Suicide risk assessment and risk formulation part I: a focus on suicide ideation in assessing suicide risk

Association between exposure to organophosphorus pesticide and suicidal ideation among U.S. adults: A population-based study

OBJECTIVE

This study aims to investigate the potential link between exposure to organophosphorus pesticides (OPPs) and suicidal ideation (SI) among adults.

METHODS

This study encompassed four cycles of the National Health and Nutrition Examination Survey (NHANES), involving 5244 participants aged 20 and above. SI was assessed using the Patient Health Questionnaire-9. The levels of exposure to OPPs were estimated by analyzing concentrations of OPP metabolites in urine samples. Multivariate logistic regression models were used to explore the association between exposure to each OPP and SI. Stratified analyses and interaction tests were conducted across various groups, including pairwise combinations of gender and age, as well as body mass index, smoking status, hypertension, and diabetes. Weighted Quantile Sum (WQS) regression and Bayesian Kernel Machine Regression (BKMR) models were applied to assess the cumulative impact of exposure to the four OPPs on SI, along with their respective contributions. Additionally, the potential interactions among these four OPPs were evaluated.

RESULTS

Multivariate logistic regression revealed that only dimethylthiophosphate (DMTP) among OPPs demonstrated a statistically significant positive association with SI [OR: 1.18; 95 % CI: 1.02-1.37]. Stratified analyses indicated that the influence of OPPs on SI was particularly pronounced in young and older men. The WQS regression analysis revealed a statistically significant association between the mixed metabolites of OPPs and SI [OR = 1.10, 95 % CI: 1.04-1.16], with DMTP (weighted 0.63) contributing the most. Furthermore, the BKMR model supported a positive trend in the overall impact of these OPP metabolites on SI, displaying notable individual exposure-response relationships for DMTP (PIP: 0.77).

CONCLUSIONS

Our study suggests an association between exposure to DMTP and an increased risk of SI. Specifically, young adult males and older males appear particularly susceptible to the effects of OPP exposure.

Suicide Following a Near-Death Experience

Background: Sometimes during real or presumed life-threatening and/or near-death circumstances, an individual undergoes an altered state of consciousness referred to as a near-death experience (NDE). The prevalent position in the field of NDE research for the last several decades has been that such experiences result in positive antisuicidal attitudes and that it is highly unlikely that experients will try to kill themselves afterward. In addition, the important consideration of passive suicidal ideation is neglected in NDE research. Aims: To question the premature assumption that people are highly unlikely to die by suicide after an NDE. Method: Four case studies of suicide after an NDE are provided and examined. Results: Although important quantitative data are still needed, it can no longer be argued that people do not die by suicide after an NDE. Limitations: Only four cases were available for examination, and the degree of impact that the NDE had on their suicide is uncertain. Conclusion: Much more research is needed on suicide risk post NDE. In the meantime, the NDE should not be ignored in suicide assessments, but therapists and other relevant professionals need to be attentive to any possible indications of either active or passive suicidal ideation post NDE.

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.

Determining the MMPI-3 SUI scale's cross-sectional and prospective utility in suicide risk assessment

OBJECTIVE

In-depth suicide risk assessments are particularly important to long-term suicide prevention. Broadband measures of psychopathology, such as the Minnesota Multiphasic Personality Inventory (MMPI) instruments, assess suicide risk factors and various mental health comorbidities. With the recent release of the MMPI-3, the Suicidal/Death Ideation (SUI) scale underwent revisions to improve its construct validity and detection of suicide risk factors. Thus, we hypothesized the MMPI-3 SUI scale would demonstrate medium to large associations with suicidal experience and behaviors, future ideation, and interpersonal risk factors of suicide.

METHODS

A sample of 124 college students screened for elevated depressive symptoms completed a brief longitudinal study. Participants completed a baseline session including the MMPI-3 and criterion measures and three brief follow-ups every 2 weeks.

RESULTS

SUI scores were most robustly associated with increased risk for past suicidal ideation, planning, and perceived burdensomeness. Prospectively assessed suicidal ideation was also meaningfully associated with SUI. SUI scale elevations indicate an increased risk of suicide-related risk factors.

CONCLUSION

The MMPI-3 is a valuable tool to inform long-term suicide prevention for those experiencing elevated depressive symptoms as the SUI scale can assess past, current, and future suicide-related risk factors, including suicidal ideation and behaviors.

Mapping clinical interactions in an Australian tertiary hospital emergency department for patients presenting with risk of suicide or self-harm: Network modeling from observational data

BACKGROUND

Reliable assessment of suicide and self-harm risk in emergency medicine is critical for effective intervention and treatment of patients affected by mental health disorders. Teams of clinicians face the challenge of rapidly integrating medical history, wide-ranging psychosocial factors, and real-time patient observations to inform diagnosis, treatment, and referral decisions. Patient outcomes therefore depend on the reliable flow of information through networks of clinical staff and information systems. This study aimed to develop a quantitative data-driven research framework for the analysis of information flow in emergency healthcare settings to evaluate clinical practice and operational models for emergency psychiatric care.

METHODS AND FINDINGS

We deployed 2 observers in a tertiary hospital emergency department during 2018 for a total of 118.5 h to record clinical interactions along patient trajectories for presentations with risk of self-harm or suicide (n = 272 interactions for n = 43 patient trajectories). The study population was reflective of a naturalistic sample of patients presenting to a tertiary emergency department in a metropolitan Australian city. Using the observational data, we constructed a clinical interaction network to model the flow of clinical information at a systems level. Community detection via modularity maximization revealed communities in the network closely aligned with the underlying clinical team structure. The Psychiatric Liaison Nurse (PLN) was identified as the most important agent in the network as quantified by node degree, closeness centrality, and betweenness centrality. Betweenness centrality of the PLN was significantly higher than expected by chance (>95th percentile compared with randomly shuffled networks) and removing the PLN from the network reduced both the global efficiency of the model and the closeness centrality of all doctors. This indicated a potential vulnerability in the system that could negatively impact patient care if the function of the PLN was compromised. We developed an algorithmic strategy to mitigate this risk by targeted strengthening of links between clinical teams using greedy cumulative addition of network edges in the model. Finally, we identified specific interactions along patient trajectories which were most likely to precipitate a psychiatric referral using a machine learning model trained on features from dynamically constructed clinical interaction networks. The main limitation of this study is the use of nonclinical information only (i.e., modeling is based on timing of interactions and agents involved, but not the content or quantity of information transferred during interactions).

