Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

The U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) updated the 2019 joint clinical practice guideline (CPG) for assessing and managing patients who are at risk for suicide. This synopsis provides primary care physicians with a summary of the updated 2024 recommendations regarding evaluation and management of military members and veterans at risk for suicide.

METHODS

In 2023, the VA/DOD Evidence-Based Practice Work Group convened to develop a joint VA/DOD guideline, including clinical stakeholders, which conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The Work Group drafted 12 key questions, reviewed systematically identified literature (1 April 2018 to 15 March 2023), evaluated the evidence, created algorithms, and advanced 24 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system.

RECOMMENDATIONS

Despite insufficient evidence to recommend for or against suicide risk screening programs as a means for reducing suicide attempts or deaths, the VA/DOD Work Group identified validated tools that could be used to identify populations at higher risk for suicide-related behaviors. Cognitive behavioral therapy was also recommended for reducing the risk for suicide attempts and decreasing suicidal ideation among those with a history of suicidal behavior or a history of self-directed violence. Periodic communications after previous suicide attempts were also recommended as a prevention strategy. Pharmacologic treatments, such as clozapine or ketamine infusion, also have a role in the management of suicide risk among those with schizophrenia or major depressive disorder, respectively.

Neuroticism and extraversion as predictors of first-lifetime onsets of depression, anxiety, and suicidality in high-risk adolescents

There is substantial evidence that personality traits, in particular neuroticism and extraversions predict depressive and anxiety episodes as well as suicidal ideation. However, little research has examined whether these traits predict the first onset of depressive and anxiety disorders and suicidal ideation. Moreover, the few studies to date have not adjusted for pre-existing subthreshold symptoms, assessed dimensionally. In this study, 144 adolescents were assessed at baseline, 9-, and 18-month follow-ups. Neuroticism and extraversion were assessed via self-report, and depressive and anxiety disorders and suicidal ideation were assessed with diagnostic interviews. Adjusting for age, sex, and baseline symptoms, logistic regression analyses showed that neuroticism predicted the first onset of depressive disorders. However, neither neuroticism nor extraversion predicted first onsets of anxiety disorders, extraversion did not predict depressive disorders, and neither trait predicted suicidal ideation onset or severity after adjusting for baseline symptoms. Neuroticism and extraversion may respectively predispose youth to depressive or anxiety disorders but not to suicidal ideation over and above pre-existing symptoms. Results have implications for the early identification of at-risk youth and prevention of depressive and anxiety disorders and suicidal ideation.

Antecedents, reasons for, and consequences of suicide attempts: Results from a qualitative study of 89 suicide attempts among army soldiers

Most studies aimed at understanding suicidal behavior have focused on quantifying the associations between putative risk factors and suicidal behavior in comparative studies of cases and controls. The current study, in comparison, exclusively focused on cases-89 Army soldiers presenting for hospital care following a suicide attempt-and attempted to reveal the antecedents of, reasons for, and consequences of suicide attempts. This mixed-methods study using qualitative interviews and self-report surveys/interviews revealed that in most cases, the most recent onset of suicidal thoughts began shortly before the suicide attempt and were not disclosed to others, limiting opportunities for intervention via traditional approaches. The primary reason given for attempting suicide was to escape from psychologically aversive conditions after concluding that no other effective strategies or options were available. Participants reported both negative (e.g., self-view, guilt) and positive (e.g., learning new skills, receiving support) consequences of their suicide attempt-and described things they believe would have prevented them from making the attempt. These findings provide new insights into the motivational and contextual factors for suicidal behavior and highlight several novel directions for prevention and intervention efforts. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Examining the predictive utility of suicidal ideation characteristics in relation to real-time monitoring of suicidal ideation and suicide attempts at follow-up

INTRODUCTION

Several characteristics of suicidal ideation, including frequency, duration, perceived controllability, and intensity, have been identified. The present study examined whether these characteristics of baseline suicidal ideation uniquely predicted (1) the severity, variability, and frequency of suicidal ideation assessed through real-time monitoring; and (2) suicide attempts at 3-week and 6-month follow-up among recently discharged psychiatric inpatients.

METHODS

A sample of 249 adults (Mage = 40.43, 55.1% female, 91.4% White) completed a baseline assessment of their suicidal ideation characteristics during psychiatric hospitalization, five daily ecological momentary assessments (EMA) for 21 days following discharge, and follow-up assessments of suicide-related outcomes at 3-week and 6-month follow-up.

RESULTS

Perceived controllability of suicidal thoughts was uniquely associated with the variability of EMA-assessed suicidal ideation and the presence of suicide attempts at 3-week, but not 6-month follow-up. No other characteristic of baseline suicidal ideation was uniquely associated with EMA-assessed suicidal ideation or the presence of suicide attempts at follow-up.

CONCLUSIONS

Given links between the perceived controllability of suicidal ideation and (1) momentary variability of suicidal ideation and (2) suicide attempts over the subsequent 3 weeks, perceived controllability of suicidal thinking may be a useful marker of short-term risk that may be malleable to clinical intervention.

Average ages of onset and time to transition between self-injurious thoughts and behaviors: Retrospective evidence from two developmentally distinct samples

BACKGROUND

Suicidal thoughts and behaviors often emerge in a predictable sequence, with suicidal ideation (SI) preceding planning, and planning preceding actions. Few studies, however, have considered the timing and duration of non-suicidal self-injury (NSSI) in these transitions. Accordingly, this study examined: 1) the developmental sequencing of NSSI, SI and suicide attempts, and 2) whether age of onset or duration predict transitions from NSSI to other SITB, and from SI to NSSI.

METHODS

704 first-year students from a mid-sized Canadian university (Sample 1) and 2095 adults from an online research volunteer panel (Sample 2) completed the Self-Injurious Thoughts and Behaviors Interview self-report, which assessed the presence, age of onset, and recency of SITB.

RESULTS

NSSI and SI typically onset before age 15, while suicide planning and attempt usually began at or after age 15. Transition from NSSI to SI was likeliest in the first year after NSSI onset. Transition from NSSI to suicide attempt was likeliest in the second and third year after NSSI onset in Sample 1, and up to four years after NSSI onset in Sample 2. Early (before age 13) and late (after age 16) onsets of NSSI predicted higher odds of transitioning from NSSI to SI or attempt. Transition from SI to NSSI was likeliest in the first two years after SI onset and when SI began before age 13.

CONCLUSIONS

The first year after NSSI or SI onset are critical for transitions to other SITB. Targeted prevention and monitoring should be considered for people who recently initiated NSSI.

The neural connectome of suicidality in adults with mood and anxiety disorders

Although suicide risk is a major public health issue, attempts to understand the neural basis of suicidality have been limited by small sample sizes and a focus on specific psychiatric disorders. This sample comprised 579 participants, of whom 428 had a psychiatric disorder (depression, anxiety or stress-related disorder) and 151 were non-psychiatric controls. All participants underwent structured clinical interviews, including an assessment of suicidality in the past month, and completed a functional magnetic resonance imaging scan. There were 238 (41.1%) participants who met criteria for suicidality and 341 (58.9%) were non-suicidal. Task-derived functional connectivity was calculated for 436 brain regions, comprising 8 intrinsic connectivity networks. Participants who were suicidal had decreased connectivity in a network of 143 connections across 86 brain regions. This pattern was characterized primarily by decreased connectivity within the visual, somatomotor and salience networks, between these networks, and also with the default mode and limbic networks. By adopting a transdiagnostic approach with a very large sample of individuals with mood disorders, anxiety and stress and non-psychiatric participants, this study highlights the hypoconnectivity that characterizes suicidality and points to altered connectivity within and between key networks involved in emotional, sensory and cognitive processes that are implicated in suicidal risk.

Facets of Suicidal Ideation

According to SAMHSA (2023), approximately 16,600,000 American adults and teens reported having serious thoughts of suicide in 2022. While suicide prevention has primarily focused on suicide deaths and attempts, we contend that suicidal ideation (SI) deserves more in-depth investigation and should be an essential intervention target on its own. In support of this point, we provide three examples of ways to improve specificity in understanding of SI through the study of controllability of SI, the language used to assess SI, and measuring SI in real time. We also consider qualitative work on the content of SI, its treatment, and definitional considerations. We thus call for an increased general focus on SI within research, clinical care, and policy.

Why Do Some Depressive Patients Have Suicidal Ideation but Others Not? Suicidal Ideation From the Perspective of Affective Neuroscience Personality Traits

INTRODUCTION

Although major depression is the disorder most frequently associated with suicidal behavior, it is unclear that major depressive disorder patients may develop suicidal ideation. Basic affective system theory may provide a novel and beneficial viewpoint in this field. The goal of this study was to investigate the basic affective system in relation to suicidal ideation in individuals with depression.

