Challenges in Assessing Intent to Die: Can Suicide Attempters Be Trusted?

Sleep measures as a predictor of suicidal ideation among high-risk adolescents

Suicide is the second leading cause of death among youth aged 15-24 years. Identifying modifiable risk factors relevant to adolescents is crucial for suicide prevention. Sleep patterns have been linked to suicidality in adults, but lack sufficient study in youth. This ecological momentary assessment (EMA) study aimed to explore the relationship between objectively and subjectively measured sleep characteristics and next-day suicidal ideation in high-risk youth. We included 29 adolescents (12-18 years old) admitted to the inpatient psychiatric ward post-suicide attempt or due to suicidal intent within the previous month. We conducted objective (actigraphy) and subjective (sleep diary) sleep pattern assessments over ten consecutive days. Daily suicidal ideation was evaluated using a questionnaire based on the validated C-SSRS interview. A significant positive association was observed between sleep onset latency (SOL) and expressing a "death wish" the following day (OR = 1.06, 95% CI [1-1.11], p = .04), with each minute of longer SOL increased the risk for a death wish the following day by 6%. In addition, a marginally significant negative association was observed between total sleep time (TST) and expressing a "death wish" the following day (OR = 0.57, 95% CI [0.3-1.11], p = 0.1), with each one-hour decrease in objectively measured TST increasing the odds of a death wish by 43%. Our study highlights the interplay between sleep patterns and suicidal ideation, with SOL and TST playing a significant role that may function as proximal risk factors for suicidality and as a target for intervention while treating suicidal youth.

"I didn't do it!": Lived experiences of suicide attempts made without perceived intent or volition

Suicide is considered to be a conscious and intentional act that is carried out within a social and cultural context. This study examines the unique phenomenon of a cluster of suicide attempts conducted without perceived intent, ideation, plan, volition, or agency in a remote province in Central Asia. This study investigated the lived experiences of individuals who made such unintended suicide attempts and examined the differences between these experiences and those of individuals who made their suicide attempt with intent and agency. The authors conducted a secondary analysis of qualitative data originally collected for a prior grounded theory study. The present study examined a specific and unique set of participant experiences related to suicide attempts made without agency. Results found that instances of suicide attempts made without perceived intent by participants included themes of impulsivity, not knowing what happened, feeling out of control, attributing these experiences to the supernatural, and being fearful of such events occurring again. Clinical practice may need to be adapted to address experiences of such unique suicide attempt experiences. In addition, further research is warranted to understand and examine the phenomenon of suicide attempts carried out without perceived intent, ideation, plan, volition, or agency.

The use of analgesics for intentional self-poisoning: Trends in U.S. poison center data

In the U.S., intentional self-poisonings with analgesics that are available without a prescription increased from 2000 to 2018. Given concerns regarding mental health outcomes during the COVID-19 pandemic, we examined and compared trends in pediatric and adult intentional self-poisoning with acetaminophen, aspirin, ibuprofen, and naproxen from 2016 to 2021 using the National Poison Data System (NPDS) to see if these trends have continued. We extracted annual case counts of all suspected suicide attempts from intentional poisoning, and of suspected suicide attempts resulting in major effects or death, from the NPDS for non-prescription single ingredient adult formulation acetaminophen, non-prescription single ingredient adult formulation aspirin, single ingredient formulation ibuprofen, and single ingredient formulation naproxen. We enumerated the cases by year, age, and gender. Most cases of intentional self-poisoning within the review period involved acetaminophen and ibuprofen and the 13-19-year-olds constituted the highest proportion of intentional self-poisoning cases across age groups for all four analgesics. Cases involving females predominated cases involving males by 3:1 or greater. The 13-19-year-old age group also represented the largest proportion of cases that resulted in major clinical effects or deaths. An increasing trend in suicide poisoning cases with acetaminophen and ibuprofen was observed in the 6-19-years age group and this trend appeared to exacerbate from 2020 to 2021 corresponding with the start of the COVID-19 pandemic period.

The relationship between physician burnout and depression, anxiety, suicidality and substance abuse: A mixed methods systematic review

Introduction

The World Health Organization defines burnout as a problem associated with employment, a category distinct from psychological disorders such as depression, anxiety, suicidality and disorders of substance abuse. Evaluating the association between burnout as an occupational exposure and psychological morbidity may indicate that burnout can act as an occupational risk factor for mental ill-health. The systematic review explores this relationship in physicians due to the increased risk in this population and the implications for healthcare delivery.

Methods

A mixed methods systematic review of the literature was conducted across Medline, Cinahl Plus, PsycInfo, Web of Science and The Cochrane Library. Databases were systematically searched using keywords relating to physician burnout and depression, anxiety, suicidality and substance abuse. Identified articles were screened for eligibility by two independent researchers. Data extraction was performed and studies assessed for risk of bias. Quantitative and qualitative results were integrated using a convergent segregated approach and results portrayed as a narrative synthesis.