CONCLUSIONS

This study demonstrates a data-driven research framework, new to the best of our knowledge, to assess and reinforce important information pathways that guide clinical decision processes and provide complementary insights for improving clinical practice and operational models in emergency medicine for patients at risk of suicide or self-harm. Our findings suggest that PLNs can play a crucial role in clinical communication, but overreliance on PLNs may pose risks to reliable information flow. Operational models that utilize PLNs may be made more robust to these risks by improving interdisciplinary communication between doctors. Our research framework could also be applied more broadly to investigate service delivery in different healthcare settings or for other medical specialties, patient groups, or demographics.

Exploring Counselor Practices and Risk Assessment in a Proactive Digital Intervention Through Instagram in Young People: Qualitative Study

BACKGROUND

Suicide is one of the leading causes of preventable death in young people, and the way young people are communicating suicidality has evolved to include web-based disclosures and help-seeking. To date, mental health intervention services, both on the web and in person, have been conceived in the traditional model, whereby support is provided if a young person (or their family) actively seeks out that support when distressed. On the other hand, proactive outreach is an innovative approach to intervention that has been shown to be effective in other areas of health care. Live for Tomorrow chat was delivered on Instagram and comprised of counselors who reach out to provide brief person-centered intervention to young people who post content indicating distress or suicidality.

OBJECTIVE

Our aim was to explore how counselors engaged young people in a proactive digital intervention and how risk assessment was conducted in this context.

METHODS

We analyzed 35 transcripts of conversations between counselors and young people aged 13-25 years using the 6-step approach of Braun and Clarke's reflexive thematic analysis. These transcripts included a counseling intervention and a follow-up chat that was aimed at collecting feedback about the counseling intervention.

RESULTS

A total of 7 themes emerged: using microskills to facilitate conversations, building confidence and capacity to cope with change, seeking permission when approaching conversations about suicidality or self-harm, conversations about suicidality following a structured approach, providing assurances of confidentiality, validation of the experience of suicidality, and using conversations about suicidality to identify interventions. Counselors were able to translate counseling microskills and structured questioning regarding suicidality into a digital context. In particular, in the digital context, counselors would use the young person's post and emojis to further conversations and build rapport.

CONCLUSIONS

The findings highlight the importance of the counselor's role to listen, empathize, validate, and empower young people and that all these skills can be transferred to a digital text counseling intervention. Counselors used a structured approach to understanding suicidality in a permission-seeking, validating, and confidential manner to identify interventions with the young person. These practices allowed the conversation to move beyond traditional risk assessment practices to meaningful conversations about suicidality. Moving beyond traditional risk assessment practices and into conversations about suicidality allowed for the validation of the young person's experience and exploration of interventions and support that made sense and were seen to be helpful to the young person. This study highlighted the benefits of a proactive digital chat-based intervention, which is a novel approach to engaging with young people experiencing psychological distress and suicidality. Furthermore, this research demonstrates the feasibility and benefit of moving mental health intervention and support to a medium where young people are currently disclosing distress and intervening proactively.

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.

Identification of young females at high risk of suicide following hospital-treated self-harm in Victoria, Australia

OBJECTIVE

We conducted a data linkage study in Victoria, Australia, to determine the proportion of young females who are treated in hospital for self-harm who go on to die by suicide within 5 years and to identify factors associated with increased suicide risk in this same cohort.

METHOD

We undertook a cohort study following 3689 female patients aged 10-24 years, who were initially treated in hospital for self-harm during the 2-year period January 2011 to December 2012. We followed each patient for 5 years unless they died first, in which case, they were followed until their date of death. We used inpatient admissions from the Victorian Admitted Episodes Dataset and emergency department presentations from the Victorian Emergency Minimum Dataset linked to death data from two sources, the Victorian Suicide Register and the National Death Index.

RESULTS

Twenty-eight individuals (0.76% of the total cohort) died by suicide within 5 years of their index admission. In multivariate survival analysis, only suicide ideation at the time of self-harm (hazard ratio = 4.59; 95% confidence interval: 1.70, 12.38) and a decreasing time between successive self-harm episodes (hazard ratio = 4.38; 95% confidence interval: 1.28, 15.00) were associated with increased suicide risk.

CONCLUSION

Although the vast majority of young females who present to hospital for self-harm do not die by suicide within 5 years, our results suggest young females expressing suicide ideation and those presenting frequently with decreasing time between successive episodes should be prioritised for suicide-prevention efforts.

Cross-national presence and sociodemographic correlates of the suicide crisis syndrome

BACKGROUND

The Suicide Crisis Syndrome (SCS) has been proposed as an acute, pre-suicidal mental state that precedes imminent suicidal behavior; however, its cross-national applicability and sociodemographic correlates have not yet been determined. The present study assessed the presence and severity of the SCS in ten countries and examined several potential sociodemographic correlates (i.e., age, gender, marital status, race/ethnicity) of the SCS.

METHODS

5528 community-based adults across 10 participating countries provided information on their SCS symptoms and sociodemographic characteristics in an anonymous online survey obtained via convenience sampling during the first year of the COVID-19 pandemic.

RESULTS

The SCS occurred cross-nationally, with rates ranging from 3.6% (Israel) to 16.2% (Poland). Those in the United States, South Korea, Poland, and Turkey had the highest severity of symptoms. Participants who were older, identified as cisgender men, and married tended to have lower rates of the SCS than their respective counterparts. There were minimal differences in the SCS by race/ethnicity.

LIMITATIONS

These data were both cross-sectional and collected via convenience sampling, limiting generalizability of findings and information about the SCS's predictive utility.

CONCLUSIONS

These findings support the cross-national presence of the SCS during the COVID-19 pandemic. Sociodemographic correlates aligned with those of suicidal behavior more generally, providing additional evidence for the concurrent/predictive validity of the SCS.

Who are the patients who deny suicidal intent? Exploring patients' characteristics associated with self-disclosure and denial of suicidal intent

BACKGROUND

Patients' non-disclosure of suicidal ideation and intent concealment represent a major obstacle to the effective assessment of suicide risk and to the delivery of suicide prevention treatments. The present study aimed to investigate this phenomenon and to assess (1) if outpatient psychiatric patients are more or less likely to disclose intent to mental health clinicians in the context of psychiatric/psychological treatment than they are to in the context of research interviews with non-clinicians; and (2) if certain demographic, trait-like, and state-like characteristics may predict such disclosure differences.

