Identifying adolescents at highly elevated risk for suicidal behavior in the emergency department

Catching Suicide Before It Harms: Universal Suicide Screening in a Pediatric Emergency Department

OBJECTIVES

Suicide is the second leading cause of death in people aged 10 to 24 years. We aim to assess the effectiveness of universal suicide screening in a pediatric ED.

METHODS

Since April 7, 2019, all patients 10 years and older who presented to the pediatric ED of our freestanding children's hospital were screened with the validated Columbia Suicide Severity Rating Scale and categorized as mild, moderate, or severe risk for suicide. Screenings from 2019 were reviewed by investigators. All children aged 10 to 18 years who were screened were included. Data collected included demographic information, previous ED visits, past chief complaints), suicidal ideation, suicide attempt, and disposition.

RESULTS

A total of 11,469 subjects were screened for suicide risk. Of those screened, 340 were positive on Columbia Suicide Severity Rating Scale, and 5 were excluded for being outside of the age range. Of the remaining 335 subjects who screened positive, 116 (34.5%) of them presented with a primarily medical chief complaint. A total of 120 subjects screened mild risk (35.8%), 46 were moderate (13.7%), and 169 were severe (50.4%). Overall, 141 positive subjects were admitted for mental health concerns.

CONCLUSIONS

Several patients who screened positive for suicide risk did not present with a mental health concern. Nearly half of screen-positive children who were admitted for mental health concerns had been seen in the ED in the year before their visit. Initiation of universal suicide screening in the pediatric ED identified a significant number of children with unrecognized suicide risk.

Implicit Identification with Death, Clinician Evaluation and Suicide Ideation among Adolescent Psychiatric Outpatients-The Mediating Role of Depression

Implicit identification with death (i.e., subconsciously self-associating oneself with death), measured by the Death-Suicide Implicit Association Test (D/S-IAT), is associated with Suicide Ideation (SI). Our understanding of the mechanisms underlying this association is limited. The current study examined (1) the mediating role of depression between D/S-IAT and recent SI and (2) the association between SI, D/S-IAT, and clinician evaluation of SI among a clinical sample of adolescents. 148 adolescents aged 10-18 years (69.4% female) from two outpatient clinics were assessed at intake. Participants completed D/S-IAT and self-report measures for recent SI and depression during intake. Findings indicate that depression is a mediator between D/S-IAT and recent SI, controlling for gender, site differences, and past suicidal thoughts and behaviors. D/S-IAT and clinician evaluation were correlated with recent SI but not beyond depression. Our findings highlight the importance of examining the underlying psychological mechanisms regarding the association between D/S-IAT and suicide.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community

Importance

There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations.

Objective

To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals.

Design, Setting, and Participants

This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated.

Main Outcomes and Measures

Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1.

Results

Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks.

Conclusions and Relevance

This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

Suicidal behaviors and associated factors among patients attending an emergency department: a facility-based cross-sectional study

BACKGROUND

Emergency departments (ED) are an important site for screening patients with suicidal behaviors. However, there is insufficient data in low-and middle-income countries regarding the magnitude of suicidal attempts among patients attending EDs. Therefore, the present study aimed to screen suicidal behavior and factors associated with suicide in patients attending an ED of Addis Ababa Burn, Emergency and Trauma Hospital, Ethiopia.

METHOD

A facility-based quantitative cross-sectional study was conducted between April and June 2018. A total of 398 participants were recruited using a consecutive sampling technique. The collected data collected includes structured questionnaires containing sociodemographic determinants, chronic medical illness conditions, substance use characteristics, social support level, common mental disorders (CMD) screening, suicidal behaviors assessment and suicidal attempts reason and method.

RESULTS

The prevalence of suicidal behavior and suicidal attempts were 8% and 6.3%, respectively. Suicide was attempted most frequently in the 18-24 age group. There was no overall difference in sex distribution for suicidal attempts. However, there were sex-based differences when the age group was taken into consideration. The commonest underlying reason for the attempt was social reasons (44%), while the most frequently reported attempt method was hanging (36%). No single factor was found to be significantly associated with the suicidal attempt.

CONCLUSION

Although suicidal behaviors are more common in patients attending the ED than in the general population, these facts have previously got little attention in patient attending EDs in low and middle income countries. The present findings support the need for a more detailed assessment of suicidal behaviours in patients attending ED and in patients with CMD.

Longitudinal associations among dimensional symptoms of depression and anxiety and first onset suicidal ideation in adolescents

INTRODUCTION

Depression and anxiety are implicated in suicide risk, but the contributionof specific symptom dimensions within these disorders is not well understood. The present study examined longitudinal associations of transdiagnostic symptoms (General Distress[GD]) and unique symptom dimensions (Anhedonia-Apprehension [AA], Fears, and Narrow Depression [ND]) of depression and anxiety and suicidal ideation (SI).

