Risk Factors, Warning Signs, and Drivers of Suicide: What Are They, How Do They Differ, and Why Does It Matter?

24-Hour warning signs for adolescent suicide attempts

BACKGROUND

Little is known about when youth may be at greatest risk for attempting suicide, which is critically important information for the parents, caregivers, and professionals who care for youth at risk. This study used adolescent and parent reports, and a case-crossover, within-subject design to identify 24-hour warning signs (WS) for suicide attempts.

METHODS

Adolescents (N = 1094, ages 13 to 18) with one or more suicide risk factors were enrolled and invited to complete bi-weekly, 8-10 item text message surveys for 18 months. Adolescents who reported a suicide attempt (survey item) were invited to participate in an interview regarding their thoughts, feelings/emotions, and behaviors/events during the 24-hours prior to their attempt (case period) and a prior 24-hour period (control period). Their parents participated in an interview regarding the adolescents' behaviors/events during these same periods. Adolescent or adolescent and parent interviews were completed for 105 adolescents (81.9% female; 66.7% White, 19.0% Black, 14.3% other).

RESULTS

Both parent and adolescent reports of suicidal communications and withdrawal from social and other activities differentiated case and control periods. Adolescent reports also identified feelings (self-hate, emotional pain, rush of feelings, lower levels of rage toward others), cognitions (suicidal rumination, perceived burdensomeness, anger/hostility), and serious conflict with parents as WS in multi-variable models.

CONCLUSIONS

This study identified 24-hour WS in the domains of cognitions, feelings, and behaviors/events, providing an evidence base for the dissemination of information about signs of proximal risk for adolescent suicide attempts.

Men's Behavior and Communication in the Days Prior to a Suicide-A Psychological Autopsy Study

Men show a significantly higher suicide rate, are less often recognized as persons at risk, and are more difficult to reach for suicide prevention interventions. Warning signs and deterioration in mental health are often not recognized by their surroundings. This study aims to retrospectively analyze the behavior and communication of men before a suicide, how relatives noticed changes, and how the interaction was perceived. N = 15 individuals who lost a close male relative to suicide were interviewed using psychological autopsy interviews. The interviews were evaluated following a deductive-inductive approach while using a comprehensive category system. The majority of men showed changes in behavior before the suicide, especially social withdrawal, irritability, and generally a deterioration in mental health. In fact, men did communicate their suicidal thoughts before they died through suicide, but mainly indirectly. While only one-third of the deceased made preparations before suicide, the majority of relatives noticed a deterioration in the mental health of the individual as well as increased alcohol and substance use. Men show signs of suicide, which are little recognized by their surroundings. Suicide prevention interventions should be adapted more to the needs of men.

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

OBJECTIVES

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

DESIGN

Population-based cross-sectional study.

SETTING AND PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

Development and Validation of the Self-Rating Suicide Risk Screening Questionnaire

Since suicide is one of the major health problems worldwide, the goal of the present study is to develop a psychometrically sound suicide risk screening tool named Suicide Screening Questionnaire- Self-Rating (SSQ-SR) to quantify the risk of suicidal behavior. The development process includes item generation, item revision and refinement, and validation. A total sample of 2,238 adults in South Korea was used for analysis. The results of factor analysis showed that the SSQ-SR, containing 25 items, supported a three-factor model: "Situational factors," "Negative self-perceptions and mental health factors," and "Suicidal thoughts and behaviors." Also, SSQ-SR showed satisfying internal consistency, concurrent validity and discriminant validity. Lastly, the results of ROC analysis showed a cut-off point of 33.5 for the low-risk group and 36.5 for the high-risk group. Considering these results, the current results demonstrate the SSQ-SR is a valid scale and therefore can contribute to future suicide-related studies and prevention.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group

INTRODUCTION

Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative.

METHODS

Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6 months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion.

RESULTS

Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster.