METHODS

A total of 780 psychiatric outpatient participants aged 18 to 84 and 193 clinician participants aged 25 to 54 were included in the study. The proportion of patients who disclosed to clinicians only, to research assistants (RAs) only, to both, and to none, was compared using a z-test. Univariate analyses were used to compare the participants' variables across disclosure groups, and significant individual predictors were included in multilevel regression analyses.

RESULTS

Participants were more significantly more likely to disclose to RAs (10.4%) than to clinicians (5.6%), p < 0.001. Neuroticism and trait anxiety predicted disclosure to RAs vs no disclosure; low extraversion predicted disclosure to clinician versus no disclosure; and extraversion and trait anxiety predicted disclosure to RAs versus to clinicians.

DISCUSSION

Patients' disclosure patterns, the personality variables predicting them, and their clinical implications were discussed in the context of the extant literature on patients' reasons for concealing suicidal ideation and intent.

Identifying the suicidal ideation risk group among older adults in rural areas: Developing a predictive model using machine learning methods

AIMS

The aim of this study was to develop a predictive model that can identify the suicidal ideation risk group among older adults in rural areas using machine learning methods.

DESIGN

This study applied an exploratory, descriptive and cross-sectional design.

METHODS

The participants were older adults (N = 650) aged over 65 living in rural areas of South Korea. Self-report questionnaires were used to collect the demographics, suicidal ideation, depression, socioeconomic information and basic health information from September to October 2020. The collected data were analysed using machine learning methods with R statistical software 4.1.0.

RESULTS

The predictive models indicated that depression, pain, age and loneliness were significant factors of suicidal ideation. Good performance was observed based on the area under the receiver operating characteristic curve in the decision tree, random forest and logistic regression. Finally, the evaluation of model performance indicated moderate to high sensitivity and specificity.

CONCLUSION

The predictive models using machine learning methods may be useful to predict the risk of suicidal ideation. Furthermore, depression with pain, age and feelings of loneliness should be included in the initial screening to assess suicide risk among older adults in rural areas.

IMPACT

Identifying suicidal risk among older adults is challenging. Thus, employing predictive models that can assess depression, pain, age and loneliness can enable public healthcare providers to detect suicidal risk groups. Particularly, the presented models from this study can facilitate healthcare providers with initiating early interventions to prevent suicide among older adults in clinical and community nursing care settings.

REPORTING METHOD

The reporting of this study (Observational, cross-sectional study) conforms to the STROBE statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. This study did not involve patients, service users, caregivers or members of the public.

IMPLICATION FOR THE PROFESSION AND/OR PATIENTS CARE

Applying this model may help to prevent geriatric suicide because the nursing staff will have a greater awareness regarding the suicide ideation risk of older adults, thereby reducing the possibility of their suicide.

Factor Structure and Validation of the Revised Suicide Crisis Inventory in a Korean Population

OBJECTIVE

Because of the exceptionally high suicide rates in South Korea, new assessment methods are needed to improve suicide prevention. The current study aims to validate the revised Suicide Crisis Inventory-2 (SCI-2), a self-report measure that assesses a cognitiveaffective pre-suicidal state in a Korean sample.

METHODS

With data from 1,061 community adults in South Korea, confirmatory factor analyses were first conducted to test the proposed one-factor and five-factor structures of the SCI-2. Also, an exploratory factor analysis (EFA) was performed to examine possible alternative factor structure of the inventory.

RESULTS

The one-factor model of the SCI-2 resulted in good model fit and similarly, the five-factor model also exhibited strong fit. Comparing the two models, the five-factor was evaluated as the superior model fit. An alternative 4-factor model derived from EFA exhibited a comparable model fit. The Korean version of the SCI-2 had high internal consistency and strong concurrent validity in relation to symptoms of suicidal ideation, depression, and anxiety.

CONCLUSION

The SCI-2 is an appropriate and a valid tool for measuring one's proximity to imminent suicide risk. However, the exact factor structure of the SCI-2 may be culture-sensitive and warrants further study.

Identifying suicide ideation in mental health application posts: A random forest algorithm

The growing use of digitized mental health applications requires new reliable early screening tools to identify user suicide risk. We used a lexicon-based random forest machine learning algorithm to predict suicide ideation scores from 714 online community text posts from December 2019 to April 2020. We validated predicted scores against expert-rated suicide ideation scores. The algorithm-predicted scores offered high validity and a low error rate and correctly identified 95% of expert-rated high-risk suicide ideation posts. Our findings highlight a potential new method to detect suicidal ideation of digital mental health application users.

Assessment of acute and non-acute suicide crisis symptoms: Validation of the Korean version of the acute suicidal affective disturbance inventory

Suicide risk assessment is predominantly based on assessing current/recent suicidal ideation and past suicidal behavior. However, suicidal ideation and lifetime suicide attempt are poor predictors of imminent suicide risk or crisis. The acute suicidal affective disturbance inventory-lifetime (ASADI-L) was developed to assess symptoms of acute suicidal affective disturbance, which includes a drastic increase in suicidal intent, perceptions of social and/or self-alienation, hopelessness, and overarousal. However, the ASADI-L has not yet been validated in a Korean population. Also, the ASADI-L has only been validated for people who experience a drastic increase in suicidal intention over the course of hours or days (i.e., the acute suicidal intention group) and not validated for those who experience suicidal intention for a longer period (i.e., the non-acute suicidal intention group). Thus, the aims of this study were to (1) validate the ASADI-L in a sample of Korean community adults; and (2) compare clinical characteristics of the acute and non-acute suicidal intention groups. Among 1,675 community adults, data from 682 participants who reported a lifetime drastic increase in suicidal intent were analyzed. Results indicated that the ASADI-L has relevant reliability, validity, and a unidimensional factor structure. The acute suicidal intention group had higher ASAD symptoms as well as clinical symptoms than the non-acute group, but the two groups did not differ in history of suicide attempt. Overall, these findings suggest that the ASADI-L is a valid measure of acute and non-acute suicidal affective disturbance among Korean adults. Further investigation of the differences in acute and non-acute suicide risk is warranted.