METHODS

Data from 551 adolescents oversampled on high neuroticism were examined in a series of discrete-time survival analyses to predict first SI onset over an 8-year period.

RESULTS

Results indicate that GD, AA, and ND were independent predictors of increased likelihood of SI onset and remained significant when controlling for effects of fears. Furthermore, AA and GD remained significant when controlling for one another. ND effects reduced by 24% when adjusting for AA and 74% when adjusting for GD. Fears did not significantly predict SI onset.

CONCLUSION

Results suggest that broad levels of distress across depression and anxiety, deficits in positive affect, and elevated negative affect specific to depression increase the likelihood of suicidal thoughts. As such, attention to broader distress and a lack of pleasure, interest, and motivation-potentially more so than negative affect characterizing depression-are particularly important for addressing suicide risk in adolescents.

Trends in Suicidal Ideation-Related Emergency Department Visits for Youth in Illinois: 2016-2021

BACKGROUND AND OBJECTIVES

Increasing suicide rates and emergency department (ED) mental health visits reflect deteriorating mental health among American youth. This population-based study analyzes trends in ED visits for suicidal ideation (SI) before and during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

We analyzed Illinois hospital administrative data for ED visits coded for SI from January 2016 to June 2021 for youth aged 5 to 19 years. We characterized trends in patient sociodemographic and clinical characteristics, comparing three equal 22 month periods and analyzed patient and hospital characteristics associated with the likelihood of hospitalization.

RESULTS

There were 81 051 ED visits coded for SI at 205 Illinois hospitals; 24.6% resulted in hospitalization. SI visits accounted for $785 million in charges and 145 160 hospital days over 66 months. ED SI visits increased 59% from 2016 through 2017 to 2019 through 2021, with a corresponding increase from 34.6% to 44.3% of SI principal diagnosis visits (both P < .001). Hospitalizations increased 57% between prepandemic fall 2019 and fall 2020 (P = .003). After controlling for demographic and clinical characteristics, youth were 84% less likely to be hospitalized if SI was their principal diagnosis and were more likely hospitalized if coded for severe mental illness, substance use, anxiety, or depression, or had ED visits to children's or behavioral health hospitals.

CONCLUSIONS

This study documents child ED SI visits in Illinois spiked in 2019, with an additional surge in hospitalizations during the pandemic. Rapidly rising hospital use may reflect worsening mental illness and continued difficulty in accessing low cost, high-quality outpatient mental health services.

Reminder-Focused Positive Psychiatry: Suicide Prevention Among Youths With Comorbid Posttraumatic Stress Disorder and Suicidality

OBJECTIVE

This study aimed to investigate the effect of brief reminder-focused positive psychiatry and suicide prevention (RFPP-S) on suicidal ideation, posttraumatic stress disorder (PTSD) symptoms, and clinical outcomes among youths with PTSD treated in psychiatric emergency rooms.

METHODS

This study included youths with PTSD and suicidality who received either RFPP-S (N=50) or treatment as usual (N=150). The Columbia Suicide Severity Rating Scale (C-SSRS), Clinician-Administered PTSD Scale for children and adolescents, University of California, Los Angeles Trauma Reminder Inventory, Patient Health Questionnaire-9, Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment Scale, and positive psychiatry test batteries were administered at baseline, on day 2, and 1 week and 1 month after discharge.

RESULTS

On day 2, the RFPP-S group showed a greater reduction in PTSD symptoms (55%) and reactivity to trauma and loss reminders (80%) compared with the control group (10% for both) (p=0.001). A significantly greater reduction in C-SSRS score for RFPP-S (80%), compared with treatment as usual (15%), was noted (p=0.001), and RFPP-S showed more rapid stabilization (mean±SD=2.0±0.5 days) and enhanced postdischarge follow-up (100%) compared with treatment as usual (5.0±2.0 days and 50%, respectively) (p<0.05). RFPP-S, but not treatment as usual, was associated with significant increases in well-being, flexible thinking, and coping skills (p<0.05). Hospital readmission due to suicidality 1 month after discharge was 0% for the RFPP-S group and 20% for the control group.

CONCLUSIONS

RFPP-S was associated with reduced PTSD symptoms, enhanced coping skills while experiencing trauma reminders, adoption of safety skills, rapid stabilization of acute crises of PTSD with suicidality, adherence to post-emergency room visits and treatment, and favorable clinical outcomes.

The Impact of Universal Mental Health Screening on Pediatric Emergency Department Flow

OBJECTIVE AND HYPOTHESIS

Assess the impact of universal mental health screening with MyHEARTSMAP on emergency department (ED) flow, an important aspect of feasibility. We hypothesized that the difference in departmental level ED length of stay (LOS) for screening and matched nonscreening days is less than 30 minutes.

