Fearlessness about death: the psychometric properties and construct validity of the revision to the acquired capability for suicide scale

Development and Validation of the Fearlessness About Suicide Scale

Recent work has identified fearlessness about suicide, rather than fearlessness about death, as more theoretically relevant in the assessment of capability for suicide and thus a more appropriate construct of measurement. The aim of the current project was to develop and validate a scale specifically assessing fearlessness about suicide. Across two studies, support for a 7-item, single-factor structure of the Fearlessness About Suicide Scale (FSS) emerged. The FSS factor structure demonstrated a good fit in the first study and was replicated in the second study. Measurement invariance was examined across those identifying as men and women and found to be comparable. The FSS also demonstrated test-rest reliability and good convergent and divergent validity in community and undergraduate samples. Overall, findings indicate that the FSS has a replicable factor structure that generalizes across those identifying as men and women and may better assess components of capability for suicide than existing scales.

Pre-suicidal attempt: An intermediate type within ideation-to-action framework

INTRODUCTION

Understanding the mechanisms of suicidal behavior is a prerequisite for suicide prevention and intervention. The current study aims to propose and verify the utility of pre-suicidal attempt as an intermediate type in the transition from suicidal ideation to suicidal attempt within the ideation-to-action framework.

METHODS

A sample of 1084 college students completed a measurement package consisting of suicide history, suicide risk factors, and demographic information. Stratified stepwise multiple regression models and mediated moderation models were used to examine the relationship among the variables.

RESULTS

Pre-suicidal attempts rather than suicidal ideation are predictive of suicide attempts. Age, depression, thwarted belongingness, fearlessness about death, perceived burdensomeness and suicidal ideation were predictors of pre-suicidal attempts. Supporting the interpersonal theory of suicide, pre-suicidal attempts mediated the relationship between suicidal ideation and suicidal attempts and were positively moderated by pain tolerance and fearlessness about death. The pre-suicidal attempters scored higher on fearlessness about death and suicide risk than the ideators, while pre-suicidal attempters scored significantly lower on suicide risk than suicide attempters.

CONCLUSION

As an independent intermediate type within the ideation-to-action framework, pre-suicidal attempts contribute to deepen the understanding of the intermediate transition from suicidal ideation to suicidal attempts.

Emotional reactivity and past self-injurious behavior moderate the association between trauma exposure and fearlessness about death

INTRODUCTION

As suicide remains a global public health concern, recent work has sought to characterize mechanisms underlying the transition from suicidal ideation to action. Acquired capability for suicide, or fearlessness about death, has been identified as one key factor underlying this transition; however, understanding how this capability emerges remains limited. This study sought to extend previous work on the correlates of fearlessness about death by examining its relationship with painful and provocative events and emotional reactivity.

METHODS

We tested the extent to which trait emotional reactivity and past self-injurious behavior moderated the relationship between assaultive trauma exposure and fearlessness about death in a diverse sample of 273 community adults (aged 18-55, M/SD = 32.77/10.78).

RESULTS

A three-way interaction emerged, such that among individuals with heightened emotional reactivity and a history of self-injurious behavior (suicide attempt or non-suicidal self-injury), assaultive trauma was associated with increased fearlessness about death. In contrast, among adults with low emotional reactivity and a history of self-injurious behavior, assaultive trauma was associated with reduced fearlessness about death.

CONCLUSIONS

Results suggest that emotional reactivity may be a key dispositional factor that influences how trauma exposure and self-injurious behavior impact fearlessness about death.

Acquired Capability for Suicide: An Evolutionary Concept Analysis

While virtually all suicide attempters experience ideations, not all who think about suicide will attempt or die by suicide. The ideation-to-action framework has led to new theories distinguishing suicide ideators from suicide attempters. The framework suggests that suicide progresses on a spectrum of thoughts and behaviors with different identifiers and explanations. The concept of acquired capability for suicide (ACS), conceptualized by the Interpersonal Psychological Theory of Suicide, is the first to explain the movement from ideation to action. This concept analysis of ACS is timely and relevant for greater clarification of the role ACS has in the movement from ideation to action. Rodgers' evolutionary concept analysis method is used. The six-step evolutionary method highlights the concept's attributes, antecedents, and consequences and provides a basis for further inquiry and development rather than a final definition.

The Interpersonal Psychological Theory of Suicide in Italian University Students: Validation of the INQ-15 and the ACSS-FAD

In the frame of the interpersonal psychological theory of suicide (IPTS), Interpersonal Needs Questionnaire (INQ-15) assesses thwarted belongingness (TB) and perceived burdensomeness (PB), related to suicidal ideation (SI); Acquired Capability for Suicide Scale-Fearlessness About Death (ACSS-FAD) measures this component which contributes to lethal self-harm. The objective was to evaluate the psychometric properties of INQ-15 and ACSS-FAD in a population of Italian university students. Since the Italian INQ-15 was already validated, we translated ACSS-FAD through a multistage procedure and administered both to 1,665 Italian university students. Factor analysis confirmed a two-factor-related model of INQ-15, one factor of ACSS-FAD, and good reliability for both. We proved the association between INQ-15 and current SI and between ACSS-FAD and lifetime suicidal planning and/or suicide attempt. The convergent and discriminant validities were in line with those of previous studies. Both tools are valid and reliable to assess the constructs associated with suicide outcomes according to IPTS.

Associations between fearlessness about death and suicidal ideation in individuals with psychosis

BACKGROUND

Despite high rates of suicide among people with psychosis, relatively little is known about the mechanisms underlying the transition from suicidal ideation to behavior in this population. The Interpersonal Psychological Theory of Suicide (IPTS) proposes that fearlessness about death (FAD) may play a role in this relationship. The present study tested whether constructs of the IPTS [thwarted belongingness (TB), perceived burdensomeness (PB), and FAD] were associated with the severity of suicidal ideation in a sample of adults with histories of psychosis.

METHOD

261 adults with histories of psychosis completed measures of IPTS constructs, current severity of suicidal ideation, and history of suicidal attempts. We examined differences between those with past suicide attempts and those without and conducted regression analyses to evaluate the associations among TB, PB, FAD and severity of current suicidal ideation.

RESULTS

Contrary to expectations, a history of suicidal behavior was not uniquely associated with FAD. Regression analyses revealed TB × PB and FAD × PB interactions emerged as significant correlates of the severity of suicidal ideation, with the relationship between PB and suicidal ideation more pronounced at higher levels of FAD and TB. Interestingly, positive symptoms of psychosis were positively associated with PB.

IMPLICATIONS

This study provides support for broadening the investigation of FAD as a contributor to suicidal ideation in individuals with psychotic symptoms. Future research investigating the role of other contributors that may influence capability for suicide (e.g., impulsivity) may add additional understanding of suicide in this population.

Testing the interpersonal theory of suicide in adolescents: A multi-wave longitudinal study

BACKGROUND

Suicide is a major public health crisis among youth. Several prominent theories, including the Interpersonal Theory of Suicide (IPTS), aim to characterize the factors leading from suicide ideation to action. These theories are largely based on findings in adults and require testing and elaboration in adolescents.