Results

Sixty-one articles were included in the review. There was notable heterogeneity in the measurement and criteria used to define burnout limiting the assimilation of results. Despite this, all studies that measured the association between depression and burnout reported a significant association. Studies that reported association between burnout and anxiety were similarly uniformly consistent. Most studies that reported the association between burnout and suicidality indicated that a significant association exists however difficulty in measurement of suicidality may have influenced variability of results. The reported association between substance abuse and burnout was more variable, suggesting that any association is likely to be weak or influenced by other variables. Qualitative studies described the manifestations of chronic workplace stress as well as perceived links with psychological morbidity. These included lack of time for work-life balance, the contribution of professional relationships and a culture of invulnerability that exists among physicians.

Conclusion

The systematic review cannot conclude causality but suggests that physician burnout is associated with depression, anxiety and suicidality. Qualitative data provides insight into the nature of this association. The review indicates the need for longitudinal research and provides considerations for intervention strategies to prevent the development and progression of burnout.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172938, identifier: CRD42020172938.

How is suicide risk assessed in healthcare settings in the UK? A systematic scoping review

A high proportion of people contact healthcare services in the 12 months prior to death by suicide. Identifying people at high-risk for suicide is therefore a key concern for healthcare services. Whilst there is extensive research on the validity and reliability of suicide risk assessment tools, there remains a lack of understanding of how suicide risk assessments are conducted by healthcare staff in practice. This scoping review examined the literature on how suicide risk assessments are conducted and experienced by healthcare practitioners, patients, carers, relatives, and friends of people who have died by suicide in the UK. Literature searches were conducted on key databases using a pre-defined search strategy pre-registered with the Open Science Framework and following the PRISMA extension for scoping reviews guidelines. Eligible for inclusion were original research, written in English, exploring how suicide risk is assessed in the UK, related to administering or undergoing risk assessment for suicide, key concepts relating to those experiences, or directly exploring the experiences of administering or undergoing assessment. Eighteen studies were included in the final sample. Information was charted including study setting and design, sampling strategy, sample characteristics, and findings. A narrative account of the literature is provided. There was considerable variation regarding how suicide risk assessments are conducted in practice. There was evidence of a lack of risk assessment training, low awareness of suicide prevention guidance, and a lack of evidence relating to patient perspectives of suicide risk assessments. Increased inclusion of patient perspectives of suicide risk assessment is needed to gain understanding of how the process can be improved. Limited time and difficulty in starting an open discussion about suicide with patients were noted as barriers to successful assessment. Implications for practice are discussed.

For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt

Nonsuicidal self-injury (NSSI) has been repeatedly associated with increased suicide risk. However, the transition from NSSI to suicidal thoughts and behaviors still remains as an enigma. One possible construct that may influence this relationship is cognitive flexibility, which refers to the ability to adapt responses/strategies based on environmental feedback. It may be that greater cognitive flexibility increases one's cognitive accessibility to suicide, making it a more viable option upon distress especially for those with a prior history of NSSI. Conversely, it may be that less cognitive flexibility creates a negative bias that exacerbates the effects of NSSI on suicide. Thus, in this study, we examined how NSSI characteristics (i.e., frequency and methods) interact with cognitive flexibility to predict lifetime suicide attempt (SA) history. Participants were 505 individuals with a lifetime history of NSSI who completed a survey assessing for their NSSI experiences, cognitive flexibility, and SA history. Moderation analyses were conducted while controlling for sexual orientation, which significantly predicted SA history. Results indicated a significant interaction between number of NSSI methods endorsed and cognitive flexibility. In particular, individuals were more likely to have had a history of SA if they scored higher on the alternative subscale of cognitive flexibility. The results suggest that the adaptive value of cognitive flexibility may be context dependent, and highlight the importance of personalized care among those who engage in self-harm.

Risk factors for self-harm repetition in adolescents: A systematic review

Self-harm behavior can begin in early adolescence, with the highest rates of self-harm, between 1990 and 2000 in England, being among adolescents aged 16 to 24 years and there being considerable risk of fatal and non-fatal repetition. Previous systematic reviews have identified risk factors for self-harm in adolescents, but not for the repetition of this behavior. The aim of this review was to synthesise the psychological, psychosocial and sociodemographic risk factors for self-harm repetition in adolescents. By searching four databases, 27 studies were identified and included in the review. Several psychological (e.g., psychiatric morbidity, features of previous self-harm, psychological distress), psychosocial (e.g., alcohol misuse, poor family and peer relationships) and sociodemographic (e.g., age, gender and ethnicity) risk factors were identified for self-harm repetition in adolescents. Several risk factors across all categories for self-harm overlapped with that of self-harm repetition, such as depression, alcohol misuse and female gender. The clinical implications of these findings for practitioners were discussed. As was the case with prior reviews in this area, comparability between studies was limited and a meta-analysis was not possible due to considerable heterogeneity in outcome definitions, measures and methodologies.