Hazards of Using Constant Observation With Suicidal Patients

Constant observation is a necessary albeit controversial procedure. Although widely used in psychiatric hospitals to maintain the safety of patients experiencing acute suicidality, constant observation is associated with many medicolegal hazards. Some hazards threaten patients directly, others undermine the effectiveness of treatment, and still others challenge clinical decision-making and suicide risk assessment. Nevertheless, clinicians can take proactive steps to minimize potentially adverse effects of constant observation on patients, preserve the integrity of treatment, and limit legal exposure.

Child Sexual Abuse and Suicide: Essentials for the Forensic Nurse

Sexual abuse can result in significant negative sequelae for victims. One particularly harmful consequence is suicidal ideation, which can lead to suicide attempts and even death. It is essential to screen children and adolescents for suicidal ideation when providing medical forensic care after disclosure of acute or nonacute sexual abuse/assault. Forensic nurses must feel confident in their abilities to assess suicide risk and provide appropriate intervention and referrals. A thorough understanding of the relationship between sexual abuse and suicidal ideation and behaviors can assist the forensic nurse in the development of practice behaviors to better identify, intervene, and prevent suicidal ideation and behaviors among youth experiencing sexual abuse.

Risk factors observed in the last 30 days of life among student suicides: distinguishing characteristics of college and university student suicides

Purpose: Studies of college and university student suicide have identified predictors only of suicide ideation and attempts and have relied solely on self-report data. This study explores risk factors observed in the last 30 days of life of college and university students who died by suicide, compared to those of high school and middle school students. Methods: Retrospective chart reviews of 16 college and university students (aged 19-26) were abstracted and compared to those of 24 middle and high school students (aged 12-18), all in, or recently in, clinical care. Results: Near-term risk factors for deaths by suicide largely were equivalent in compared groups, with only sleep problems, conduct problems, and passive suicide ideation found to be significantly different between student cohorts. Conclusions: These preliminary findings are hypotheses-generating for larger studies of more restricted age ranged youth cohorts needed to better differentiate near-term risk factors for suicide.

Differential disclosure of suicidal intent to clinicians versus researchers: Associations with concurrent suicide crisis syndrome and prospective suicidal ideation and attempts

Several patient and setting characteristics have been found to predict disclosure of suicidality to clinicians versus researchers. Less understood, however, is whether differential disclosure of suicidality predicts concurrent indirect indicators of suicide risk and future suicide-related outcomes. The present study examined differential disclosure of suicidal intent in clinical versus research settings as a predictor of (1) concurrent symptoms of the Suicide Crisis Syndrome (SCS); and (2) suicidal ideation and attempts within one month in patients (n = 1039) and their clinicians (n = 144), who completed a battery of self-report and interview measures at baseline. Patients who reported suicidal intent to anyone had higher concurrent SCS symptoms than those who denied suicidal intent, with no differences between those who reported intent to clinicians versus researchers only. Severity of suicidal ideation and rates of suicide attempts at one-month follow-up were higher among those who disclosed suicidal intent to a research assistant than among those who did not-regardless of whether suicidal intent was disclosed to their clinician. Overall, an improved understanding of the factors contributing to differential disclosure will improve both scientific inquiry and patient safety.

The roles of school in supporting LGBTQ+ youth: A systematic review and ecological framework for understanding risk for suicide-related thoughts and behaviors

The extant literature on suicide-related thoughts and behaviors (STB) has highlighted increased patterns of risk among specific minoritized populations, including lesbian, gay, bisexual, transgender, questioning, intersex, two spirit, and queer (LGBTQ+) youth. Compared to their heterosexual and cisgender peers, LGBTQ+ youth are at increased risk for having STB. Identity-specific stressors such as homonegativity and anti-queerness are among the unique factors posited to contribute to this risk and inhibit factors that protect against suicide. The school setting has been a focal point for suicide prevention and intervention and may also play a key role in linking students to care; however, schools also hold the potential to provide supports and experiences that may buffer against risk factors for STB in LGBTQ+ students. This systematic literature review presents findings from 44 studies examining school-related correlates of STB in LGBTQ+ students, informing an ecological approach to suicide prevention for school settings. Findings underscore the importance of school context for preventing STB in LGBTQ+ youth. Approaches that prioritize safety and acceptance of LGBTQ+ youth should span multiple layers of a student's ecology, including district and state level policies and school programs and interventions, such as Gender and Sexuality Alliances and universal bullying prevention programs. Beyond their role as a primary access point for behavioral health services, schools offer a unique opportunity to support suicide prevention by combating minority stressors through promoting positive social relationships and a safe community for LGBTQ+ students.

Hospital-Based Suicides: Challenging Existing Myths

Myths are widely held and often based on false beliefs. To improve patient safety and speed the translation of research to clinical practice, we highlight and then debunk 10 common myths regarding the assessment, treatment, and management of hospitalized patients at risk for suicide. Myths regarding hospital-based suicides are examined and empirical evidence that counters each myth is offered. Ten common myths regarding hospital-based suicides are found to be untrue or unsupported based on existing empirical evidence. Rethinking common beliefs and practices that lack empirical support and seeking alternatives based on research evidence is consistent with an emphasis on evidence-based practices leading to improved patient care and protection.

A Trauma- and Justice, Equity, Diversity, and Inclusion (JEDI)-Informed Approach to Suicide Prevention in School: Black Boys' Lives Matter

Black boys have been dying by suicide at an increasing rate. Although the reasons for this increase are unknown, suicide in Black boys is likely influenced by multiple, intersecting risk factors, including historical and ongoing trauma. Schools can serve as an important mechanism of support for Black boys; however, without intentional anti-racist frameworks that acknowledge how intersecting identities can exacerbate risk for suicide, schools can overlook opportunities for care and perpetuate a cycle of racism that compromises the mental health of Black youth. By recognizing their own implicit biases, modeling anti-racist practices, listening to and recognizing the strengths and diversity of Black youth, and fostering school-family-community partnerships, school psychologists can help transform the school environment to be a safe and culturally affirming place for Black youth. This paper outlines how school psychologists can apply a trauma- and Justice, Equity, Diversity, and Inclusion (JEDI)-informed approach to suicide prevention in order to more holistically support Black boys, disrupt patterns of aggressive disciplinary procedures, and improve school-based suicide prevention programs. By applying this lens across a multitiered systems of support (MTSS) framework, school psychologists can help to prevent the deaths of Black boys and begin to prioritize the lives of Black boys.