CONCLUSION

This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

When people die by suicide: Introducing unacceptable loss thresholds as a potential missing link between suicide readiness states and actively suicidal clinical states

INTRODUCTION

Contemporary models of suicide have largely overlooked why a person at high risk for suicide attempts suicide at a specific time. We propose the construct of unacceptable loss thresholds (i.e., a person's tolerance limit for a negative life event, which if violated results in an increase in suicide risk), which addresses many paradoxes in the literature related to suicide triggers. The aim of this paper is to provide preliminary proof of concept and to stimulate replication and further empirical study.

METHODS

We recruited an online community sample of individuals with a suicide attempt history (n = 144). These individuals answered questions about the time leading up to their most recent suicide attempt.

RESULTS

The majority (70.8% yes; 18.1% cannot remember; 11.1% no) reported creating a threshold of unacceptable loss, and that relatively small events were enough to trigger feelings that life was not worth living (63.9% yes; 30.6% maybe; 5.6% no). Further, the majority (57.6% yes; 21.5% yes, but only if asked; 20.8% - no) reported they would be willing to tell their therapist/doctor about their thresholds of unacceptable loss.

CONCLUSION

The construct of unacceptable loss deserves further empirical inquiry. Individuals contemplating suicide set them and if the loss occurs, it may trigger suicidal action in suicide ready individuals. Thresholds could provide risk assessment and safety planning data currently being overlooked.

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

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

Returning to School Following Hospitalization for Suicide-Related Behaviors: Recognizing Student Voices for Improving Practice

Adolescent hospitalizations for suicide-related behaviors have increased in recent years, with the highest rates occurring during the academic school year. Schools are a primary environment that adolescents return to following hospitalization, making them an important context for understanding recovery following a suicidal crisis. Although previous research highlights provider perceptions for improving this transition, limited research has focused on adolescent views. This qualitative study presents findings from interviews with 19 adolescents previously hospitalized for a suicide-related crisis. Results highlight the need to strengthen social supports for returning youth. Specifically, findings suggest the importance of emotional supports (e.g., positive school relationships and a safer psychosocial school climate), instrumental supports (e.g., collaborations and communication around re-entry), informational supports (clearer procedures for academics and re-entry processes), and appraisal supports that acknowledge the complexity of adolescent functioning upon return. Findings reinforce the importance of the school psychologist's role in partnering with returning youth and their families and providing consultation to other school professionals about supporting their recovery.

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.

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.

Effects of somatic treatments on suicidal ideation and completed suicides

OBJECTIVE

This work was undertaken to define and characterize the role of currently available somatic treatments in psychiatry in either increasing or reducing the risk for suicide.

METHODS

Members of the Suicide Prevention Task Group of the National Network of Depression Centers performed a literature review of somatic treatments known to increase or reduce the risk for suicide. The reviews ventured to include all relevant information about the risk for both suicide ideation and completed suicides.

RESULTS

Lithium and clozapine are the only two somatic treatments that have high-quality data documenting their antisuicide effects in mood disorders and schizophrenia, respectively. Lithium discontinuation is also associated with increased suicide risk. Ketamine and esketamine may have a small, but immediate, antisuicide effect. Despite the recent Food and Drug Administration approval of esketamine use in depressed suicidal patients, the small disproportional overrepresentation of suicide in subjects who had received esketamine versus placebo (3 vs. 0 among > 3500 subjects) requires ongoing evaluation. The purported antisuicide effect of electroconvulsive therapy is based on low-quality data. The effect of antidepressants is not at all clear. There appears to be direct evidence for antidepressants increasing suicidal ideation and the risk for suicide over the short-term in young people, but indirect (low quality) evidence that antidepressants reduce suicide risk over the long term.

CONCLUSIONS

Clinicians have an expanding pharmacopeia to address suicide potential in their patients. Some of the agents with documented antisuicide effects may also increase suicidality under specific circumstances.

The association between the suicide crisis syndrome and suicidal behaviors: The moderating role of personality traits

BACKGROUND

Personality traits have been associated with long-term suicide risk but their relationship with short-term risk is still unknown. Therefore, to address this gap, we explored the moderating effect of personality traits on the relationship between the Suicide Crisis Syndrome (SCS) and short-term suicidal behaviors (SB).