METHODS

We conducted a 2-center, retrospective cohort study between December 2017 and June 2019. At each center, random mental health screening days were assigned over the course of 15 consecutive months. We matched each 24-hour screening day to a unique nonscreening day based on: location (Center 1 or Center 2); day type (weekday: Monday-Thursday or weekend: Friday-Sunday); date (±28 days); and 24-hour volume (±15 patients). We collected retrospective patient flow data, including LOS, across all ED visits to determine the difference in departmental level median LOS between matched screening and nonscreening days.

RESULTS

There was not a statistically significant difference in departmental LOS between screening and nonscreening days. Overall, the difference in departmental LOS was -4.0 minutes (95% confidence interval, -9.8, 1.8) for screening days compared to nonscreening days, with a difference of -2.0 minutes (-9.0, 4.9) at Center 1 and -6.0 minutes (-15.4, 3.4) at Center 2.

CONCLUSIONS

Our findings show that universal mental health screening with MyHEARTSMAP can be implemented without a significant impact of ED LOS.

Universal Suicide Risk Screening for Youths in the Emergency Department: A Systematic Review

OBJECTIVES

To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts.

METHODS

A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included.

RESULTS

All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%.

CONCLUSIONS

Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

Grief as a predictor of long-term risk for suicidal ideation and attempts of parentally bereaved children and adolescents

Although children who experience the death of a parent have a heightened risk of suicidality, the long-term associations between grief and suicidality among bereaved youth have yet to be examined. Research is needed to test the specific aspects of grief associated with suicidality, after controlling for other risk factors, in this population. Grief and covariates, including age, gender, parental cause of death, time since parental death, depression, anxiety, internalizing problems, posttraumatic stress symptoms, and child treatment involvement, were assessed at baseline, 6-year, and 15-year follow-ups in a sample of 244 parentally bereaved youth aged 8-16 years. Utilizing multiple grief measures, a bifactor approach was used to identify a general factor and two uncorrelated specific factors: Intrusive Grief Thoughts and Social Detachment/Insecurity. Suicidal thoughts and attempts were assessed at both follow-ups. The Intrusive Grief Thoughts specific factor had a prospective nonlinear association with suicidality at both follow-ups after controlling for all baseline covariates. The nonlinear relation consisted of a large effect, OR > 73 (using the rescaled scores), on the increased risk of suicidality from low to moderate levels of intrusive grief, with no association from moderate to high levels. At 6-year follow-up, the specific Social Detachment/Insecurity factor was significantly associated with suicidality after controlling for covariates. Specific grief factors assessed at different points were associated with suicidal thoughts or attempts among parentally bereaved youth. These findings highlight the significance of specific aspects of child and adolescent grief that have implications for the development of upstream suicide prevention services.

Suicide in African American Adolescents: Understanding Risk by Studying Resilience

Historically, suicide rates for African American adolescents have been low,relative to rates for youth of other racial-ethnic backgrounds. Since 2001, however, suicide rates among African American adolescents have escalated: Suicide is now the third leading cause of death for African American adolescents. This disturbing trend warrants focused research on suicide etiology and manifestation in African American adolescents, along with culturally sensitive and effective prevention efforts. First, we revisit leading suicide theories and their relevance for African American adolescents. Next, we discuss health promotive and protective factors within the context of African American youth development. We also critique the current status of suicide risk assessment and prevention for African American adolescents. Then, we present a heuristic model of suicide risk and resilience for African American adolescents that considers their development within a hegemonic society. Finally, we recommend future directions for African American adolescent suicidology. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Emergency Department Visits for Suicidal Ideation and Self-Harm in Rural and Urban Youths

OBJECTIVES

To compare emergency department (ED) visit rates for suicidal ideation and/or self-harm among youth by urban-rural location of residence.

STUDY DESIGN

This is a retrospective analysis of ED visits for suicidal ideation and/or self-harm by youths aged 5-19 years (n = 297 640) in the 2016 Nationwide Emergency Department Sample, a representative sample of all US ED visits. We used weighted Poisson generalized linear models to compare population-based visit rates by urban-rural location of patient residence, adjusted for age, sex, and US Census region. For self-harm visits, we compared injury mechanisms by urban-rural location.

RESULTS

Among patients with ED visits for suicidal ideation and/or self-harm, the median age was 16 years, 65.9% were female, 15.9% had a rural location of patient residence, and 0.1% resulted in mortality. The adjusted ED visit rate for suicidal ideation/or and self-harm did not differ significantly by urban-rural location. For the subset of visits for self-harm, the adjusted visit rate was significantly higher in small metropolitan (adjusted incidence rate ratio [aIRR], 1.39; 95% CI, 1.01-1.90), micropolitan (aIRR, 1.46; 95% CI, 1.10-1.93), and noncore areas (aIRR, 1.39; 95% CI, 1.03-1.87) compared with large metropolitan areas. When stratified by injury mechanism, ED visit rates for self-inflicted firearm injuries were higher among youths living in rural areas compared with those in urban areas (aIRR, 3.03; 95% CI, 1.32-6.74).

