The ABC's of Suicide Risk Assessment: Applying a Tripartite Approach to Individual Evaluations

The Migration Experience: A Conceptual Framework and Systematic Scoping Review of Psychological Acculturation

ACADEMIC ABSTRACT

One of the key challenges to researching psychological acculturation is the immense heterogeneity in theories and measures. These inconsistencies make it difficult to compare past literature, hinder straightforward measurement selections, and stifle theoretical integration. To structure acculturation, we propose to utilize the four basic aspects of human experiences (wanting, feeling, thinking, and doing) as a conceptual framework. We use this framework to build a theory-driven assessment of past theoretical (final N = 92), psychometric (final N = 233), and empirical literature (final N = 530). We find that the framework allows us to examine and compare past conceptualizations. For example, empirical works have understudied the more internal aspects of acculturation (i.e., motivations and feelings) compared with theoretical works. We, then, discuss the framework's novel insights including its temporal resolution, its comprehensive and cross-cultural structure, and how the framework can aid transparent and functional theories, studies, and interventions going forward.

PUBLIC ABSTRACT

This systematic scoping review indicates that the concept of psychological acculturation can be structured in terms of affect (e.g., feeling at home), behavior (e.g., language use), cognition (e.g., ethnic identification), and desire (e.g., independence wish). We find that the framework is useful in structuring past research and helps with new predictions and interventions. We, for example, find a crucial disconnect between theory and practice, which will need to be resolved in the future.

Understanding the mediated relationship between moral distress, depression, and suicide risk in undergraduate nursing students

BACKGROUND

Nursing students are at higher risk for depression, suicide, and other mental health concerns as compared to the general college student population. Moral distress and other ethical issues may be a significant source of psychological harm within nursing student experiences and warrants further attention.

PURPOSE

The purpose of this study was to understand the mediating effect of depression on the relationship between moral distress and suicide risk among undergraduate nursing students.

METHODS

This cross-sectional analysis was derived from a larger sequential mixed methods study. The first phase was an online survey completed by a national sample of N = 679 nursing students in the United States.

FINDINGS

The relationship between moral distress and suicide risk was fully mediated by depression and statistically significant at the alpha = 0.05 level.

CONCLUSION

All three psychological variables (depression, moral distress, suicide risk) impact nursing students and require innovative solutions within nursing and educational programs.

Measuring the suicidal mind: The 'open source' Suicidality Scale, for adolescents and adults

Clinicians are expected to provide accurate and useful mental health assessments, sometimes in emergency settings. The most urgent challenge may be in calculating suicide risk. Unfortunately, existing instruments often fail to meet requirements. To address this situation, we used a sustainable scale development approach to create a publicly available Suicidality Scale (SS). Following a critical review of current measures, community input, and panel discussions, an international item pool survey included 5,115 English-speaking participants aged 13-82 years. Revisions were tested with two follow-up cross-sectional surveys (Ns = 814 and 626). Pool items and SS versions were critically examined through item response theory, hierarchical cluster, factor and bifactor analyses, resulting in a unidimensional eight-item scale. Psychometric properties were high (loadings > .77; discrimination > 2.2; test-retest r = .87; internal consistency, ω = .96). Invariance checks were satisfied for age, gender, ethnicity, rural/urban residence, first language, self-reported psychiatric diagnosis and suicide attempt history. The SS showed stronger psychometric properties, and significant differences in bivariate associations with depressive symptoms, compared with included suicide measures. The 'open source' Suicidality Scale represents a significant step forward in accurate assessment for people aged 13+, and diverse populations. This study provides an example of sustainable scale development utilizing community input, emphasis on strong psychometric evidence from diverse samples, and a free-to-use license allowing instrument revisions. These methods can be used to develop a wide variety of psychosocial instruments that can benefit clinicians, researchers, and the public.

What seems to explain suicidality in Yucatan Mexican young adults? Findings from an app-based mental health screening test using the SMART-SCREEN protocol

The relationship between suicidality, depression, anxiety, and well-being was explored in young adults (median age 20.7 years) from the State of Yucatan (Mexico), which has a suicide rate double that of other Mexican states. A cross-sectional study was carried out in 20 universities in Yucatan and 9,366 students were surveyed using validated questionnaires built into a smartphone app, applying partial least squares structural equation models. High suicide risk was assessed in 10.8% of the sample. Clinically relevant depression and anxiety levels were found in 6.6% and 10.5% of the sample, respectively, and 67.8% reported high well-being. Comparably higher levels of suicide risk, depression and anxiety, and lower well-being were found in women, who were also somewhat older than men in our study. Furthermore, path analysis in the structural equation model revealed that depression was the main predictor of suicidal behaviour as well as of higher anxiety levels and lower self-perceived well-being in the total sample and in both genders. Our findings draw attention to the association between suicidality, depression, anxiety, and well-being in Yucatan young adults and gender differences with this regard. Mental health screening via smartphone might be a useful tool to reach large populations and contribute to mental health policies, including regional suicide prevention efforts.

Vulnerable individuals and changes in suicidal behaviour during the COVID-19 pandemic in Korea

BACKGROUND

The COVID-19 pandemic poses a major threat to mental health and is associated with an increased risk of suicide. An understanding of suicidal behaviours during the pandemic is necessary for establishing policies to prevent suicides in such social conditions.

AIMS

We aimed to investigate vulnerable individuals and the characteristics of changes in suicidal behaviour during the COVID-19 pandemic.

METHOD

We retrospectively reviewed the medical records of patients with suicide attempts who visited the emergency department from February 2019 to January 2021. We analysed the demographic and clinical characteristics, risk factors and rescue factors of patients, and compared the findings between the pre-pandemic and pandemic periods.