METHODS

Data were examined from high-risk 13-18-year-old adolescents (N = 167) participating in a multi-wave, longitudinal study; 63% of the sample exhibited current suicidal thoughts or recent behaviors (n = 105). The study included a 6-month follow-up period with clinical interviews and self-report measures at each of the four assessments as well as weekly smartphone-based assessments of suicidal thoughts and behaviors. Regression and structural equation models were used to probe hypotheses related to the core tenets of the IPTS.

RESULTS

Feelings of perceived burdensomeness were associated with more severe self-reported suicidal ideation (b = 0.58, t(158) = 7.64, p < .001). Similarly, burdensomeness was associated with more frequent ideation based on weekly smartphone ratings (b = 0.11, t(1460) = 3.41, p < .001). Contrary to IPTS hypotheses, neither feelings of thwarted belongingness, nor interactions between burdensomeness and thwarted belongingness were significantly associated with ideation (ps > .05). Only elevated depression severity was associated with greater odds of suicide events (i.e., suicide attempts, psychiatric hospitalizations, and/or emergency department visits for suicide concerns) during the follow-up period (OR = 1.83, t(158) = 2.44, p = .01). No effect of acquired capability was found.

CONCLUSIONS

Perceptions of burdensomeness to others reflect a critical risk factor for suicidal ideation among high-risk adolescents. Null findings with other IPTS constructs may suggest a need to adopt more developmentally sensitive models or measures of interpersonal and acquired capability risk factors for youth. Refining methods and theoretical models of suicide risk may help improve the identification of high-risk cases and inform clinical intervention.

Suicidality in Veterinarians: Trends at Different Career Stages and a Test of the Interpersonal Theory of Suicide

OBJECTIVE

The aim of this study was to investigate sex differences in suicide ideation and attempt at different career stages and test hypotheses derived from the Interpersonal Theory of Suicide (IPTS) in a sample of veterinarians.

METHOD

The sample of currently practicing veterinarians used for this study (N = 10,319) was derived from a larger sample. Participants completed an online self-report questionnaire.

RESULTS

As predicted, women generally had a higher prevalence of suicide ideation and attempt across career stages, except men and women showed similar rates of suicide attempt after veterinary school. Contrary to hypotheses, no interaction effects between IPTS variables were observed. However, perceived burdensomeness, thwarted belongingness, and hopelessness exhibited the main effects of suicide ideation, and there were main effects of perceived burdensomeness and hopelessness on suicide attempt. Compared with perceived burdensomeness and thwarted belongingness, hopelessness had a relatively more robust relationship with suicide ideation. We also found a significant relationship between fearlessness about death and suicide attempt, but no relationship between self-reported pain tolerance and suicide attempt.

CONCLUSIONS

Some of our findings were consistent with the IPTS while others were not. Future research would benefit from a longitudinal examination of suicidality in veterinarians.

Exploring the structure of fearlessness using self-report measures

OBJECTIVE

The present study examined the hierarchical structure of self-reported fearlessness and compared this structure to external criterion measures.

BACKGROUND

Fearlessness is often discussed in relation to clinical and personality research. However, there is a paucity of research focusing on its empirical structure, in particular with self-report measures.

METHOD

Using a preregistered analytical approach, we employed Goldberg's 2006 "bass-ackward" factor analysis on self-reported trait fear and fearlessness items to uncover the hierarchical structure of the construct. The final sample consisted of 619 participants and 562 informants.

RESULTS

By assessing fit statistics and interpretability of the factors, we found a six-factor model fit the data best. The six-factor solution emerged as comprehensive and included components labeled Assertiveness, Low Anxiety, Sociability, Recklessness, Openness to Action, and Adventurousness. Criterion variables measuring boldness, fear, anxiety, psychopathy, basic personality traits, and impulsivity, were correlated with the factor scores at each factor level of the model. Conclusions The findings from this study elucidate how trait fearlessness unfolds at varying levels and how these factors relate to and diverge from various outcomes.

A Prospective Examination of the Interpersonal-Psychological Theory of Suicidal Behavior in Adolescents

OBJECTIVE

Given the large and complex array of suicide risk factors, theoretical frameworks are critical to furthering our understanding of risk. This study prospectively examined several key constructs of the interpersonal-psychological theory of suicidal behavior (IPTS) in a large, geographically diverse sample of U.S. adolescents.

METHOD

Conducted in collaboration with the Pediatric Emergency Care Applied Research Network, adolescents, ages 12 to 17, were recruited from emergency departments. Baseline and 6-month follow-up samples were comprised of 6,448 (59% female sex) and 2,009 (64% female sex) adolescents, with self-identified race/ethnicity as follows (baseline/follow-up): White (52%/54%), Black (22%/23%), Multiracial (6%/6%), American Indian (3%/3%), other/unknown race (15%/14%), and Latinx (25%/23%). Youth and parents completed adolescent suicide risk surveys at baseline and 6-month follow-up (retention, 69%). Latent class analysis was used to identify classes of painful and provocative events (PPE), considered a precursor to acquired capability.

RESULTS

In keeping with IPTS tenets, thwarted belongingness (TB), perceived burdensomeness (PB), and the interaction between TB and PB were each significant predictors of suicidal ideation at baseline and follow-up. However, only PB and PPE were significant predictors of cross-sectional suicide attempts and only TB and PPE were significant predictors of prospective suicide attempts in models that adjusted for baseline suicidal ideation. The three-way interaction among PB, TB and PPE was nonsignificant.

CONCLUSIONS

Results from this large-scale prospective study suggest the importance of TB, PB, and PPE to our understanding of suicidal thoughts and suicide attempts among adolescents, pointing to promising prevention and intervention targets.

A Psychometric Evaluation of the Interpersonal Hopelessness Scale Among Individuals With Elevated Suicide Risk

The interpersonal theory of suicide hypothesizes that suicide ideation (SI) emerges specifically in the context of hopelessness about the immutability of thwarted belongingness (TB) and perceived burdensomeness (PB; i.e., interpersonal hopelessness). The psychometrics of the Interpersonal Hopelessness Scale (IHS), which could be used to test this hypothesis directly, have not been rigorously evaluated. Participants (U.S. adults reporting past-year SI) completed online self-report assessments at Waves 1 (W1; N = 595) and 2 (W2; N = 215), 1 week apart. Confirmatory factor analyses supported a two-factor structure, IHS-TB and IHS-PB. Correlations indicated strong concurrent validity. Hurdle negative binomial regressions indicated that W1 IHS-TB and IHS-PB scores were associated with SI presence and severity at both waves, but this was inconsistent when adjusting for other W1 variables. IHS-TB and IHS-PB demonstrated excellent internal consistency and moderate to good test-retest reliability. The IHS could improve theory testing and suicide risk assessment and management.

Psychiatric profiles in suicidal attempters: Relationships with suicide behaviour features

BACKGROUND

Suicide constitutes a major health concern worldwide, being a significant contributor of death, globally. The diagnosis of a mental disorder has been extensively linked to the varying forms of suicidal ideation and behaviour. The aim of our study was to identify the varying diagnostic profiles in a sample of suicide attempters.

METHODS

A sample of 683 adults (71.3% females, 40.10±15.74 years) admitted at a hospital emergency department due to a suicide attempt was recruited. Latent class analysis was used to identify diagnostic profiles and logistic regression to study the relationship between comorbidity profile membership and sociodemographic and clinical variables.