SAMPLING AND METHODS

Adult participants (N = 459) were administered the Suicide Crisis Inventory (SCI), a validated self-report questionnaire designed to measure the intensity of the Suicidal Crisis Syndrome, the Big Five Inventory for personality traits, and the Columbia Suicide Severity Rating Scale for SB at intake and at a 1-month follow-up. The PROCESS macro in SPSS was used to test the moderation model. Covariates hypothesized to influence the results were added: age, gender, ethnicity, years of education, and depressive symptomatology on the Beck Depression Inventory. This study was a secondary analysis drawn from a larger study on the SCS.

RESULTS

SCI total score had a significant positive relationship with SB at the 1-month follow-up for patients with lower levels of extraversion, agreeableness, conscientiousness, and openness, respectively. Hence, these four traits were protective against SB. There was an association between SCI and SB for patients with high levels of neuroticism at the 1-month follow-up.

CONCLUSIONS

High levels of neuroticism served as a risk factor, whereas high levels of the other Big Five traits were protective factors against short-term SB in the context of elevated SCS symptoms. Thus, personality traits play a role in moderating the relationship between the SCS and imminent SB.

Associations between goal orientation and suicidal thoughts and behaviors at one-month follow-up: Indirect effects through ruminative flooding

Previous research has identified both goal orientation and ruminative flooding as potential risk factors for suicidal thoughts and behaviors, as well as positive associations between goal orientation and rumination. The present study examined whether the association between goal orientation and suicidal thoughts and behaviors, assessed one month later, was accounted for by ruminative flooding. A sample of 924 psychiatric outpatients (M_age = 39.09 years, SD = 14.82, range = 18 to 84; 61.7% female; 37.0% White) completed self-report and interview measures at baseline and provided information about suicide-related outcomes at one-month follow-up. Goal orientation was positively associated with ruminative flooding, and both goal orientation and ruminative flooding were associated with suicidal thoughts and behaviors at one-month follow-up. Controlling for lifetime suicidal thoughts and behaviors, as well as patient age and sexual orientation, ruminative flooding accounted for the relationship between goal orientation and suicidal thoughts and behaviors at one-month follow-up. These findings were especially relevant for individuals with a history of multiple suicide attempts. Overall, this study provided evidence that difficulties with goal orientation may relate to suicidal thoughts and behaviors through intense ruminations perceived as a loss of cognitive control. Interventions that address ruminative thinking and cognitive flexibility may, in turn, assist in reducing emotion dysregulation and managing suicidality among those who struggle with goal orientation.

Predicting self-injurious thoughts in daily life using ambulatory assessment of state cognition

Self-injurious thoughts (SITs) fluctuate considerably from moment to moment. As such, "static" and temporally stable predictors (e.g., demographic variables, prior history) are suboptimal in predicting imminent SITs. This concern is particularly true for "online" cognitive abilities, which are important for understanding SITs, but are typically measured using tests selected for temporal stability. Advances in ambulatory assessments (i.e., real-time assessment in a naturalistic environment) allow for measuring cognition with improved temporal resolution. The present study measured relationships between "state" cognitive performance, measured using an ambulatory-based Trail Making Test, and SITs. Self-reported state hope and social connectedness was also measured. Data were collected using a specially designed mobile application (administered 4x/week up to 28 days) in substance use inpatients (N = 99). Consistent with prior literature, state hope and social connectedness was significantly associated with state SITs. Importantly, poorer state cognitive performance also significantly predicted state SITs, independent of hallmark static and state self-report risk variables. These findings highlight the potential importance of "online" cognition to predict SITs. Ambulatory recording reflects an efficient, sensitive, and ecological valid methodology for evaluating subjective and objectives predictors of imminent SITs.

The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness

Objectives

This paper aims to identify potential areas for refinement in existing theoretical models of suicide, and introduce a new integrative theoretical framework for understanding suicide, that could inform such refinements.

Methods

Literature on existing theoretical models of suicide and how they contribute to understanding psychological processes involved in suicide was evaluated in a narrative review. This involved identifying psychological processes associated with suicide. Current understanding of these processes is discussed, and suggestions for integration of the existing literature are offered.

