas work inhibition had significant relationships with suicide attempts.

CONCLUSIONS

Anhedonia and its component of dissatisfaction could be a risk factor for suicidal ideation and could mediate the relationship between suicidal ideation and perceived burdensomeness or thwarted belongingness in physicians. Dissatisfaction, in particular in the workplace, may be explored as a strong predictor of suicidal ideation in physicians.

Entrapment as a mediator of suicide crises

BACKGROUND

Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients.

METHODS

The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated.

RESULTS

Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI.

CONCLUSION

Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior.

Clinicians' conflicting emotional responses to high suicide-risk patients-Association with short-term suicide behaviors: A prospective pilot study

BACKGROUND

Clinician's emotional responses to patients have been recognized as potentially relating to treatment outcome, however they have received little attention in the literature on suicide risk. We examine the relationship between a novel targeted measure of clinicians' emotional responses to high-risk psychiatric inpatients and their short-term post-discharge suicide behavior.

METHODS

First-year psychiatry residents' emotional responses to their patients were assessed anonymously with the novel self-report 'Therapist Response Questionnaire-Suicide Form' (TRQ-SF). Patient outcomes were assessed at 1-2months post-discharge, and post-discharge suicide outcomes were assessed with the Columbia Suicide Severity Rating Scale. Following exploratory factor analysis of the TRQ-SF, scores on the resultant factors were examined for relationships with clinical and demographic measures and post-discharge suicide behavior.

RESULTS

A two-factor model fit the data, with factors reflecting dimensions of affiliation/rejection and distress/non-distress. Two items that did not load robustly on either factor had face validity for hopefulness and hopelessness and were combined as a measure along a hopefulness/hopelessness dimension. The interaction Distress×Hopefulness, reflecting a conflicting emotional response pattern, significantly predicted post-discharge suicide outcomes even after covarying for depression, entrapment, and suicidal ideation severity.

CONCLUSION

Clinicians' conflicting emotional responses to high-risk patients predicted subsequent suicidal behavior, independent of traditional risk factors. Our findings demonstrate the potential clinical value of assessing such responses.

Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory

BACKGROUND

We have developed the Suicide Crisis Inventory (SCI) to evaluate the intensity of the Suicidal Crisis Syndrome, an acute state hypothesized to precede suicide attempt. The psychometric properties of the SCI, including predictive validity for suicidal behavior (SB), were assessed.

METHODS

Adult psychiatric patients (n = 201) hospitalized for high suicide risk were assessed. Logistic regression models assessed the SCI's predictive validity for SB in the 4-8 weeks following hospital discharge and its incremental predictive validity over traditional risk factors (n = 137, 64% f/u rate). Internal structure, reliability, convergent and discriminant validity, and state versus trait properties were also assessed.

RESULTS

The SCI had excellent internal consistency (Cronbach's α 0.970). The SCI total score at discharge predicted short-term SB with 64% sensitivity 88% specificity (OR = 13, P = .003) at its optimal cut score. In a test of its incremental predictive validity, SCI total score at discharge improved prediction of SB over traditional risk factors (Chi-squared 5.597, P = .024, model P = .001), with AOR 2.02 (P = .030). The SCI admission versus discharge test-retest reliability and score distributions showed it to be an acute state measure.

CONCLUSION

The SCI was predictive of future SB in high-risk psychiatric inpatients during the crucial weeks following their hospital discharge. Further validation in diverse patient populations is needed.