The Interpersonal-Psychological Theory of Suicide in Adolescents: A Preliminary Report of Changes Following Treatment

Why do adolescents attempt suicide? Insights from leading ideation-to-action suicide theories: a systematic review

Suicide is a leading cause of death among adolescents, and recent suicide theories have sought to clarify the factors that facilitate the transition from suicide ideation to action. Specifically, the Interpersonal Theory of Suicide (IPTS), Integrated Motivational-Volitional Model (IMV), and Three Step Theory (3ST) have highlighted risk factors central to the formation of suicidal ideation and suicidal behaviors, which is necessary for suicide death. However, these models were initially developed and tested among adults, and given core socioemotional and neurodevelopmental differences in adolescents, the applicability of these models remains unclear. Directly addressing this gap in knowledge, this systematic review aimed to (1) describe the evidence of leading ideation-to-action theories (i.e., IPTS, IMV, 3ST) as they relate to suicide risk among adolescents, (2) integrate ideation-to-action theories within prevailing biological frameworks of adolescent suicide, and (3) provide recommendations for future adolescent suicide research. Overall, few studies provided a complete test of models in adolescent samples, and empirical research testing components of these theories provided mixed support. Future research would benefit from integrating neurodevelopmental and developmentally sensitive psychosocial frameworks to increase the applicability of ideation-to-action theories to adolescents. Further, utilizing real-time monitoring approaches may serve to further clarify the temporal association among risk factors and suicide.

Examining the integrated model of the interpersonal-psychological theory of suicide and intersectionality theory among Black male adolescents

INTRODUCTION

Guided by Opara et al.'s (2022), Integrated Model of the Interpersonal Psychological Theory of Suicide and Intersectionality Theory, the current study examined contextual stressors experienced disparately by Black youth (racial discrimination, poverty, and community violence) as moderators of the association between individual motivating factors for suicidal thoughts and behaviors (perceived burdensomeness, thwarted belongingness, and hopelessness) and active suicidal ideation.

METHOD

Participants were 457 Black adolescent boys (mean age = 15.31, SD = 1.26) who completed self-report surveys.

RESULTS

As predicted, the association between perceived burdensomeness and active suicidal ideation was significantly moderated by economic stress. In addition, the association between peer belongingness and suicidal ideation was significantly moderated by racial discrimination, but there were no moderating effects for school belongingness. Finally, the association between hopelessness and suicidal ideation was significantly moderated by both racial discrimination and witnessing community violence.

CONCLUSION

These findings highlight the need for research, interventions, and policy work devoted to using integrated approaches of individual and socioeconomically relevant patterns of suicidal thoughts and behaviors to support Black youth exposed to various forms of structural oppression.

Sequential bilateral accelerated theta burst stimulation in adolescents with suicidal ideation associated with major depressive disorder: Protocol for a randomized controlled trial

BACKGROUND

Suicide is a leading cause of death in adolescents worldwide. Previous research findings suggest that suicidal adolescents with depression have pathophysiological dorsolateral prefrontal cortex (DLPFC) deficits in γ-aminobutyric acid neurotransmission. Interventions with transcranial magnetic stimulation (TMS) directly address these underlying pathophysiological deficits in the prefrontal cortex. Theta burst stimulation (TBS) is newer dosing approach for TMS. Accelerated TBS (aTBS) involves administering multiple sessions of TMS daily as this dosing may be more efficient, tolerable, and rapid acting than standard TMS.