RESULTS

In total, 519 patients were included. During the pre-pandemic and pandemic periods, 303 and 270 patients visited the emergency department after a suicide attempt, respectively. The proportion of suicide attempts by women (60.1% v. 69.3%, P = 0.035) and patients with a previous psychiatric illness (63.4% v. 72.9%, P = 0.006) increased during the COVID-19 pandemic. In addition, patients' rescue scores during the pandemic were lower than those during the pre-pandemic period (12 (interquartile range: 11-13) v. 13 (interquartile range: 12-14), P < 0.001).

CONCLUSIONS

Women and people with previous psychiatric illnesses were more vulnerable to suicide attempts during the COVID-19 pandemic. Suicide prevention policies, such as continuous monitoring and staying in touch with vulnerable individuals, are necessary to cope with suicide risk.

Graded response item response theory in scaling suicidal thoughts and behaviors among trauma-exposed women with substance use disorders

Objective: The co-occurrence of substance use disorders (SUD) and trauma-exposure is a risk factor for suicidal thoughts and behaviors (STB). However, traditional methods of measurement for suicidal thoughts and behaviors are limited by an overreliance on dichotomous (i.e., yes or no) and averaged/summed scale score measurements. Further, among trauma-exposed individuals with SUD, it remains unclear which specific demographic factors, types of SUDs, and trauma sequelae (e.g., posttraumatic stress disorder [PTSD] symptom clusters) may be associated with elevated STB. The present study utilized item response theory to (a) generate empirically derived STB severity scores and, (b) examine which demographic factors, SUD diagnoses, and DSM-IV PTSD symptom clusters are associated with suicidality in a trauma-exposed sample with SUDs. Method: Female trauma-exposed participants with SUDs (N = 544) were recruited from community substance use treatment facilities in the National Drug Abuse Treatment Clinical Trials Network (CTN). Clinician-administered interviews assessed STB, SUDs, and PTSD symptoms. Results: Results indicated that the unidimensional item response theory (IRT) model used to estimate latent STB severity scores fit well, with strong local reliability at higher levels of latent STB severity. Regression predictors of elevated STB severity included younger age, opioid dependence, and higher PTSD reexperiencing symptoms. Conclusions: Clinicians are advised to screen for and target opioid use disorders and reexperiencing symptoms when addressing suicidal thoughts and behavior in trauma-exposed individuals with SUDs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Suicide and Suicide Attempts Among Patients Attending Primary Health Care Facilities in Uganda: A Medical Records Review

Background

Suicide is one of the leading causes of death globally, accounting for about 800,000 deaths annually. The suicide burden drastically increased since the beginning of the COVID-19 pandemic. In Uganda, no known study has determined the suicide rate since the beginning of the COVID-19 pandemic.

Objective

To determine the suicide mortality rate and describe the characteristics of victims of suicide attempts from January to December 2020 in south western Uganda.

Methods

This study was based on the health management information systems (HMIS) of patients' registered data for the year 2020 at 15 selected primary health care facilities in four districts in south-western Uganda. We used a data extraction tool to capture demographic and clinical characteristics of the individuals who had attempted or completed suicide. We estimated yearly incidence rates of fatal and non-fatal suicide attempts, and used chi-square and t-test to determine the statistical difference between suicide attempt outcomes.

Results

A total of 130 non-fatal suicide attempts and 26 suicides were identified. Majority were male 69.87% (n = 109/156) and the mean age was 27.16 (SD = 14.71) years. The overall incidence of suicide attempts was about 60 attempts per 100,000 people, while that of completed suicide was about three deaths per 100,000 people. The suicide attempts increased following the first month of COVID-19 lockdown in the country (March 2020) and most individuals attempted suicide by poisoning (n = 144).

Conclusion

Suicide is a common occurrence in primary health care settings of Uganda and there has been a rapid increase in suicide attempts since the onset of the COVID-19 pandemic. With suicide by poisoning being common, there is need for proactive interventions, such as the control of pesticides and herbicides, to prevent suicide among members of this community, especially during pandemic conditions.

Deep Hierarchical Ensemble Model for Suicide Detection on Imbalanced Social Media Data

As a serious worldwide problem, suicide often causes huge and irreversible losses to families and society. Therefore, it is necessary to detect and help individuals with suicidal ideation in time. In recent years, the prosperous development of social media has provided new perspectives on suicide detection, but related research still faces some difficulties, such as data imbalance and expression implicitness. In this paper, we propose a Deep Hierarchical Ensemble model for Suicide Detection (DHE-SD) based on a hierarchical ensemble strategy, and construct a dataset based on Sina Weibo, which contains more than 550 thousand posts from 4521 users. To verify the effectiveness of the model, we also conduct experiments on a public Weibo dataset containing 7329 users’ posts. The proposed model achieves the best performance on both the constructed dataset and the public dataset. In addition, in order to make the model applicable to a wider population, we use the proposed sentence-level mask mechanism to delete user posts with strong suicidal ideation. Experiments show that the proposed model can still effectively identify social media users with suicidal ideation even when the performance of the baseline models decrease significantly.

Technology-facilitated sexual violence and suicide risk: A serial mediation model investigating bullying, depression, perceived burdensomeness, and thwarted belongingness

Technology-facilitated sexual violence (TFSV) is a comprehensive term used to encompass all sexually aggressive and harassing behaviours involving technology. Although there is a growing knowledge base investigating the prevalence and consequences of TFSV, relatively little is known about the extent of aversive consequences experienced by victims and the pathways from victimization to suicidal affect, cognition, and behaviour. TFSV victimization and subsequent suicide has been a subject of several high-profile media cases in recent years. We examine TFSV in relation to two main constructs embedded within the interpersonal theory of suicide (ITS), perceived burdensomeness (PB) and thwarted belongingness (TB). Quantitative survey data ( N = 521) were used to evaluate PB and TB in the context of TFSV victimization. The objective was to analyze mechanisms underlying the relationship between TFSV victimization and suicide risk, exclusively accounting for mediating factors of interpersonal victimization, depression, TB, and PB. Pathway results showed that TFSV victimization increased suicide risk (i.e., suicidal affect, cognition, and behaviour) serially through bullying, depression, and PB—suggesting a cascade of victimization experiences. TB was not a significant mediator. The present results provide novel quantitative data substantiating the devastating risks of TFSV victimization and thus evidencing the importance of legal protections for victims of TFSV.