Evolution in French University Students' Mental Health One Month After the First COVID-19 Related Quarantine: Results From the COSAMe Survey

INTRODUCTION

The COVID-19 related quarantine had negative psychological effects among University students. Evidence from previous epidemics suggests that negative psychological effects of quarantine measures can last or even worsen after the quarantine lift. The objective of this study was to assess the evolution of students' mental health and to identify factors associated with mental health outcomes 1 month after the lift of the lockdown.

MATERIALS AND METHODS

This repeated cross-sectional study collected data during the first quarantine in France (T1, N = 68,891) and 1 month after its lift (T2, N = 22,540), through an online questionnaire sent to all French University students. Using cross-sectional data, we estimated prevalence rates of suicidal thoughts, severe anxiety (State-Trait Anxiety Inventory, State subscale), depression (Beck Depression Inventory), and stress (Perceived Stress Scale) at T1 and T2. Using longitudinal data (N = 6,346), we identified risk factors of poor mental health outcomes among sociodemographic characteristics, precariousness indicators, health-related data, information on the social environment, and media consumption, adjusting for baseline mental health status.

RESULTS

We found lower prevalence rates of severe stress (21.7%), anxiety (22.1%), and depression (13·9%) one month after the quarantine compared to the quarantine period (24.8%, 27.5%, and 16.1%, respectively). The prevalence rate of suicidal thoughts increased from 11.4 to 13.2%. Regardless of the existence of symptoms during quarantine, four factors were systematically associated with poor mental health outcomes 1 month after the quarantine was lifted: female gender, a low feeling of integration before the quarantine period, a low quality of social ties during the quarantine, and a history of psychiatric follow-up.

CONCLUSIONS

The prevalence rates of severe stress, anxiety, and depression, although being lower than during the first lockdown, remained high after its lift. The prevalence rate of suicidal ideation increased. This stresses the need to consider the enduring psychological impact of the pandemic on students as a critical public health issue.

School Risk and Protective Factors of Suicide: A Cultural Model of Suicide Risk and Protective Factors in Schools

There are known cultural variations in correlates of and symptoms related to suicide-related thoughts and behaviors; however, the majority of research that informs suicide prevention in school systems has focused on research based on Euro-American/White students. By exploring school-related risk and protective factors in ethnic-racial minoritized students, we expand existing multicultural models of suicide prevention for school settings. Specifically, this systematic literature review identified 33 studies conducted with American Indian and Alaskan Native, Hispanic and Latinx, Black and African American, and Asian American and Pacific Islander students. Findings underscore the importance of building relationships with the school community and fostering a sense of safety for students, the need to approach school-based suicide prevention and intervention with cultural considerations, and the importance of connecting students and families with providers in culturally sensitive and informed ways. Taken together, schools need to build school-family-community partnerships that promote culturally sensitive approaches to suicide prevention.

Psychological and behavioral characterization of suicide ideators and suicide attempters in adolescence

Suicide is a global cause of death, a chronic disability, and a significant public health problem. Recent works emphasize the importance of differentiating people with suicide ideation (SI) and people with suicidal attempts (SA), so we conducted a clinical cross-sectional study to better characterize the features most associated with SA. We enrolled 88 adolescents (77 females) from 12 to 18 years of age (M = 15.21, SD = 1.63) admitted to Northern Italian Child Neurology and Psychiatry Service who presented SI and/or SA. We conducted an assessment using the Columbia-Suicide Severity Rating Scale, and divided participants into two groups: adolescents with SA, and adolescents with thoughts about killing themselves which may include a plan but no suicidal attempts (SI). We found that the SA group showed greater severity of SI [t ₍₈₆₎ = -3.485, p < 0.001], higher levels of subjective depression [t ₍₇₀₎ = -2.65, p = 0.01)], and a higher prevalence of personality disorders [ χ ( 3 ) 2 = 8.775, p = 0.032] than the SI group. Both groups presented a prevalence of internalizing problems compared to the externalizing ones in the Youth Self-Report (YSR). Higher scores on YSR internalizing problems correlate positively with the "Repulsion by Life" subscale of the Multi-Attitude Suicide Tendency (MAST) Scale in both SA and SI groups (p = 0.41 and p = 0.67, respectively), while low levels of the MAST "Attraction to Life" subscale appear more often in the SA one (p = -0.71). In conclusion, results showed that some features (e.g., prevalence of personality disorders, SI intensity, and subjective depression) might help clinicians distinguish between patients with SI and those with SA and support the importance of carefully pursuing this distinction in research.

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up

BACKGROUND AND AIM

The Suicide Crisis Syndrome (SCS) is an evidence-based pre-suicidal cognitive and affective state predictive of short-term suicide risk. The most recent SCS formulation, proposed as a suicide-specific DSM diagnosis, features a feeling of Entrapment accompanied by four additional symptom clusters: Affective Disturbance; Loss of Cognitive Control; Hyperarousal; and Social Withdrawal. The aim of the present study was to revise the Suicide Crisis Inventory (SCI; Barzilay et al., 2020), a self-report measure assessing the presence of the SCS,in accordance with the current SCS formulation, as well as to assess the psychometric properties and clinical utility of its revised version, the Suicide Crisis Inventory-2 (SCI-2).

METHODS

The SCI-2, a 61-item self-report questionnaire, was administered to 421 psychiatric inpatients and outpatients at baseline. Prospective suicidal outcomes including suicidal ideation, preparatory acts, and suicidal attempts were assessed after one month. Internal structure and consistency were assessed with confirmatory factor analysis, convergent, discriminant, and current criterion validity. Receiver-operating characteristic (ROC) curves with Area under the Curve (AUC) were used to examine the predictive validity of the SCI-2 to prospective outcomes. Exploratory analyses assessed the predictive validity of the five SCI-2 dimensions.

RESULTS

The SCI-2 demonstrated excellent internal consistency (Cronbach's α = 0.971), good convergent, discriminant, and current criterion validity. The SCI-2 significantly predicted all three outcomes, and was the only significant predictor of suicidal attempts with AUC = 0.883.

DISCUSSION

The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness to disclose suicidal ideation.

How Common is Recent Denial of Suicidal Ideation among Ideators, Attempters, and Suicide Decedents? A Literature Review

OBJECTIVE

It is sometimes stated that most people who die by suicide deny suicidal thoughts before their deaths. This narrative review examines the empirical basis for this assertion.