Results

Existing approaches to understanding suicide have advanced the current knowledge of suicide in various ways. They have guided valuable research in the following areas: motivations for suicide and the psychological distress which influences suicide attempts; ambivalence about suicide; suicidal individuals’ focus of attention; and ways in which individuals who contemplate suicide differ from individuals who attempt suicide. We outline a new theoretical framework as a means to integrating all of these concepts into the three principles of control, conflict, and awareness. Within this framework, suicide is regarded as occurring due to a long standing conflict between an individual’s personal goals, culminating in an episode of acute loss of control. The new framework posits that the individual then strives to regain control through the means of suicide because of a narrowed awareness of consequences of their actions on other valued goals. This psychological mechanism of limited awareness is posited to be the common pathway by which individuals make a suicide attempt, regardless of which risk factors are present.

Conclusion

This article introduces a theoretical framework that generates several hypotheses for future research, and focuses on psychological processes occurring during immediate crisis. One of the key hypotheses resulting from our predictions on how individuals progress from contemplating to attempting suicide will be tested in an ongoing program of research: Individuals who attempt suicide have a significantly reduced awareness of consequences of suicide, which would negatively impact on their important life goals, values, principles, or ideals, compared to individuals who contemplate suicide. Therapy guided by the new framework may be more flexible, immediate, and client-focused than other therapies for suicidal individuals.

The Common Factors of Grit, Hope, and Optimism Differentially Influence Suicide Resilience

No study to date has simultaneously examined the commonalities and unique aspects of positive psychological factors and whether these factors uniquely account for a reduction in suicide risk. Using a factor analytic approach, the current study examined the relationships between grit, hope, optimism, and their unique and overlapping relationships in predicting suicide ideation. Results of principle axis factor analysis demonstrated close relationships between these variables at both the construct and item level. Item-level analyses supported a five-factor solution (Stick-to-Itiveness, Poor Future, Consistency of Interest, Positive Future, and Poor Pathways). Four of the five factors (excluding Stick-to-Itiveness) were associated with suicide ideation. Additionally, results of a multiple regression analysis indicated that two of the five factors (Consistency of Interest and Positive Future) negatively predicted suicide ideation while Poor Future positively predicted suicide ideation. Implications regarding the interrelationships between grit, hope, and optimism with suicide ideation are discussed.

How do distal and proximal risk factors combine to predict suicidal ideation and behaviors? A prospective study of the narrative crisis model of suicide

AIM

The Narrative Crisis Model of suicide posits that when individuals with trait vulnerabilities for suicide face stressful life events, they may develop distorted perceptions of themselves and society that culminate in a sense of no future. Referred to as the suicide narrative, these perceptions makes them more likely to experience the Suicidal Crisis Syndrome, an acute affective condition that increases the risk of engaging in suicidal ideation behaviors. The goal of this study was to assess the stage components of this model.

METHODS

The stage components of the NCM were assessed among adult psychiatric inpatients (N = 223; listwise N = 85) aged 18-65 years old and admitted for suicidal ideation or attempts. Suicidal outcomes were assessed at one month follow-up. Structural equation modeling (SEM) was used to assess the model and its prediction of prospective suicidal outcomes.

RESULTS

The model was supported by the SEM and proved to be a good fit for the data. Each temporal stage was significantly predicted by the precedent stage in the model and 13% of the variance in suicidal ideation and behaviors (when assessed conjointly) were explained by the model. When suicidal ideation and attempts were assessed separately, the amount of variance explained was 10.8% for suicidal ideation and 40.7% for suicidal attempts.

DISCUSSION

The progression from trait vulnerabilities to suicidal outcomes proposed by the NCM was supported by our findings. These findings have clinical implications in the assessment and treatment of suicide risk and will need replication with larger samples.