Physical multimorbidity and lifetime suicidal ideation and plans among rural older adults: the mediating role of psychological distress

BACKGROUND

Previous studies have revealed that single physical chronic condition was associated with suicidal ideation/plans, but few studies have examined the relationship between multimorbidity and suicidal ideation/plans, and no studies have explored the underlying potential mechanism on this relationship in China. This study aimed to explore association between physical multimorbidity and suicidal ideation as well as plans, and further examine the mediating role of psychological distress (PD) on this relationship.

METHODS

This study was based on the data from a survey about the health service of rural elderly household in Shandong, China. A total of 3242 adults aged 60 years and older were included in this study. PD was measured by Kessler Psychological Distress Scale (K10). Ordinal and binary logistic regression analyses were employed to explore the association between physical multimorbidity, PD and suicide ideation/plans. Bootstrapping analysis was further used to examine the mediation effect of PD on the association of multimorbidity and suicidal ideations/plans.

RESULTS

The prevalence of multimorbidity, lifetime suicidal ideation, and suicidal plan in rural older adults was 35.2, 10.6 and 2.2%, respectively. Older adults living in rural areas with two or more chronic physical conditions experienced significantly higher risk of suicidal ideation and suicidal plans. The association between multimorbidity and suicidal ideations/plans was partially mediated by PD, of which, the mediating effect of PD accounted for 31.7 and 25.5% of the total effect, respectively.

CONCLUSION

This study demonstrated the associations between physical multimorbidity and suicidal ideation/plans, and the mediating role of PD on this relationship among Chinese rural elderly. Healthcare providers in rural community should provide regular surveillance for the mental health status among the rural elderly with multimorbidity, and carry out various effective intervention measures to improve the mental health status, so as to reduce the risk of suicide.

Negative self-appraisal: Personal reasons for dying as indicators of suicidality

Reasons for dying (RFD) are one of the most authentic factors illustrating the lived experience of suicidal individuals. However, the field has been criticized for inadequate evaluation of risk factors and suicidal symptoms, such as RFD, to develop more robust theoretical models and risk assessments. In this study, we aimed to critically examine RFD themes as predictors of suicidal symptoms to improve our understanding of the suicidal mind, test suicide theory validity and improve risk assessment. This cross-sectional mixed-method study included anonymous survey data (N = 713) with a subsample (n = 474; 77% female; age M = 31.48, SD = 13.53) who provided RFD. Participants were asked to write down five RFD (ranked 1st to 5th most important) and completed the Suicidal Affect-Behavior-Cognition Scale (SABCS). Thematic analysis revealed eight valid RFD themes-Negative Self-appraisal, Hopelessness, Desire to Escape, Escape Pain, Relationships, Loneliness, Financial Hardship, and Physical Health. Themes were quantified by rank and total endorsements of the theme. Hierarchical regression modelling, statistically controlling for demographics, showed all RFD themes, except Physical Health, were positive predictors of suicidality, accounting for 26% of variance in suicidal symptoms. Negative Self-appraisal was the strongest predictor. RFD differences were also found by gender, age and education. From these findings, we determined current suicide theories do not fully account for suicidal persons' RFD. There is a pressing need for more critical review of current theories, as current theories only partially represent this key attribute of the suicidal mind, and none of the reviewed theories accurately reflected suicidal participants' RFD. Clinical implications include integrating financial therapies into suicide prevention treatments and incorporating RFD into assessments and treatments. To aid research and risk assessment efforts, we propose a new RFD Index, with eight five-point response items.

Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in U.S. military veterans: a nationally representative study

BACKGROUND

Military veterans with a history of childhood abuse are at increased risk for suicidality. To date, however, little research has examined whether exposure to childhood abuse may heighten veterans' susceptibility to the effects of combat exposure and increase risk for suicidal behavior. This study examined whether childhood abuse has an additive or interactive effect on the association between combat exposure and suicide-related outcomes in a national sample of veterans.

METHODS

Data were from the National Health and Resilience in Veterans Study, a nationally representative survey of U.S. veterans (n = 3,157). Analyses compared veterans with/without current suicidal ideation and lifetime suicide attempts (SI/SA) on sociodemographic, military, and clinical characteristics; and examined the unique contribution of childhood physical and sexual abuse and combat exposure, and their interaction, with SI/SA.

RESULTS

After adjusting for sociodemographic characteristics and lifetime trauma burden, a significant interaction emerged between childhood sexual abuse and combat exposure predicting SI, such that combat-exposed veterans with histories of abuse were nearly three times more likely to currently be contemplating suicide relative to those without such histories. Childhood sexual abuse predicted lifetime suicide attempt, above and beyond sociodemographic characteristics, lifetime trauma burden, and combat exposure.

LIMITATIONS

Cross-sectional design precludes causal inference.

CONCLUSIONS

Results indicate that childhood sexual abuse exposure may operate both independently and synergistically with combat exposure to increase risk for suicidality among veterans. Findings suggest that veterans who experience childhood sexual abuse represent a subgroup that may be especially vulnerable to experiencing suicidal ideation following combat exposure.

Measuring suicide risk in the elderly with non-institutionalized depression: an integrative review

OBJECTIVE

Analyze the state of the art about instruments, at national and international levels, for assessing the risk of suicide in elderly people with depression assisted in the community.