CONCLUSIONS

Compared with youths living in urban areas, youths living in rural areas had higher ED visit rates for self-harm, including self-inflicted firearm injuries. Preventive approaches for self-harm based in community and ED settings might help address these differences.

Feasibility of an Integrated Treatment Approach for Youth with Depression, Suicide Attempts, and Substance Use Problems

Depression, suicidal behaviors and substance use problems frequently co-occur, and treatment for youth with these co-occurring problems is often fragmented and challenging. An integrated cognitive-behavioral treatment approach that builds upon a relapse prevention framework and applies common core skills, language, and approach for treating these related problems may be clinically beneficial. Following a description of the integrated approach, we present results of a pilot trial (n = 13) to examine the acceptability and feasibility of the Cognitive-Behavioral Therapy - Relapse Prevention (CBT-RP) intervention plus enhanced treatment as usual (TAU) compared to enhanced TAU alone. The feasibility of the CBT-RP + TAU intervention was reflected by high rates of retention (86%). The acceptability was reflected in positive evaluations regarding the helpfulness of the intervention by adolescents and families. The majority of youth in both CBT-RP + TAU and TAU alone groups evidenced reductions in depression and suicide ideation from study entry to Week 20. Patterns of reduction were more consistent, however, for youth receiving CBT-RP + TAU, and reductions were slower to emerge for some youth receiving TAU alone. Reductions in alcohol and marijuana problems were similar, but half of the youth in TAU alone (and none in the CBT-RP + TAU group) had emergency department visits related to psychiatric crises or substance related problems. These findings, although based on a small sample, underscore the feasibility and acceptability of an integrated cognitive-behavioral relapse prevention approach for youth with depression, suicide attempt histories, and substance use problems.

Saving Lives: Recognizing and Intervening with Youth at Risk for Suicide

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

The Affordable Care Act Young Adult Mandate and Suicidal Behavior

This article aimed to determine the association between the Affordable Care Act young adult mandate and suicidal behavior. From 2007 to 2013, we used the Nationwide/National Inpatient Sample and National Poison Data System to examine suicide attempt, and Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research to examine suicide. We aggregated each outcome by quarter/year and conducted a difference-in-differences linear regression to compare young adults aged 19 to 25 years with those 27 to 29 years before and after implementation. There were not statistically significant associations between the mandate and suicide attempt inpatient hospitalizations (unstandardized beta coefficient [b] = -0.72, p = .12, standard error [SE] = 0.42) and percentage of poisoning cases due to suspected suicidal intent (b = 0.23, p = .19, SE = 0.16). There was a statistically significant association when examining suicide prevalence (b = -0.03, p = .01, SE = 0.001). The results suggest that health insurance may buffer against but is unlikely to reverse the increasing suicide rate.

Sleep and suicide: A systematic review and meta-analysis of longitudinal studies

The current review provides a quantitative synthesis of the empirical literature on sleep disturbance as a risk factor for suicidal thoughts and behaviors (STBs). A systematic search of PsycINFO, MEDLINE, and the references of prior reviews resulted in 41 eligible studies included in this meta-analysis. Sleep disturbance, including insomnia, prospectively predicted STBs, yielding small-to-medium to medium effect sizes for these associations. Complicating interpretation of these findings however, is that few studies of suicidal ideation and suicide attempts, as well as none of suicide deaths, assessed short-term risk (i.e., employed follow-up assessments of under a month). Such studies are needed to evaluate current conceptualizations of sleep dysregulation as being involved in acute risk for suicidal behavior. This want of short-term risk studies also suggests that current clinical recommendations to monitor sleep as a potential warning sign of suicide risk has a relatively modest empirical basis, being largely driven by cross-sectional or retrospective research. The current review ends with recommendations for generating future research on short-term risk and greater differentiation between acute and chronic aspects of sleep disturbance, and by providing a model of how sleep disturbance may confer risk for STBs through neuroinflammatory and stress processes and associated impairments in executive control.

Predicting suicidal behavior among lesbian, gay, bisexual, and transgender youth receiving psychiatric emergency services