MATERIALS AND METHODS

This is a randomized, double-blind, sham-controlled trial of sequential bilateral aTBS in adolescents with major depressive disorder (MDD) and suicidal ideation. Three sessions are administered daily for 10 days. During each session, continuous TBS is administered first to the right DPFC, in which 1,800 pulses are delivered continuously over 120 seconds. Then intermittent TBS is applied to the left DPFC, in which 1,800 pulses are delivered in 2-second bursts and repeated every 10 seconds for 570 seconds. The TBS parameters were adopted from prior research, with 3-pulse, 50-Hz bursts given every 200 ms (at 5 Hz) with an intensity of 80% active motor threshold. The comparison group will receive 3 daily sessions of bilateral sham TBS treatment for 10 days. All participants will receive the standard of care for patients with depression and suicidal ideation including daily psychotherapeutic skill sessions. Long-interval intracortical inhibition (LICI) biomarkers will be measured before and after treatment. Exploratory measures will be collected with TMS and electroencephalography for biomarker development.

DISCUSSION

This is the first known randomized controlled trial to examine the efficacy of sequential bilateral aTBS for treating suicidal ideation in adolescents with MDD. Results from this study will also provide opportunities to further understand the neurophysiological and molecular mechanisms of suicidal ideation in adolescents.

TRIAL REGISTRATION

Investigational device exemption (IDE) Number: G200220, ClinicalTrials.gov (ID: NCT04701840). Registered August 6, 2020. https://clinicaltrials.gov/ct2/show/NCT04502758?term=NCT04701840&draw=2&rank=1.

Borderline personality features influence treatment response to suicide prevention

BACKGROUND

Suicide is a notable risk for individuals with features of borderline personality disorder. Given the centrality of interpersonal difficulties in this disorder, we proposed that the negative interpersonal cognitions (perceived burdensomeness and thwarted belongingness) identified by the Interpersonal Theory of Suicide (IPTS) may explain the associations between suicidal ideation and borderline personality features.

METHOD

Participants were 322 suicidal youth (74% girls) aged 11-18 years (M, SD = 14.74, 1.6) in an intensive outpatient program in the southwest United States. Youth completed measures assessing borderline personality features at program entry, and suicidal ideation and IPTS variables at entry and exit.

RESULTS

Borderline personality features did not moderate associations of IPTS variables and suicidal ideation. For the entire sample, changes in suicidal ideation from entry to discharge occurred in tandem with changes in perceived burdensomeness and depressive symptoms, but not thwarted belongingness. Youth with elevated borderline personality features entered with greater suicidal ideation, but improved more from treatment entry to exit. Regardless of level of borderline personality features, changes in negative interpersonal cognitions over treatment were associated with changes in suicidal ideation.

LIMITATIONS

Self-report measures and lack of sample diversity are study limitations.

CONCLUSIONS

This research highlights the clinical utility of the IPTS variables and the importance of promoting competence and interpersonal connectedness when treating this population. Findings indicate that the IPTS variables carry the same fundamental information for contributing to suicidal ideation, regardless of level of borderline personality features.

Suicidal Desire in Adolescents: An Examination of the Interpersonal Psychological Theory Using Daily Diaries

OBJECTIVE

Despite decades of research, relatively little is known about short-term predictors of suicidal thoughts and behavior. Intensive longitudinal methods are increasingly applied to investigate near-term risk factors of suicidal thoughts in daily life. The aim of this study was to examine short-term predictors of daily-level suicidal thoughts in a high-risk adolescent sample using the interpersonal-psychological theory of suicidal behavior (IPTS) as a guiding framework; the theory proposes that interpersonal experiences of thwarted belongingness in combination with perceived burdensomeness lead to suicidal desire.

METHODS

Seventy-eight adolescents hospitalized due to suicide risk responded to one survey/day for 28 days after discharge (n = 1621 unique observations). Multilevel models examined IPTS-informed predictors of same- and next-day suicidal urge intensity.

RESULTS

Partial and time-dependent support for the theory was found. The hypothesized two-way interaction between burdensomeness and thwarted belongingness (either family or peer) was significantly associated with increasing same-day, but not next-day, suicidal ideation; specifically, greater belongingness attenuated adverse impact of burdensomeness. The only significant predictor of next-day ideation was higher previous-day burdensomeness. Baseline burdensomeness also emerged as a predictor of day-to-day suicidal ideation.