METHODS

Integrative review of 38 complete articles, published in journals indexed in the databases: US National Library of Medicine (PubMed Central), Scopus, CINAHL and Web of Science, located using controlled descriptors combined with Boolean operators: elderly OR aged OR older OR elder OR geriatric AND depression AND suicide AND risk assessment.

RESULTS

Six instruments were found, all international and published in the English language, in order to identify suicidal behavior and ideation in the elderly. Of these, two are specific scales for assessing the risk of suicide in the elderly in the community: 5-item GDS subscale and Geriatric Suicide Ideation Scale.

FINAL CONSIDERATIONS

With the scarcity of national instruments to assess such risk, research is recommended to cross-culturally adapt one of these scales to the Brazilian Portuguese language.

The utility of smartphone-based, ecological momentary assessment for depressive symptoms

BACKGROUND

Major Depressive Disorder (MDD) is a common and debilitating mood disorder. Individuals with MDD are often misdiagnosed or diagnosed in an untimely manner, exacerbating existing functional impairments. Ecological momentary assessment (EMA) involves the repeated sampling of an individual's symptoms within their natural environment and has been demonstrated to assist in illness assessment and characterization. Capturing data in this way would set the stage for improved treatment outcomes and serve as a complementary resource in the management and treatment of depressive symptoms.

METHODS

Online databases PubMed/MedLine and PsycINFO were searched using PRISMA guidelines and combinations of the following keywords: EMA, depression, smartphone app, diagnosing, symptoms, phone, app, ecological momentary assessment, momentary assessment, data mining, unobtrusive, passive data, GPS, sensor.

RESULTS

A total of nineteen original articles were identified using our search parameters and ten articles met the inclusion criteria for full-text review. Among the ten relevant studies, three studies evaluated feasibility, seven evaluated detection, and three evaluated treatment of MDD.

LIMITATIONS

Limitations include that the design of all of the studies included in this review are non-randomized. It should be noted that most of the studies included were pilot studies and/or exploratory trials lacking a control group.

CONCLUSIONS

Available evidence suggests that the use of passive smartphone-based applications may lead to improved management of depressive symptoms. This review aids the creation of new EMA applications, highlights the potential of EMA usage in clinical settings and drug development, emphasizes the importance for regulation of applications in the mental health field, and provides insight into future directions.

Psychometric properties of the psychological strain scales (PSS) in suicide attempters and community controls of rural China

BACKGROUND

Psychological Strain Scales (PSS) were developed to measure four types of strain comprising value strain, deprivation strain, aspiration strain, and coping strain. This study aimed to evaluate the psychometric properties of the Chinese version of 40-item PSS in suicide attempters and community controls of rural China.

METHODS

Data of this study came from the investigation of 132 suicide attempters and their paired community controls matched with the same sex, age (±3 years) and residence in five counties in rural Shandong, China. The Chinese version of PSS, the Center for Epidemiologic Studies Depression Scale (CES-D), the Trait Anxiety Inventory (TAI) and the Self-esteem Scale (SES) were administered and reliability test and validity test of the PSS were conducted.

RESULTS

Cronbach's α and Guttman Spilt-Half coefficient of PSS was 0.942 and 0.842 for suicide attempters, and 0.950 and 0.874 for community controls. For both suicide attempters and community controls, the Exploratory Factor Analysis indicated a one-factor structure of each strain scale, which accorded with the original factor structure proposed by the authors. The scores of the total PSS and four subscales were positively correlated with the scores of CES-D and TAI; and negatively correlated with the score of SES, which indicated a good performance in convergent validity.

LIMITATIONS

This study was limited to its generalizability to the Chinese urban population.

CONCLUSIONS

The Chinese version of the 40-item PSS has satisfactory psychometric properties in terms of reliability and validity in Chinese rural suicide attempters and community controls.

Emergency department and hospital care prior to suicide: A population based case control study

BACKGROUND

High proportions of those who die by suicide in Northern Ireland (NI) are not known to mental health services, making it important to understand contact with the wider health services. Previous research has not examined the patterns of emergency department (ED) attendance and hospital admissions amongst those who have died by suicide in NI.

OBJECTIVES

The study objectives are to examine the relationships between ED attendances, hospital admissions, and death by suicide.

METHODS

A case control methodology was used, drawing on routinely collected administrative data on all deaths by suicide in Northern Ireland between 1/1/2012 and 31/12/2015. Each death was matched to 5 live controls, based on age and gender (n = 6630).

RESULTS

Death by suicide is associated with a recent ED attendance, with the highest odds for those who attended within the past three months (odds = 3.2, 95% CI = 2.5-4.2). Death by suicide is also associated with recent hospital admission, with the highest odds of death for admission within the past three months (odds = 6.6, 95% CI = 5.2-8.3). The odds of suicide are also higher for those living in a more deprived or urban area.

LIMITATIONS

The study is limited to administrative data.

CONCLUSIONS

Staff in EDs and hospitals may have a role in suicide prevention. These findings again support the importance of addressing economic deprivation and other area level factors, such as contagion in suicide prevention strategies.