METHODS

Studies from 2000 to 2021 that examined the prevalence of the denial of suicidal thoughts among ideators in general, denial before suicide, and denial before and immediately after a suicide attempt were reviewed. Twenty-two papers met the inclusion criteria.

RESULTS

About 50% of ideators denied suicidal ideation (SI) during interviews. In addition, about half of decedents denied SI in the previous week or month before suicide, whereas about 30% denied SI in the previous week or month before a suicide attempt.

CONCLUSIONS

The denial of SI among ideators, attempters, and suicide decedents is an alarmingly common occurrence. Findings support the clinical wisdom that denial of SI is, by itself, an inadequate indicator of suicide risk.

Suicidal ideation predicted by changes experienced from pre-treatment to 3-month postdischarge from residential substance use disorder treatment

PURPOSE

Individuals with substance use disorders (SUD) are at an elevated risk for suicide. Abstinence and drug-related treatment outcomes remain integral to SUD treatment, but recovery incorporates more than just the absence of substance use or mental illness and including positive mental health indices in assessment and treatment of suicidality is needed.

AIMS

The current study investigates the role of traditional indicators of recovery, as well as positive psychology constructs, in predicting suicidal ideation following residential SUD treatment.

METHOD

The study utilized a longitudinal design with baseline and 3-month postdischarge follow-up assessments of 791 individuals who attended residential SUD treatment in Australia.

RESULTS

Rates of suicidal ideation decreased from baseline to follow-up, and the magnitude of change in most indices was associated with suicidal ideation at follow-up assessment. In a hierarchical logistic regression, baseline suicidal ideation, as well as a reduction in psychological distress, increase in refusal self-efficacy, and increase in self-forgiveness, emerged as significant predictors of follow-up suicidal ideation. The final model correctly classified 98.8% of participants as not experiencing SI, and 8.7% of participants as experiencing SI at follow-up, resulting in a total predictive accuracy of 86.9%.

CONCLUSIONS

The results suggested that changes in traditional recovery indices may facilitate reductions in suicidality. As a whole, changes in positive psychology indices did not add to the ability to predict suicidal ideation once traditional indices had been accounted for, but this does not preclude the importance of these indices to SUD treatment and suicide prevention efforts.

Analysis of Suicides Reported as Adverse Events in Psychiatry Resulted in Nine Quality Improvement Initiatives

Background: The majority of persons who die by suicide have a mental disorder. Preventive strategies should include addressing social and psychological factors and the treatment of the mental disorder. Aim: We aimed to identify breaches in clinical care and identify areas for quality improvement initiatives. Method: An aggregate analysis of suicides reported as adverse events during 2012-2016 to Psychiatry, North Denmark Region was carried out. We developed an audit chart and identified items through (a) medical chart review and (b) consensus meetings in an expert panel. Results: A total of 35 cases were analyzed. Suicide risk assessments were adequately documented in the medial chart in six of 35 cases. Risk assessments emphasized suicidal ideation rather than well-known risk factors such as previous suicide attempts, substance abuse, physical illness, or job loss. Relatives were involved in four of 35 of the risk assessments. The panel suggested nine areas for quality improvement. Limitations: Most people who die by suicide are not seen in mental health facilities prior to suicide, and hence conclusions can only be generalized to these patients. Information on the gap between "Work-as-Done" and "Work-As-Imagined" was not recognized. Conclusion: Most of the risk assessments among suicides reported as adverse events to our mental health facilities were insufficient. Quality improvement initiatives focusing on training, documentation, involving relatives, communication, and data sharing must be planned to improve clinical care.

The Importance of Suicide Risk Formulation in Schizophrenia

Suicide is a cause of early mortality in nearly 5% of patients with schizophrenia, and 25-50% of patients with schizophrenia attempt suicide in their lifetime. Evidence points to numerous individual, clinical, social, and psychological risk factors for suicide in patients with schizophrenia. Although recognizing suicidal risk factors in schizophrenia is extremely important in suicidal risk assessment, we have recently witnessed a change in suicide risk management that shifts the focus from suicide risk assessment to suicide risk formulation. Suicide risk formulation is dependent on the data gathered in the suicide risk assessment and assigns a level of suicide risk that is indispensable for the choice of treatment and the management of patients with a high suicidal risk. In this article, we extend the suicide risk formulation model to patients with schizophrenia. Suicide risk formulation results from four different areas that help clinicians collect as much information as possible for the management of suicidal risk. The four distinct judgments comprise risk status (the risk relating to the specific group to which the patient belongs), risk state (the risk for the person compared with his baseline or another reference point in the course of his life), available resources (on whom the person can count during a crisis) and foreseeable events (which can exacerbate the crisis). In schizophrenia, the suicide risk formulation model allows the clinician to evaluate in depth the clinical context of the patient, the patient's own history and patient-specific opportunities for better choosing and applying suicide prevention strategies.

Assessment of near-term risk for suicide attempts using the suicide crisis inventory

BACKGROUND

The Suicide Crisis Syndrome (SCS) describes a pre-suicidal mental state marked by entrapment accompanied by affective disturbances, loss of cognitive control, hyperarousal and social withdrawal. This study tested the consistency and validity of the Suicide Crisis Inventory (SCI), a proposed measure of SCS severity, amongst a large, heterogeneous patient sample.

METHODS

The SCI was used to assess 867 adult psychiatric inpatients and outpatients. Confirmatory factor analysis, logistic regressions and area under the curve analyses (AUC) were used to examine internal structure, construct validity and predictive validity for suicide ideation, plan and attempt one-month post-assessment.

RESULTS

The five-factor model of the SCS demonstrated good fit and excellent internal consistency. SCI scores indicated significant associations but non-redundancy with depression, anxiety, and independence from other dimensions of psychiatric distress. SCI scores specifically predicted suicide attempts with an AUC of 0.733 and odds ratio=8.62 (p<0.001) at optimal cut-off point. SCI incremental predictive validity over and beyond suicidal ideation and attempts history reported at baseline was supported for predicting suicide attempts (β= 0.012, S.E = 0.006; p=0.046).

LIMITATIONS

The SCI is subject to self-report bias and does not include the SCS social withdrawal component. Follow-up assessment retention was partial (68%, n=591).