RESULTS

Two comorbidity profiles were identified (Class I: low comorbidity class, 71.3% of attempters; Class II: high comorbidity class, 28.7% of attempters). Class I members were featured by the diagnosis of depression and general anxiety disorder, and low comorbidity; by contrast, the high comorbidity profile was characterized by a higher probability of presenting two or more coexisting psychiatric disorders. Class II included more females, younger, with more depressive symptoms and with higher impulsivity levels. Moreover, Class II members showed more severe suicidal ideation, higher number of suicide behaviours and a greater number of previous suicide attempts (p<.01, for all the outcomes), compared to Class I members.

CONCLUSIONS

Psychiatric profiles may be considered for treatment provision and personalized psychiatric treatment in suicidal attempters as well as tackle suicide risk.

Do bipolar disorder symptom profiles matter for suicide risk? A latent class approach to investigating differences in suicidal desire and acquired capability

INTRODUCTION

Depressive and mixed symptoms in bipolar disorder (BD) have been linked to higher suicide risk. Based on Klonsky and May's three-step theory and Joiner's Interpersonal Psychological Theory of Suicide, we hypothesized that patients diagnosed with BD who reported severe levels of depressive symptoms and mixed depressive and manic symptoms would also report higher levels of suicidal desire and acquired capability of suicide, as well as suicidal thoughts and behaviors.

METHODS

The sample included 177 outpatients diagnosed with BD. Latent class analysis was conducted to replicate the identified groups of a previously conducted study using a smaller but overlapping dataset. Between-class and pairwise analyses with measures of suicidal desire and acquired capability were conducted.

RESULTS

As expected, the classes characterized by severe depressive symptoms and mixed symptoms reported higher levels of suicidal desire. However, the results regarding acquired capability were less consistent.

CONCLUSION

Given the overall elevated suicide risk of BD and the consistent relationship between depressive symptoms and other strong correlates of suicide, clinicians who work with patients diagnosed with BD should closely monitor changes in their depressive symptoms.

An analysis of the Painful and Provocative Events Scale: Some painful and provocative findings

This research investigated the latent structure and correlates of the 26-item Painful and Provocative Events Scale (PPES). For a sample of 290 community respondents, results from parallel analysis indicated a 5-factor structure. Based on principal axis factoring with varimax rotation, scales of Intense physicality, Physical and mental trauma, Physical risk taking, Psychopathy, and Body enhancement were constructed, and these demonstrated a pattern of convergent and discriminant correlations with suicide-associated and demographic variables that supported the delineation of these scales as being distinct. In general, results challenge the current scoring of the PPES and, with developed scales being differentially related to demographic variables, indicate that both respondent age and sex require consideration for scale score interpretation.

Pain tolerance and threshold in suicide attempters: A systematic review and meta-analysis

It has been hypothesized that individuals less sensitive to pain could be at higher risk of suicide. However, data on pain sensitivity in suicide attempters (SA) obtained using experimental procedures are heterogeneous. The aim of this systematic review and meta-analysis was to investigate and compare pain tolerance and threshold in SA (patients with lifetime history of suicide attempt), non-attempters (psychiatric controls, PC), and healthy controls (HC). A random effects meta-analysis was used to estimate the standardized mean differences using data from 16 studies that compared physical pain tolerance and threshold in SA and PC or HC. Pain tolerance and threshold were not significantly different in SA and PC. However, pain tolerance, but not threshold, was higher in SA than HC. Our findings do not support the hypothesis of an altered pain perception related as a trait for suicidal vulnerability, but rather suggest altered pain perception related to psychiatric vulnerability.

Suicide risk profiles among service members and veterans exposed to suicide

OBJECTIVES

Rates of suicide exposure are high among service members and Veterans and are especially concerning given the link between suicide exposure and subsequent suicide risk. However, to date, it is unclear which individuals who are exposed to suicide are subsequently at high risk for suicide. Latent profile analysis (LPA) can provide information on unique risk profiles and subgroups of service members and Veterans who have higher suicide risk after suicide exposure, which has not yet been empirically studied. The purpose of this study was to utilize LPA to identify subgroups of service members and Veterans who are at the highest risk for suicidal thoughts and behaviors following suicide exposure.

METHODS

We analyzed data using LPA from 2570 service members and Veterans (82.1% male, 69.5% White, and 12.1% Latino/a/x) who completed the Military Suicide Research Consortium's Common Data Elements, a battery of self-report suicide-related measures. Psychopathology, substance use, mental health service utilization, interpersonal theory of suicide, and suicide exposure variables were used to validate classes.

RESULTS

Three latent classes emerged from analyses, one low-risk class and two-high risk classes with differing profile compositions (one primarily differentiated by anxiety symptoms and one differentiated by substance use).

CONCLUSION

Class-specific recommendations for suicide prevention efforts will be discussed.

Instagram Content Analysis in the Context of the Interpersonal Theory of Suicide

The Interpersonal Theory of Suicide posits that interpersonal factors, specifically perceived burdensomeness and thwarted belongingness, increase suicidal ideation. Many modern social interactions take place over social media and, as such, examining social media content may offer a novel way to assess interpersonal relationships. In this preregistered study of 386 young adults, we examined the relationship between the amount of interaction with friends- and whether or not individuals interacted with family-related Instagram content and perceived burdensomeness, thwarted belongingness, and suicidal ideation. Instagram content was assessed via self-report and participants' Instagram profiles. Participants who endorsed interacting with family on Instagram demonstrated lower thwarted belongingness and suicidal ideation, but not perceived burdensomeness. Non-preregistered analyses of friend Instagram content demonstrated similar results. Consistent with the Interpersonal Theory, participants' interaction with family and frequency of interacting with friends on Instagram was associated with interpersonal variables and suicidal ideation but not aspects of acquired capability. Our study suggests that social media-based measures of interpersonal relationships are relevant to suicidality.

Evidence-based treatment for posttraumatic stress disorder decreases suicidal ideation by reducing perceived burdensomeness among veterans in an outpatient program

Evidenced-based posttraumatic stress disorder (PTSD) treatments generally reduce suicidal ideation (SI), and the interpersonal theory of suicide (ITS) may theoretically account for this finding. The ITS posits that SI stems from feeling like a burden (i.e., perceived burdensomeness) and a lack of belonging (i.e., thwarted belongingness). Previous research suggests that change in PTSD severity has a significant indirect effect on change in SI through changes in perceived burdensomeness, but not thwarted belongingness, among patients receiving residential PTSD treatment in a Veterans Affairs (VA) medical center; however, no research has investigated these associations in an outpatient VA setting with fewer confounding factors that might affect ITS constructs. Therefore, the current sample included veterans (N = 126) who completed PTSD treatment and pre- and posttreatment assessments in a VA outpatient clinic. Results from parallel models of multiple indirect effects suggest that change in PTSD severity was indirectly associated with change in SI through changes in perceived burdensomeness, B = 0.35, p < .001; β = .36, p < .001, SE = .10, 95% CI [.15, .54], but not thwarted belongingness, B = 0.14, p = .146; β = .14, p = .161, SE = .10, 95% CI [-.05, .33]. Additional models were examined using PTSD cluster scores for exploratory purposes. The results indicate that PTSD treatment reduces the perceived and objective burden of PTSD to decrease SI. Study findings support the importance of access to evidence-based care to treat PTSD and alleviate burdensomeness for suicide prevention.