Neuroimaging Studies of Suicidal Behavior and Non-suicidal Self-Injury in Psychiatric Patients: A Systematic Review

Background: With around 800,000 people taking their own lives every year, suicide is a growing health concern. Understanding the factors that underlie suicidality and identifying specific variables associated with increased risk is paramount for increasing our understanding of suicide etiology. Neuroimaging methods that enable the investigation of structural and functional brain markers in vivo are a promising tool in suicide research. Although a number of studies in clinical samples have been published to date, evidence about neuroimaging correlates for suicidality remains controversial. Objective: Patients with mental disorders have an increased risk for both suicidal behavior and non-suicidal self-injury. This manuscript aims to present an up-to-date overview of the literature on potential neuroimaging markers associated with SB and NSSI in clinical samples. We sought to identify consistently reported structural changes associated with suicidal symptoms within and across psychiatric disorders. Methods: A systematic literature search across four databases was performed to identify all English-language neuroimaging articles involving patients with at least one psychiatric diagnosis and at least one variable assessing SB or NSSI. We evaluated and screened evidence in these articles against a set of inclusion/exclusion criteria and categorized them by disease, adhering to the PRISMA guidelines. Results: Thirty-three original scientific articles investigating neuroimaging correlates of SB in psychiatric samples were found, but no single article focusing on NSSI alone. Associations between suicidality and regions in frontal and temporal cortex were reported by 15 and 9 studies across four disorders, respectively. Furthermore, differences in hippocampus were reported by four studies across three disorders. However, we found a significant lack of replicability (consistency in size and direction) of results across studies. Conclusions: Our systematic review revealed a lack of neuroimaging studies focusing on NSSI in clinical samples. We highlight several potential sources of bias in published studies, and conclude that future studies should implement more rigorous study designs to minimize bias risk. Despite several studies reporting associations between SB and anatomical differences in the frontal cortex, there was a lack of consistency across them. We conclude that better-powered samples, standardized neuroimaging and analytical protocols are needed to continue advancing knowledge in this field.

Literature review to identify standardized scales for assessing adult suicide risk in the primary health care setting

According to the World Health Organization, suicide has become a public health problem of global dimensions. Forty-five percent of suicide fatalities had consulted with a primary care doctor in the month preceding the event, but no suicide risk assessment had been conducted. Although suicide is an avoidable event, there is no standardized scale for assessment of suicide risk in the primary health care setting, where mental health care competencies vary and decisions are often guided by clinical judgment. A search and review of the best available evidence was carried out to identify scales for assessment of suicide risk for the nonspecialist doctor (i.e., ideally, brief, predictive, and validated). We searched PubMed/MEDLINE, Cochrane, Epistemonikos, and Scholar Google. We also contacted national and international experts on the subject. We retrieved 3 092 documents, of which 2 097 were screened by abstract, resulting in 70 eligible articles. After screening by full text, 20 articles were selected from which four scales were ultimately extracted and analyzed. Our review concludes that there are no suicide risk assessment scales accurate and predictive enough to justify interventions based on their results. Positive predictive values range from 1 to 19%. Of the patients classified as "high risk," only 5% will die by suicide. Half of the patients who commit suicide come from "low-risk" groups. We also discuss 1) the importance of evaluating a patient with suicidal behavior according to socio-demographic variables, history of mental health problems, and stratification within a scale, and 2) possible initial actions in the challenging context of primary care.

Features for medically serious suicide attempters who do not have a strong intent to die: a cross-sectional study in rural China

OBJECTIVE

Previous studies have implied that there were many Chinese suicide attempters who did not want to die by suicide. In the current study, we explored the factors which were associated with low levels of suicide intent. We also examined features for medically serious suicide attempters who do not have a strong intent to die in rural china.

DESIGN

Cross-sectional study.

SETTING

The interviews occurred between May 2012 and July 2013 in 13 rural counties in Shandong and Hunan provinces, China.

PARTICIPANTS

Subjects were 791 medically serious suicide attempters whose injury and wounds were so serious they required hospitalisation or immediate medical care.

RESULTS

The results supported that less years of education (β=-0.11, p=0.037), religious beliefs (β=1.20, p=0.005), living alone (β=1.92, p=0.017), negative life events (β=0.29, p=0.003), low levels of impulsivity (β=-0.10, p=0.013) and mental disorders (β=2.82, p<0.001) were associated with higher levels of suicide intent.

CONCLUSION

Results imply that there are some medically serious suicide attempters with a higher education and/or exhibit impulsivity who do not want to die by suicide. These findings can inform practice to prevent suicide in rural China.

Rethinking Suicidal Behavior Disorder

Background: It is a peculiar fact that the deadliest psychiatric disturbance - suicidality - cannot be formally diagnosed. Suicidal behavior disorder (SBD), a condition for further study in the DSM-5, is the field's first attempt to capture suicidality in a diagnosis. Aims: To provoke discussion about the standing of suicidality as a diagnosable psychiatric condition. Method: I present pragmatic and conceptual rationales for why a diagnosis of suicidality is clinically useful but conclude that SBD does little to aid clinicians in assessing suicidality's symptoms, planning treatment, or monitoring progress. Results: To improve the clinical utility of SBD, I re-conceptualize it from the vantage point of descriptive psychiatry. I hypothesize that this revised SBD is an independent, episodic, and frequently co-occurring condition and propose new cognitive, affective, and behavioral criteria that more completely capture the phenomenology of suicidality. Conclusion: The revised SBD is a starting place for dialogue about whether a clinically significant presentation of suicidality is a mental illness and, if it is, what its defining features should be.

Gender differences in exposure and vulnerability to psychosocial and behavioral factors of suicide attempt among Korean adolescents

INTRODUCTION

This study examined gender differences in suicide attempts and their association with exposure and vulnerability to psychosocial, behavioral, and structural factors among Korean adolescents.

METHODS

Data of 74 854 adolescents, taken from the 2010 Korea Youth Risk Behavior Survey, were used. Logistic regression analysis was used to assess the contribution of differential exposure to psychosocial, behavioral, and structural factors for gender differences of suicidal attempt.

RESULTS

Gender differences were observed in the degree of exposure to the various factors. Females were more likely to report psychosocial problems, whereas males were more likely to report experience of smoking and drinking alcohol and to engage in vigorous physical activity. Stress and unhappiness were significantly associated with suicide attempts in both males and females, and gender differences in these variables were nonsignificant. Depressive symptoms were associated with a higher risk of suicide attempts, and this relationship was significantly stronger for males. The effects of cigarette smoking and risky drinking were significantly stronger in females.