METHOD

The study population comprised 160 participants who had been formally diagnosed with major depressive disorder. Participants were divided into two groups according to whether they had suicide ideation (depression with suicide [DS]) (N = 93) or not (depression with no suicidal ideation [DNS]) (N = 67). The Beck Depression Inventory (BDI), the Suicide Probability Scale (SPS), the Beck Hopelessness Scale (BHS), and the Affective Neuroscience Personality Scale (ANPS) were applied. Statistical Product and Service Solutions (SPSS) 24 and the SPSS macroprocess, which were specifically developed for assessing complex models including serial mediators, were used to analyze the data.

RESULTS

The mean age of all participants was 31.1 ± 11 years, and most of them were female (65%). The DS group had a higher family history of psychiatric medication use and suicidal attempts. In addition, BDI, BHS, and SPS total scores were higher, as well as ANGER subscale scores were higher in the DS group. In mediation analysis, the ANGER subscale significantly predicted the presence of suicide ideation. We observed a direct effect of the ANGER subscale score on suicide ideation as well as an indirect effect of the ANGER subscale score on suicidal ideation via depression severity.

CONCLUSION

Higher scores on ANGER are associated with suicidal ideation. Neurobiological correlates, including the ANGER system, may be promising in understanding suicidal behaviors.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Collaboration matters: A randomized controlled trial of patient-clinician collaboration in suicide risk assessment and intervention

BACKGROUND

Clinician collaboration can help high-risk individuals to manage their suicidal crises. However, limited research has directly examined how higher patient-clinician collaboration during assessment and intervention can effectively reduce suicidal ideation. This novel randomized clinical trial compared a high vs. low level of patient-clinician collaboration by pairing commonly used assessment (Structured Interview vs. Narrative Assessment) and intervention approaches (Safety Planning Intervention vs. Crisis Response Planning). We hypothesized that the interventions involving higher (than lower) patient-clinician collaboration during assessment (Narrative Assessment) or intervention (Crisis Response Planning) would lead to larger reductions in suicidal ideation.

METHODS

Eighty-two participants with a history of suicide ideation and/or attempts were randomly assigned to one of the four interventions varying in patient-clinician collaboration. After attrition, sixty-six participants completed the study. Suicidal ideation via ecological momentary assessment was measured 14 days before and 14 days after treatment.

RESULTS

Although the severity of suicidal ideation decreased in all groups, the two groups that included highly collaborative assessment had larger pre-post reductions in suicidal ideation (Narrative Assessment+Safety Plan; dwithin = 0.26, and Narrative Assessment+Crisis Response Plan; dwithin = 0.19) than the groups that included a checklist-based assessment (Structured Interview).

LIMITATIONS

Longer follow-up periods with a larger sample would have provided an understanding of the durability of intervention effects.

CONCLUSION

Results suggest that the inclusion of higher patient-clinician collaboration techniques during suicide risk assessment can effectively reduce suicidal thoughts. Thus, clinician-led collaborative risk assessment approaches can enhance the effects of safety planning-type interventions among patients with elevated risk for suicide versus checklist-based assessment approaches.

Assessing a Suicide Prevention Helpline's Impact on Caller Crisis Level and Suicidality

OBJECTIVE

Worldwide helplines are considered an important part of suicide prevention strategies. Nevertheless, evidence regarding the impact of suicide prevention helplines on the suicidality of its users remains limited and is frequently confronted with methodological issues. This study aimed to assess the impact of crisis calls on callers' levels of crisis and suicidality both immediately after the call and at follow-up compared to before the call. After the call, the satisfaction of the callers with the intervention was also assessed.

METHODS

A pre-post study, generated automatically by a telephone system, was conducted in order to compare the level of crisis and suicidality (operationalized by five indicators: hopelessness, entrapment, controllability, suicidal intent, and social support) experienced by callers before and immediately after the call and at follow-up (one to two weeks after the call).

RESULTS

Callers (n = 487) showed significant improvement in their level of crisis (p < .001, d = -0.31), hopelessness (p < .001, d = -0.22), entrapment (p < .001, d = -0.25), suicide intent (p < .001, d = -0.37), and social support (p < .001, d = 0.33) after the call compared to before the call. Improvements were also found at follow-up compared to pretest. The satisfaction of callers with the helpline was high.

CONCLUSIONS

This study adds to the growing evidence on suicide prevention helplines and addresses some important methodological issues in helpline research. Furthermore, it shows promising results regarding the potential supportive impact of helplines on callers who feel suicidal.

Assessment of suicidal thoughts and behaviors in adults: A systematic review of measure psychometric properties and implications for clinical and research utility

High-quality clinical care and research on suicidal thoughts and behaviors (STBs) depends on availability and implementation of reliable and valid measures of STBs. In contrast to studies examining STB risk factors, screening instruments, or treatment, little research has rigorously examined the content, characteristics, and psychometric properties of STB measures themselves. This systematic review (1) identified STB measures that conform to empirically supported definitions of STBs, and (2) identified peer-reviewed papers reporting on the psychometric properties of these measures in adults. Data on psychometric properties and other measure characteristics were extracted. A total of 21 eligible measures were identified in the first stage. In the second stage, 70 articles (with 79 independent samples) were included with psychometric data in adult samples for 19 measures. Although there was support for strong internal consistency and content validity across many measures, face validity and clinical utility concerns were prevalent. Few measures comprehensively assessed suicidal behaviors, and interview-based assessments tended to show the strongest psychometric properties and clinical utility. Findings are discussed in the context of recommendations for improving existing measures, including future research to increase utility and translatability across clinical settings, delivery methods, and diverse populations.

Attachment Style, Social Support Network, and Lifetime Suicide Ideation and Suicide Attempts Among New Soldiers in the U.S. Army

OBJECTIVE

Attachment style and social support networks (SSN) are associated with suicide ideation (SI) and suicide attempt (SA). How these two factors interact is important to understanding the mechanisms of risk for suicidal behaviors and identifying interventions.

METHOD

Using the Army Study to Assess Risk and Resilience in Servicemembers New Soldier Study (N = 38,507 soldiers), we examined how three attachment styles (preoccupied, fearful, and secure) and SSN (smaller vs larger) were associated with lifetime SI, SA, and SA among soldiers with SI. The interaction of each attachment style by SSN was examined.

RESULTS

All three attachment styles were associated with SI and SA in the total sample (for SA: preoccupied OR = 2.82, fearful OR = 2.84, and secure OR = 0.76). Preoccupied and fearful attachment were associated with SA among suicide ideators. Smaller SSN was associated with a higher risk for all three outcomes (range of ORs = 1.23-1.52). The association of SSN with SI and with SA among suicide ideators was significantly modified by the presence or absence of preoccupied attachment style. Among soldiers without preoccupied attachment, larger SSN was associated with lower risk of SI. Among suicide ideators with preoccupied attachment, a larger SSN was associated with lower risk of SA.

CONCLUSION

This study highlights the need for increased understanding of the role of attachment style and social networks in suicide risk, in particular preoccupied attachment among soldiers with SI. A critical next step is to explore these relationships prospectively to guide intervention development.

Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans

OBJECTIVES

To examine the role of subjective cognitive difficulties (SCD), posttraumatic stress disorder (PTSD), and their interaction in predicting suicidal ideation and current suicidal intent in middle-aged and older United States (US) military veterans.

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

Data were analyzed from the 2019 to 2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3602 US veterans aged 50 years and older (mean age = 69.0).

MEASUREMENTS

Questionnaires including the Medical Outcomes Study Cognitive Functioning Scale (SCD), PTSD Checklist for DSM-5 (PTSD), Patient Health Questionnaire-9 (suicidal ideation in the previous two weeks), and the Suicide Behaviors Questionnaire-Revised (current suicidal intent).

RESULTS

A total of 154 (4.4%) veterans screened positive for current PTSD, 239 (6.7%) reported past two-week suicidal ideation, and 37 (1.0%) reported current suicidal intent. The probability of suicidal ideation among veterans with both SCD and PTSD was more than six times higher than that observed in the full sample (44.5% vs. 6.7%) and more than 2.5 times higher than that observed in veterans with SCD and no PTSD (44.5% vs. 17.5%). Veterans with both subjective memory and concentration difficulties were more likely to report suicidal intent, though the interaction between SCD and PTSD was not significantly associated with suicidal intent.

CONCLUSION

Middle-aged and older U.S. veterans with subjective cognitive impairment and PTSD report higher rates of suicidal ideation than those with SCD alone. Interventions targeting SCD and PTSD may mitigate suicide risk among middle-aged and older veterans.

Dynamic learning of individual-level suicidal ideation trajectories to enhance mental health care

There has recently been an increase in ongoing patient-report routine outcome monitoring for individuals within clinical care, which has corresponded to increased longitudinal information about an individual. However, many models that are aimed at clinical practice have difficulty fully incorporating this information. This is in part due to the difficulty in dealing with the irregularly time-spaced observations that are common in clinical data. Consequently, we built individual-level continuous-time trajectory models of suicidal ideation for a clinical population (N = 585) with data collected via a digital platform. We demonstrate how such models predict an individual's level and variability of future suicide ideation, with implications for the frequency that individuals may need to be observed. These individual-level predictions provide a more personalised understanding than other predictive methods and have implications for enhanced measurement-based care.