Reports on the Perceived Advantages and Disadvantages of Suicidal Behavior by Patients With Depression

Background: Studies suggest there may be perceived secondary advantages to engaging in suicidal behavior that impact the help-seeking behavior of at-risk individuals. Aims: The aim of this study was to assess the views of patients with depression regarding the advantages and disadvantages of engaging in suicidal behavior using a decisional balance worksheet (DBW) to inform prevention and intervention efforts. Method: Participants were adults with depression between the ages of 18 and 75 presenting to the emergency department with suicidal ideation (N = 42) who participated in a larger pilot study of a brief intervention aimed focused on treatment engagement. Using a content analysis approach, common themes were extracted. Results: Escaping from problems and negative thoughts, ending pain and suffering, and eliciting support and help were the most commonly cited advantages of engaging in suicidal behavior. Negatively impacting family, violating one's values, and missing out on the future were the most commonly reported disadvantages of suicidal behavior. Limitations: Results may not be generalizable to patients without depression who are experiencing suicidality. Conclusion: Results suggest intervention efforts focused on addressing decision-making and problem-solving skills and reinforcing the important role patients play in the lives of their significant others may help patients to resist the urge to act on suicidal thoughts.

Suicide Attempts: How Does the Acute Use of Alcohol Affect Suicide Intent?

BACKGROUND

Very few studies have specifically addressed the role of the acute use of alcohol (AUA) in suicide attempts.

OBJECTIVE

Our study compared the suicide intent scores of self-poisoning patients with and without AUA in order to examine the role of alcohol in attempted suicides.

METHODS

We recruited 516 patients admitted to the emergency department for self-poisoning. We screened blood alcohol concentrations (BACs) to determine whether these were positive or negative in the two groups. We collected data about covariates such as psychiatric disorders and sociodemographic and suicide characteristics. We then compared suicide intent between the groups, adjusted according to the covariates.

RESULTS

The patients with AUA had lower scores for suicide intent, but this factor only reduced the self-reporting score, with the scores for objective circumstances and risk similar between the groups. There was a correlation between BACs and self-reported suicide intentionality, but this was not significant.

CONCLUSION

Acute use of alcohol patients presented with lower suicide intent, as particularly explained by the self-report scores, but there were no differences between the groups in terms of risk and/or the objective circumstances. The role of alcohol in the self-reporting of suicide attempts must be addressed in future studies.

Suicidal and self-harm presentations to Emergency Departments: The challenges of identification through diagnostic codes and presenting complaints

BACKGROUND

The accuracy of data on suicide-related presentations to Emergency Departments (EDs) has implications for the provision of care and policy development, yet research on its validity is scarce.

OBJECTIVE

To test the reliability of allocation of ICD-10 codes assigned to suicide and self-related presentations to EDs in Queensland, Australia.

METHOD

All presentations due to suicide attempts, non-suicidal self-injury (NSSI) and suicidal ideation between 1 July 2017 and 31 December 2017 were reviewed. The number of presentations identified through relevant ICD-10-AM codes and presenting complaints in the Emergency Department Information System were compared to those identified through an application of an evolutionary algorithm and medical record review (gold standard).

RESULTS

A total of 2540 relevant presentations were identified through the gold standard methodology. Great heterogeneity of ICD-10-AM codes and presenting complaints was observed for suicide attempts (40 diagnostic codes and 27 presenting complaints), NSSI (27 and 16, respectively) and suicidal ideation (38 and 34, respectively). Relevant ICD codes applied as primary or secondary diagnosis had very low sensitivity in detecting cases of suicide attempts (18.7%), NSSI (38.5%) and suicidal ideation (42.3%). A combination of ICD-10-AM code and a relevant presenting complaint increased specificity, however substantially reduced specificity and positive predictive values for all types of presentations. ED data showed bias in detecting higher percentages of suicide attempts by Indigenous persons (10.1% vs. 6.9%) or by cutting (28.1% vs. 10.3%), and NSSI by female presenters (76.4% vs. 67.4%).

CONCLUSION

Suicidal and self-harm presentations are grossly under-enumerated in ED datasets and should be used with caution until a more standardised approach to their formulation and recording is implemented.

Motivations for attempting suicide in mid- and late-life

ABSTRACTObjectives:To understand pathways to suicide by investigating the association between personality and suicidal motivations in mid- and late-life attempts.

DESIGN

In a two-study approach, we measured different components of suicidal motivations using an existing self-report investigating reasons for suicide and a semi-qualitative assessment of motivational states preceding attempts.

SETTING

Inpatient and outpatient psychiatric services in Pittsburgh, PA.

PARTICIPANTS

Study 1 (n = 50, mean age at attempt = 60.4) was a smaller sample of suicide attempters included in Study 2 (n = 69, mean age at attempt = 60.9). Non-psychiatric healthy controls (n = 50, mean age = 67.1) were used as benchmarks for dispositional measures.