DISCUSSION

Greater exposure to perceived stress, feelings of unhappiness, depression, and higher vulnerability of smoking and heavy drinking accounted for higher suicide attempts of female adolescents. Higher exposure to health-related behaviors and greater vulnerability to depressive symptoms in male were also noted. In conclusion, differences in exposure and vulnerability to psychosocial and behavioral factors may partly explain gender differences in suicide attempts among Korean adolescents.

Suicidality, psychopathology, and the internet: Online time vs. online behaviors

This study investigated whether several psychopathology variables, including suicidality, could predict the time people spend using the internet (hours online). Next, we examined a specific at-risk population (suicidal individuals) by their online behaviors, comparing suicidal individuals who went online for suicide-related purposes with suicidal individuals who did not go online for suicide-related purposes. An anonymous online sample of 713 (aged 18-71) reported hours online, psychiatric histories, and completed several standardized scales. After accounting for age and education, hierarchical regression modeling showed that the assessed psychopathology variables, including suicidality, did not explain significant variance in hours online. Hours online were better predicted by younger age, greater willingness to develop online relationships, higher perceived social support, higher curiosity, and lower extraversion. Suicidal participants, who did or did not go online for suicide-related purposes, did not differ on hours online. Multiple regression modeling showed that those who went online for suicide-related purposes were likely to be younger, more suicidal, and more willing to seek help from online mental health professionals. These findings revealed that hours online are not a valid indicator of psychopathology. However, studying online behaviors of specific at-risk groups could be informative and useful, including for suicide prevention efforts.

Assessing Suicide Risk and Emotional Distress in Chinese Social Media: A Text Mining and Machine Learning Study

BACKGROUND

Early identification and intervention are imperative for suicide prevention. However, at-risk people often neither seek help nor take professional assessment. A tool to automatically assess their risk levels in natural settings can increase the opportunity for early intervention.

OBJECTIVE

The aim of this study was to explore whether computerized language analysis methods can be utilized to assess one's suicide risk and emotional distress in Chinese social media.

METHODS

A Web-based survey of Chinese social media (ie, Weibo) users was conducted to measure their suicide risk factors including suicide probability, Weibo suicide communication (WSC), depression, anxiety, and stress levels. Participants' Weibo posts published in the public domain were also downloaded with their consent. The Weibo posts were parsed and fitted into Simplified Chinese-Linguistic Inquiry and Word Count (SC-LIWC) categories. The associations between SC-LIWC features and the 5 suicide risk factors were examined by logistic regression. Furthermore, the support vector machine (SVM) model was applied based on the language features to automatically classify whether a Weibo user exhibited any of the 5 risk factors.

RESULTS

A total of 974 Weibo users participated in the survey. Those with high suicide probability were marked by a higher usage of pronoun (odds ratio, OR=1.18, P=.001), prepend words (OR=1.49, P=.02), multifunction words (OR=1.12, P=.04), a lower usage of verb (OR=0.78, P<.001), and a greater total word count (OR=1.007, P=.008). Second-person plural was positively associated with severe depression (OR=8.36, P=.01) and stress (OR=11, P=.005), whereas work-related words were negatively associated with WSC (OR=0.71, P=.008), severe depression (OR=0.56, P=.005), and anxiety (OR=0.77, P=.02). Inconsistently, third-person plural was found to be negatively associated with WSC (OR=0.02, P=.047) but positively with severe stress (OR=41.3, P=.04). Achievement-related words were positively associated with depression (OR=1.68, P=.003), whereas health- (OR=2.36, P=.004) and death-related (OR=2.60, P=.01) words positively associated with stress. The machine classifiers did not achieve satisfying performance in the full sample set but could classify high suicide probability (area under the curve, AUC=0.61, P=.04) and severe anxiety (AUC=0.75, P<.001) among those who have exhibited WSC.

CONCLUSIONS

SC-LIWC is useful to examine language markers of suicide risk and emotional distress in Chinese social media and can identify characteristics different from previous findings in the English literature. Some findings are leading to new hypotheses for future verification. Machine classifiers based on SC-LIWC features are promising but still require further optimization for application in real life.

Subcortical brain structure and suicidal behaviour in major depressive disorder: a meta-analysis from the ENIGMA-MDD working group

The aetiology of suicidal behaviour is complex, and knowledge about its neurobiological mechanisms is limited. Neuroimaging methods provide a noninvasive approach to explore the neural correlates of suicide vulnerability in vivo. The ENIGMA-MDD Working Group is an international collaboration evaluating neuroimaging and clinical data from thousands of individuals collected by research groups from around the world. Here we present analyses in a subset sample (n=3097) for whom suicidality data were available. Prevalence of suicidal symptoms among major depressive disorder (MDD) cases ranged between 29 and 69% across cohorts. We compared mean subcortical grey matter volumes, lateral ventricle volumes and total intracranial volume (ICV) in MDD patients with suicidal symptoms (N=451) vs healthy controls (N=1996) or MDD patients with no suicidal symptoms (N=650). MDD patients reporting suicidal plans or attempts showed a smaller ICV (P=4.12 × 10^-3) or a 2.87% smaller volume compared with controls (Cohen's d=-0.284). In addition, we observed a nonsignificant trend in which MDD cases with suicidal symptoms had smaller subcortical volumes and larger ventricular volumes compared with controls. Finally, no significant differences (P=0.28-0.97) were found between MDD patients with and those without suicidal symptoms for any of the brain volume measures. This is by far the largest neuroimaging meta-analysis of suicidal behaviour in MDD to date. Our results did not replicate previous reports of association between subcortical brain structure and suicidality and highlight the need for collecting better-powered imaging samples and using improved suicidality assessment instruments.