Early Trauma Subtypes are Differentially Related to Anxiety Symptomatology and Suicidal Ideation in Panic Disorder

OBJECTIVE

Early trauma significantly affects the severity of panic disorder (PD) symptoms and suicidal ideation. However, few studies have explored the specific effects of different early trauma subtypes on PD. This study analyzed how childhood trauma subtypes, including general, physical, emotional, and sexual, influence panic and phobia levels and suicidal ideation in adults with PD and healthy controls (HCs).

METHODS

In total, 455 adults with PD and 149 HCs participated in this study. The independent variables were sociodemographic and clinical variables such as coping strategies and early trauma subtypes from the Early Trauma Inventory Self Report-Short Form. The dependent variables were the Albany Panic and Phobia Questionnaire (APPQ), the Panic Disorder Severity Scale, and the Scale for Suicide Ideation (SSI).

RESULTS

Early emotional trauma significantly influenced the APPQ scores, whereas early physical trauma significantly influenced the SSI scores in patients with PD. However, in HCs, only early emotional trauma was significantly associated with the APPQ and SSI scores.

CONCLUSION

These findings highlight the influence of early trauma subtypes on the phobic symptom severity of PD and suicidal ideation among patients with PD. Early emotional trauma is associated with the severity of phobic symptoms, whereas early physical trauma is associated with suicidal ideation, suggesting distinct clinical outcomes based on the type of trauma in patients with PD.

Understanding suicidal transitions in Australian adults: protocol for the LifeTrack prospective longitudinal cohort study

BACKGROUND

The factors that influence transition from suicidal ideation to a suicide attempt or remission of suicidal thoughts are poorly understood. Despite an abundance of research on risk factors for suicidal ideation, no large-scale longitudinal population-based studies have specifically recruited people with suicidal ideation to examine the mechanisms underlying critical transitions to either suicide attempt or recovery from suicidal ideation. Without longitudinal data on the psychological, behavioural, and social determinants of suicide attempt and the remission of suicidal ideation, we are unlikely to see major gains in the prevention of suicide.

AIM

The LifeTrack Project is a population-based longitudinal cohort study that aims to identify key modifiable risk and protective factors that predict the transition from suicidal ideation to suicide attempt or remission of suicidal ideation. We will assess theory-informed risk and protective factors using validated and efficient measures to identify distinct trajectories reflecting changes in severity of suicidal ideation and transition to suicide attempt over three years.

METHODS

A three-year prospective population-based longitudinal cohort study will be conducted with adults from the general Australian population who initially report suicidal ideation (n = 842). Eligibility criteria include recent suicidal ideation (past 30 days), aged 18 years or older, living in Australia and fluent in English. Those with a suicide attempt in past 30 days or who are unable to participate in a long-term study will be excluded. Participants will be asked to complete online assessments related to psychopathology, cognition, psychological factors, social factors, mental health treatment use, and environmental exposures at baseline and every six months during this three-year period. One week of daily measurement bursts (ecological momentary assessments) at yearly intervals will also capture short-term fluctuations in suicidal ideation, perceived burdensomeness, thwarted belongingness, capability for suicide, and distress.

CONCLUSION

This study is intended to identify potential targets for novel and tailored therapies for people experiencing suicidal ideation and improve targeting of suicide prevention programs. Even modest improvements in current treatments may lead to important reductions in suicide attempts and deaths.

STUDY REGISTRATION

Australian New Zealand Clinical Trials Registry identifier: ACTRN12623000433606.

The fearlessness about death scale's efficacy for differentiating suicide attempts from non-suicidal self-injury, a meta-analysis

We used multivariate meta-analysis modeling variances and covariances of suicidal ideation, suicide attempts, and non-suicidal self-injury to investigate if the Fearlessness About Death scale differentiated between suicide attempts and non-suicidal self-injury. The systematic search yielded 27 studies that fulfilled the inclusion criteria. The association of suicidal ideation with suicide attempts was comparable to the association of suicidal ideation with non-suicidal self-injury. The Fearlessness About Death scale weakened both associations to a comparative degree. These results cast doubt on the clinical utility of the Fearlessness About Death scale, as well as the self-assessment of suicidal ideation, suicide attempts and non-suicidal self-injury.

A structural test of the three-step theory (3ST) of suicide in the Iranian population: From ideation to action

Background and Aims

Suicide is one of the leading causes of death, especially in adolescents and young adults. This study aimed to perform a structural test of the three-step theory (3ST) of suicide in the Iranian population.

Methods

The research population included Iranian people over 18 years of age. The participants were 600 persons selected through convenience sampling. The data in this study were collected using the Suicide Attempt Questionnaire, the Suicide Behaviors Questionnaire-Revised, the Interpersonal Needs Questionnaire, the Impulsiveness Scale, the Depressive Symptom-Suicidality Subscale, ACSSACSS-Fearlessness About Death, the Psychache Scale, the Beck Hopelessness Scale, and the Suicide Capacity Scale.

Results

Data analysis showed that pain and positive helplessness (β = 0.45; p < 0.05) positively interact with suicidal behavior. Moreover, pain and negative helplessness significantly interact with suicidal ideation (β = 0.65; p < 0.001). The data also showed that the absence of interpersonal needs plays a protective role. A comparison of the three suicidal capacity factors indicated that only the practical capacity differentiates the ideation and action subgroups.

Conclusions

The insights from this study provide a clear picture of the underlying causes of suicidal ideation and behavior and can help counselors and other human health professionals working with people with suicidal thoughts and behavior to prevent suicide attempts. Following functional models, they can also make serious efforts to perform therapeutic interventions to eliminate or reduce suicidal thoughts and feelings.

The interactive effects of AS and trauma exposure on suicide capability and suicide risk

BACKGROUND

Trauma exposure has been linked with heightened suicide risk purportedly through habituation to threatening stimuli, thereby reducing fear of suicide. However, no research has examined variables that may influence this process. Anxiety sensitivity (AS) is one cognitive-affective factor that may strengthen the relationship between trauma exposure and reduced fear of suicide by amplifying traumatic reactivity. The present study evaluated this by examining the interaction of AS and trauma exposure type (e.g., direct vs. witnessed) predicting fear of suicide and self-reported suicide risk.

METHODS

Participants (n = 124) were recruited for a long-term (∼3-4 years) follow-up after participation in a clinical trial targeting suicide risk factors and were asked to complete self-report measures of trauma history, AS, fear of suicide, and suicide risk.

RESULTS

Significant interactions emerged such that a greater number of direct traumasexperienced predicted lower fear of suicide and greater suicide risk among those with greater AS. The interactive effect of witnessed traumas and AS predicting suicidality was insignificant. Results remained even after including relevant covariates.

DISCUSSION

The current findings suggest that AS augments the effects of repeated trauma exposure on fear of suicide and suicide risk. It is plausible these painful and provocative events are more potent among those with high AS due to the amplification of traumatic affective responses, though future research examining the longitudinal relations is needed to confirm this process.

Hope and Suicidal Ideation Among Older Adults Living in the Rural Mid-Hills of Nepal

OBJECTIVES

The current study investigated whether hope and its two components (agency and pathways) weakened the relations between perceived burdensomeness, thwarted belongingness, and fearlessness about death and suicidal ideation among older adults living in rural Nepal.