Lesbian, gay, bisexual, and transgender (LGBT) youth are at elevated risk for self-injurious thoughts and behaviors (SITBs). However, few studies have comprehensively examined SITBs and their longitudinal course in LGBT youth at high risk for suicide. The aims of the present study were to characterize histories of SITBs among high-risk LGBT youth and to examine prospective associations with suicidal behavior. Participants were 285 youth (41.8% LGBT) ages 13-25 years receiving psychiatric emergency department (ED) services. Post-discharge suicidal behavior was assessed via 4-month phone interviews and 12 month chart reviews. The sample was 42.1% male, 57.9% female, 2.5% gender minority, 41.8% sexual minority. LGBT participants were more likely to have prior psychiatric ED visits and hospitalizations, more frequent past week suicide ideation, and more severe nonsuicidal self-injury (NSSI). We conducted stratified survival analyses to identify predictors of time to suicidal behavior post discharge. The final model for LGBT youth included past week suicide ideation and past month NSSI episodes. Among non-LGBT youth, the final model included number of lifetime NSSI methods and use of a highly lethal suicide attempt method. Within this sample of youth receiving psychiatric emergency services, LGBT youth were overrepresented and had more severe histories of SITBs. Results suggest the importance of assessing both lifetime and recent factors (i.e., past week and month), particularly for LGBT youth. Future research should replicate these findings in larger samples to explore whether there are unique risk factors that can aid in predicting and preventing suicide among LGBT youth.

Efficacy of a problem-solving intervention for the indicated prevention of suicidal risk in young Brazilians: Randomized controlled trial

OBJECTIVE

The aim of this study was to evaluate the efficacy of a problem-solving intervention for the prevention of suicidal risk in Brazilian adolescents with elevated suicidal potential and depressive symptoms.

METHODS

A randomized controlled trial was conducted involving 100 participants (mean age 17.2 years, 60% women, 46% mixed race), allocated to the problem-solving intervention (n = 50) or the usual care control group (n = 50). Blinded interviewers conducted assessments at pretreatment, posttreatment, 1, 3, and 6 months of follow-up. The main outcome was suicidal orientation; secondary outcomes were suicidal risk, suicidal plans and attempts, depressive symptoms, and problem-solving skills.

RESULTS

At posttreatment and up to 6-month follow-up, there was lower suicidal orientation and suicidal risk in the problem-solving group compared to the control group. There were lower suicidal plans and attempts (0.0% participants vs 2.2% with a suicide plan and 2.2% with both suicide plan and attempt); risk difference was 0.04 (95% CI: 0.01-0.09) and the number needed to treat was 25 (95% CI: 11-70). Significant effects of the intervention on depressive symptoms were found at posttreatment and maintained for 6 months. The change in global and functional problem-solving skills mediated the reduction in suicide orientation.

CONCLUSIONS

Thus, suicidal risk can be successfully prevented in adolescents.

[Age-related features of mental development and mental state of adolescents, who committed suicide]

OBJECTIVE

To identify age-related psychopathological disorders and psychological characteristics of mental development and mental state of minors who committed suicide.

MATERIAL AND METHODS

The study included a continuous sample of 285 reports of post-mortem psychological-psychiatric forensic assessment (CSPE) of juveniles, aged 11 to 17 years (average age 14.92±1.82), who committed suicide, in 7 federal districts of the Russian Federation. Within the total sample, two age groups were compared: adolescents from 11 to 14 years old (1) and 15-17 years old (2). Document analysis, clinical-psychopathological, clinical-psychological, qualitative and statistical methods were used.

RESULTS AND CONCLUSION

Within the period from 11 to 17 years, the exponential growth of suicide rate is observed. An increase of family- and school-related psychological problems as well as difficulties in the relationship with the opposite sex are typical for the older group. Simultaneously, the effect of maladaptive individual features increases and psychopathological states and disorders, including, stress and adjustment disorders and depressive disorders, develop.

Assessment tools of immediate risk of self-harm and suicide in children and young people: A scoping review

There are increasing numbers of children presenting to paediatric hospital settings in mental health crisis. Typically, non-mental health professionals are responsible for the initial assessment of these children and are required to identify immediate physical and emotional health needs. To ensure the safety of these children, immediate risk of suicide and self-harm should be assessed. However, no standardized assessment tool is used in clinical practice, and for those tools that are used, their validity and reliability is unclear. A scoping review was conducted to identify the existing assessment tools of immediate self-harm and suicide risk. Searches of electronic databases and relevant reference lists were undertaken. Twenty-two tools were identified and most assessed acute risk of suicide with only four tools incorporating a self-harm assessment. The tools varied in number of items (4-146), subscales (0-11) and total scores (16-192). Half incorporated Likert-type scales, and most were completed via self-report. Many tools were subject to limited psychometric testing, and no single tool was valid or reliable for use with children presenting in mental health crisis to non-mental health settings. As such, a clinically appropriate, valid and reliable tool that assesses immediate risk of self-harm and suicide in paediatric settings should be developed.

Linguistic adaptation and psychometric properties of the Columbia-Suicide Severity Rating Scale among a heterogeneous sample of adolescents in Turkey

OBJECTIVE

The Columbia-Suicide Severity Rating Scale is a semistructured, interview-based assessment tool, which is increasingly being used for clinical and research purposes across the globe, despite its limited psychometric evaluation outside of English-speaking populations. The aim of this study was to linguistically adapt the measure and investigate reliability, validity, and factor structure of the Turkish version of the Columbia-Suicide Severity Rating Scale in a heterogeneous sample of psychiatric and nonpsychiatric outpatient adolescents.