MEASUREMENTS

Motives for suicide were measured by the Reasons for Attempting Suicide Questionnaire (RASQ). Participants' written descriptions of the thoughts and feelings preceding their attempt captured motivational states. Measures of personality for both studies included assessments of impulsivity, five-factor model, interpersonal dysfunction, and borderline traits.

RESULTS

In study 1, escape/self-punishment motives on the RASQ were associated with multiple attempts and borderline pathology, while interpersonal motives were less frequently endorsed and associated with poorly planned attempts. In study 2, experiences of defeat (i.e. powerlessness, poor coping to threats to autonomy/status) were more frequently endorsed by men and associated with disagreeableness.

CONCLUSIONS

Study 1 revealed that attempters high in dysfunctional psychopathology were more likely to report self-oriented escape motives for suicide, while study 2 identified a putative pathway to suicide in men involving antagonism and the experience of defeat.

Alcohol and Suicide Risk: Examining the Role of Meaning-Making

OBJECTIVE

Conceptual understandings of meaning-making suggest that it may have protective value in regard to alcohol misuse and suicidal behavior. Accordingly, the aim of this study was to examine whether meaning-making attenuated the relationship between alcohol misuse and suicide risk severity in a population of active-duty service members.

METHODS

The sample (N = 97) was recruited while presenting for emergency behavioral health services in circumstances indicative of high-risk suicidality: endorsing current suicidal ideation with intent to die. Those who reported ideation with a lifetime history of a past suicide attempt were conceptualized as being in a more severe category of suicide risk than ideation without a lifetime history of a past suicide attempt. Participants completed the Suicidal Behaviors Questionnaire-Revised, Meaning in Life Questionnaire, Alcohol Use Disorders Identification Test consumption questions, and items that assessed demographic variables. Data were analyzed using chi-squared test of independence, Fisher's exact test, Kendall rank correlation coefficient, and logistic regression modeling.

RESULTS

Regression analysis identified a statistically significant association between number of drinks consumed daily and reporting a lifetime history of a past suicide attempt, odds ratio (OR) = 1.60, 95% confidence interval (CI) [1.11, 2.32], p = .01. Number of drinks consumed remained significant even after adjusting for both the search for and presence of meaning, OR = 1.70, 95% CI [1.16, 2.51], p = .01. These results remained unchanged even when adjusting for gender, race, ethnicity, and relationship status. No statistically significant interaction effects were noted between meaning-making and alcohol consumption.

CONCLUSIONS

Meaning-making did not appear to attenuate the effect of alcohol misuse on suicide risk severity in a sample of service members at high-risk of suicidality. Additional research is needed to better understand the relationship among meaning-making, alcohol misuse, and suicidal behavior.

Developing a framework of behaviours before suicides at railway locations

Better knowledge of behaviours of people at railway property could help with identifying those at risk of suicide. Literature has been reviewed from a range of disciplines on what is known about studying behaviour in this type of public location. Secondary analysis has been carried out on descriptions of behaviour from structured exercises with experts and other pre-existing sources. A framework has been produced with five main classes (display of emotion, appearance, posture/movements, activities and interactions) and associated sub-classes. Commentary has been provided on factors that influence identification of suspicious behaviours, how to distinguish these from normal behaviours and the circumstances that inhibit timely reactions to the behaviour amidst the complexity of the operational railway. Opportunities to develop and use the framework are discussed, including using this to prompt collection of additional behavioural data from wider resources, enhancing staff training and developing requirements for effective use of surveillance technologies. Practitioner Summary: Many railway suicides could be prevented with better understanding of behaviours before events. Pre-existing data sources have been analysed, producing a framework highlighting five aspects of behaviour. This can prompt the collection of better evidence on pre-suicidal behaviours, with future applications in developing surveillance technologies, training staff and public awareness.

Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to Classify Suicidal Behaviors

Efforts to better understand and prevent suicide have increasingly pointed to the prospective assessment of suicidal behaviors in clinical trials. These assessments are aided by instruments such as the Columbia-Suicide Severity Rating Scale (C-SSRS), which have sought to improve the conceptual uniformity and ease by which suicidal behaviors are classified. At the same time, assessment and classification of suicidal behaviors has been a longtime challenge in the field. To aid users of the C-SSRS, this article illustrates the use of the C-SSRS in instances where classification complexities arise. Illustrations are presented based on cases encountered during a clinical trial for a suicide prevention intervention. Key decision points are summarized and classification issues that warrant consideration for future refinement of such decisions are discussed.

Does the timing of suicide risk assessments influence ratings of risk severity?