METHODS

A community sample of 300 people aged from 60 to 90 years (Mage = 67.07, SDage = 6.23) who resided in the rural mid-hills of Nepal completed standardized measures.

RESULTS

Hope and agency moderated the relationship between perceived burdensomeness and suicidal ideation and pathways moderated the relationship between thwarted belongingness and suicidal ideation.

CONCLUSIONS

Hope, and particularly agency, may play a protective role in reducing suicidal ideation among older Nepali adults living in rural areas who experience perceived burdensomeness. In contrast, pathways may be an additional risk factor for older adults experiencing unmet belongingness needs. Research is required to understand fearlessness about death and suicidality among older Nepali adults.

CLINICAL IMPLICATIONS

Increasing hope and particularly agency may be associated with a reduction in suicidal ideation among older Nepali adults who experience feelings of being a burden. However, increasing pathways may be associated with an increase in suicidal ideation among those who experience unmet belongingness needs. Research is needed to understand how to accurately assess suicide risk among Nepali older adults.

Clinical predictors and psychosocial risk factors of suicide attempt severity

BACKGROUND

Suicide attempts are an important predictor of completed suicide and may differ in terms of severity of medical consequences or medical lethality. There is little evidence on serious suicide attempt (SSA) and very few studies have compared SSA with non-SSA.

OBJECTIVE

The aim of this multisite, coordinated, cohort study was to analyze the role of clinical variables and the sociodemographic and psychological risk factors of SSA.

METHOD

In this multisite, coordinated, cohort study, 684 participants (222 for the mild suicide attempt group, 371 for the moderate suicide attempt group and 91 for the SSA group) were included in the study. Ordinal regression models were performed to analyze the predictor variables of SSA.

RESULTS

Early physical abuse (OR=1.231) and impulsivity (OR=1.036) were predictors of SSA, while depressive symptoms were associated with a lower risk of SSA.

CONCLUSION

Environmental and psychological factors as physical abuse and impulsivity are related with severe suicide severity. These findings will help to develop strategies to prevent suicide and may be considered for the treatment and management of suicide.

Self-hate, dissociation, and suicidal behavior in bulimia nervosa

BACKGROUND

Individuals with eating disorders (EDs) often struggle with markedly low self- esteem and are at risk for suicidal behavior. Dissociation and perceived burdensomeness are often cited as facilitators of suicidal outcomes. Specifically, perceived burdensomeness is comprised of self-hate and liability on others, although it remains unclear which variables most heavily influence suicidal behavior in EDs.

METHODS

In a sample of 204 women with bulimia nervosa, the present study examined the potential impact of self-hate and dissociation on suicidal behavior. We hypothesized that suicidal behavior would be equally, and potentially more strongly, related to self-hate than dissociation. Regression analyses investigated the unique effects of these variables on suicidal behavior.

RESULTS

Consistent with our hypothesis, a significant relationship emerged between self-hate and suicidal behavior (B = 0.262, SE = 0.081, p < .001, CIs = 0.035-0.110, R-squared =0.07) but not between dissociation and suicidal behavior (B = 0.010, SE = 0.007, p = .165, CIs = -0.389-2.26, R-squared =0.010). Additionally, when controlling for one another, both self-hate (B = 0.889, SE = 0.246, p < .001, CIs = 0.403-1.37) and capability for suicide (B = 0.233, SE = 0.080, p = .004, CIs = 0.076-0.391) were uniquely and independently associated with suicidal behavior.

LIMITATIONS

Future work should include longitudinal analyses to understand temporal relationships among study variables.

CONCLUSIONS

In sum, when considering suicidal outcomes, these findings support a view that highlights personal loathing rooted in self-hate rather than de-personalizing aspects of dissociation. Accordingly, self-hate may emerge as a particularly valuable target for treatment and suicide prevention in EDs.

The Relationship Between Chronic Pain, Depression, Psychosocial Factors, and Suicidality in Adolescents

BACKGROUND

Chronic pain in youth is often associated with social conflict, depression, and suicidality. The interpersonal theory of suicide posits that there are psychosocial factors, such as peer victimization and lack of fear of pain, that may also influence suicidality.

OBJECTIVES

The objective of this study was to determine whether depressive symptoms, peer victimization, and lack of fear of pain predict suicidality in adolescents with chronic pain. It was hypothesized that higher levels of depressive symptoms and peer victimization, and lower levels of fear of pain, would predict a higher lifetime prevalence of suicidality.

METHODS

Participants consisted of 184 youth with primary chronic pain conditions (10 to 18 y, M = 14.27 y). Measures included diagnostic clinical interviews assessing suicidality and self-report questionnaires assessing depressive symptoms, peer victimization, and fear of pain.

RESULTS

Forty-two (22.8%) participants reported suicidality. Regression analyses demonstrated that the occurrence of suicidality was associated with higher rates of depressive symptoms (β = 1.03, P = 0.020, 95% CI: 1.01, 1.06) and peer victimization (β = 2.23, P < 0.05, 95% CI: 1.07, 4.63), though there was no association between lower fear of pain and suicidality.

DISCUSSION

These results suggest that depressive symptoms and peer victimization are significant predictors of suicidality in adolescents with chronic pain; however, lower fear of pain was not shown to be a significant predictor. Given these findings, depression and peer victimization should be further explored and considered in the design and implementation of prevention and early intervention strategies that target chronic pain and suicidality in youth.

Is physical pain causally related to suicidal behavior: An experimental test

Existing evidence suggests a link between physical pain and suicide, but the nature of this relationship remains unknown. To address this critical gap in knowledge, the present study leveraged a validated virtual reality (VR) suicide paradigm to experimentally examine the causal effects of physical pain on subsequent virtual suicidal behaviors. Based on previous findings, we hypothesized that physical pain would causally drive virtual suicidal behavior only if suicide was conceptualized as having desirable anticipated consequences (e.g., a means of escaping from current pain; an opportunity to avoid future pain). We tested this by randomizing 326 participants across four different conditions: a physical pain condition, an anticipated escape condition, an anticipated avoidance condition, and a control condition. As predicted, physical pain alone did not result in statistically significant increases in VR suicide rates; however, the anticipation that virtual suicidal behavior would result in the avoidance of future physical pain had a large causal effect on VR suicide rates (B = 1.61, p < .001, IRR = 5.01). We failed to find evidence that anticipating that VR suicide would provide an escape from currently experienced physical pain increases the likelihood of VR suicide. Our findings add to a growing body of evidence suggesting that the anticipated consequences of suicide (e.g., avoidance of future physical pain) may serve as primary causes of suicidal behavior.

A systematic review of the relationship between death anxiety, capability for suicide, and suicidality

This systematic review aimed to examine the relationship between death anxiety and suicidality in adults, and the impact of death anxiety interventions on the capability for suicide and suicidality. MEDLINE, PsycINFO, PubMed, and Web of Science were extensively searched using purpose-related keywords from the earliest to July 29th, 2022. A total of 376 participants were included across four studies which met inclusion. Death anxiety was found to relate significantly and positively with rescue potential, and although weak, negatively with suicide intent, circumstances of attempt, and a wish to die. There was no relationship between death anxiety and lethality or risk of lethality. Further, no studies examined the effects of death anxiety interventions on the capability for suicide and suicidality. It is imperative that future research implements a more rigorous methodology to establish the relationship between death anxiety and suicidality and establish the impacts of death anxiety interventions on the capability for suicide and suicidality.