CONCLUSION

The SCI is validated as a tool for the assessment of the SCS intensity and of imminent suicidal behavior. The SCI is suggested as a tool that could aid both researchers and clinicians in comprehensive assessment of a pre-suicidal mental state within moderate to high-risk populations, regardless of self-report on suicidal intent.

Managing post-sexual assault suicide risk

Suicidal ideation and suicidal behavior are common after experiencing a sexual assault. Therefore, it is imperative to assess for and manage suicidal ideation using evidence-based techniques after a sexual assault medical forensic examination (SAMFE). We assessed factors associated with higher suicidal ideation identified in a post-SAMFE mental health screening conducted over the phone and strategies to manage suicide risk. We also discuss three case examples and unique considerations when assessing post-SAMFE suicide risk. It was found that among individuals who completed a post-SAMFE screen, individuals who have been previously hospitalized for a mental health problem, who had higher acute stress symptoms, and who were homeless reported more suicidal ideation than those without those histories or symptom presentations. No matter the risk factors for suicidal ideation post-SAMFE, it is essential to screen all individuals post-SAMFE due to their high risk for suicidal ideation and death by suicide.

How Clinicians Incorporate Suicide Risk Factors Into Suicide Risk Assessment

Background: The literature has focused on explicit communications of suicidal ideation, although such communications are infrequent and less overt symptoms are comparable indicators of suicide risk. Aims: Our aim was to understand how clinicians consider inexplicit suicide risk factors in assessments of risk. Method: A national sample of 75 psychiatric crisis clinicians were provided with three vignettes, which varied in nine variables related to suicide risk. Clinicians rated imminent suicide risk and identified an appropriate level of care for each hypothetical patient. Results: Prior suicide attempt, intent to die, presence of a suicide plan, desire to die, hopelessness, burdensomeness, and passive suicidal ideation (defined as a combination of hopelessness, burdensomeness, desire to die, and anhedonia) significantly impacted risk perception while depression and anhedonia did not. Level of care was significantly associated with passive suicidal ideation, suicide plan, desire to die, and hopelessness. Limitations: Limitations of the study include its small sample size, experienced clinicians, and reliance on hypothetical patients. The study design did not allow for all variables to be compared against one another. Conclusion: Clinicians considered less overt risk factors for suicide when assessing risk. Future research should examine whether this knowledge is applied in real-life scenarios and if less experienced clinicians equally consider these risk factors.

Conducting Research with Individuals at Risk for Suicide: Protocol for Assessment and Risk Management

OBJECTIVE

Suicide prediction, prevention, and intervention are urgent research areas. One barrier for research with high-risk populations is limited resources to manage risk in a research setting. We describe using the University of Washington Risk Assessment Protocol (UWRAP) to assess and manage suicide risk during phone-administered eligibility assessments in two clinical trials.

METHOD

Study 1 (N = 151) recruited suicidal adults who were not engaged in mental health treatment and Study 2 (N = 135) recruited suicidal adults who used alcohol to regulate emotions. Pre- and postassessment ratings of stress, urge to harm self, urge to use drugs/alcohol, and intent to harm self were compared and strategies to manage increased suicide risk following screening interviews were implemented, as indicated.

RESULTS

In both studies, average postassessment ratings were significantly lower than pre-assessment. A minority of participants reported higher ratings on one or more domains; however, following more thorough suicide risk assessment, risk was appropriately managed by providing low-level interventions (e.g., validation).

CONCLUSIONS

Suicide risk in research involving community participants can be managed by using appropriate risk protocols.

Near Term Suicide Risk Assessment: A Commentary on the Clinical Relevance of Protective Factors

In this article we examine the clinical relevance of protective factors to the assessment and formulation of near-term risk of death by suicide. Contrary to current clinical belief and practice, we posit that there is no evidence base to support these factors as mitigating or buffering risk for suicide for the individual patient, especially in the near-term assessment of that suicide risk. We show that evidence-based protective factors derive from population-based studies and, applicably, have relevance to public health promotion/primary prevention and are significant in informing treatment/secondary prevention, but they lack evidence to support their often-proposed role in mitigating or buffering risk for suicide on an individual basis, especially when applied to the assessment of near-term risk of suicide. Accordingly, we argue for the need for empirical study of the role protective factors may or may not play in the formulation of a patient's risk for suicide and, in the interim, for clinical caution in assuming that protective factors have any significant buffering effect on a patient's level of near-term risk.

Is suicidality a mental disorder? Applying DSM-5 guidelines for new diagnoses

Suicidality-specific diagnoses have been proposed recently, but suicidologists are only just beginning to evaluate their merits. To advance this discussion, I introduce the term suicidal syndrome to describe the underlying entity, present a rationale for why a formal diagnosis is necessary, define the major features of the syndrome, and show how the syndrome could meet the requirements for new diagnostic candidates used in the development of the DSM-5. Against this backdrop, I examine common objections to a suicidality-specific diagnosis. Finally, I discuss several challenges with the creation of new diagnostic entities as they apply to suicidal syndrome.

The role of prediction in suicide prevention

It is widely believed that suicide prevention involves the consideration of risk and protective factors and related interventions. Preventative interventions can be classified as “universal” (targeting whole populations), “selective” (targeting higher-risk groups), and “indicated” (protecting individuals). This review explores the range of preventative measures that might be used commensurately with different types of suicide prediction. The author concludes that the best prospects for suicide prevention lie in universal prevention strategies. While risk assessments do generate some information about future suicide, suicide risk categorization results in an unacceptably high false positive rate, misses many fatalities, and therefore, is unable to usefully guide prevention strategies. The assessment of suicidal patients should focus on contemporaneous factors and the needs of the patient, rather than probabilistic notions of suicide risk.

Accuracy of Clinician Predictions of Future Self-Harm: A Systematic Review and Meta-Analysis of Predictive Studies

Assessment of a patient after hospital-treated self-harm or psychiatric hospitalization often includes a risk assessment, resulting in a classification of high risk versus low risk for a future episode of self-harm. Through systematic review and a series of meta-analyses looking at unassisted clinician risk classification (eight studies; N = 22,499), we found pooled estimates for sensitivity 0.31 (95% CI: 0.18-0.50), specificity 0.85 (0.75-0.92), positive predictive value 0.22 (0.21-0.23), and negative predictive value 0.89 (0.86-0.92). Clinician classification was too inaccurate to be clinically useful. After-care should therefore be allocated on the basis of a needs rather than risk assessment.