Transition to suicide ideation and attempt among emergency room patients

BACKGROUND

Suicidal thoughts and behaviours (STB) represent a persistent and serious public health problem, and suicide is among the leading causes of death worldwide. We focus on predictors of transition rates and time courses through the STB spectrum among psychiatric emergency room (PER) patients.

AIMS

We aimed to investigate (a) whether currently suicidal patients had prior referrals to the PER, (b) for which reason they were previously referred to the PER and (c) the timing of this referral.

METHOD

We performed a retrospective study spanning 20 years with 24 815 PER referrals. Descriptive statistics of patients' sociodemographic and clinical characteristics are provided and expressed as weighted proportions and means. Logistic regression was used to identify risk profiles of patients who had a higher chance of being referred for reasons of STB given their PER history. Multiple imputation and data weighting techniques were implemented.

RESULTS

STB among PER patients was persistent and led to repeated referrals (up to five times more likely), often within a short period (18% <1 month). Those previously referred for ideation/plan had 66% higher risk of making the transition to suicide attempt, with 25% making this transition within a month after previous referral. This is similar to the transition from depressed mood to suicide ideation/plan.

CONCLUSIONS

STBs in PER patients are persistent and lead to repeated referrals, often within a short period, including transitions to more severe forms of STB.

The role of premeditation in suicide: Identifying factors associated with increased planning among suicide decedents

INTRODUCTION

Suicide premeditation is a critical factor to consider when assessing suicide risk. Understanding which individuals are more or less likely to plan their suicidal behavior can shed light on how suicidal thoughts turn into actions.

METHOD

The present study used psychological autopsy data to identify factors associated with level of premeditation among 131 adults who died by suicide.

RESULTS

Logistic regression analyses indicated that suicide decedents with higher premeditation scores had higher odds of being diagnosed with a depressive disorder and choosing a violent suicide method, specifically a firearm. Individuals with lower premeditation scores had higher odds of being diagnosed with a polysubstance use disorder.

CONCLUSION

Suicide decedents exhibiting greater premeditation before their deaths were different in several ways from suicide decedents exhibiting less premeditation. A better understanding of suicide premeditation can ultimately aid in the development of improved risk assessments and targeted safety interventions for those struggling with suicidal thoughts.

Specificity, frequency, and intent: Multiple characteristics of adolescents' suicide plan correlate with their history of suicidal behavior

BACKGROUND

Suicide plans (SP) can be a common precipitant to suicidal behavior (SB) during adolescence, and SPs can vary in how specific they are, how frequently they are thought about, and how strongly they are intended to be enacted. To date, we have limited understanding of how discrete SP characteristics (i.e., specificity, frequency, and intent to act) present among adolescents, and whether they relate to SB. In the current study, we investigated SP characteristics and their association with SB history among adolescents who had previously considered suicide.

METHODS

Participants were 142 community-based adolescents (14-19 years; M = 17.6, SD = 1.4) who reported a history of suicidal ideation. Adolescents provided responses pertaining to their SP history, SP characteristics, and SB history, via the Self-Injurious Thoughts and Behaviors Interview-Revised (SITBI-R).

RESULTS

Greater specificity, frequency, and intent were each associated with modestly increased odds of reporting an SB history. The associations between plan specificity and SB history, as well as between frequency of thinking about one's SP and SB history, were mediated by adolescents' intent to act on their SP.

CONCLUSIONS

It may not only be whether, but how, adolescents plan for suicide that relates to their tendency to engage in SB.

Uncontrollability of suicidal ideation adds incremental explanatory power in prediction of later suicidal ideation

OBJECTIVE

Suicidal ideation and suicidal behaviors are major public health concerns in the United States and are difficult to treat and predict. Risk factors that are incrementally informative are needed to improve prediction and inform prevention of suicidal thoughts and behaviors. Uncontrollability of suicidal ideation, one parameter of suicidal ideation, is one such candidate.

METHOD

In the current study, we assessed the predictive power of uncontrollability of suicidal ideation, over and above overall suicidal ideation, for future suicidal ideation in a large sample of active-duty service members. A total of 1044 suicidal military service members completed baseline assessments, of whom 664 (63.6%) completed 3-month follow-up assessments.

RESULTS

While baseline overall suicidal ideation itself was the strongest predictor of future suicidal ideation, uncontrollability of suicidal ideation added some incremental explanatory power.

CONCLUSION

Further study of uncontrollability of suicidal thought is needed to elucidate its impact on suicidal outcomes.

TransformEHR: transformer-based encoder-decoder generative model to enhance prediction of disease outcomes using electronic health records

Deep learning transformer-based models using longitudinal electronic health records (EHRs) have shown a great success in prediction of clinical diseases or outcomes. Pretraining on a large dataset can help such models map the input space better and boost their performance on relevant tasks through finetuning with limited data. In this study, we present TransformEHR, a generative encoder-decoder model with transformer that is pretrained using a new pretraining objective-predicting all diseases and outcomes of a patient at a future visit from previous visits. TransformEHR's encoder-decoder framework, paired with the novel pretraining objective, helps it achieve the new state-of-the-art performance on multiple clinical prediction tasks. Comparing with the previous model, TransformEHR improves area under the precision-recall curve by 2% (p < 0.001) for pancreatic cancer onset and by 24% (p = 0.007) for intentional self-harm in patients with post-traumatic stress disorder. The high performance in predicting intentional self-harm shows the potential of TransformEHR in building effective clinical intervention systems. TransformEHR is also generalizable and can be easily finetuned for clinical prediction tasks with limited data.

Suicide Characteristics of Veterans Hospitalized for Suicide Ideation or Attempt

INTRODUCTION

Veteran suicide rates continue to be unacceptably high, with the most common risk factor being a past suicide attempt (SA). However, some characteristics of suicidal ideation (SI) and behavior among Veterans hospitalized for suicide risk remain under-reported.

MATERIALS AND METHODS

One hundred and eighty-three Veterans hospitalized for either an SA or SI with intent were screened for enrollment in a treatment study to prevent suicide. Veterans completed a demographic form, the Columbia-Suicide Severity Rating Scale, and the McLean borderline personality disorder screening measure shortly after inpatient psychiatric admission. Chi-squared and t-tests were used to compare suicide characteristics (e.g., intensity, duration, deterrents, and controllability) between Veterans with and without a lifetime history of SA. Thematic analyses of the reported method of SI were conducted.

RESULTS

Sixty-seven percent of participants were hospitalized for SI and 33% were hospitalized for SA. Twenty-one percent of Veterans hospitalized for SI also endorsed a recent SA in the weeks preceding hospitalization. Most participants reported at least one lifetime SA (71%). Veterans with a lifetime history of SA reported greater frequency and duration of ideation in the week before hospitalization (t[169] =  -2.56, P = .01; t[168] =  -2.04, P = .04) while also reporting that deterrents were less likely to prevent an SA (t[107.09] =  -3.58, P = .001) compared to those with no lifetime SA.

CONCLUSION

Overall, Veterans hospitalized for SI/SA demonstrated markers of chronic suicide risk, as most participants endorsed a past attempt in their lifetime. Some Veterans admitted for SI also reported a past month's attempt, suggesting that in certain cases, hospitalization does not immediately follow an acute suicidal crisis. A past SA differentiated Veterans on average frequency and duration of SI as well as the perception of deterrents preventing suicidal behavior. Therefore, a thorough evaluation of suicide methods and intensity may be informative in treatment planning for Veterans at greatest risk of suicide.

External Validation and Updating of a Statistical Civilian-Based Suicide Risk Model in US Naval Primary Care

Importance

Suicide remains an ongoing concern in the US military. Statistical models have not been broadly disseminated for US Navy service members.

Objective

To externally validate and update a statistical suicide risk model initially developed in a civilian setting with an emphasis on primary care.

Design, Setting, and Participants

This retrospective cohort study used data collected from 2007 through 2017 among active-duty US Navy service members. The external civilian model was applied to every visit at Naval Medical Center Portsmouth (NMCP), its NMCP Naval Branch Health Clinics (NBHCs), and TRICARE Prime Clinics (TPCs) that fall within the NMCP area. The model was retrained and recalibrated using visits to NBHCs and TPCs and updated using Department of Defense (DoD)-specific billing codes and demographic characteristics, including expanded race and ethnicity categories. Domain and temporal analyses were performed with bootstrap validation. Data analysis was performed from September 2020 to December 2022.

Exposure

Visit to US NMCP.

Main Outcomes and Measures

Recorded suicidal behavior on the day of or within 30 days of a visit. Performance was assessed using area under the receiver operating curve (AUROC), area under the precision recall curve (AUPRC), Brier score, and Spiegelhalter z-test statistic.