METHOD

The study included four clinical groups: two psychiatric, nonsuicidal outpatient groups (depression group (N = 50) and nondepression group (N = 50)), suicidal group (N = 43), and nonpsychiatric general practitioners' group (N = 70). All participants were interviewed with the Columbia-Suicide Severity Rating Scale and suicidality module of the Mini International Neuropsychiatric Interview for children and adolescents. They also completed the Suicide Probability Scale, Child Depression Inventory, Beck Hopelessness Scale, and their parents filled in the Child Behavior Checklist.

RESULTS

The scale was found to be a solidly reliable measure with good internal consistency and agreement among interviewers. It correlated in the expected direction with self- and parent-report measures of associated constructs (e.g., depression) as well as suicidality. Consistent with the developers' intent of theoretical subscales, a three-factor solution (i.e., the severity of suicidal ideation, the intensity of suicidal ideation, and suicidal behavior) fit the data well, and it fit the data significantly better than the alternative models. Last, the Turkish Columbia-Suicide Severity Rating Scale successfully discriminated the adolescents with a recent history of suicide attempts from other clinical groups.

CONCLUSION

The Turkish version of the Columbia-Suicide Severity Rating Scale is a reliable and valid instrument to assess suicide risk among adolescents.

Prospective prediction of first lifetime onset of suicidal ideation in a national study of substance users

Suicide rates have increased over the past several decades. Prior research has evaluated risk factors for suicidal behavior, but much of this work does not adequately differentiate between risk factors for suicidal ideation (SI) and suicide attempts, nor does it differentiate between first-onset SI and recurrent ideation. This study seeks to identify risk factors for first-onset SI among a high-risk group: individuals receiving treatment for substance use disorders. Data were drawn from the National Treatment Improvement Evaluation Study, a prospective study examining the impact of addiction treatment programs. Patients with no lifetime history of suicide attempts or ideation (n = 2560) were assessed at baseline and one year later for prospectively-occurring SI. Sociodemographic variables, mental health indices, interpersonal factors, and substance use severity indicators were evaluated as prospective predictors of first-onset SI in linear regression models. Current mental health problems (OR = 1.54, 95% CI = 1.19-2.01), current substance use problems (OR = 1.33, 95% CI = 1.04-1.70), and difficulty accessing treatment for substance use problems (OR = 1.90, 95% CI = 1.16-3.11) emerged as significant predictors of first-onset SI in a multivariate analysis, suggesting that individuals with current mental health or substance use related symptoms are among the most at risk for developing SI. Difficulty obtaining treatment remained significant, highlighting the importance of treatment accessibility. Future clinical work and research would benefit by addressing these issues, potentially by focusing on mental health treatment in substance abuse programs and evaluating barriers to treatment.

Aggressive Behaviors and Suicide Ideation in Inpatient Adolescents: The Moderating Roles of Internalizing Symptoms and Stress

The present study examined a conceptual model in which the association between aggressive behaviors and suicide ideation is moderated by internalizing symptoms and ongoing stress. Participants were 304 psychiatric inpatient adolescents (65.8% girls) ranging in age from 12 to 17 years (Mean age = 14.69). The association between aggressive behaviors and suicide ideation was significantly moderated by internalizing symptoms and ongoing stress; the association was positive in adolescents low in internalizing symptoms or high in ongoing stress, but negative in adolescents high in internalizing symptoms or low in ongoing stress. The three-way interaction between aggressive behaviors, internalizing symptoms, and ongoing stress was not statistically significant. The current findings indicate that in adolescents who display high levels of aggressive behaviors, the presence of high ongoing stress provides a more useful indicator of levels of suicide ideation than the presence of high internalizing symptoms. Implications for case identification and prevention are discussed.

Emerging trends in adolescent suicide prevention research

A comprehensive public health strategy for adolescent suicide prevention includes upstream prevention strategies, strategies for risk recognition, and services for those at risk. Interpersonal trauma and substance use are important prevention targets as each is associated with risk for suicide attempts. Multiple prevention programs target these factors; however, the Family Check-Up, designed to reduce substance use and behavioral problems, also has been associated with reduced suicide risk. Several youth screening instruments have shown utility, and a large-scale trial is underway to develop a computerized adaptive screen. Similarly, several types of psychotherapy have shown promise, and sufficiently powered studies are underway to provide more definitive results. The climbing youth suicide rate warrants an urgent, concerted effort to develop and implement effective prevention strategies.

Suicide Evaluation in the Pediatric Emergency Setting

Suicide is 1 of the top 3 leading causes of death in the pediatric population and a serious public health concern. There are evidence-based screening tools for suicide in the pediatric population; however, predicting suicide risks can be a difficult task. The emergency department is an essential source of mental health care for youths and can serve as an important opportunity for suicide screening and subsequent targeted interventions and resource management. More research is needed in emergency department-based screening algorithms and evidence-driven interventions in the pediatric population.

Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk

Suicide is the tenth leading cause of death in the United States, accounting for more than 42,000 deaths in 2014. Although this tragedy cuts across groups defined by age, gender, race/ethnicity, and geographic location, it is striking that nearly four times as many males as females die by suicide in the U.S. We describe the current regulations and recommendations for suicide risk screening in healthcare systems and also describe the aspirational goal of "Zero Suicide," put forth by the National Action Alliance for Suicide Prevention. We then provide information about suicide risk screening tools and steps to take when a patient screens positive for suicide risk. Given the substantially higher suicide rate among males than females, we argue that it is important to consider how we could optimize suicide risk screening strategies to identify males at risk and females at risk. Further research is needed to accomplish this goal. It is recommended that we consider multi-factorial suicide risk screens that incorporate risk factors known to be particularly important for males as well as computerized, adaptive screens that are tailored for the specific risk considerations of the individual patient, male or female. These strategies are not mutually exclusive. Finally, universal suicide risk screening in healthcare settings, especially primary care, specialty medical care, and emergency department settings, is recommended.

Suicidal ideation, suicide attempts, and psychological distress among intoxicated adolescents in the pediatric emergency department

BACKGROUND

Studies have emphasized screening for psychiatric disorders, especially suicide risk in emergency departments. Psychiatric disorders and experimentation with alcohol increase in adolescence and intoxications among patients challenge the staff in emergency departments.

AIMS

This study examined the degree of suicidal ideation (SI) and suicidal behavior in adolescents, and the extent to which they differed from non-suicidal patients in terms of alcohol use, psychological distress, self-esteem, and perceived social support.

METHODS

The study comprised 120 adolescents, a mean age of 14.2 years. Of them 60% were females. We collected data on the clinical characteristics and assessed the patient's psychiatric status using self-report scales and analyzed blood samples for alcohol. A consulting psychiatrist interviewed each patient before discharge to evaluate potential SI or suicide attempt (SA) using structured and semi-structured scales.

RESULTS

Of the 120 patients 20% had SI or had made a SA. High psychological distress in girls, low blood alcohol levels (BALs), as well as low scores on self-esteem, on social support and on familial support were associated with patients with SI/SA. Logistic regression showed that the most significant variables with suicidal patients included low BAL and low self-esteem and high alcohol consumption. Psychological distress had a direct and mediational role in the suicidal patients.

CONCLUSIONS

Adolescents referred to the pediatric emergency department with intoxication displaying high psychological distress and low self-esteem represent a high-risk group of teens. In this group, careful assessment of mental health status, screening for suicidal ideation, and SAs seems warranted.

Emergency Department Youth Patients With Suicidal Ideation or Attempts: Predicting Suicide Attempts Through 18 Months of Follow-Up

This prospective study of suicidal emergency department (ED) patients (ages 10-18) examined the timing, cumulative probability, and predictors of suicide attempts through 18 months of follow-up. The cumulative probability of attempts was as follows: .15 at 6 months, .22 at 1 year, and .24 by 18 months. One attempt was fatal, yielding a death rate of .006. Significant predictors of suicide attempt risk included a suicide attempt at ED presentation (vs. suicidal ideation only), nonsuicidal self-injurious behavior, and low levels of delinquent symptoms. Results underscore the importance of both prior suicide attempts and nonsuicidal self-harm as risk indicators for future and potentially lethal suicide attempts.

Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department

The pediatric emergency department (ED) is a critical location for the identification of children and adolescents at risk for suicide. Screening instruments that can be easily incorporated into clinical practice in EDs to identify and intervene with patients at increased suicide risk is a promising suicide prevention strategy and patient safety objective. This study is a retrospective review of the implementation of a brief suicide screen for pediatric psychiatric ED patients as standard of care. The Ask Suicide Screening Questions (ASQ) was implemented in an urban pediatric ED for patients with psychiatric presenting complaints. Nursing compliance rates, identification of at-risk patients, and sensitivity for repeated ED visits were evaluated using medical records from 970 patients. The ASQ was implemented with a compliance rate of 79 %. Fifty-three percent of the patients who screened positive (237/448) did not present to the ED with suicide-related complaints. These identified patients were more likely to be male, African American, and have externalizing behavior diagnoses. The ASQ demonstrated a sensitivity of 93 % and specificity of 43 % to predict return ED visits with suicide-related presenting complaints within 6 months of the index visit. Brief suicide screening instruments can be incorporated into standard of care in pediatric ED settings. Such screens can identify patients who do not directly report suicide-related presenting complaints at triage and who may be at particular risk for future suicidal behavior. Results have the potential to inform suicide prevention strategies in pediatric EDs.