Clinicians are often tasked with identifying and managing patients who are at risk for suicide. Therefore, greater understanding of factors that impact the efficacy of suicide risk assessments (SRA) are of critical importance. One potential factor that may affect assessments of risk severity is the timing of the evaluation during clinical interview. Given that some patients are reluctant to disclose suicide-related symptoms, it is possible that asking about suicide at the beginning of an interview elicits more false negatives. It is also possible that if risk assessments are conducted in a manner that is encouraging to the patient, timing does not significantly impact patient report. This study examined whether SRA timing within an initial intake interview affects risk severity ratings. Adult psychiatric outpatients (N=169) were randomly assigned to receive a SRA during the beginning or middle of a one-hour intake. We failed to find a significant difference in suicide risk ratings between those who were evaluated at the beginning as compared to the middle of intake (14% versus 15% rated at elevated risk). Findings were not moderated by age, gender, or attempt history. Our results provide preliminary evidence that the timing of SRA may not impact risk severity ratings.

Suicide attempters with high and low suicide intent: Different populations in rural China

This paired case-control study aimed to compare characteristics between suicide attempters with high and low suicide intent in rural China. We evaluated 409 suicide attempters and their paired controls who were matched with the same gender, age (a difference of no more than 3 years), and similar residence. Compared to paired control, suicide attempt with high and low suicide intent shared the 3 common risk factors of negative life event, high depression score, and low social support score. In addition, mental disorder was an independent risk factor of suicide attempt with high intent. Having a low education level and occupation as a farmer were risk factors of suicide attempt with low intent. Mental disorder and depression were associated with a significantly increased risk of suicide attempt with high intent compared to low intent. Depression was found to be related to suicide attempt with high intent compared to low intent in the subgroups of male or female aged 35-54 or 55-70 years. Distinct characteristics were found in the suicide attempters with different intent. These findings are important and the aim is to transform them into concrete ideas for the prevention of suicide attempt in rural China.

Misclassification of Self-Directed Violence

BACKGROUND

Inconsistent nomenclature and classification of suicidal behaviour have plagued the field of suicidology for a long time. Recently, the United States Centers for Disease Control (CDC) advocated for the usage of a specific classification system. Aim of the current study was to determine the extent of misdiagnosed acts of self-directed violence-controlling for the level of expertise in psychology/psychotherapy. Additionally, the effect of gender and diagnosis on misclassifications was assessed.

METHOD

A total of 426 participants (laypersons, psychology students, psychotherapists-in-training, licensed psychotherapists) were presented with an array of case vignettes describing different acts of self-directed violence (e.g., non-suicidal self-directed violence, suicide attempt, suicide ideation) and were asked to make a classification. Gender and given diagnosis were varied systematically in two vignettes.

RESULTS

Overall 51.6% of the cases were misclassified (according to the Self-Directed Violence Classification System). The level of expertise was almost unrelated to classification correctness. Yet, psychotherapists were more confident about their judgments. Female gender of the character described in the vignette and an ascribed diagnosis of Borderline Personality Disorder were associated with higher misclassification rates.

LIMITATIONS

The validity of case vignettes is discussible.

CONCLUSIONS

The results highlight the importance of more methodological and diagnostic training of psychologists regarding suicidal issues. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Misclassification of non-suicidal and suicidal events is common. Expertise is only weakly associated with classification correctness. Misclassification of suicide attempts occurs more often in women. Misclassification of suicide attempts occurs more often in Borderline Personality Disorder. The use of standardized diagnostic tools in relation to self-directed violence is highly recommended.

Who leaves suicide notes? A six-year population-based study

Popular culture insists on the significance of suicide notes, but research has yielded conflicting results about who leaves notes. Utilizing 6 years of suicides from a comprehensive statewide data surveillance system, differences were examined between cases with suicide notes and those without in terms of demographics, circumstances of the suicide, and precipitating circumstances. Of the 2,936 suicides, 18.25% included a note. Demographics and circumstances did not differ for cases with a note compared to cases with no note. Results have implications for working with people bereaved by suicide in helping understand that the notes are uncommon and not systematic. However, it is also possible that for some individuals, the content of a note is meaningful and can help or hinder their course of bereavement.

Are people at risk of psychosis also at risk of suicide and self-harm? A systematic review and meta-analysis

BACKGROUND

Suicide and self-harm are prevalent in individuals diagnosed with psychotic disorders. However, less is known about the level of self-injurious thinking and behaviour in those individuals deemed to be at ultra-high risk (UHR) of developing psychosis, despite growing clinical interest in this population. This review provides a synthesis of the extant literature concerning the prevalence of self-harm and suicidality in the UHR population, and the predictors and correlates associated with these events.

METHOD

A search of electronic databases was undertaken by two independent reviewers. A meta-analysis of prevalence was undertaken for self-harm, suicidal ideation and behaviour. A narrative review was also undertaken of analyses examining predictors and correlates of self-harm and suicidality.

RESULTS

Twenty-one eligible studies were identified. The meta-analyses suggested a high prevalence of recent suicidal ideation (66%), lifetime self-harm (49%) and lifetime suicide attempts (18%). Co-morbid psychiatric problems, mood variability and a family history of psychiatric problems were among the factors associated with self-harm and suicide risk.