Results

Of the 260 583 service members, 6529 (2.5%) had a recorded suicidal behavior, 206 412 (79.2%) were male; 104 835 (40.2%) were aged 20 to 24 years; and 9458 (3.6%) were Asian, 56 715 (21.8%) were Black or African American, and 158 277 (60.7%) were White. Applying the civilian-trained model resulted in an AUROC of 0.77 (95% CI, 0.74-0.79) and an AUPRC of 0.004 (95% CI, 0.003-0.005) at NBHCs with poor calibration (Spiegelhalter P < .001). Retraining the algorithm improved AUROC to 0.92 (95% CI, 0.91-0.93) and AUPRC to 0.66 (95% CI, 0.63-0.68). Number needed to screen in the top risk tiers was 366 for the external model and 200 for the retrained model; the lower number indicates better performance. Domain validation showed AUROC of 0.90 (95% CI, 0.90-0.91) and AUPRC of 0.01 (95% CI, 0.01-0.01), and temporal validation showed AUROC of 0.75 (95% CI, 0.72-0.78) and AUPRC of 0.003 (95% CI, 0.003-0.005).

Conclusions and Relevance

In this cohort study of active-duty Navy service members, a civilian suicide attempt risk model was externally validated. Retraining and updating with DoD-specific variables improved performance. Domain and temporal validation results were similar to external validation, suggesting that implementing an external model in US Navy primary care clinics may bypass the need for costly internal development and expedite the automation of suicide prevention in these clinics.

Investigating the co-occurrence of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation

This study investigated the co-occurrent association of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation. Data came from the 2019 Youth Risk Behavior Survey. The sample was comprised of adolescents ages 14-18 who reported suicidal ideation during the past year (n = 2,562). Multinomial logistic regression was used to examine the co-occurring association of marijuana use and prescription opioid misuse with multiple suicide attempts. Of the 2,562 adolescents who experienced suicidal ideation, 19.2 % also attempted suicide multiple times during the past year and 19.0 % reported ever using marijuana and misusing prescription opioids, 8.8 % misused prescription opioids only, and 33.3 % used marijuana only. In the multivariate model, for adolescents who used marijuana and misused prescription opioid, the risk of attempting suicide once was 1.77 times higher (RRR = 1.77, 95 % CI = 1.22-2.59) and the risk of multiple suicide attempts was 3.23 times higher (RRR = 3.23, 95 % CI = 1.95-5.33) when compared to adolescents who had never used marijuana nor misused prescription opioid. The risk of multiple suicide attempts was greater for bisexual and racial/ethnic minority adolescents and adolescents who felt sad or hopeless. Interventions that prevent prescription opioid misuse among adolescents may be effective in mitigating suicide attempts.

Genetic liability to suicidal thoughts and behaviors and risk of suicide attempt in US military veterans: moderating effects of cumulative trauma burden

BACKGROUND

Little is known about environmental factors that may influence associations between genetic liability to suicidality and suicidal behavior.

METHODS

This study examined whether a suicidality polygenic risk score (PRS) derived from a large genome-wide association study (N = 122,935) was associated with suicide attempts in a population-based sample of European-American US military veterans (N = 1664; 92.5% male), and whether cumulative lifetime trauma exposure moderated this association.

RESULTS

Eighty-five veterans (weighted 6.3%) reported a history of suicide attempt. After adjusting for sociodemographic and psychiatric characteristics, suicidality PRS was associated with lifetime suicide attempt (odds ratio 2.65; 95% CI 1.37-5.11). A significant suicidality PRS-by-trauma exposure interaction emerged, such that veterans with higher levels of suicidality PRS and greater trauma burden had the highest probability of lifetime suicide attempt (16.6%), whereas the probability of attempts was substantially lower among those with high suicidality PRS and low trauma exposure (1.4%). The PRS-by-trauma interaction effect was enriched for genes implicated in cellular and developmental processes, and nervous system development, with variants annotated to the DAB2 and SPNS2 genes, which are implicated in inflammatory processes. Drug repurposing analyses revealed upregulation of suicide gene-sets in the context of medrysone, a drug targeting chronic inflammation, and clofibrate, a triacylglyceride level lowering agent.

CONCLUSION

Results suggest that genetic liability to suicidality is associated with increased risk of suicide attempt among veterans, particularly in the presence of high levels of cumulative trauma exposure. Additional research is warranted to investigate whether incorporation of genomic information may improve suicide prediction models.

Prospective associations of emotion reactivity and risk behaviors with suicide attempts in US Army soldiers

BACKGROUND

Emotion reactivity and risk behaviors (ERRB) are transdiagnostic dimensions associated with suicide attempt (SA). ERRB patterns may identify individuals at increased risk of future SAs.

METHODS

A representative sample of US Army soldiers entering basic combat training (n = 21 772) was surveyed and followed via administrative records for their first 48 months of service. Latent profile analysis of baseline survey items assessing ERRB dimensions, including emotion reactivity, impulsivity, and risk-taking behaviors, identified distinct response patterns (classes). SAs were identified using administrative medical records. A discrete-time survival framework was used to examine associations of ERRB classes with subsequent SA during the first 48 months of service, adjusting for time in service, socio-demographic and service-related variables, and mental health diagnosis (MH-Dx). We examined whether associations of ERRB classes with SA differed by year of service and for soldiers with and without a MH-Dx.

RESULTS

Of 21 772 respondents (86.2% male, 61.8% White non-Hispanic), 253 made a SA. Four ERRB classes were identified: 'Indirect Harming' (8.9% of soldiers), 'Impulsive' (19.3%), 'Risk-Taking' (16.3%), and 'Low ERRB' (55.6%). Compared to Low ERRB, Impulsive [OR 1.8 (95% CI 1.3-2.4)] and Risk-Taking [OR 1.6 (95% CI 1.1-2.2)] had higher odds of SA after adjusting for covariates. The ERRB class and MH-Dx interaction was non-significant. Within each class, SA risk varied across service time.

CONCLUSIONS

SA risk within the four identified ERRB classes varied across service time. Impulsive and Risk-Taking soldiers had increased risk of future SA. MH-Dx did not modify these associations, which may therefore help identify risk in those not yet receiving mental healthcare.

Rumination as a Transdiagnostic Phenomenon in the 21st Century: The Flow Model of Rumination

Rumination and its related mental phenomena share associated impairments in cognition, such as executive functions and attentional processes across different clinical conditions (e.g., in psychotic disorders). In recent decades, however, the notion of rumination has been increasingly narrowed to the "self-focused" type in depressive disorders. A closer review of the literature shows that rumination may be construed as a broader process characterized by repetitive thoughts about certain mental contents that interfere with one's daily activities, not only limited to those related to "self". A further examination of the construct of rumination beyond the narrowly focused depressive rumination would help expand intervention opportunities for mental disorders in today's context. We first review the development of the clinical construct of rumination with regard to its historical roots and its roles in psychopathology. This builds the foundation for the introduction of the "Flow Model of Rumination (FMR)", which conceptualizes rumination as a disruption of a smooth flow of mental contents in conscious experience that depends on the coordinated interactions between intention, memory, affect, and external events. The conceptual review concludes with a discussion of the impact of rapid technological advances (such as smartphones) on rumination. Particularly in contemporary societies today, a broader consideration of rumination not only from a cognition viewpoint, but also incorporating a human-device interaction perspective, is necessitated. The implications of the FMR in contemporary mental health practice are discussed.

Co-occurring suicidal ideation and alcohol-related problems: An intersectional analysis of Native American and White adults with minoritized sexual identities

BACKGROUND

Disparities in suicidal ideation (SI) and alcohol use disorder (AUD) are evident in both Native American and minoritized sexual identity groups, relative to non-Hispanic White and heterosexual groups. However, Native Americans report lower drinking and binge drinking rates than White adults. Persons with intersecting identities, specifically Native Americans with minoritized sexual identities, may be at greater risk for SI and drinking, binge drinking, and AUD than White and Native American heterosexual adults.

METHODS

Five years (2015-2019) of National Survey of Drug Use and Health data were combined (N = 130,157). Multinomial logistic regressions tested racial (Native American vs White) and sexual identity (lesbian/gay/bisexual vs heterosexual) differences in odds of SI, drinking, and co-occurring SI + drinking, versus neither SI/drinking. Subsequent analyses examined SI + binge drinking, and SI + AUD.

RESULTS

Compared to White heterosexual adults, Native American heterosexual adults reported lower co-occurring SI + drinking odds, whereas Native American sexual minoritized adults reported higher odds. Native American sexual minoritized groups showed greater co-occurring SI + binge drinking odds and greater co-occurring SI + AUD odds compared to White heterosexual adults. Native American sexual minoritized adults showed greater SI only compared to White sexual minoritized adults. Sexual minoritized Native Americans showed higher odds of co-occurring SI + drinking, binge drinking, and AUD than White heterosexual adults.

CONCLUSIONS

Native American sexual minoritized groups showed higher likelihood of co-occurring SI + drinking, binge drinking, and AUD relative to both White and Native American heterosexual adults. Disparities warrant outreach for suicide and AUD prevention for Native American sexual minoritized adults.