Psychopathology profiles of acutely suicidal adolescents: Associations with post-discharge suicide attempts and rehospitalization

BACKGROUND

Suicidal adolescents are heterogeneous, which can pose difficulties in predicting suicidal behavior. The Youth Self-Report (YSR) psychopathology profiles predict the future onset of psychopathology and suicide-related outcomes. The present study examined the prevalence and correlates of YSR psychopathology profiles among suicidal adolescents and prospective associations with post-discharge rates of suicide attempts and psychiatric rehospitalization.

METHODS

Participants were acutely suicidal, psychiatrically hospitalized adolescents (N=433 at baseline; n=355 at follow-up) who were enrolled in a psychosocial intervention trial during hospitalization. Psychopathology profiles were assessed at baseline. Suicide attempts and rehospitalization were assessed for up to 12 months following discharge.

RESULTS

Latent profile analysis identified four psychopathology profiles: subclinical, primarily internalizing, and moderately and severely dysregulated. At baseline, profiles differed by history of non-suicidal self-injury (NSSI) and multiple suicide attempts (MA) as well as severity of suicide ideation, hopelessness, depressive symptoms, anxiety symptoms, substance abuse, and functional impairment. The dysregulation profiles predicted suicide attempts within 3 months post-discharge. The internalizing profile predicted suicide attempts and rehospitalization at 3 and 12 months.

LIMITATIONS

This study's participants were enrolled in a randomized trial and were predominantly female, which limit generalizability. Additionally, only a history of NSSI was assessed.

CONCLUSIONS

The dysregulation profile was overrepresented among suicidal youth and associated with impairment in several domains as well as suicide attempts shortly after discharge. Adolescents with a severe internalizing profile also reported adverse outcomes throughout the study period. Psychopathology profiles warrant further examination in terms of their potential predictive validity in relation to suicide-related outcomes.

Coping with suicidal urges among youth seen in a psychiatric emergency department

This study of youth seeking psychiatric emergency department (ED) services examined (1) youth self-efficacy to use suicide-specific coping strategies, (2) whether these self-efficacy beliefs varied by demographic and clinical characteristics, (3) and associations of these beliefs with suicide attempts and ED visits 3-5 months later. Participants were 286 psychiatric ED patients (59% Female), ages 13-25. Ratings of self-efficacy to engage in 10 suicide-specific coping behaviors were assessed at index visit. A total of 226 participants (79%) were assessed 3-5 months later. Youth endorsed low-to-moderate self-efficacy for different suicide-specific coping behaviors, with lowest ratings endorsed for limiting access to lethal means and accessing professional resources. More severe baseline psychopathology was associated with lower self-efficacy. Males endorsed higher self-efficacy for coping behaviors not requiring external support. Lower coping self-efficacy for some of the key strategies, and lower confidence that these strategies will be helpful, differentiated those with and without follow-up suicide attempts and ED visits. The generally low-to-moderate confidence in youths' ability to engage in coping behaviors to manage suicidal crises, and its association with follow-up suicidal crises, is concerning because many of these strategies are commonly included as part of discharge recommendations or safety planning. Implications of findings are discussed.

SELF-RATED EXPECTATIONS OF SUICIDAL BEHAVIOR PREDICT FUTURE SUICIDE ATTEMPTS AMONG ADOLESCENT AND YOUNG ADULT PSYCHIATRIC EMERGENCY PATIENTS

BACKGROUND

This study's purpose was to examine the predictive validity and clinical utility of a brief measure assessing youths' own expectations of their future risk of suicidal behavior, administered in a psychiatric emergency (PE) department; and determine if youths' ratings improve upon a clinician-administered assessment of suicidal ideation severity. The outcome was suicide attempts up to 18 months later.

METHODS

In this medical record review study, 340 consecutively presenting youths (ages 13-24) seeking PE services over a 7-month period were included. Subsequent PE visits and suicide attempts were retrospectively tracked for up to 18 months. The 3-item scale assessing patients' perception of their own suicidal behavior risk and the clinician-administered ideation severity scale were used routinely at the study site.

RESULTS

Cox regression results showed that youths' expectations of suicidal behavior were independently associated with increased risk of suicide attempts, even after adjusting for key covariates. Results were not moderated by sex, suicide attempt history, or age. Receiver-operating characteristic (ROC) analyses indicated that self-assessed expectations of risk improved the predictive accuracy of the clinician-administered suicidal ideation measure.

CONCLUSIONS

Youths' ratings indicative of lower confidence in maintaining safety uniquely predicted follow-up attempts and provided incremental validity over and above the clinician-administered assessment and improved its accuracy, suggesting their potential for augmenting suicide risk formulation. Assessing youths' own perceptions of suicide risk appears to be clinically useful, feasible to implement in PE settings, and, if replicated, promising for improving identification of youth at risk for suicidal behavior.