CONCLUSION

Using a theoretically informed model, this study offers an in-depth examination of short-term predictors of suicidal ideation among high-risk adolescents. Findings underscore the importance of fostering peer and family relationships in reducing suicidal thoughts in the post-discharge period. Results additionally suggest that both state- and trait-level burdensomeness have lasting influence on suicidal thoughts during this high-risk period. These findings could inform intervention efforts for high-risk youth.

Fearlessness about death and suicide planning predict lethality of adolescent suicide attempts during and following treatment

INTRODUCTION

The rate of adolescent suicide attempt has increased drastically over the past 10 years. However, little is known regarding what predicts a more versus less lethal attempt, which is of critical interest to clinicians managing this at-risk population. We sought to extend the study of lethality in adolescents by exploring its relationship with two recognized risk-factors for suicide attempt: fearlessness about death (FAD) and suicide planning.

METHODS

Participants (N = 254) were administered measures of FAD and depressive symptoms upon entering intensive outpatient treatment for adolescents exhibiting suicidal thoughts and behaviors. Attempts made between treatment entry and 6 months following discharge (n = 47) were scored on a 4-point ordinal scale of lethality. The resulting continuum ranged from no attempt to attempts of low to moderate levels of lethality.

RESULTS

FAD and suicide planning distinguished between levels of lethality of future attempt at the bivariate and multivariate level. FAD's predictive relationship with lethality while controlling for age, sex, depression, and prior attempt diminished when suicide planning was covaried.

CONCLUSION

FAD and suicide planning significantly predicted more versus less lethal future attempts in our sample of adolescents in a clinical setting. Our findings suggest that FAD influences the lethality of a future attempt by promoting planning for suicide. More studies are needed to assess whether the brief FAD scale might be a valuable adjunct in the clinical management of youth with suicidal thoughts and behaviors.

Psychometric Properties of the Interpersonal Needs Questionnaire-15 in Spanish Adolescents

BACKGROUND

Thwarted Belongingness (TB) and Perceived Burdensomeness (PB) are considered risk factors of suicide behavior in the Interpersonal Theory of Suicide and constitute the main factors of the Interpersonal Needs Questionnaire-INQ.

AIMS

The present study analyzes the internal consistency, construct validity, and invariance across sex and age of the INQ-15, which comprises two subscales, in a sample of Spanish community adolescents.

METHODS

Participants were 1,536 adolescents from 12 to 19 years old. The INQ-15, the total number of non-suicidal self-injuries (NSSI), the Hopelessness Scale, and the Purpose in Life Test-Adolescents (PIL-A) were used.

RESULTS

The INQ-15 showed good internal consistency for TB ( ω ¯ = 0.88) and PB ( ω ¯ = 0.78) subscales and construct and concurrent/discriminant validity in the whole sample. Both the PB and TB subscales showed a good fit { S B χ 2 ( 9 ) = 6.448, p = 0.694, CFI = 1.000, RMSEA = 0.000 [90% CI (0.000, 0.022)] and S B χ 2 ( 27 ) = 248.973, p = 0.000, CFI = 0.922, RMSEA = 0.073 [90% CI (0.065, 0.082)]}, respectively. Regarding the invariance analyses, we found (1) non-invariance in the PB subscale across sex groups and metric, scalar, and stric invariance across age groups, and (2) that it was not possible to perform the invariance analysis for the TB subscale across both sex and age because the fit was not adequate for both boys and 12-15 years old groups. Positive and significant relationships were found between the INQ-15 subscales and hopelessness and NSSI frequency, and negative and significant correlations with meaning in life.

CONCLUSIONS

The INQ-15 is a valid instrument for assessing TB and PB in Spanish adolescents. Future studies should analyze the invariance of this instrument in adolescents across sex and age.