Prevalence and correlates of suicidal behaviours in a representative epidemiological youth sample in Hong Kong: the significance of suicide-related rumination, family functioning, and ongoing population-level stressors

BACKGROUND

Young people are most vulnerable to suicidal behaviours but least likely to seek help. A more elaborate study of the intrinsic and extrinsic correlates of suicidal ideation and behaviours particularly amid ongoing population-level stressors and the identification of less stigmatising markers in representative youth populations is essential.

METHODS

Participants (n = 2540, aged 15-25) were consecutively recruited from an ongoing large-scale household-based epidemiological youth mental health study in Hong Kong between September 2019 and 2021. Lifetime and 12-month prevalence of suicidal ideation, plan, and attempt were assessed, alongside suicide-related rumination, hopelessness and neuroticism, personal and population-level stressors, family functioning, cognitive ability, lifetime non-suicidal self-harm, 12-month major depressive disorder (MDD), and alcohol use.

RESULTS

The 12-month prevalence of suicidal ideation, ideation-only (no plan or attempt), plan, and attempt was 20.0, 15.4, 4.6, and 1.3%, respectively. Importantly, multivariable logistic regression findings revealed that suicide-related rumination was the only factor associated with all four suicidal outcomes (all p < 0.01). Among those with suicidal ideation (two-stage approach), intrinsic factors, including suicide-related rumination, poorer cognitive ability, and 12-month MDE, were specifically associated with suicide plan, while extrinsic factors, including coronavirus disease 2019 (COVID-19) stressors, poorer family functioning, and personal life stressors, as well as non-suicidal self-harm, were specifically associated with suicide attempt.

CONCLUSIONS

Suicide-related rumination, population-level COVID-19 stressors, and poorer family functioning may be important less-stigmatising markers for youth suicidal risks. The respective roles played by not only intrinsic but also extrinsic factors in suicide plan and attempt using a two-stage approach should be considered in future preventative intervention work.

Predictors of suicide attempt within 30 days of first medically documented major depression diagnosis in U.S. army soldiers with no prior suicidal ideation

BACKGROUND

Understanding mental health predictors of imminent suicide attempt (SA; within 30 days) among soldiers with depression and no prior suicide ideation (SI) can inform prevention and treatment. The current study aimed to identify sociodemographic and service-related characteristics and mental disorder predictors associated with imminent SA among U.S. Army soldiers following first documented major depression diagnosis (MDD) with no history of SI.

METHODS

In this case-control study using Army Study to Assess Risk and Resilience in Servicemembers (STARRS) administrative data, we identified 101,046 active-duty Regular Army enlisted soldiers (2010-2016) with medically-documented MDD and no prior SI (MDD/No-SI). We examined risk factors for SA within 30 days of first MDD/No-SI using logistic regression analyses, including socio-demographic/service-related characteristics and psychiatric diagnoses.

RESULTS

The 101,046 soldiers with documented MDD/No-SI were primarily male (78.0%), < 29 years old (63.9%), White (58.1%), high school-educated (74.5%), currently married (62.0%) and < 21 when first entering the Army (56.9%). Among soldiers with MDD/No-SI, 2,600 (2.6%) subsequently attempted suicide, 16.2% (n = 421) within 30 days (rate: 416.6/100,000). Our final multivariable model identified: Soldiers with less than high school education (χ²₃ = 11.21, OR = 1.5[95%CI = 1.2-1.9]); combat medics (χ²₂ = 8.95, OR = 1.5[95%CI = 1.1-2.2]); bipolar disorder (OR = 3.1[95%CI = 1.5-6.3]), traumatic stress (i.e., acute reaction to stress/not PTSD; OR = 2.6[95%CI = 1.4-4.8]), and "other" diagnosis (e.g., unspecified mental disorder: OR = 5.5[95%CI = 3.8-8.0]) diagnosed same day as MDD; and those with alcohol use disorder (OR = 1.4[95%CI = 1.0-1.8]) and somatoform/dissociative disorders (OR = 1.7[95%CI = 1.0-2.8]) diagnosed before MDD were more likely to attempt suicide within 30 days. Currently married soldiers (χ²₂ = 6.68, OR = 0.7[95%CI = 0.6-0.9]), those in service 10 + years (χ²₃ = 10.06, OR = 0.4[95%CI = 0.2-0.7]), and a sleep disorder diagnosed same day as MDD (OR = 0.3[95%CI = 0.1-0.9]) were less likely.

CONCLUSIONS

SA risk within 30 days following first MDD is more likely among soldiers with less education, combat medics, and bipolar disorder, traumatic stress, and "other" disorder the same day as MDD, and alcohol use disorder and somatoform/dissociative disorders before MDD. These factors identify imminent SA risk and can be indicators for early intervention.

Factors associated with transitioning from suicidal ideation to suicide attempt in the short-term: Two large cohorts of depressed outpatients

BACKGROUND

This study explores factors associated with transitioning from recent suicidal ideation (SI) to suicide attempt (SA) in depressed outpatients.

METHODS

This is a case-control study nested in two cohorts (LUEUR and GENESE) of depressed adult outpatients recruited in France and followed up for six weeks. SI, depression, anxiety, insomnia, impulsivity, and hopelessness were assessed with validated scales. Differences between patients with SI who attempted suicide during follow up and those who did not were explored using logistic regressions.

RESULTS

There was a slight majority of females in both cohorts. Mean age was 47.2 years in LUEUR and 49.4 years in GENESE. Of the 3785 participants in the LUEUR cohort, 72 (2.1 %) attempted suicide within the 6-week period vs. 19 of the 2698 participants (0.7 %) in the GENESE cohort. In LUEUR, factors associated with SA within the 6-week period were lifetime history of SA (OR = 5.35, 95 % CI = 3.30-8.66), high SI at baseline (OR = 3.87, 95 % CI = 2.4-6.24), associated treatments (OR = 3.28, 95 % CI = 2.00-5.38), and less improvement over follow-up in the following symptoms: SI (OR = 3.64, 95 % CI = 1.89-7.02), depression (OR = 3.66, 95 % CI = 1.76-7.62), and anxiety (OR = 3.26, 95 % CI = 1.46-7.27). In GENESE, associated factors were lifetime history of SAs (OR = 9.93, 95 % CI = 3.83-25.80), and less improvement in SI (OR = 9.20, 95 % CI = 3.61-23.44).

LIMITATIONS

Heterogeneity of cohorts prevented from performing a pooled analysis with a greater sample size.

CONCLUSIONS

In depressed outpatients, lack of improvement was strongly associated with a short-term SA, particularly in patients with a history of previous SAs. Fast acting treatment on SI and depression may help prevent SAs.

Revisiting the factor structure of the suicide-related coping scale: Results from two samples of Australian online help-seekers

The Suicide-Related Coping Scale (SRCS) measures how well a person manages suicidal thoughts through the use of internal and external coping strategies. Many studies using SRCS, including the original scale validation, used samples of treatment-engaged military veterans or personnel, which may limit the generalizability of study findings to other help-seeking and cultural contexts. The present study evaluated factor structure, internal consistency, convergent and divergent validity of SRCS in two Australian online help-seeking samples: visitors to a mental health website with experience of suicidal ideation (N = 1,266) and users of a suicide safety planning mobile app (N = 693). Factor analyses found a reduced 15-item version of the scale (SRCS-15) provided the best fit in both samples, with three factors found: Internal Coping, External Coping and Perceived Control. Internal consistency was good (α = 0.89). Strong negative associations were found between SRCS-15, recent suicidal ideation and future suicide intent. Perceived Control demonstrated the strongest associations with suicidal ideation and future suicide intent (negative) and distress tolerance (positive). External Coping demonstrated the strongest associations with help-seeking (positive). Items relating to means restriction and hospital location knowledge were dropped from SRCS-15 due to low factor loadings but may still contain clinically relevant information. SRCS-15 appears to be reliable and valid in capturing aspects of self-efficacy and belief-based barriers to coping, making it a useful additional outcome measure for suicide-related services and interventions.

The rate of transition to a suicide attempt among people with suicidal thoughts in the general population: A systematic review

INTRODUCTION

While suicidal thoughts are relatively common in the general population, roughly affecting one in ten people during their lifetime, the transition from suicidal thoughts to a suicide attempt is rarer. There is limited consensus on the transition rate from suicidal ideation to suicide attempts.

OBJECTIVE

To review and summarize evidence on the rate of transition from suicidal ideation to a suicide attempt, and the factors associated with this transition, in the general population.

METHODS

A comprehensive search was conducted using MEDLINE, PsycINFO, and Embase for relevant articles published between January 1, 2000, and March 3, 2021. We identified 18 eligible studies that examined the transition from suicidal ideation to a suicide attempt in non-clinical populations. We assessed the quality of the included studies using the MASTER scale. The review has been registered with PROSPERO (CRD42021248325).