Does ethnicity matter in risk and protective factors for suicide attempts and suicide lethality?

This study explored ethnic differences in risk and protective factors for suicide attempts, for the major ethnic groups in Singapore, and ethnic differences in prediction of lethality. Three years of medical records related to suicide attempters (N = 666) who were admitted to the emergency department of a large teaching hospital in Singapore were subjected to analysis. Of the sample, 69.2% were female, 30.8% male; 63.8% Chinese, 15.8% Indian, and 15.0% Malay. Indians were over-represented in this sample, as compared with the ethnic distribution in the general population. Ages ranged from 10 to 85 years old (M = 29.7, SD = 16.1). Ethnic differences were found in risk and protective factors, and perceived lethality of suicide attempts. All available variables were subjected to regression analyses for Chinese, Indian and Malay attempters to arrive at parsimonious models for prediction of perceived lethality. The findings were discussed in regards to implications in assessment of suicide risk and primary prevention for the multiethnic society in Singapore.

Is suicide assessment harmful to participants? Findings from a randomized controlled trial

There is considerable debate on whether suicide assessment carries an iatrogenic risk for participants/patients. A double-blind randomized controlled trial (registration: R000022314) tested the emotional impact of suicide assessment on participants (n = 259) randomly assigned to experimental (n = 122) or control conditions (n = 137). The experimental condition included the Suicidal Affect-Behavior-Cognition Scale and intensive death-related questions, the control condition a quality of life scale. Both included measures of depression, social support and loneliness. Affective states were assessed immediately before and after testing, and research biases minimized. Post-test debriefing interviews collected qualitative reactions. Experimental participants ranged from nonsuicidal to highly suicidal. Between-groups ANCOVAs and repeated measures ANOVAs showed no differences by study condition, and no pre-post-test affect changes for either condition or suicidal participants (P > 0.10), supporting the null hypothesis of no iatrogenic effects. However, depressive participants in both conditions showed significant decreases in positive affect (P < 0.05). Smallest real difference (SRD) scores approximated clinically meaningful differences and showed 20% of participants had a significant positive survey reaction, 24% a negative reaction, with the rest neutral. Linear regressions revealed depressive symptoms and perceived family support, but not suicidality or other factors, predicted negative affect changes, which was supported by qualitative findings. Social desirability bias was also found in qualitative survey responses. No evidence of iatrogenic effects of suicide assessment were found. Recommendations are made to counter possible negative assessment effects on depressive participants/patients, and nurses and other caregivers are encouraged to talk to patients about suicidal symptoms.

Exposure to suicidal behaviors: A common suicide risk factor or a personal negative life event?

BACKGROUND

Numerous suicide risk factors have been proposed but not adequately validated for epidemiology, treatment and prevention efforts.

AIMS

Exposures to suicidal behaviors (ESB), from family and friend suicide attempts and completions, were tested for validity as a suicidal risk factor and also for measurement and construct adequacy.

METHODS

An anonymous online survey yielded 713 participants (aged 18-71), who reported ESB, completed the Suicidal Affect-Behavior-Cognition Scale (SABCS), and comprised a broad spectrum on those variables.

RESULTS

Tests of dimensionality and internal consistency showed the four ESB variables (attempts/completions through family/friends) were independent and did not form a common factor or an identifiable ESB latent trait. ESB variables were, however, associated with demographic and psychiatric histories. A battery of tests revealed no meaningful associations between ESB and total suicidality or suicide risk factors (social support, depression, anxiety, stress, satisfaction with life and emotional stability). In addition, in contrast to previous reports, young adults ( n = 200; aged 18-20) showed no increased suicidality due to ESB.

CONCLUSION

Results showed no validity for ESB as a common risk factor for suicidality or other psychopathology, or as a latent trait. ESB showed evidence as a personal negative life event with individual effects and interpretations.

A model for continuous monitoring of patients with major depression in short and long term periods

BACKGROUND AND OBJECTIVE

Major depressive disorder causes more human suffering than any other disease affecting humankind. It has a high prevalence and it is predicted that it will be among the three leading causes of disease burden by 2030. The prevalence of depression, all of its social and personal costs, and its recurrent characteristics, put heavy constraints on the ability of the public healthcare system to provide sufficient support for patients with depression. In this research, a model for continuous monitoring and tracking of depression in both short-term and long-term periods is presented. This model is based on a new qualitative reasoning approach.

METHOD

This paper describes the patient assessment unit of a major depression monitoring system that has three modules: a patient progress module, based on a qualitative reasoning model; an analysis module, based on expert knowledge and a rules-based system; and the communication module. These modules base their reasoning mainly on data of the patient's mood and life events that are obtained from the patient's responses to specific questionnaires (PHQ-9, M.I.N.I. and Brugha). The patient assessment unit provides synthetic and useful information for both patients and physicians, keeps them informed of the progress of patients, and alerts them in the case of necessity.

RESULTS

A set of hypothetical patients has been defined based on clinically possible cases in order to perform a complete scenario evaluation. The results that have been verified by psychiatrists suggest the utility of the platform.

CONCLUSION

The proposed major depression monitoring system takes advantage of current technologies and facilitates more frequent follow-up of the progress of patients during their home stay after being diagnosed with depression by a psychiatrist.

Development of a Suicidal Ideation Detection Tool for Primary Healthcare Settings: Using Open Access Online Psychosocial Data

BACKGROUND

Suicidal patients often visit healthcare professionals in their last month before suicide, but medical practitioners are unlikely to raise the issue of suicide with patients because of time constraints and uncertainty regarding an appropriate approach.

INTRODUCTION

A brief tool called the e-PASS Suicidal Ideation Detector (eSID) was developed for medical practitioners to help detect the presence of suicidal ideation (SI) in their clients. If SI is detected, the system alerts medical practitioners to address this issue with a client. The eSID tool was developed due to the absence of an easy-to-use, evidence-based SI detection tool for general practice.