Exploring the relations between interpersonal risk and adolescent suicidality during treatment

OBJECTIVE

Despite considerable evidence that supports perceived burdensomeness (PB) and thwarted belongingness (TB) as risk factors for suicidal ideation (SI), far less is known about the direction of effects between these constructs in treatments for suicidal adolescents. The present study examined bidirectional relations between PB, TB, and adolescents' suicidal ideation (SI) during a 16-week randomized clinical trial.

METHOD

129 depressed and suicidal adolescents completed PB, TB, and SI measures at three time points: baseline (T1), mid-treatment (T2), and treatment completion (T3). Random-intercept cross-lagged panel models (RI-CLPM) examined within-subject direction of effects between interpersonal variables (PB & TB) and suicidal ideation (SI) in the first and second halves of treatment.

RESULTS

Within-subjects, autoregressive paths indicated significant carryover in PB and SI. In the first half of treatment, a significant cross-lagged path indicated that T1 PB predicted change in T2 SI, and in the last half of treatment change in T2 SI predicted change in T3 PB. There were no significant auto-regressive or cross-lagged effects for TB.

CONCLUSIONS

In the first half of treatment, baseline PB predicted fewer reductions in SI suggesting that PB initially moderated adolescents' response to treatment. However, in the last half of treatment, initial reductions in SI predicted subsequent reductions in PB suggesting that adolescents' initial response to treatment decreased their perceptions of burdening others. The clinical and treatment implications of these bidirectional findings are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Examining the temporal stability of suicide capability among undergraduates: A latent growth analysis

BACKGROUND

Relatively few studies test the interpersonal psychological theory's monotonicity hypothesis. The monotonicity hypothesis proposes that suicide capability (i.e., fearlessness about death and pain tolerance) is stable or increases linearly with exposure to painful and provocative events. Research is conflicted, suggesting that suicide capability is static, decreases, or increases and returns to baseline. The current study thus tested this hypothesis in a sample of college students with histories of suicidal ideation. We hypothesized a stable and an increasing trajectory.

METHODS

Participants were 206 undergraduates; primarily women (73%), on average 19.05 years old, heterosexual (85%), and first-years (69%). Participants completed a baseline battery of questionnaires on suicide risk factors and daily diaries on suicide capability and suicidal ideation for 90 days (n = 7,342 surveys, 40% compliance rate). Group-based trajectory analyses were conducted with the SAS macro PROC TRAJ.

RESULTS

Modeling revealed a three group quadratic model.  Low (27.7%), Moderate (41.3%), and High (31.1%) suicide capability groups remained static over time. Baseline suicidal ideation, but not history of suicide attempts or family history of suicidal behavior, distinguished groups; participants with suicidal ideation at baseline were less likely to be in the low suicide capability group.

LIMITATIONS

Brief, dichotomized assessments, and a high attrition rate.

CONCLUSIONS

These data showed temporal stability of suicide capability and suggest that the "acquired" component of capability may be overemphasized. Clarifying the stability and modifiability of suicide capability will enable empirically-based applications of the theory to suicide prevention.

Refinement of the Role of Hopelessness in the Interpersonal Theory of Suicide: An Exploration in an Inpatient Adolescent Sample

Hopelessness is a well-established risk factor for suicidal ideation. Recent research has indicated that hopelessness can be split into two subsets: pessimism (PESS) and lack of optimism (LOO) and that LOO is more salient of the two in predicting suicide ideation (SI). The aim of this study was to examine the relationship of PESS and LOO to SI in the context of the Interpersonal Psychological Theory of Suicide (IPTS). Participants were 294 inpatient adolescents. LOO but not PESS was associated with SI. LOO interacted with the IPTS variable of perceived burdensomeness to differentiate between passive and active SI, partly consistent with the theory. These results support the value of separating the two components of hopelessness in understanding adolescent SI.