RESULTS

Rates of transitioning to a suicide attempt among people with suicidal ideation varied substantially across studies, from 2.6 % to 37 %. Follow-up periods also varied substantially, from 12 to 300 months, impeding reliable comparisons across studies or pooling data for further analyses. The most examined risk factors were mental health disorders such as major depressive and anxiety disorders, which were typically associated with higher odds of transition to a suicide attempt.

LIMITATIONS

High level of heterogeneity and limited quality of the studies.

CONCLUSION

The risk of transition from suicidal thoughts to a suicide attempt is moderate to high. Further longitudinal research is required to refine the rate and explore social determinants of transition from suicidal ideation to suicide attempts.

Prospective Association of Unmet Mental Health Treatment Needs With Suicidal Behavior Among Combat-Deployed Soldiers

OBJECTIVE

Military personnel frequently report discontinuing or not pursuing psychiatric treatment despite perceiving a need for services. This study aimed to examine how unmet need for treatment or support among U.S. Army soldiers relates to future suicidal ideation (SI) or suicide attempt (SA).

METHODS

Mental health treatment need and help seeking in the past 12 months were evaluated for soldiers (N=4,645) who subsequently deployed to Afghanistan. Weighted logistic regression models were used to examine the prospective association of predeployment treatment needs with SI and SA during and after deployment, with adjustment for potential confounders.

RESULTS

Compared with soldiers without predeployment treatment needs, those who reported not seeking help despite needing it had increased risk for SI during deployment (adjusted OR [AOR]=1.73), past-30-day SI at 2-3 months postdeployment (AOR=2.08), past-30-day SI at 8-9 months postdeployment (AOR=2.01), and SA through 8-9 months postdeployment (AOR=3.65). Soldiers who sought help and stopped treatment without improvement had elevated SI risk at 2-3 months postdeployment (AOR=2.35). Those who sought help and stopped after improving did not have increased SI risk during or 2-3 months after deployment but had elevated risks for SI (AOR=1.71) and SA (AOR=3.43) by 8-9 months postdeployment. Risks for all suicidality outcomes were also elevated among soldiers who reported receiving ongoing treatment before deployment.

CONCLUSIONS

Unmet or ongoing needs for mental health treatment or support before deployment are associated with increased risk for suicidal behavior during and after deployment. Detecting and addressing treatment needs among soldiers before deployment may help prevent suicidality during deployment and reintegration periods.

Phenotyping suicidal ideation and behavior: Comparing clinical characteristics and future suicide attempts between suicidal subtypes in two clinical samples

OBJECTIVES

To further validate the concept of suicidal subtypes distinguished by indicators of suicidal thinking and behavior with regard to clinical characteristics and past and future suicide attempts.

METHODS

Psychiatric inpatients were assessed (study 1: ecological momentary assessments in 74 depressed inpatients with suicidal ideation; study 2: clinical assessments in 224 inpatients after a suicide attempt and over a 12-month follow-up period). Subtypes were identified using latent profile analysis (based on indicators of real-time suicide ideation) and latent class analysis (based on features of past suicide ideation and suicide attempt characteristics). Comparisons between subtypes included clinical characteristics (depression, suicidal ideation, trait impulsivity, childhood trauma) as well as past (study 1) and future (study 2) suicide attempts.

RESULTS

Suicidal subtypes emerged that are characterized by suicidal ideation means and stability and features of past suicidal behavior (four in study 1, three in study 2). The subtypes differed in terms of depression/suicidal ideation, but not in terms of trait impulsivity/childhood trauma. Although not significant, the subtypes "high-stable" and "low-moderate stable" reported multiple re-attempts more frequently during follow-up than the "low-stable" subtype in study 2.

CONCLUSION

Differences in clinical variables (and by trend in future suicide attempts) clearly point to the clinical relevance of suicidal subtypes (with variability of suicidal thoughts playing a particularly important role).

Psychological mediators of the associations between pandemic-related stressors and suicidal ideation across three periods of the COVID-19 pandemic in Canada

BACKGROUND

The COVID-19 pandemic's mental health impact is well-established. While early evidence suggested suicide deaths remained stable or declined, suicidal ideation (SI) became more prevalent than before the pandemic. Our study: (1) examined the prevalence and distribution of SI among Canadian adults, (2) compared SI among those with and without pre-existing mental illnesses, and (3) evaluated associations between pandemic-related stressors (i.e., unemployment, insecure employment, loss of income, medical vulnerability, COVID-19 exposure) with SI, and whether such associations were mediated by depression, thwarted belongingness, perceived burdensomeness, or perceived discrimination.

METHODS

The sample was comprised of data gathered at three timepoints (Wave 1 08/18/2020-10/01/2020, n = 6629; Wave 2 12/21/2020-03/31/2021, n = 5920; Wave 3 09/07/2021-12/07/2021, n = 7354). Quota-based responses from survey research panels which matched the geographic, age, and sex distribution of the Canadian population were supplemented with convenience-sampled responses.

RESULTS

The prevalence of SI was 4.1 % (Wave 1), 5.3 % (Wave 2), and 5.8 % (Wave 3). Odds of SI were higher for respondents under the age of 35 years and with pre-existing mental illnesses. SI was associated with quarantining due to suspected or confirmed COVID-19 exposure, potential COVID-19 exposure at work, medical vulnerability toward COVID-19, insecure employment or unemployment, and income loss. These associations were mediated by psychological experiences, particularly depression and thwarted belongingness.

LIMITATIONS

This cross-sectional, observational study cannot establish temporality or causality.

CONCLUSION

Results highlight groups who may benefit from enhanced screening for depression and suicide risk. Reducing depression and increasing sense of belonging should be prioritized.

Suicide among soldiers and social contagion effects: An interrupted time-series analysis

BACKGROUND

Suicide has become an increasingly concerning problem among soldiers in recent years. Previous research has hypothesized that media-related social contagion effects, termed "Werther effects," may contribute to military suicide numbers. Unfortunately, there is limited empirical knowledge on such social contagion effects in soldiers. We contribute to the literature by investigating this phenomenon in the context of a specific historical suicide case, allowing us to provide a longitudinal assessment: Crown Prince Rudolf, heir to the Imperial throne of the Austro-Hungarian Empire, who died by suicide in January 1889. His death was a well-known news story that shook the monarchy to its foundations. Notably, soldiers of the late nineteenth century were an especially vulnerable portion of the population, proven by the fact that the Austro-Hungarian military had one of the highest suicide rates at the time compared to other European countries.

METHODS AND RESULTS

An interrupted time-series analysis, relying on annual military suicide rates between 1873 and 1910, indicated a significant increase in the suicide rate the year of Rudolf's death, a pattern consistent with a social contagion effect. In fact, time series analysis estimated that there were about 30 excess suicides per 100,000 population within the year of Rudolf's death. Additionally, we identified a substantial change in the trend after Rudolf's death, pointing to a long-term decrease in military suicide rates. The latter was not observed in the general population but appeared to be unique to soldiers.

DISCUSSION

Although we are very careful when interpreting causal effects with our historical data, we discuss the latter finding by questioning whether a change in military culture, that is, the establishment of better conditions for soldiers in the aftermath of Rudolf's suicide, contributed to decreasing suicide numbers. Although tentative, these findings are also highly relevant for the study of military suicide today.

Suicide risk among combatants: The longitudinal contributions of pre-enlistment characteristics, pre-deployment personality factors and moral injury

BACKGROUND

Recent studies have shown that exposure to potentially morally injurious events (PMIEs) in deployment situations facilitates higher suicide risk among combatants. However, knowledge about pre-deployment factors that may moderate the negative contribution of PMIEs to suicide risk is rare. In this prospective study, we examined pre-enlistment characteristics and pre-deployment personality factors as possible moderators in the link between exposure to self, other, and betrayal dimensions of PMIEs and post-deployment suicide risk among Israeli active-duty combatants.

METHODS

A sample of 335 active-duty Israeli combatants participated in a 2.5-year prospective study with three waves of measurements: T1-12 months before enlistment, T2-6 months following enlistment (pre-deployment), and T3-18 months following enlistment (post-deployment). Participants were assessed via semi-structured interviews of personal characteristics (e.g., cognitive index) at T1, validated self-report measures of personality factors for emotional regulation, impulsivity, and aggression at T2, and combat exposure, PMIEs, and suicide risk at T3 between 2019 and 2021.

RESULTS

All three dimensions of PMIEs were significantly associated with higher suicidal risk among combatants. Importantly, higher levels of pre-deployment aggression and lower levels of emotional regulation moderated the association between PMIEs and suicide risk post-deployment, above and beyond pre-enlistment psychiatric difficulties and life events.

CONCLUSIONS

Our results highlight the roles of pre-deployment factors of emotional regulation and aggressiveness as possible moderators in the PMIEs-suicide risk link. These results emphasize the need for higher awareness of suicide risk among deployed combatants with low emotional regulation and high aggressiveness. Moreover, tailored interventions aiming to decrease emotional dysregulation and aggressiveness levels should be considered, as such interventions may help reduce suicide risk following combat-related transgressive acts.