Suicide Risk and Restricted Emotions in Women: The Diverging Effects of Masculine Gender Norms and Suicide Capability

This study investigated whether gender moderated the association between masculine socialization pressures of restrictive emotionality and suicide risk through suicide capability (i.e., fearlessness about death). A sample of inpatients admitted for recent suicidality (n = 194) completed validated measures of restrictive emotionality, fearlessness about death, and current suicide risk. A moderated mediation effect was found opposite the hypothesized direction: fearlessness about death mediated the relationship between endorsement of the masculine gender norm of restrictive emotionality and suicide risk in women, but not men. Gender did not moderate the association between restrictive emotionality and fearlessness about death. The diverging gender effects suggest that the masculine gender norm of restrictive emotionality is associated with suicide capability in men and women, while acquired fearlessness about death is more informative of risk for suicide in women than men.

An examination of the Entrapment Scale: Factor structure, correlates, and implications for suicide prevention

Entrapment is an emerging theoretical and empirical factor associated with suicide. The current study expanded our understanding of entrapment by examining the Entrapment Scale factor structure, demographic correlates, and association with suicidal thoughts and behaviors (STBs). Data from an online cross-national study of suicide were analyzed from two samples of young adults aged 18-34 (United Kingdom [U.K.] sample N = 418; United States [U.S.] N = 414). Primary findings included: (1) factor-analytic support for a two factor (i.e., internal and external) Entrapment Scale structure; (2) variation in external entrapment subscale factor loadings by sample; (3) significant demographic correlates of elevated entrapment of younger age, female gender, and U.S. sample; (4) significant convergent positive associations for both entrapment types with cognitive (e.g., perceived burdensomeness), mental health (e.g., anxiety), and STB correlates; and (5) significant, robust associations of internal entrapment and perceived burdensomeness with STBs in the U.K. sample. Implications are reviewed for suicide prevention theory, research and practice.

Examining the link between prior suicidality and subsequent suicidal ideation among high-risk US military service members

BACKGROUND

Research is needed to identify the factors that explain the link between prior and future suicidality. This study evaluated possible mediators of the relationship between: (1) the severity of prior suicidality and (2) suicidal ideation severity at 3-month follow-up among a sample of high-risk military personnel.

METHODS

US military service members referred to or seeking care for suicide risk (N = 624) completed self-report psychiatric domain measures and a clinician interview assessing prior suicidality severity at baseline. Three months later, participants completed a self-report measure of suicidal ideation severity. Three separate percentile bootstrap mediation models were used to examine psychiatric factors (i.e. alcohol abuse, anxiety sensitivity, hopelessness, insomnia, posttraumatic stress symptoms, suicidal ideation, and thwarted belongingness) as parallel mediators of the relationship between prior suicidality severity (specifically, suicidal ideation, suicide attempt, and overall suicidality - i.e. ideation/attempt severity combined) at baseline and suicidal ideation severity at follow-up.

RESULTS

Hopelessness, specifically, and the total effect of all mediators, each significantly accounted for the relationship between prior suicidality severity and subsequent ideation severity across models. In the models with attempt severity and overall suicidality severity as predictors, thwarted belongingness was also a significant mediator.

CONCLUSIONS

Hopelessness, thwarted belongingness, and overall severity of psychiatric indices may explain the relationship between prior suicidality severity and future suicidal ideation severity among service members at elevated suicide risk. Research is needed to replicate these findings and examine other possible mediators.

What Is "High Risk" and What Are We Actually Supposed to Do About It?

Regulatory agencies are increasingly taking on the important issue of effective risk assessment, risk stratification, and treatment planning for youth with psychiatric illness.¹ The Joint Commission mandates a suicide assessment for patients "who exhibit suicidal behavior or who have screened positive for suicidal ideation" followed by risk stratification: after "this assessment, patients should be classified as high, medium or low risk of suicide."² We anticipate that just as screening for depression and suicidality was initially restricted to emergency departments and inpatient units before being rolled out across all care settings, so risk stratification requirements will roll out to these other settings as well.

Identifying factors associated with suicidal ideation and suicide attempts following military sexual trauma

BACKGROUND

As increasing research demonstrates that military sexual trauma (MST) is associated with suicidal ideation and attempts, discerning factors that place MST survivors at risk for these outcomes is critical. The present study aimed to: (1) characterize suicidal ideation and attempts among MST survivors; (2) identify factors associated with post-MST suicide attempts, post-MST suicidal ideation, and past-week suicidal ideation.