Fearlessness about death predicts adolescent suicide attempt: A preliminary analysis

OBJECTIVE

Several theories of suicide suggest that people will only attempt suicide if they have both the desire to die and the capability for suicide. Fearlessness about death is a key component of capability for suicide. There is little information in the literature about the prospective relationship between fearlessness about death and suicide attempt in adolescents.

METHOD

We obtained baseline fearlessness about death from adolescents (N = 122; ages 12-18; 80% girls; 82% Caucasian) who received intensive outpatient treatment for active suicidal ideation and/or a recent attempt. We tested if fearlessness about death at treatment entry predicted an attempt (n = 14) between entry and six-month follow-up after discharge from the program.

RESULTS

Fearlessness about death significantly predicted the presence of an attempt between treatment entry and six-month follow-up after controlling for common covariates (Quade F = 2.15, p < .02).

CONCLUSIONS

In a preliminary analysis of a group of suicidal adolescents, fearlessness about death was a significant independent predictor of attempt between treatment entry and six months post-discharge, even when controlling for other commonly cited risk factors.

Suicide-related interpersonal needs of young Iranian people: A preliminary validation of thwarted belongingness and perceived burdensomeness constructs

The aim of the current study was to validate the Interpersonal Needs Questionnaire (INQ-15) and to test its reliability in Persian-speaking Iranian undergraduate students. In this cross-sectional study, 485 undergraduate students (age: 20.66 ± 1.42, 60% female) were assessed on the two subscales of perceived burdensomeness (PB) and thwarted belongingness (TB) and the Suicide Behavior Questionnaire-Revised (SBQ-R). Exploratory structural equation modelling (ESEM) confirmed the construct validity of INQ-14, excluding INQ#9. In addition, INQ#8, articulated in an equivalent Persian phrasing, loaded well on TB. The measurement model tested by confirmatory factor analysis (CFA) suggested INQ#11 to be eliminated, resulting in INQ-13-P to consist of PB and TB-7. The internal consistency and convergent/discriminant validity were established. The concurrent validity of PB was solidly established in terms of past year suicidal ideation (PY-SI) above and beyond anxiety, depression, prior suicidality, and TB-7. The effect of PB on PY-SI was stronger, where prior suicidality had already occurred or the perceived likelihood of future suicide (PLFS) was high. Moreover, TB-7 could only indicate PY-SI, where prior suicidality had already occurred or PLFS was high, albeit when PB was omitted. The interaction term was significant; however, beyond anxiety and depression, the effect of TB-7 on PY-SI was significant where PB was very high (n = 40, 8.25%). Therefore, future studies can utilize INQ-13-P as a valid and reliable instrument in Persian-speaking populations. However, further studies should examine the construct validity of TB and its relationship with suicide ideation in different populations.

Relevance of the interpersonal theory of suicide in an adolescent psychiatric inpatient population

The interpersonal theory of suicide (IPTS) has been widely studied in adults, but not adolescent populations at acute risk for suicide. Accordingly, this study aimed to evaluate IPTS clinical utility in a high-risk sample of suicidal adolescent inpatients. We assessed whether constructs of the IPTS (1) are associated with suicidal thoughts and behaviors (STBs) on admission to a psychiatric hospitalization, and (2) prospectively predict suicide attempt (SA) or psychiatric rehospitalization 90 days after discharge. On admission, adolescent patients self-reported recent STBs, perceived burdensomeness (PB), thwarted belongingness (TB), and depression. Parents reported their child's rehospitalization and suicide attempts 90 days after discharge. Generalized linear regression modelling was used to determine how key constructs of the IPTS are associated with STBs prior to admission and whether they prospectively predict SA or rehospitalization 90 days after discharge. IPTS constructs did not predict rehospitalization or SA within 90 days of discharge. Although PB and TB interacted to associate with prehospitalization SI frequency, and PB, TB and NSSI interacted to associate with prehospitalization SA, the nature of these interactions were not as the IPTS predicts. IPTS constructs are relevant proximal predictors of prehospitalization STB in adolescents, but may operate differently than in adults.