Examining the relationship between dysmorphia symptoms and suicidality through the lens of the Interpersonal Theory of Suicide

OBJECTIVE

Using the Interpersonal Theory of Suicide (IPTS) as a framework, this two-study investigation tested whether burdensomeness and low belongingness explained the association between body and muscle dysmorphia symptoms and suicidal ideation (tested in Study 1 and Study 2), and if fearlessness about death and pain tolerance explained the association between dysmorphia symptoms and previous suicide attempt frequency (tested in Study 2).

METHODS

Study 1 used a community sample (n = 273) and Study 2 used an at-risk population sample (n = 261). Participants completed cross-sectional questionnaires online.

RESULTS

In Study 1, both types of dysmorphic symptoms related to suicidal ideation through burdensomeness, but only body dysmorphic symptoms related to suicidal ideation through low belongingness. In Study 2, results were replicated as both types of dysmorphic symptoms related to suicidal ideation through burdensomeness. While both types of symptoms related to low belonging, low belonging did not relate to suicidal ideation. Neither dysmorphic symptoms nor capability for suicide related to frequency of suicide attempts.

CONCLUSIONS

Results suggest that improving interpersonal needs, such as feeling more effective, may be important treatment targets for individuals with dysmorphic symptoms who also experience suicidal ideation. Future work should continue to identify mediators for suicide attempts among individuals with dysmorphia symptoms.

For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt

Nonsuicidal self-injury (NSSI) has been repeatedly associated with increased suicide risk. However, the transition from NSSI to suicidal thoughts and behaviors still remains as an enigma. One possible construct that may influence this relationship is cognitive flexibility, which refers to the ability to adapt responses/strategies based on environmental feedback. It may be that greater cognitive flexibility increases one's cognitive accessibility to suicide, making it a more viable option upon distress especially for those with a prior history of NSSI. Conversely, it may be that less cognitive flexibility creates a negative bias that exacerbates the effects of NSSI on suicide. Thus, in this study, we examined how NSSI characteristics (i.e., frequency and methods) interact with cognitive flexibility to predict lifetime suicide attempt (SA) history. Participants were 505 individuals with a lifetime history of NSSI who completed a survey assessing for their NSSI experiences, cognitive flexibility, and SA history. Moderation analyses were conducted while controlling for sexual orientation, which significantly predicted SA history. Results indicated a significant interaction between number of NSSI methods endorsed and cognitive flexibility. In particular, individuals were more likely to have had a history of SA if they scored higher on the alternative subscale of cognitive flexibility. The results suggest that the adaptive value of cognitive flexibility may be context dependent, and highlight the importance of personalized care among those who engage in self-harm.

Spanish Validation of the Interpersonal Needs Questionnaire and the Acquired Capability for Suicide Scale Among Mexican University Students

Introduction

the rate of death by suicide has increased in Mexico, representing a significant public health problem. To prevent and treat this phenomenon, it is crucial to identify reliable suicide risk factors among Mexicans. The Interpersonal Theory of Suicide has demonstrated empirical support for the role of thwarted belongingness, perceived burdensomeness, and acquired capability in the development of suicidal desire and behaviors. The measure of the theory's constructs-the Interpersonal Needs Questionnaire (INQ) and the Acquired Capability for Suicide Scale (ACSS)-has also shown good psychometric qualities.

Objective

translate, culturally adapt and validate these instruments.

Method

495 university students from Mexico City participated in two independent samples (n = 239; n = 256). For the INQ, the available version in Spanish was used. For the ACSS, the most current version in English was used. Based on the results from the first sample, items were modified, eliminated, or added for the second sample.

Results

the INQ demonstrated good fit (RMSEA = .054, TLI = .97, IFI = .97, NFI = .95) with an internal consistency of .77 and .87 for thwarted belongingness and perceived burdensomeness, respectively. The ACSS obtained similar results (RMSEA = .011, CFI = .99, TLI = .99, IFI = .99, NFI = .91); the internal consistency was .77.

Discussion and conclusions

the Spanish version of the instruments display good psychometric properties and can be used to measure the constructs of the interpersonal theory of suicide. However, further replication is needed to support generalizability in other Spanish-speaking populations.

The Suicide Prevention and Intervention Study (SURVIVE): Study protocol for a multisite cohort study with nested randomized-controlled trials

INTRODUCTION

Suicide is one of the leading causes of avoidable death. Gathering national data on suicidal behaviour incidence is crucial to develop evidence-based public policies. The study has two primary objectives: (1) to determine the incidence of suicide attempts in Spain and related risk factors, and (2) to analyze the efficacy of secondary prevention programmes to prevent suicide re-attempting in comparison to treatment as usual (TAU).

MATERIALS AND METHODS

Multisite, coordinated, cohort study with three nested randomized controlled trials. A cohort of 2000 individuals (age >=12) with suicidal behaviour will be recruited at ten sites distributed across Spain. Assessments will be conducted within 10 days of the suicide attempt (V0-baseline visit) and after 12 months (V4-last visit) and will include clinician reported and participant reported outcomes (PROs). Between V0 and V4, PROs will be collected remotely every three months (V1, V2 and V3). Optatively, cohort participants will participate in three nested randomized-controlled-trials (RCTs) evaluating different secondary prevention interventions: Participants aged 18 years and older will be randomly allocated to: Telephone-based Management+TAU vs. TAU or iFightDepression-Survive+TAU vs. TAU. Participants aged between 12 and 18 years will be allocated to a specific intervention for youths: Self Awareness of Mental Health+TAU vs. TAU.

RESULTS

This study will provide interesting data to estimate suicide attempt incidence in Spain. and will provide evidence on three.

CONCLUSIONS

Evidence on three potentially efficacious interventions for individuals at high risk of suicide will be obtained, and this could improve the treatment given to these individuals.

TRIAL REGISTRATION

NCT04343703.

Examining associations between suicidal desire, implicit fearlessness about death, and lifetime frequency of suicide attempts

INTRODUCTION

Suicide models propose that the capability for suicide, such as fearlessness about death (FAD), is necessary for the transition from suicidal desire to a suicide attempt. Most studies have relied on self-report methods to assess FAD. However, this research has produced equivocal results. As individuals may have limited awareness of learned or pre-existing associations between fearlessness and death, implicit measures of FAD hold promise. This study used a novel implicit association test (IAT), the IAT-FAD, to examine associations between suicidal desire, implicit FAD, and lifetime suicide attempt frequency.

METHODS

Patients in residential substance use treatment (N = 75), a population with increased suicide risk and exposure to painful and provocative events, completed the IAT-FAD and assessments of suicidal desire and past suicide attempts.

RESULTS

Implicit FAD moderated the association between suicidal desire and lifetime frequency of suicide attempts associated with an intent to die and requiring medical attention (although not ambivalent suicide attempts). Suicidal desire related to medically attended suicide attempts only at high implicit FAD levels, and to suicide attempts with a clear intent to die only at high or mean implicit FAD levels.

CONCLUSION

Results provide initial support for the relevance of implicit measures of FAD for understanding suicide risk.

Caring Texts, a strength-based, suicide prevention trial in 5 native communities: Research design and methods

BACKGROUND

Despite their intrinsic strengths and resilience, some American Indian and Alaska Native (AI/AN) communities experience among the highest rates of suicide of any racial and ethnic group. Caring Contacts is one of the only interventions shown to reduce suicide in clinical trials, but it has not been tested in AI/AN settings.