Suicide risk assessment training using an online virtual patient simulation

BACKGROUND

Improving the identification of and intervention with patients at risk for suicide requires innovative training techniques that safely and effectively teach or enhance practitioners' skills. Virtual patient simulations (VPS) can be particularly effective for this purpose because they allow for repetition in skill building as well as a safe space to practice difficult interactions with patients. The purpose of this study was to assess the feasibility and acceptability of a novel VPS that trains practitioners in suicide risk assessment, as well as to examine pre-post changes in suicide-related knowledge through a pilot of the VPS training.

METHODS

Practitioners (n=20) were recruited from a Federally Qualified Health Center in the northeastern United States to test the feasibility and acceptability of a VPS suicide risk assessment training. A paired samples t-test was conducted to compare mean differences in practitioners' suicide risk assessment knowledge scores from pre- to post-training, on a scale of 0 to 10.

RESULTS

The VPS was feasible to implement, with 18 of 20 participants using the VPS for an average of 21 to 95 minutes, and was acceptable to participants, with an average satisfaction rating of 5.82 out of 7. Participants' knowledge scores improved significantly by an average of 1.86 points from pre- to post-training.

CONCLUSIONS

The VPS was feasible and acceptable to this sample of practitioners and significantly increased knowledge from pre- to post-training. As such, VPS holds promise as a technique to develop skills in suicide risk assessment.

Is a brief self-report version of the Columbia severity scale useful for screening suicidal ideation in Chilean adolescents?

BACKGROUND

Given the high rates of suicide in the adolescent population and the reluctance of this population to seek help, developing proactive and effective strategies to timely detect individuals at high risk for suicide in non-clinical contexts is a worldwide recognized need. A series of brief self-report questionnaires have been developed for this purpose, however there are few studies providing evidence on their capability to accurately classify suicidal risk levels in specific populations. One of the instruments frequently used to evaluate suicide risk is the Columbia-Suicide Severity Rating Scales (C-SSRS). The goal of this study is to provide psychometric evidence about the accuracy of the Suicidal Ideation subscale (SI) of the C-SSRS to classify suicidal risk levels in a sample of Chilean adolescents using Item Response Theory (IRT).

METHODS AND MATERIALS

Through the two parameter logistic model (2-PLM), we analyzed the capability of a self-report questionnaire addressing suicidal ideation (SI) to differentiate and classify participants according to their SI severity levels. We tested two main parameters: difficulty (localization) and discriminating power of 6 items extracted and adapted from the Columbia-Suicide Severity Rating Scales (C-SSRS). We administered this questionnaire to a general sample of 1645 adolescents aged 13 to 18.

RESULTS

Our results show that the items differentiate symptoms addressing suicidal thoughts according to their severity, providing an accurate classification of the SI risk level.

CONCLUSIONS

These findings support the usage of the C-SSRS in Chilean adolescents. Further research is needed to test its predictive value in different populations.

Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation

Health care providers have significant opportunities to identify individuals at near-term risk for suicide, but lack empirical data on near-term risk factors. This study aimed to identify dynamic, state-related risk factors observed by clinical practitioners within the last 30 days of life of 157 patients who died by suicide and to compare these near-term risk factors among patients who denied versus responded positively to having suicide ideation (SI) when last asked by a clinical practitioner prior to their death. Risk factors charted for the majority of all decedents were a history of prior suicide ideation and/or suicide attempt, current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, and a family history of mental disorder. Two-thirds of patients denied having SI when last asked and one-half of these patients were dead by suicide within 2 days. Decedents who denied having SI were quite similar in charted diagnoses, symptoms, behaviors, and environmental circumstances to decedents who responded affirmatively to having SI. Reliance on verbalized or reported SI as a gateway to a suicide risk assessment is questioned and the need for better understanding near-term risk for suicide, particularly in the absence of stated SI, is highlighted.

The Feasibility and Clinical Utility of Conducting a Confidential Inquiry Into Suicide in Southwestern Ontario

BACKGROUND AND AIMS

Given the effectiveness of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI) in the UK, the present study evaluated this approach in Southwestern Ontario. A systematic confidential examination of suicides in Ontario was developed to guide quality improvement of services and suicide prevention.

METHOD

A 3-year case series of consecutive suicides in Southwestern Ontario identified by the Office of the Chief Coroner was compiled. Clinicians who provided care to suicide decedents completed an online confidential suicide questionnaire offered through a secured portal.

RESULTS

A total of 476 suicide cases were analyzed. In all, 270 invitations to clinicians were sent, 237 (87.8%) responded to the invitation and 187 (69.3%) completed the online questionnaire. The majority of the suicide decedents (54.6%, n = 260), were between the ages of 40 and 64 (x = 47.2, SD = 17.1), White (91.4%, n = 416), single (34.2%, n = 439), and male (74.4%, n = 476). Of the 86 cases of self-poisoning, prescription medications were used in 66.3%. Almost two thirds of decedents visited the clinician in the month prior to their death.

LIMITATIONS

The results of the survey were drawn from suicides in Southwestern Ontario and generalizing these findings should be done with caution.

CONCLUSION

This study highlights (a) the value of the clinicians' survey to identify gaps in clinical services and (b) the necessity of improvements in suicide risk assessment/management and restriction of prescription medications.

Understanding Suicide Across the Lifespan: A United States Perspective of Suicide Risk Factors, Assessment & Management

Suicide is a troubling, preventable phenomenon. Prior to attempts, individuals often seek help, prompting practitioners to perform risk assessments that ideally use evidence-based risk management strategies. A literature review was performed using Harvard Countway Library of Medicine, Google Scholar, PubMed. Key words used were "Forensic Science," "Suicide Risk Management," "Pediatric Suicide Risk Factors," "Adult Suicide Risk Factors," "Geriatric Suicide Risk Factors," "Suicide Risk Assessment." Parameters limited articles to studies/reviews completed in the past twenty years in the United States. Results indicated predictors of suicide in juveniles were insomnia, burdensomeness, and recent conflicts with family or a romantic partner. Adults had greater risk if male, substance abusing, with marital/job loss. Elderly individuals with multiple medical comorbidities, hopelessness, and isolation were at higher risk. Everyone evaluated should be screened for access to firearms. Management of suicide risk involves providing the least restrictive form of treatment which maintains an individual's safety.