Measuring Thwarted Belongingness and Perceived Burdensomeness in Clinically Depressed and Suicidal Youth: Refinement and Reduction of the Interpersonal Needs Questionnaire

OBJECTIVE

The Interpersonal-Psychological Theory of Suicide (IPTS) posits two constructs (thwarted belongingness (TB) and perceived burdensomeness (PB)) contribute to suicide ideation. These constructs are typically measured by the Interpersonal Needs Questionnaire (INQ); however, available INQ versions have demonstrated poor psychometric properties with youth. This study examined the INQ using Item Response Theory (IRT) to refine and reduce the scale for clinically depressed and suicidal youth.

METHODS

Participants were 378 youth (Age M (SD) = 14.78 (1.41), 82.54% female) who completed the INQ. The INQ contains 25 items across two subscales (i.e., TB and PB) rated on a 7-point Likert-type scale. Rating scale performance, dimensionality, model fit, and instrument-level statistics were examined using IRT methodology. Post hoc analyses were performed to further reduce the scale.

RESULTS

The INQ was reduced from 25 to 10 items (five per subscale), and response options were refined to four choices. Correlations between original and IRT-refined items were large (r = .97 for PB; r = .98 for TB). Additional item-level (e.g., fit, difficulty) and instrument-level (e.g., dimensionality) characteristics were examined.

CONCLUSIONS

The newly refined INQ resulted in improved scale reliability and validity. The psychometrically improved INQ can assist clinicians and researchers identify adolescents at risk of experiencing suicide ideation.

Editorial: Identifying Predictors of Treatment Response Trajectories of Suicidal Adolescents

In this issue of the Journal, Abbott et al.¹ present findings from an important secondary analysis of a randomized controlled trial that identifies predictors of treatment response. Previous research has highlighted the importance of varying trajectories of treatment response.^2,3 There is a need to identify factors related to varied treatment outcomes. Determining those who will benefit from treatment compared to those who will not is an important step to personalizing treatments.

Perceived Burdensomeness Among Adolescents: A Mixed-Methods Analysis of the Contexts in Which Perceptions of Burdensomeness Occur

Introduction: This study explored the contexts in which adolescents report perceptions of being a burden on others, via a mixed-methods approach, to inform the development of interventions targeting perceived burdensomeness as a risk factor for suicide ideation.

Method: Participants were 41 adolescents, 13–19 years of age (M = 16.95, SD = 1.61), with elevated perceived burdensomeness on the Interpersonal Needs Questionnaire. Adolescent were predominantly female (70.7%) and Hispanic (73.2%). Adolescents provided up to three examples of times they experienced perceived burdensomeness. Examples (N = 102) were qualitatively coded to identify common themes, followed by quantitative analyses of demographic factors associated with identified themes.

Results: Seven main categories emerged from the qualitative analyses of examples: Drain on Resources, Perceptions of Failure and Brokenness, Relationship Conflict/Withdrawal, Misbehavior, Emotional Distress, Academic Problems, and Lack of Belongingness. Adolescent boys reported a greater proportion of burdensomeness attributions related to Misbehavior and a lower proportion related to Emotional Distress, relative to girls.

Discussion: Major themes aligned with theorized components of perceived burdensomeness. Adolescent examples focused predominantly on normative experiences, supporting the notion that perceived burdensomeness may represent a distorted cognition. The results may inform the development of interventions targeting perceived burdensomeness.

Predicting Patterns of Treatment Response and Outcome for Adolescents Who Are Suicidal and Depressed

OBJECTIVE

Although several treatments have been shown to be effective in treatment of youth suicidal thoughts and behaviors (STBs), there is a pressing need to account for the substantial variation in adolescents' response to and outcomes from these treatments.

METHOD

Secondary analyses of data from a 16-week randomized trial of Attachment-Based Family Therapy (ABFT) and Family-Enhanced NonDirective Supportive Therapy (FE-NST) identified distinct classes of adolescents' treatment response. Established risk factors for STBs, along with treatment condition and sociodemographic variables, were then tested as predictors of class membership.