OBJECTIVE

To compare the effectiveness of Enhanced Usual Care (control) to Enhanced Usual Care augmented with a culturally adapted version of Caring Contacts (intervention) for reducing suicidal ideation, suicide attempts, and suicide-related hospitalizations.

METHODS

We are implementing a single blind randomized controlled trial of Caring Contacts in five AI/AN communities across the country (South Dakota, Montana, Oklahoma, and Alaska). Eligible participants have to be (1) actively suicidal or have made a suicide attempt within the past year; (2) at least 18 years of age; (3) AI/AN; (4) able to speak and read English; (5) able to participate voluntarily; (6) willing to be contacted by text, email or postal mail; and (7) able to provide consent. Following consent and baseline assessment, participants are randomized to receive either Enhanced Usual Care alone, or Enhanced Usual Care with 12 months (25 messages) of culturally adapted Caring Contacts. Follow-up assessments are conducted at 12 and 18 months.

CONCLUSIONS

If effective, this study of Caring Contacts will inform programs to reduce suicide in the study communities as well as inform future research on Caring Contacts in other tribal settings. Modifications to continue the trial during the COVID-19 pandemic are discussed.

CLINICAL TRIALS REGISTRATION

NCT02825771.

Invariance-based causal prediction to identify the direct causes of suicidal behavior

Despite decades of research, the direct causes of suicide remain unknown. Some researchers have proposed that suicide is sufficiently complex that no single variable or set of variables can be determined causal. The invariance-based causal prediction (ICP) is a contemporary data analytic method developed to identify the direct causal relationships, but the method has not yet been applied to suicide. In this study, we used ICP to identify the variables that were most directly related to the emergence of suicidal behavior in a prospective sample of 2,744 primary care patients. Fifty-eight (2.1%) participants reported suicidal behavior during the following year. Of 18 predictors tested, shame was most likely to be directly causal only under the least restrictive conditions. No single variable or set of variables was identified. Results support the indeterminacy hypothesis that suicide is caused by many combinations of factors, none of which are necessary for suicide to occur.

Suicide capability within the ideation-to-action framework: A systematic scoping review

Suicide capability is theorised to facilitate the movement from suicidal ideation to suicide attempt. Three types of contributors are posited to comprise suicide capability: acquired, dispositional, and practical. Despite suicide capability being critical in the movement from ideation-to-attempt, there has been no systematic synthesis of empirical evidence relating to suicide capability that would enable further development and refinement of the concept. This study sought to address this synthesis gap. A scoping review was conducted on suicide capability studies published January 2005 to January 2022. Eleven electronic databases and grey literature sources were searched returning 5,212 potential studies. After exclusion criteria application, 90 studies were included for final analysis. Results synthesis followed a textual narrative approach allocating studies based on contributors of suicide capability. Most studies focused on investigating only one factor within contributors. Painful and provocative events appear to contribute to acquired capability more so than fearlessness about death. Whilst emerging evidence for dispositional and practical contributors is promising, the small number of studies prevents further conclusions from being drawn. An unexpected additional cognitive contributor was identified. The focus of a single factor from most studies and the limited number of studies on contributors other than acquired capability limits the theoretical development and practical application of suicide capability knowledge. Given that suicide is a complex and multifaceted behaviour, future research that incorporates a combination of contributors is more likely to advance our understandings of suicide capability.

Assessing the clinical utility of MMPI-2-RF interpersonal theory of suicide proxy indices in psychiatric hospitalization setting

INTRODUCTION

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF Ben-Porath & Tellegen, 2008/2011) has been applied to suicide risk assessment through derived proxy indices of perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide (Anestis et al., 2018, Joiner, 2005). However, limited research has examined the clinical utility of these proxy indices outside the outpatient setting. This study examined the performance of these proxy indices in identifying past-month suicide ideation intensity and attempts upon admission to a psychiatric inpatient program and changes in suicidal ideation intensity at discharge. We expected these indices and their interaction would be associated with suicide ideation intensity and attempts at baseline and with a lack of significant improvement in suicide ideation intensity at discharge, including when controlling for MMPI-2-RF Suicide/Death Ideation (SUI) scale scores.

METHOD

Participants were 1007 patients in a private inpatient psychiatric hospital in the southwestern United States, 968 of whom completed study measures at admission and discharge. Participants were administered the C-SSRS and MMPI-2-RF upon admission, while the C-SSRS was administered again prior to discharge. A series of moderation analyses were conducted to examine the main and interaction effects of the MMPI-2-RF derived proxy indices on suicidal ideation intensity and suicide attempts at admission. Logistic regression analyses were conducted to examine whether MMPI-2-RF proxy index scores at admission were associated with changes in suicidal ideation intensity at discharge.

RESULTS

Neither the proxy indices nor their interaction was associated with all study outcomes. The acquired capability for suicide proxy index and its interaction with other indices were not associated with suicide attempt status at admission. However, high thwarted belongingness proxy index scores were associated with greater suicidal ideation intensity at admission; high perceived burdensomeness proxy index scores were indicative of a lack of significant change in suicide ideation intensity at discharge.

CONCLUSION

These results indicate a need to further examine these proxy indices in high acuity samples.

"Explode into small pieces": Suicidal ideation among child sexual abuse survivors

BACKGROUND

Child sexual abuse (CSA) has been acknowledged as predisposing survivors to an increased risk of suicidal ideation and attempts. Despite this risk being widely recognized, the study of suicidality has mainly focused on psychopathology, while less attention has been given to survivors' experiences and perceptions.

OBJECTIVE

This study aims to uncover the experiences and perceptions of suicidality among adult CSA survivors.

PARTICIPANTS AND SETTINGS

The sample consisted of 41 adult CSA survivors' written narratives of abuse that included references to suicide.

METHODS

Written narratives of CSA experiences were collected from 41 adult participants as part of the Israeli Independent Public Inquiry on CSA to change public policy. An inductive thematic analysis guided the exploration of the stories.

RESULTS

The findings portrayed several main themes regarding the survivors' experiences before, during and after suicidal thoughts and behaviors. These themes elucidated their motivations leading to suicidal attempts, including the wish to end one's self and suffering, self-blame, communicate the abuse and the request for recognition. Additionally, the survivors' stories illuminated their experiences following the suicidal attempts, depicting inadequate treatment and difficulties with the psychiatric labeling of a mental health disorder.

CONCLUSIONS

The findings of this study uncover new insights regarding the link between trauma, posttraumatic suffering, and suicidality within a social interaction context. Furthermore, these findings call medical and psychosocial health practitioners to view post-CSA suffering as trauma-related rather than personal psychopathology and to adjust practices to adapt to survivors' experiences and needs.