Prediction of Suicidal Behaviors in the Middle-aged Population: Machine Learning Analyses of UK Biobank

BACKGROUND

Suicidal behaviors, including suicide deaths and attempts, are major public health concerns. However, previous suicide models required a huge amount of input features, resulting in limited applicability in clinical practice.

OBJECTIVE

We aimed to construct applicable models (ie, with limited features) for short- and long-term suicidal behavior prediction. We further validated these models among individuals with different genetic risks of suicide.

METHODS

Based on the prospective cohort of UK Biobank, we included 223 (0.06%) eligible cases of suicide attempts or deaths, according to hospital inpatient or death register data within 1 year from baseline and randomly selected 4460 (1.18%) controls (1:20) without such records. We similarly identified 833 (0.22%) cases of suicidal behaviors 1 to 6 years from baseline and 16,660 (4.42%) corresponding controls. Based on 143 input features, mainly including sociodemographic, environmental, and psychosocial factors; medical history; and polygenic risk scores (PRS) for suicidality, we applied a bagged balanced light gradient-boosting machine (LightGBM) with stratified 10-fold cross-validation and grid-search to construct the full prediction models for suicide attempts or deaths within 1 year or between 1 and 6 years. The Shapley Additive Explanations (SHAP) approach was used to quantify the importance of input features, and the top 20 features with the highest SHAP values were selected to train the applicable models. The external validity of the established models was assessed among 50,310 individuals who participated in UK Biobank repeated assessments both overall and by the level of PRS for suicidality.

RESULTS

Individuals with suicidal behaviors were on average 56 years old, with equal sex distribution. The application of these full models in the external validation data set demonstrated good model performance, with the area under the receiver operating characteristic (AUROC) curves of 0.919 and 0.892 within 1 year and between 1 and 6 years, respectively. Importantly, the applicable models with the top 20 most important features showed comparable external-validated performance (AUROC curves of 0.901 and 0.885) as the full models, based on which we found that individuals in the top quintile of predicted risk accounted for 91.7% (n=11) and 80.7% (n=25) of all suicidality cases within 1 year and during 1 to 6 years, respectively. We further obtained comparable prediction accuracy when applying these models to subpopulations with different genetic susceptibilities to suicidality. For example, for the 1-year risk prediction, the AUROC curves were 0.907 and 0.885 for the high (>2nd tertile of PRS) and low (<1st) genetic susceptibilities groups, respectively.

CONCLUSIONS

We established applicable machine learning-based models for predicting both the short- and long-term risk of suicidality with high accuracy across populations of varying genetic risk for suicide, highlighting a cost-effective method of identifying individuals with a high risk of suicidality.

Nonfatal suicidal behaviors among former active duty servicemembers-United States, 2013-2019

Introduction

Examine characteristics associated with increased odds of nonfatal suicidal behaviors among former active-duty servicemembers (F-ADSM) using data from the 2013-2019 National Survey on Drug Use and Health (NSDUH).

Methods

F-ADSM were respondents who reported being separated/retired from the military and previously serving on active-duty. For each outcome of interest (suicidal ideation, made a suicide plan, made a suicide attempt), we used multivariable logistic regression with backwards elimination to identify characteristics with statistically significant associations.

Results

In the 12 months preceding the survey, 3.6% of F-ADSM reported suicidal ideation, 1.0% reported making a plan, and 0.3% reported making a suicide attempt. There were increased odds of self-reported suicide attempts among F-ADSM who were female; aged 18-49 years; non-Hispanic black; gay or bisexual; divorced/separated or widowed; not employed; in poverty; binged alcohol in the past month; or ever had a major depressive episode.

Conclusions

Suicide can be prevented through a comprehensive, upstream approach addressing veteran's holistic needs to prevent them from becoming suicidal in the first place, and support veterans at increased risk.

Real-time digital monitoring of a suicide attempt by a hospital patient

Suicide is among the most devastating problems facing clinicians, who currently have limited tools to predict and prevent suicidal behavior. Here we report on real-time, continuous smartphone and sensor data collected before, during, and after a suicide attempt made by a patient during a psychiatric inpatient hospitalization. We observed elevated and persistent sympathetic nervous system arousal and suicidal thinking leading up to the suicide attempt. This case provides the highest resolution data to date on the psychological, psychophysiological, and behavioral markers of imminent suicidal behavior and highlights new directions for prediction and prevention efforts.

Non-Suicidal Self-Injury and Suicide Risk Among Adult Medical Inpatients

Background

Non-suicidal self-injury (NSSI) is a potent risk factor for suicide among youth. There is limited research, however, on the association between NSSI and suicide risk among adults, particularly among adult medical patients, who are a population at increased risk for suicide. To address this research gap, the current analysis aimed to describe the association between lifetime history of NSSI and suicide risk in an adult medical inpatient population.

Method

Adult medical inpatients aged 18 or older from one of four United States hospitals were screened for suicide risk and a lifetime history of NSSI. Suicide risk was determined using the Ask Suicide-Screening Questions (ASQ). NSSI history, methods, frequency, and severity were assessed via a structured interview based on the Self-Injurious Thoughts and Behaviors Interview.

Results

A total of 621 adult medical inpatients were included in this secondary analysis (55.2% male; 60.9% White; M[SD] age = 50.3[16.7]); 5.8% of patients (36/621) reported a lifetime history of NSSI and 16.1% (100/621) screened positive for suicide risk. Patients with a lifetime history of NSSI were significantly more likely to screen positive for suicide risk (OR = 9.4 [95% CI, 4.4-20.8]; p < .0001).

Limitations

This analysis used cross sectional data and could not examine any causal relationships between NSSI and suicide risk.

Conclusions

Adult medical inpatients with a lifetime history of NSSI were significantly more likely to screen positive for suicide risk. Research examining NSSI among adult medical patients is especially relevant for suicide risk detection and prevention efforts.

Burnout, Surface Acting, and Suicidal Ideation Among Military Personnel: Results of a Longitudinal Cohort Study

Introduction: Chronic life stressors are positively correlated with suicidal ideation and suicidal behaviors among military personnel. Surface acting, a strategy that involves hiding or faking one's emotional state to match organizational expectations dictating when and how to express emotions, contributes to burnout and increased emotional distress. Because surface acting involves a form of emotional suppression, frequent use of surface acting may also contribute to suicidal ideation. Methods: One thousand seven-hundred fifty-four military personnel stationed at a U.S. military installation completed a self-report survey repeatedly administered 6 times from January 2020 to December 2021. Survey items assessed suicidal ideation, surface acting, burnout, and depression. Results: Burnout and surface acting were significantly correlated with severity of suicidal ideation. When depression was added as a covariate, surface acting but not burnout remained a statistically significant correlate of suicidal ideation. Discussion: Surface acting, a job-specific form of emotional suppression, may increase suicide risk among military personnel. Creating opportunities for military personnel to appropriately express their emotional states could mitigate suicide risk in this population.

Insomnia and the Interpersonal Theory of suicide among civilians, service members, and veterans

BACKGROUND

Insomnia is associated with suicide risk in civilian and military populations. Thwarted belongingness is proposed as a mediator of this relationship under the Interpersonal Theory of Suicide (IPTS). The present study explored how insomnia relates to suicidal ideation in conjunction with thwarted belongingness among civilians, Service members, and Veterans.

METHODS

Data from the Military Suicide Research Consortium for N = 6556 individuals (6316 with non-missing suicidal ideation status) were divided into 4 subgroups: civilians, never deployed Service members, previously deployed Service members, and Veterans. Robust Poisson models evaluated the associations between insomnia severity/subtype and current suicidal ideation, with bootstrap mediation models assessing thwarted belongingness as a mediator.

RESULTS

A 5-point increase in insomnia severity was associated with a 38% increased risk for current suicidal ideation among civilians, a 56% greater risk among never deployed Service members, an 83% greater risk among previously deployed Service members, and a 37% greater risk among Veterans. Moreover, active Service members showed greater associations between difficulty falling asleep and staying asleep with suicidal ideation than civilians. These associations were independent of covariates and only mediated by thwarted belongingness among Veterans.

CONCLUSIONS

The relationship between insomnia and suicide is not purely explained by thwarted belongingness except among Veterans. Future research should explore additional psychological and neurobiological mechanisms connecting insomnia and suicidality.

Emotion-related impulsivity and suicidal ideation: Towards a more specific model

OBJECTIVES

Suicidal ideation is a pervasive and painful experience that varies considerably in its phenomenology. Here, we consider how one key risk variable might inform our understanding of variation in suicidal ideation: emotion-related impulsivity, the trait-like tendency towards unconstrained speech, behaviour, and cognition in the face of intense emotions. We hypothesized that emotion-related impulsivity would be tied to specific features, including severity, perceived lack of controllability, more rapidly fluctuating course, higher scores on a measure of acute suicidal affective disturbance, and more emotional and cognitive disturbance as antecedents.