CONCLUSIONS

Results suggest that self-harm and suicidality are highly prevalent in the UHR population, with rates similar to those observed in samples with diagnosed psychotic disorders. Appropriate monitoring and managing of suicide risk will be important for services working with the UHR population. Further research in this area is urgently needed considering the high rates identified.

Impulsive suicide attempts: a systematic literature review of definitions, characteristics and risk factors

BACKGROUND

Extensive research on impulsive suicide attempts, but lack of agreement on the use of this term indicates the need for a systematic literature review of the area. The aim of this review was to examine definitions and likely correlates of impulsive attempts.

METHODS

A search of Medline, Psychinfo, Scopus, Proquest and Web of Knowledge databases was conducted. Additional articles were identified using the cross-referencing function of Google Scholar.

RESULTS

179 relevant papers were identified. Four different groups of research criteria used to assess suicide attempt impulsivity emerged: (a) time-related criteria, (b) absence of proximal planning/preparations, (c) presence of suicide plan in lifetime/previous year, and (d) other. Subsequent analysis used these criteria to compare results from different studies on 20 most researched hypotheses. Conclusions regarding the characteristics of impulsive attempts are more consistent than those on the risk factors specific to such attempts. No risk factors were identified that uniformly related to suicide attempt impulsivity across all criteria groups, but relationships emerged between separate criteria and specific characteristics of suicide attempters.

LIMITATIONS

Only published articles were included. Large inconsistencies in methods of the studies included in this review prevented comparison of effect sizes.

CONCLUSIONS

The vast disparities in findings on risk factors for impulsive suicide attempts among different criteria groups suggest the need to address the methodological issues in defining suicide attempt impulsivity before further research into correlates of such attempts can effectively progress. Specific recommendations are offered for necessary research.

Configuring the caller in ambiguous encounters: volunteer handling of calls to Samaritans emotional support services

This paper discusses volunteer strategies for handling and assessing calls to Samaritans emotional support services for the suicidal and despairing. It presents findings from the qualitative components of a two-year mixed methods study based on an online caller survey, branch observations and interviews with volunteers and callers throughout the U.K. A thematic analysis of the qualitative data analysis was undertaken using the principle of constant comparison. Many calls fell beyond the primary remit of a crisis service, and called for rapid attribution and assessment. Uncertainty about identifying 'good' calls and recognizing those which were not caused difficulty, frustration and negative attribution towards some callers. This paper presents our analysis of volunteers' accounts of how they configure the caller in intrinsically uncertain and ambiguous encounters, and how such strategies relate to the formal principles of unconditional support and non-judgemental active listening espoused by the organization.

Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters

BACKGROUND

Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt.

OBJECTIVES

To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters.

METHOD

The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression-impulsivity, mental pain, and communication difficulties.

RESULTS

The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p<.001 for all) and on anger-in, anger-out, violence, and impulsivity (p<.05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p<.05) and more schizoid tendencies (p<.001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p<.05). Analysis of aggression-impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone.

CONCLUSIONS

Aggression-impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.

Clinical features associated with suicide attempts versus suicide gestures in an inpatient sample

The objective of this study was to test whether suicide attempters and suicide gesturers can be clinically differentiated. A total of 150 subjects who had attempted suicide at least once, had made a suicide gesture, had suicidal ideation, and/or had engaged in non-suicidal self-injury were recruited from the inpatient service of the Jiménez Díaz Foundation (Madrid, Spain). A multinomial regression analysis was conducted. Histrionic and antisocial personality disorders were risk factors specific to suicide gestures. Narcissistic personality disorder was specifically associated with suicide attempts. Borderline personality disorder was associated with both suicide gestures and attempts. A high level of impulsiveness was a risk factor specific to suicide attempts.

CONCLUSION

Suicide attempters and suicide gesturers are two distinct, although partially overlapping, populations.

Pushing the boundaries: understanding self-harm in a non-clinical population

This study investigates 122 people's descriptions of their self-harm experiences using thematic analysis. Analysis revealed four themes: What counts as self-harm, What leads to self-harm, Intentions and Managing stigma. Our participants challenged commonly accepted understandings in terms of method, outcome and intentions. Several difficulties associated with discriminating between suicidal and non-suicidal self-harm were highlighted, which may be important in clinical practice. Few participants mentioned diagnosed psychiatric disorders; they best understood self-harm through their social experiences. Focusing on social understandings of self-harm may help reduce associated stigma and barriers to help-seeking.

What's In a Note: Construction of a Suicide Note Corpus

This paper reports on the results of an initiative to create and annotate a corpus of suicide notes that can be used for machine learning. Ultimately, the corpus included 1,278 notes that were written by someone who died by suicide. Each note was reviewed by at least three annotators who mapped words or sentences to a schema of emotions. This corpus has already been used for extensive scientific research.