RESULTS

Three patterns of adolescents' treatment response and outcome were identified: a) nonresponders (15.8%), b) good responders (57.5%), and c) partial responders (26.7%). After controlling for initial symptom severity, nonresponders were more likely to have higher levels of nonsuicidal self-injury and pessimism and were more likely to meet diagnostic criteria for major depressive disorder (MDD) than good or partial responders. Partial responders were more likely than good responders to meet criteria for MDD and to have higher perceived burdensomeness.

CONCLUSION

Although most adolescents showed significant symptom reductions with both treatments, adolescents with higher pretreatment levels of pessimism, MDD, nonsuicidal self-injury, and perceived burdensomeness were less likely to show an optimal pattern of treatment benefit. The findings point to heterogeneity in treatment response that may require adapting treatments for adolescents with these pretreatment profiles.

CLINICAL TRIAL REGISTRATION INFORMATION

Attachment-Based Family Therapy for Suicidal Adolescents; http://clinicaltrials.gov; NCT01537419.

Simultaneous Longitudinal Examination of Hopelessness, Thwarted Belongingness, and Perceived Burdensomeness as Predictors of Suicide Ideation

OBJECTIVE

Based on Beck's hopelessness model (Beck, Kovacs, & Weissman, Journal of the American Medical Association, 234, 1975, 1146) and Joiner's (Why people die by suicide, 2005, Harvard University Press, Boston, MA) interpersonal theory of suicide, this study simultaneously examined three cognitive risk factors (hopelessness, thwarted belongingness, and perceived burdensomeness) as predictors of suicide ideation.

METHOD

The study focused on high school and college students (ns = 192 and 142, respectively), assessed twice 4 months apart.

RESULTS

When hopelessness, perceived burdensomeness, and thwarted belongingness were examined separately, each cognitive risk factor predicted future suicide ideation in both groups. When the three cognitions were tested simultaneously, none emerged as uniquely predictive of suicide ideation. A longitudinal, latent variable model suggested that a common factor underlying all three types of cognition significantly predicted suicide ideation. Furthermore, thwarted belongingness predicted both hopelessness and perceived burdensomeness over time.

CONCLUSIONS

Results suggest ways that aspects of Beck's and Joiner's theories complement each other and could be combined to yield a more comprehensive understanding of cognitive factors associated with suicide ideation.

A Theory-Driven Investigation of the Association Between Emotion Dysregulation and Suicide Risk in a Clinical Adolescent Sample

OBJECTIVE

Emotion dysregulation has been consistently linked to suicide ideation and attempt, but an explanatory model for this relationship has not been adequately investigated in adolescents. This study examined the concurrent relationship among emotion dysregulation, variables from the Interpersonal-Psychological Theory of Suicide (IPTS), and suicide risk (operationalized as a continuous variable that increases in intensity from nonspecific to active suicide ideation to suicide ideation with a plan) in a clinical adolescent sample.

METHOD

A total of 151 adolescents (aged 12-17) were recruited from an inpatient psychiatry unit. Cross-sectional analyses were conducted to determine whether the relationship between emotion dysregulation and suicide risk was explained by the variables of perceived burdensomeness (PB), thwarted belongingness, and capability for suicide, as proposed by the IPTS.

RESULTS

As hypothesized, the relationship between emotion dysregulation and suicide risk was explained by PB and capability for suicide. Depressive symptoms had an independent relationship with suicide risk after controlling for IPTS variables.

CONCLUSIONS

The results from this study suggest that effective treatment strategies that reduce negative cognition tied to PB and depressive symptoms would address the most proximal variables related to suicide risk in adolescents. Enhancing emotion management would serve to maintain low levels of proximal influences on risk.