An Examination of Suicide Exposure and Fearlessness about Death on Suicide Risk among Active Duty Service Members, Veterans, and Civilians

Suicide exposure is associated with an increased risk for suicide. There is limited research on the mechanisms that increase this risk. This study aims to: (1) compare suicide exposure and associated variables in veteran, active duty, and civilian participants, (2) examine the extent to which fearlessness about death and suicide risk factors differ as a function of group membership and suicide exposure, and (3) determine the degree to which relationship to the decedent, perceived closeness, and reported impact of the death are associated with fearlessness about death and suicide-related outcomes. 1,533 participants were included, of whom 48% of active duty service members, 65% of veterans, and 58% of civilians reported knowing someone who died by suicide. A series of regressions were conducted. There were group differences by military service on the suicide exposure variables. Furthermore, there were significant main effects for military service group and suicide exposure on the outcome variables. In general, civilians reported greater suicide risk and active duty service members reported greater fearlessness about death. Fearlessness about death mediated the associations between perceived closeness and a history of suicide attempts. The loss of a military colleague to suicide was found to be unique and distinguishable from other important relationships. Results suggest the need to consider suicide exposure and closeness as salient variables associated with fearlessness about death and suicide risk factors. Inquiring about suicide exposure, closeness to the decedent, fearlessness about death, and beyond familial losses to suicide may indicate important avenues of intervention.

Factors associated with professional mental health service use among adults with suicidal ideation

BACKGROUND

The uptake of professional mental health services among people with suicidal ideation remains low, yet few community-based studies have characterised modifiable individual barriers to service use. Our aims were (1) to identify factors associated with use of professional mental health services among people experiencing suicidal ideation, and (2) to distinguish subgroups with varying levels of service use.

METHODS

1462 Australian adults (78.8% female) were recruited online to participate in a cross-sectional survey. Logistic regression analysis was used to identify factors associated with professional service use. A decision tree model was used to identify subgroups with varying rates of professional service use.

RESULTS

Most participants (62%) had used professional services for mental health concerns in the past 12 months. Greater rates of service use were observed in participants who were middle aged, spoke English, disclosed to informal sources or helplines, met criteria for a mental health disorder, had higher levels of entrapment, psychological distress, and disinhibition, and lower levels of detachment and antagonism. At the terminal nodes of the decision tree analysis, service use ranged from 21% to 94%. The most important determinants of service use were meeting criteria for a mental disorder and disclosure of suicidal ideation to family/friends and helplines.

CONCLUSION

These findings suggest that interventions to support the safe disclosure of suicidal ideation may assist in increasing service use. There is also the need for services that meet the needs of individuals who do not meet criteria for a mental health condition.

Childhood Trauma Associations With the Interpersonal Psychological Theory of Suicide and Social Cognitive Biases in Psychotic Disorders

Childhood trauma (CT) is associated with suicidal ideation and behaviors (SI/SB) in people with psychosis. The interpersonal psychological theory of suicide (IPTS) suggests that there are four factors that increase suicide risk: thwarted belongingness, perceived burdensomeness, acquired capacity for suicide, and hopelessness. The IPTS constructs and social cognitive biases are associated with SI/SB in psychotic disorders. However, the role of CT in IPTS constructs and social cognitive biases has not been examined in psychosis. In an outpatient community sample of persons with psychotic disorders (N = 96) assessed with the Childhood Trauma Questionnaire, the aims of this study were to a) evaluate rates of CT in this sample, b) determine the relationship between CT types and lifetime SI/SB, and c) explore the relationship between CT types, IPTS constructs, and social cognitive biases. All participants reported experiencing CT. Emotional abuse was associated with greater SI severity and higher rates of lifetime suicide attempts, as well as with greater perceived burdensomeness and more severe negative social cognitive biases. Other CT types were minimally associated with SI/SB or IPST constructs; hopelessness was not associated. Overall, negative interpersonal beliefs and social cognitive biases may explain how CT increases suicide risk in psychosis.

Suicidal attempt by disinfectant solution ingestion in case of opioid dependence

The current study presents a rare case of an opioid dependence (46‐year‐old man) ingesting a disinfectant solution (Wavicide‐01; 2.65% glutaraldehyde solution, pH:6). The doctor intubated the patient and ordered bicarbonate for systemic acidosis, anti‐proton‐pump inhibitors (PPIs), and mechanical ventilation because the patient's breathing was irregular and the endoscopy revealed grade 1 and grade 2 burns all the way through the gastrointestinal tract up to the duodenum. As a result, ingestion of glutaraldehyde compounds should be closely monitored for laryngeal edema and metabolic acidosis, which can result in upper airway obstruction requiring immediate airway stabilization. Furthermore, a better understanding of the clinical epidemiology of suicide attempts could aid in the early identification of people that use opioids and are at high risk of suicide, as well as the development of suicide prevention strategies for this vulnerable population.

The importance of paying attention to suicide risk in cases of opioid dependence with a history of psychiatric illness, even if hospitalized, maintaining patient safety issues in the hospital's ward and ICU, unavailability of dangerous equipment and careful monitoring by nurses, patient care in terms of self‐harm and/or to others, and psychiatric counseling for such patients is emphasized in the treatment of such patients.

Understanding the clinical characteristics of lesbian, gay, and bisexual military service members and adult beneficiaries within an inpatient psychiatric sample

BACKGROUND

Limited knowledge exists regarding targets for suicide-focused care among high-risk United States (U.S.) civilian and military sexual minorities.

PURPOSE

This study aimed to understand the demographic and clinical characteristics of a suicidal sexual minority sample, psychiatrically hospitalized in military treatment facilities, to advance future targeted care for this vulnerable subgroup.

METHODS

Secondary analysis of baseline data from a multisite psychotherapy randomized controlled trial was performed comparing those who self-identified as lesbian, gay, or bisexual (LGB; n = 39) to heterosexual participants (n = 170).

RESULTS

LGB participants were more likely than heterosexual participants to be younger, female, never married, and enlisted rank. LGB participants reported significantly lower family support, higher perceived burdensomeness, lower acquired capability for suicide, and were twice as likely to report that they could not control their suicidal thoughts. LGB and heterosexual participants reported similar levels of other suicide risk indicators and similar lifetime suicidal ideation and attempt histories.

CONCLUSIONS

Compared to heterosexual participants, LGB participants reported increased risk indicators for suicide yet similar lifetime suicidal ideation and attempt histories. Suicide prevention programs should address the unique needs of this vulnerable subgroup. Interventions targeting family support, perceived burdensomeness, and controllability of suicidal thoughts may be promising.

The Role of the Lateral Habenula in Suicide: A Call for Further Exploration

Despite decades of significant effort in research, policy, and prevention, suicide rates have continued to rise to the current peak of 14.6 per 100,000 deaths. This has resulted in a concerted effort to identify biomarkers associated with suicidal behavior in the brain, to provide predictions that are better than the chance of discerning who will die by suicide. We propose that the lateral habenula (LHb), and its dysfunction during a suicidal crisis, is a critical component of the transition from suicidal ideations to self-harm. Moreover, the LHb—a key functional node in brain reward circuitry—has not been ascribed a contributory role in suicidal behavior. We argue that the LHb anchors a “suicide circuit” and call for suicide researchers to directly examine the role of the LHb, and its long-term modulation, in response to the negative affect in suicidal behavior. Discerning the neural mechanisms of this contribution will require the collaboration of neuroscientists and psychologists. Consequently, we highlight and discuss research on LHb as it relates to suicidal ideation, suicidal behavior, or death by suicide. In so doing we hope to address the bench-to-bedside translational issues currently involved in suicide research and suggest a developmental framework that focuses on specific structures motivated by theoretical anchors as a way to incorporate neurobiological findings within the context of clinical theory.