METHODS

A convenience sample of 108 veterans (66 women, 42 men) who reported a history of MST participated in this cross-sectional study. Pre-MST suicidal ideation and attempt, childhood physical and sexual abuse, military sexual assault, institutional betrayal, and posttraumatic cognitions about self, world, and self-blame were examined, with age and gender as covariates.

RESULTS

Seventy-five percent of participants reported experiencing post-MST suicidal ideation, and 40.7% reported attempting suicide following MST. Pre-MST suicide attempt and posttraumatic cognitions about self were associated with post-MST suicide attempt. Pre-MST suicidal ideation, military sexual assault, childhood physical abuse, and posttraumatic cognitions about self were associated with post-MST suicidal ideation. Lastly, pre-MST suicidal ideation and posttraumatic cognitions about self were associated with past-week suicidal ideation; results were unchanged when accounting for recent PTSD or depressive symptoms.

LIMITATIONS

The cross-sectional design, retrospective self-report, and small sample are limitations.

CONCLUSIONS

Addressing negative posttraumatic beliefs about self may be important for managing suicide risk among MST survivors. Assessing for pre-MST suicidal ideation and attempt is likely also warranted. Further understanding of the longitudinal impact of posttraumatic beliefs about self on subsequent risk for suicidal ideation and attempt is warranted.

What's in a word? Clarifying terminology on suicide-related communication

Efforts to clarify suicide terminology fail to address nuances in suicide-related communication, often relying on poorly-defined terms or implying communication exists primarily as manipulation. In the present paper, we review examples from existing literature and explore how personal suicide-related communication differs from prevention and exposure communication. We also separate definitions for five common types of personal-suicide-related communication: (a) suicide-related disclosure, (b) suicide-related notification, (c) unintended suicide-related communication, (d) coerced suicide-related communication, and (e) conditional suicide-related communication. Finally, we provide specific ways in which standardized definitions can enhance both research and clinical efforts in the future.

The Suicidal Narrative and Its Relationship to the Suicide Crisis Syndrome and Recent Suicidal Behavior

In this study, we introduce the construct of the suicidal narrative, a hypothetical personal narrative linked to imminent suicide, and explore its relationship to near-term suicidal risk and the suicide crisis syndrome (SCS). Psychiatric outpatients (N = 289) were administered the Columbia Suicide-Severity Rating Scale (C-SSRS), Suicide Crisis Inventory (SCI), and Suicide Narrative Inventory (SNI), a novel instrument combining the documented risk factors of Thwarted Belongingness, Perceived Burdensomeness, Humiliation, Social Defeat, Goal Disengagement, and Goal Reengagement. Dimensional measures of past month, lifetime, and past suicidal phenomena, incorporating ideation and behavior, were calculated from the C-SSRS. Structural equation modeling was used to explore the interaction among variables. Factor analysis of the SNI yielded two orthogonal factors, termed Interpersonal and Goal Orientation. The former factor was comprised of Perceived Burdensomeness, Social Defeat, Humiliation, and Thwarted Belongingness, the latter of Goal Disengagement and Goal Reengagement. The Interpersonal factor correlated with both SCS severity and suicidal phenomena in each time frame and the Goal Orientation factor with no other variable. As hypothesized, the proposed model was significant for the past month only. Our findings support the construct of the suicidal narrative and its function as a near-term suicidal risk factor.

Suicide Crisis Syndrome Mediates the Relationship Between Long-term Risk Factors and Lifetime Suicidal Phenomena

In recent years, there has been growing attention to the distinction between acute and long-term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS), as a marker of near-term suicidal risk. Here, we test whether documented long-term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS. A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS-3) as a measure of the SCS. While both STS-3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS-3 was related to pre-admission suicide attempts. The STS-3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long-term risk factors increase suicidal risk.