High-frequency repetitive TMS for suicidal ideation in adolescents with depression

BACKGROUND

This exploratory study sought to examine the effect of an acute course of high-frequency repetitive TMS on suicidal ideation in adolescents.

METHODS

Data were pooled from 3 prior protocols providing a 30-session course of open-label TMS treatment for adolescents with treatment-resistant depression. All participants (n = 19) were outpatients taking antidepressant medication, with TMS provided as adjunctive treatment. Suicidality was assessed at baseline, after 10 treatments, after 20 treatments, and after 30 treatments. Outcome measures of suicidal ideation included the Columbia Suicide Severity Rating Scale (C-SSRS) "Intensity of Ideation" subscale and Item 13 "Suicidality" on the Children's Depression Rating Scale, Revised (CDRS-R).

RESULTS

The predicted odds of suicidal ideation (CDRS-R Item 13 and C-SSRS Intensity of Ideation subscale) significantly decreased over 6 weeks of acute TMS treatment without adjustments for illness (depression) severity. However, the magnitude of the decrease in the predicted odds of suicidal ideation across 6 weeks of treatment was attenuated and rendered non-significant in subsequent analyses that adjusted for illness (depression) severity.

LIMITATIONS

This was an exploratory study with a small sample size and no sham control. Regulatory and ethical barriers constrained enrollment of adolescents with severe suicidality.

CONCLUSIONS

The present findings suggest that open-label TMS mitigated suicidal ideation in adolescents through the treatment and improvement of depressive symptom severity. Although caution is warranted in the interpretation of these results, the findings can inform the design and execution of future interventional trials targeting suicidal ideation in adolescents.

Double trouble: Nonsuicidal self-injury and its relationship to suicidal ideation and number of past suicide attempts in clinical adolescents

BACKGROUND

Death by suicide is one of the leading causes of mortality among adolescents, and nonsuicidal self-injury (NSSI) is one of the strongest predictors of suicide attempts (SAs). The underlying bases for this relationship are unknown. We derived two hypotheses from the Interpersonal Psychological Theory of Suicide (IPTS): unmet interpersonal needs would explain NSSI's association with suicidal ideation (SI) and increased capability for suicide would explain NSSI's relationship with SA.

METHODS

Adolescents hospitalized on a psychiatric inpatient unit (N = 289) provided measures of current SI, number of past SAs, unmet interpersonal needs (perceived burdensomeness and thwarted belongingness), capability for suicide (fearlessness about death [FAD] and pain tolerance), depressive symptoms, and number of NSSI methods utilized.

RESULTS

Depressive symptoms, but not unmet interpersonal needs, explained NSSI's association with SI. FAD and SI, but not depressive symptoms or pain tolerance, accounted for NSSI's relationship with SA. FAD was associated with SA, but it did not fully account for NSSI's relationship with SA.

LIMITATIONS

This study utilized a cross-sectional design and retrospective, self-report measures.

CONCLUSIONS

Our study provides partial support for the role of the IPTS variables in NSSI's relationship with SA in adolescents. The finding that depressive symptoms and not unmet interpersonal needs explained NSSI's relationship with SI contradicts the IPTS. However, in those with SI, FAD was linearly associated with SA, which is consistent with the IPTS. Future studies are needed to clarify the persistent basis for NSSI's relationship with SA beyond FAD and SI.

From ideation to action: recent advances in understanding suicide capability

Suicide capability is one of few risk factors associated with suicide attempts among ideators. In the decade since the Interpersonal Psychological Theory of Suicide introduced the concept of acquired capability (i.e. the ability to face the fear and pain associated with death), understanding of the capability to attempt suicide has grown. Acquired (e.g. NSSI), dispositional (e.g. genetic), and practical contributors (e.g. access to firearms) appear to influence suicide capability via mechanisms such as the fear of death, persistence through pain, and familiarity with suicide methods. Self-report methods have shown mixed results, highlighting the importance of developing behavioral measures of suicide capability.