The emerging of xylazine as a new drug of abuse and its health consequences among drug users in Puerto Rico

During the last decade, the veterinary anesthetics have gained popularity as recreational drugs. The aim of this study was to document the use of "anestecia de caballo" (xylazine) and its consequences among drug users in Puerto Rico. The study combined a cross-sectional survey with 89 drug users and two focus groups conducted in Mayagüez with frontline drug treatment providers. Drug users were recruited from communities of the San Juan metropolitan area using a variety of ethnographic and outreach strategies. A short questionnaire developed for the study collected information on sociodemographics, xylazine use, and its consequences. The two focus groups were conducted to discuss the details related to xylazine use, its consequences, and utilization awareness. The sample comprised 63 males (70.8%) and 26 females with a mean age of 37.2 years. The mean number of years of drug use was 14.3, with a mean frequency of drug use of 5.9 times daily. More than 65% reported speedball as the principal drug of use. The prevalence of xylazine use was 80.7%. More than 42% of the sample used xylazine in a mixture with speedball. The main route of administration of xylazine was injection but 14% reported the use of xylazine by inhalation. More than 35% of the sample reported skin lesions and 21.1% reported at least one overdose episode. Multiple logistic regression analysis revealed that males (OR = 3.47, CI = 1.10-12.00) and those who reported speedball as their main drug of use (OR = 9.34, CI = 2.51-34.70) were significantly more likely to be xylazine users. Focus groups revealed that drug users claimed to recognize the presence of xylaxine in a mixture of speedball based on its effects, taste, the color of the drug (dark brown), and its odor. In conclusion, the use of xylazine among drug users in Puerto Rico seems to be an emerging trend with potentially serious health consequences.

Health Behavior Theories and Research: Implications for Suicidal Individuals' Treatment Linkage and Adherence

Treatment linkage and adherence to psychotherapeutic interventions can be challenging with suicidal individuals. Health behavior theories, specifically the Health Belief Model, Stages of Change, and Theory of Planned Behavior, focus on individuals' beliefs, their readiness to change, their perceptions of illness severity and "threat," their perceptions of significant others' attitudes toward illness and treatment, and their behavioral intentions to change. These constructs have relevance both for understanding suicidal individuals' behaviors related to treatment utilization and for understanding cultural variations in these behaviors. Furthermore, these theories have implications for clinical practices aimed at facilitating improved treatment follow-through and adherence. After describing the theories and their constructs, clinical examples are provided to illustrate applications to practice with suicidal individuals.

Sentiment Analysis of Suicide Notes: A Shared Task

This paper reports on a shared task involving the assignment of emotions to suicide notes. Two features distinguished this task from previous shared tasks in the biomedical domain. One is that it resulted in the corpus of fully anonymized clinical text and annotated suicide notes. This resource is permanently available and will (we hope) facilitate future research. The other key feature of the task is that it required categorization with respect to a large set of labels. The number of participants was larger than in any previous biomedical challenge task. We describe the data production process and the evaluation measures, and give a preliminary analysis of the results. Many systems performed at levels approaching the inter-coder agreement, suggesting that human-like performance on this task is within the reach of currently available technologies.

Evaluating the predictive validity of suicidal intent and medical lethality in youth

OBJECTIVES

To examine whether suicidal intent and medical lethality of past suicide attempts are predictive of future attempts, the association between intent and lethality, and the consistency of these characteristics across repeated attempts among youth.

METHOD

Suicide attempts in a 15-year prospective study of 180 formerly psychiatrically hospitalized adolescents (M(age at hospitalization) = 14.83; 51% female; 80% Caucasian) were characterized with the Subjective Intent Rating Scale and Lethality of Attempt Rating Scale. Anderson-Gill recurrent events survival models and generalized estimating equations were used to assess predictive validity. Generalized linear models were used to examine stability of characteristics across attempts.

RESULTS

Neither intent nor lethality from the most recent attempt predicted future attempts. The highest level of intent and most severe lethality of attempts during the follow-up predicted subsequent attempts, but the degree to which highest intent and most severe lethality contributed to prediction after considering methods of suicide attempts, past number of attempts, or psychiatric diagnoses was mixed. Across successive attempts, there was little consistency in reported characteristics. Intent and lethality were related to each other only for attempts occurring in early adulthood.

CONCLUSIONS

Highest intent and lethality were better predictors of future attempts than intent and lethality of the most recent attempt. However, these characteristics should be considered as predictors only within the context of other factors. For youth, clinicians should not infer true intent from the lethality of attempts, nor assume that characteristics of future suicide attempts will be similar to those of previous attempts.

Suicide Intent Scale in the prediction of suicide

OBJECTIVE

To assess the predictive value of the Suicide Intent Scale in patients with high suicide risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale may offer a better predictive value in suicide risk detection. Finally a shorter version of the scale was created after an item analysis.

METHOD

Eighty-one suicide attempters were assessed with the Beck's Suicide Intent Scale (SIS). All patients were followed up for cause of death. Receiver-operating characteristic (ROC) curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to predict suicide.