MATERIAL AND METHODS

The tool was developed using binary logistic regression analyses of data provided by clients accessing an online psychological assessment function. Ten primary healthcare professionals provided advice regarding the use of the tool.

RESULTS

The analysis identified eleven factors in addition to the Kessler-6 for inclusion in the model used to predict the probability of recent SI. The model performed well across gender and age groups 18-64 (AUR 0.834, 95% CI 0.828-0.841, N = 16,703). Healthcare professionals were interviewed; they recommended that the tool be incorporated into existing medical software systems and that additional resources be supplied, tailored to the level of risk identified.

CONCLUSION

The eSID is expected to trigger risk assessments by healthcare professionals when this is necessary. Initial reactions of healthcare professionals to the tool were favorable, but further testing and in situ development are required.

Suicide Risk Screening Tools and the Youth Population

TOPIC

The use of suicide risk screening tools is a critical component of a comprehensive approach to suicide risk assessment. Since nurses frequently spend more time with patients than any other healthcare professional, they are in key positions to detect and prevent suicidal behavior in youth.

PURPOSE

To inform nurses about suicide risk screening tools for the youth population. Suicide risk screening tools are research-based standardized instruments that are used to identify people who may be at risk for suicide.

SOURCES USED

A literature search was performed using the Athabasca University Library Resource, the databases of the Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, and Google Scholar.

CONCLUSIONS

Nurses are cautioned to utilize suicide risk screening tools as only part of the suicide risk assessment in youth populations and avoid the danger of relying on tools that may result in a blind application of evidence to the detriment of clinical experience and judgement.

Dying online: live broadcasts of Chinese emerging adult suicides and crisis response behaviors

BACKGROUND

Social media and online environments are becoming increasingly popular and integral to modern lives. The online presentation of suicidal behaviors is an example of the importance of communication technologies, and the need for professionals to respond to a changing world. These types of behaviors, however, have rarely been scientifically analyzed. This study aimed to examine the behaviors of both suicide broadcasters and their audience, with attention on prevention/crisis opportunities.

METHODS

Multiple case studies were employed to explore live-broadcast suicide by Chinese emerging adults (aged 18-25 years). Six cases were selected (four males, two females; aged 19-24, M = 21.60, SD = 2.25), retrieved from 190 public documents (case range = 5 to 32; M = 11.50, SD = 10.37). A qualitative study based on grounded theory was adopted. Information on case background, stages, participants and their behaviors were collected.

RESULTS

(1) Five stages of blogcast suicide incidents were revealed, including: Signaling, Initial reactions, Live blogcast of suicide attempts, Crisis responses, and Final outcomes. (2) Common behavioral trends (e.g., comforting, verbal abuse) were identified from the blogcast participants (e.g., active audience, peers, parents and police). (3) Suicide blogcasters exhibited tendencies to communicated signs of pain and cries for help.

CONCLUSIONS

This multi-case study found live presentations of suicidal behaviors offered unique opportunities to respond to suicidal crises, and also to learn more about the relationships between suicidal people and potential help sources. Findings showed many audience members wanted to be helpful but lacked appropriate skills or knowledge. Others engaged in suicide cyberbullying. The social media is an environment in the making. This study revealed that increasing knowledge and skills for crisis response and suicide prevention is needed. Such efforts could lead to empowered netizens and a more hospitable online world.

Estimating Suicide Rates in Developing Nations: A Low-Cost Newspaper Capture-Recapture Approach in Cambodia

This study tested a low-cost method for estimating suicide rates in developing nations that lack adequate statistics. Data comprised reported suicides from Cambodia's 2 largest newspapers. Capture-recapture modeling estimated a suicide rate of 3.8/100 000 (95% CI = 2.5-6.7) for 2012. That compares to World Health Organization estimates of 1.3 to 9.4/100 000 and a Cambodian government estimate of 3.5/100 000. Suicide rates of males were twice that of females, and rates of those <40 years were twice that of those ≥40 years. Capture-recapture modeling with newspaper reports proved a reasonable method for estimating suicide rates for countries with inadequate official data. These methods are low-cost and can be applied to regions with at least 2 newspapers with overlapping reports. Means to further improve this approach are discussed. These methods are applicable to both recent and historical data, which can benefit epidemiological work, and may also be applicable to homicides and other statistics.

Offline Versus Online Suicide-Related Help Seeking: Changing Domains, Changing Paradigms

OBJECTIVE

Suicidal individuals are among the most reluctant help-seekers, which limits opportunities for treating and preventing unnecessary suffering and self-inflicted deaths. This study aimed to assist outreach, prevention, and treatment efforts by elucidating relationships between suicidality and both online and offline help seeking.

METHOD

An anonymous online survey provided data on 713 participants, aged 18-71 years. Measures included an expanded General Help-Seeking Questionnaire and the Suicidal Affect-Behavior-Cognition Scale.

RESULTS

General linear modeling results showed that, as predicted, face-to-face help-seeking willingness decreased as risk level increased. However, for emerging adults help-seeking likelihood increased with informal online sources as risk increased, while other online help-seeking attitudes differed little by risk level. Linear regression modeling determined that, for suicidal individuals, willingness to seek help from online mental health professionals and online professional support sites was strongly related (ps < .001). Help seeking from social networking sites and anonymous online forums was also interrelated, but more complex, demonstrating the importance of age and social support factors (ps < .001).

CONCLUSION

These findings show that the Internet has altered the suicide-related help-seeking paradigm. Online help seeking for suicidality was not more popular than face-to-face help seeking, even for emerging adults. However, treatment and prevention professionals have good reasons to increase their online efforts, because that is where some of the highest risk individuals are going for help with their most severe personal problems.