METHODS

We recruited two samples of adults (Ns = 421, 221) through Amazon Mechanical Turk (MTurk), with oversampling of those with suicidal ideation. Both samples completed psychometrically sound self-report measures online to assess emotion- and non-emotion-related dimensions of impulsivity and characteristics of suicidal ideation.

RESULTS

One form of emotion-related impulsivity related to the severity, uncontrollability, dynamic course, and affective and cognitive precursors of ideation.

CONCLUSIONS

Despite limitations of the cross-sectional design and self-report measures, the current findings highlight the importance of specificity in considering key dimensions of impulsivity and suicidal ideation.

Identifying factors associated with elevated suicidal intent among U.S. military veterans

OBJECTIVE

Suicidal intent is a risk factor for engagement in suicidal behavior, use of violent means, and suicide mortality. Yet, scarce research has examined factors associated with suicidal intent among U.S. military veterans, a population at high risk for suicide. This study examined vulnerability factors associated with suicidal intent in a population-based sample of U.S. veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans. Analyses estimated the prevalence of current suicidal intent (i.e., veterans' report that they would likely attempt suicide in the future) and examined factors most strongly associated with suicidal intent.

RESULTS

Forty-nine veterans (1.4%; 95% confidence interval = 1.0-1.8%) reported suicidal intent. Recurrent past-year suicidal ideation (≥2 times), low dispositional gratitude, current depression, current insomnia, childhood sexual abuse, and a prior suicide attempt were most strongly associated with suicidal intent (7.1-50.1% of the total explained variance). Veterans with several of these co-occurring factors were at highest risk for suicidal intent; of veterans with 0, ≥1, ≥2, ≥3, and ≥4 of these factors, 0.1%, 4.4%, 10.8%, 19.5%, and 28.1% reported suicidal intent, respectively.

DISCUSSION

Specific vulnerability factors, particularly when co-occurring, may increase veterans' intention of attempting suicide. Findings underscore the importance for clinicians to continuously assess suicidal intent when working with this population, particularly as veterans' reports of suicidal thinking increases.

Characteristics of Suicidal Ideation: A Systematic Review

BACKGROUND

The exploration of inter- and intra-individual variability in suicidal ideation (SI) is vital to suicide research. However, this research relies on the identification and measurement of standardized SI characteristics.

OBJECTIVE

This review aimed to identify characteristics of SI examined in research, describe how these characteristics are measured, and assess how they are aligned with those included in the Columbia Suicide Severity Rating Scale (C-SSRS).

METHODS

Four databases were systematically searched, and relevant data was extracted. The C-SSRS provided a framework for comparing SI names, measures and operational definitions.

RESULTS

After comparing operational definitions of identified characteristics, five core domains emerged: (1) severity, (2) temporality, (3) variability, (4) controllability, and (5) deterrents/reasons for ideating. Except for variability, all SI characteristics in the literature were congruent with those measured in the C-SSRS.

CONCLUSIONS

This review highlighted conceptual and methodologic inconsistencies in the study of SI, specifically the nomenclature, measurement and definitions of SI characteristics. Standardized approaches to the study of SI characteristics are needed. These approaches will enhance accurate and reliable measurement of SI, allow for findings to be synthesized across studies and propel the exploration of inter and intra-individual SI variability leading to more individualized and effective SI treatment.

Leveraging latent profile analysis to synthesize childhood and adolescent risk factors for suicidal ideation

Person-centered typologies identified with latent profile analysis can clarify patterns of chronic and acute risk factors for suicidal ideation. We derived five profiles of individuals using cognitive, behavioral, and familial factors relating to suicidal ideation risk factors. Participants (n = 1,142) were assessed at age 8 using the Laboratory Temperament Assessment Battery and mother-reported parenting measures and at age 14 using interviews about clinical symptoms and suicidal ideation. The best-fitting model included five profiles: typical, elevated adolescent symptomology, mildly elevated typical, low childhood persistence, and very low childhood persistence/mixed symptoms. Participants in the elevated adolescent symptomology and very low childhood persistence/mixed symptoms profiles were 2.6 and 5.3 times more likely to report suicidal ideation compared with the typical profile. Overall, our results underscore how using a person-centered pattern recognition approach and incorporating facets of childhood behavior may enhance conceptualizations of adolescent suicidal ideation risk.

Non-response to questions about suicide ideation and attempts among veterans: Results from the National Health and Resilience in Veterans Study

OBJECTIVES

Veterans who decline to provide information on their history of self-injurious thoughts and behaviors (SITBs) may be at elevated suicide risk. We examined associations between non-response to a question assessing lifetime SITBs and proxy variables of suicide risk.

METHODS

In this population-based cross-sectional study of 4069 US veterans, responses to the Suicidal Behaviors Questionnaire-Revised were examined to group veterans into one of three categories: (1) denied lifetime SITBs, (2) reported lifetime SITBs, or (3) declined to respond.

RESULTS

Overall, 69.5% of veterans denied a SITB history, 29.5% reported a SITB history, and 1.0% declined to provide information regarding SITBs. In adjusted analyses, veterans who declined to provide information on SITBs were significantly more likely than veterans who explicitly denied lifetime SITBs to screen positive for posttraumatic stress disorder; report lifetime non-suicidal self-injury; and report elevated levels of total trauma burden, externalizing behaviors, loneliness, received social support, and provided social support. Across these constructs, veterans who declined to provide SITB information were statistically indistinguishable from veterans who explicitly reported lifetime SITBs.

CONCLUSIONS

Veterans who decline to provide information about suicidal thoughts and behaviors may represent a covert group at elevated risk for suicide.

Application of the RDoC Framework to Predict Alcohol Use and Suicidal Thoughts and Behaviors among Early Adolescents in the Adolescent Brain and Cognitive Development (ABCD) Study

Alcohol use confers risk for suicidal thoughts and behaviors (ideation, attempt) in early adolescents. The Research Domain Criteria provides a framework for examination of multidimensional and modifiable risk factors. We examined distinct latent profiles based on patterns of positive valence (reward responsivity) and cognitive systems (neurocognition) from the ABCD Study (age 9−10, N = 10,414) at baseline enrollment. Longitudinal associations were determined between baseline positive valence and cognitive profiles and group classification (alcohol use, suicidal thoughts and behaviors, or their co-occurrence) two-years after initial assessment (ages 11−12). Three unique profiles of positive valence, cognition, alcohol use, and suicidal thoughts and behaviors were identified. Two baseline profiles predicted alcohol use and suicidal thoughts and behaviors, two-years after initial assessment. Low positive valence with high cognition (but low impulsivity) predicted alcohol use (OR = 1.414, p< 0.001), while high positive valence with low cognition (but high impulsivity) predicted suicidal thoughts and behaviors (OR = 1.25, p = 0.038), compared to average positive valence and cognition. Unique profiles of positive valence and cognitive systems among 9−12-year-olds may be predictive of alcohol use and suicidal thoughts and behaviors over a two-year period. Findings underscore the potential for trajectory research on positive valence and cognitive profiles to enhance prevention for early-adolescents.

A Comparison of Suicide Attempt Histories of Pediatric and Adult Medical Inpatients and Implications for Screening

OBJECTIVE

A suicide attempt is the most potent predictor of future suicidal behavior, yet little is known about how to manage and respond to reports of attempt histories in hospitalized medical patients. This study aims to describe the prevalence and characteristics of pediatric and adult medical inpatients who report a past suicide attempt.

METHOD

Participants were medical inpatients, aged 10-93 years, enrolled in two suicide risk screening instrument validation studies. Participants completed the Ask Suicide-Screening Questions (ASQ) and the Patient Health Questionnaire (PHQ).

RESULTS

A total of 1324 medical inpatients (624 pediatric, 700 adult) completed the ASQ, with 114 participants (8.6%) reporting a past suicide attempt (51 pediatric; 63 adults). Comparing youth to adults, there was no significant difference between attempt rates (χ2=0.29, p = 0.59). Youth with a past attempt were significantly more likely to report past week suicidal ideation (OR = 28.22; 95% CI = 5.90, 135.06) and have a history of mental health care (OR = 9.11; 95% CI = 2.59-32.10), compared to those without a past attempt. Adults with a past attempt were significantly more likely to screen positive for depression, compared to those without attempt histories (OR = 5.00; 95% CI = 2.31-10.83).

CONCLUSIONS

Nearly 9% of hospitalized medical patients endorsed a past suicide attempt when screened. Since adolescence is a critical time for detecting suicide risk, screening that includes past suicidal behavior may be an important means to identify youth with recent suicidal thoughts. By assessing recency of suicide attempts in adults, medical settings may optimize the effectiveness of how positive suicide risk screens are managed.HIGHLIGHTSRoughly 9% of medical patients reported a past suicide attempt when screened.Adolescence is a critical time for detecting suicide risk and intervening.Assessing past suicide attempts in adults can help with managing positive screens.