RESULTS

Seven patients committed suicide during a mean follow up of 9.5 years. The major finding was that mean SIS scores distinguished between suicides and survivors. The positive predictive value was 16.7% and the Area Under Curve (AUC) was 0.74. Only the planning subscale reached statistical significance. Four items were used to test a shorter version of the SIS in the suicide prediction. The positive predictive value was 19% and the AUC was 0.82.

CONCLUSIONS

The Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a shorter version of the scale may offer a better predictive value.

Suicide by firearms on the island of Crete: a 9-year record

BACKGROUND

Whereas firearm suicide mortality has been a longstanding public concern worldwide, in Greece no systematic analysis has been reported so far despite the recent evidence of a rising rate of gun ownership.

AIMS

To estimate the proportion of firearm suicides on the island of Crete, Southern Greece, well-known for its widespread gun ownership; to describe the victims' sociodemographic profile and firearm-related suicide variables; and to assess the severity of suicidal intention in the group.

METHODS

Records of suicides between 1999 and 2007 were reviewed and information was extracted into a computerized database. A rating of the circumstances section of the Beck's Suicide Intent Scale (SIS) for each case was also performed.

RESULTS

The firearm suicide rate was 1.3 per 100,000, with males constituting the vast majority. These men were more likely to be less than 55 years of age, to have lived in the western part of the island, to have some degree of planning prior to the suicidal act, and to have used a shotgun, but less likely to have left a note.

CONCLUSIONS

As an important first step toward implementing preventive initiatives the authors stress the need for a thorough look at the sociocultural factors associated with firearms in the region.

Suicide Note Classification Using Natural Language Processing: A Content Analysis

Suicide is the second leading cause of death among 25-34 year olds and the third leading cause of death among 15-25 year olds in the United States. In the Emergency Department, where suicidal patients often present, estimating the risk of repeated attempts is generally left to clinical judgment. This paper presents our second attempt to determine the role of computational algorithms in understanding a suicidal patient's thoughts, as represented by suicide notes. We focus on developing methods of natural language processing that distinguish between genuine and elicited suicide notes. We hypothesize that machine learning algorithms can categorize suicide notes as well as mental health professionals and psychiatric physician trainees do. The data used are comprised of suicide notes from 33 suicide completers and matched to 33 elicited notes from healthy control group members. Eleven mental health professionals and 31 psychiatric trainees were asked to decide if a note was genuine or elicited. Their decisions were compared to nine different machine-learning algorithms. The results indicate that trainees accurately classified notes 49% of the time, mental health professionals accurately classified notes 63% of the time, and the best machine learning algorithm accurately classified the notes 78% of the time. This is an important step in developing an evidence-based predictor of repeated suicide attempts because it shows that natural language processing can aid in distinguishing between classes of suicidal notes.

The internal suicide debate hypothesis: exploring the life versus death struggle

Researchers and theorists (e.g., Shneidman, Stengel, Kovacs, and Beck) hyothesized that suicidal people engage in an internal debate, or struggle, over whether to live or die, but few studies have tested its tenability. This study introduces direct assessment of a suicidal debate, revealing new aspects of suicidal ideation. Results, from an online survey (N = 1,016), showed nearly all suicide-risk respondents engaged in the debate. In addition, debate frequency accounted for 54% of the variance in suicidality scores, and showed significant associations with other indicators of suicide risk. Likely factors of the debate, reasons for living and dying, showed significant differences by suicidality, and most suicide-risk participants reported going online for such purposes, demonstrating a behavioral component of the debate.

The Problematic Label of Suicide Gesture: Alternatives for Clinical Research and Practice

Historically, certain terms used to describe psychopathology have evolved over time due to changing social and political contexts. This paper explores the importance of a clear and consistent language for characterizing suicide-related behaviors with a particular focus on the commonly used label "suicide gesture." The historical and contemporary uses of the term are explored, and clinical, research, and training implications are discussed. Clinicians and researchers are strongly encouraged to consider discontinuing the use of the term suicide gesture in light of its associated dismissive connotations and inconsistent application in clinical practice and research. In lieu of the term suicide gesture, recommendations are made regarding an increased emphasis by clinicians and researchers on more precise descriptions of suicidal behaviors and the functional assessment of suicide-related behaviors.

Assessing the wish to die: a 30-year review of the suicide intent scale

This analysis drew from decades of published research to evaluate the Suicide Intent Scale (SIS), the dominant research tool for assessing intent to die in apparent suicide attempts. The review sought to 1) synthesize findings related to the scale's normative scores, reliability, and validity (factorial, convergent, and predictive), and 2) examine the objective and subjective subscales' performance. A literature search yielded 158 studies reporting findings for the SIS. Psychometric properties were summarized. Studies supported the scale's reliability, especially that of the subscale assessing self-reported (versus circumstantial indicators) of intent. Mixed findings emerged regarding convergent and predictive validity. The review identified shortcomings in factorial validity and the subscales' performance, especially for adolescents. The Suicide Intent Scale has some strengths, but the weaknesses require further investigation into how to better measure intent to die in attempted suicide.