Brain derived neurotrophic factor (BDNF) and suicidal behavior: A review of studies from Asian countries

The biological basis of suicide and suicidal behavior is actively researched. Recently, the role of Brain Derived Neurotropic Factor (BDNF) in suicidal behavior has gained attention and significant results are observed. In this review, we aimed to focus on the studies from Asian countries that have explored the role of BDNF and suicidal behavior. The review highlights the findings from these studies and discusses the possible avenues that should be explored in future studies from Asian countries to understand more on suicidal behavior and possible prevention.

Patterns of Signs That Telephone Crisis Support Workers Associate with Suicide Risk in Telephone Crisis Line Callers

Signs of suicide are commonly used in suicide intervention training to assist the identification of those at imminent risk for suicide. Signs of suicide may be particularly important to telephone crisis-line workers (TCWs), who have little background information to identify the presence of suicidality if the caller is unable or unwilling to express suicidal intent. Although signs of suicide are argued to be only meaningful as a pattern, there is a paucity of research that has examined whether TCWs use patterns of signs to decide whether a caller might be suicidal, and whether these are influenced by caller characteristics such as gender. The current study explored both possibilities. Data were collected using an online self-report survey in a Australian sample of 137 TCWs. Exploratory factor analysis uncovered three patterns of suicide signs that TCWs may use to identify if a caller might be at risk for suicide (mood, hopelessness, and anger), which were qualitatively different for male and female callers. These findings suggest that TCWs may recognise specific patterns of signs to identify suicide risk, which appear to be influenced to some extent by the callers’ inferred gender. Implications for the training of telephone crisis workers and others including mental-health and medical professionals, as well as and future research in suicide prevention are discussed.

Opportunities to intervene? "Warning signs" for suicide in the days before dying

To validate warning signs for suicide, researchers interviewed 20 respondents, representing 17 suicides in Orleans Parish, Louisiana, about characteristics of the decedent in the year, month, and days preceding the death. Decedents did exhibit behaviors consistent with existing warning signs, but these were rarely new behaviors present 7 days prior to the suicide but not previously. Research is needed to continue to test warning signs for suicide, and education campaigns that teach warning signs may not be relevant for preventing suicide among those in mental health treatment or involved in the criminal justice system.

Recognizing and addressing unique vulnerabilities of suicidal patients: Suicide research at The Menninger Clinic

Suicide risk is an inescapable presence in the treatment of people with psychiatric disorders, a fact that applies especially in inpatient psychiatric settings. This article summarizes a several-year research initiative at The Menninger Clinic aimed at better understanding psychological contributors to suicidality and developing more effective clinical interventions. Two areas of research are described, an outcomes arm focused on assessing the feasibility and effectiveness of a suicide-specific intervention (The Collaborative Assessment and Management of Suicidality) and an exploratory arm whose objective is to learn about psychological vulnerabilities that distinguish suicidal from nonsuicidal patients, with an eye toward developing interventions that address such vulnerabilities. The author concludes that, combined with other developments in the field, this body of work strongly supports the view that suicidal patients should be treated with interventions that specifically target vulnerabilities that seem to set the stage for suicidal episodes.

Assessing Suicide Risk: What is Commonly Missed in the Emergency Room?

OBJECTIVE

Although risk assessment for suicide has been extensively studied, it is still an inexact process. The current study determined how busy emergency clinicians actually assessed and documented suicide risk, while also examining the differences between psychiatric and emergency medicine opinions on the importance of various suicide predictors.

METHOD

Phase 1 of the study involved the administration of a survey on the relative importance of various suicide predictors for the specialties of psychiatry and emergency medicine. In phase 2 of the study, a chart review of psychiatric emergency room patients was conducted to determine the actual documentation rates of the suicide predictors.

RESULTS

Several predictors that were deemed to be important, including suicidal plan, intent for suicide, having means available for suicide, and practicing suicide (taking different steps leading up to suicide but not actually attempting suicide), had low documentation rates.

CONCLUSIONS

Medical specialties have different opinions on the importance of various suicide predictors. Also, some predictors deemed important had low documentation rates. Educational interventions and simple assessment tools may help to increase documentation rates of several suicide predictors in busy clinical settings.