Suicide risk assessment tools, predictive validity findings and utility today: time for a revamp?

Evidence for the biopsychosocial model of suicide: a review of whole person modeling studies using machine learning

Background

Traditional approaches to modeling suicide-related thoughts and behaviors focus on few data types from often-siloed disciplines. While psychosocial aspects of risk for these phenotypes are frequently studied, there is a lack of research assessing their impact in the context of biological factors, which are important in determining an individual's fulsome risk profile. To directly test this biopsychosocial model of suicide and identify the relative importance of predictive measures when considered together, a transdisciplinary, multivariate approach is needed. Here, we systematically review the emerging literature on large-scale studies using machine learning to integrate measures of psychological, social, and biological factors simultaneously in the study of suicide.

Methods

We conducted a systematic review of studies that used machine learning to model suicide-related outcomes in human populations including at least one predictor from each of biological, psychological, and sociological data domains. Electronic databases MEDLINE, EMBASE, PsychINFO, PubMed, and Web of Science were searched for reports published between August 2013 and August 30, 2023. We evaluated populations studied, features emerging most consistently as risk or resilience factors, methods used, and strength of evidence for or against the biopsychosocial model of suicide.

Results

Out of 518 full-text articles screened, we identified a total of 20 studies meeting our inclusion criteria, including eight studies conducted in general population samples and 12 in clinical populations. Common important features identified included depressive and anxious symptoms, comorbid psychiatric disorders, social behaviors, lifestyle factors such as exercise, alcohol intake, smoking exposure, and marital and vocational status, and biological factors such as hypothalamic-pituitary-thyroid axis activity markers, sleep-related measures, and selected genetic markers. A minority of studies conducted iterative modeling testing each data type for contribution to model performance, instead of reporting basic measures of relative feature importance.

Conclusion

Studies combining biopsychosocial measures to predict suicide-related phenotypes are beginning to proliferate. This literature provides some early empirical evidence for the biopsychosocial model of suicide, though it is marred by harmonization challenges. For future studies, more specific definitions of suicide-related outcomes, inclusion of a greater breadth of biological data, and more diversity in study populations will be needed.

A risk calculator to predict suicide attempts among individuals with early-onset bipolar disorder

OBJECTIVES

To build a one-year risk calculator (RC) to predict individualized risk for suicide attempt in early-onset bipolar disorder.

METHODS

Youth numbering 394 with bipolar disorder who completed ≥2 follow-up assessments (median follow-up length = 13.1 years) in the longitudinal Course and Outcome of Bipolar Youth (COBY) study were included. Suicide attempt over follow-up was assessed via the A-LIFE Self-Injurious/Suicidal Behavior scale. Predictors from the literature on suicidal behavior in bipolar disorder that are readily assessed in clinical practice were selected and trichotomized as appropriate (presence past 6 months/lifetime history only/no lifetime history). The RC was trained via boosted multinomial classification trees; predictions were calibrated via Platt scaling. Half of the sample was used to train, and the other half to independently test the RC.

RESULTS

There were 249 suicide attempts among 106 individuals. Ten predictors accounted for >90% of the cross-validated relative influence in the model (AUC = 0.82; in order of relative influence): (1) age of mood disorder onset; (2) non-suicidal self-injurious behavior (trichotomized); (3) current age; (4) psychosis (trichotomized); (5) socioeconomic status; (6) most severe depressive symptoms in past 6 months (trichotomized none/subthreshold/threshold); (7) history of suicide attempt (trichotomized); (8) family history of suicidal behavior; (9) substance use disorder (trichotomized); (10) lifetime history of physical/sexual abuse. For all trichotomized variables, presence in the past 6 months reliably predicted higher risk than lifetime history.

CONCLUSIONS

This RC holds promise as a clinical and research tool for prospective identification of individualized high-risk periods for suicide attempt in early-onset bipolar disorder.

Development and validation study of the suicide screening questionnaire-observer rating (SSQ-OR)

BACKGROUND

Observer rating scales are necessary to evaluate the risk of suicide because individuals at risk for suicide are often unwilling to seek help on their own. Reliability and validity were evaluated for the newly developed Suicide Screening Questionnaire-Observer Rating (SSQ-OR).

METHODS

Preliminary items were assessed by 251 experts online and 25 questions were selected. 328 individuals at high-risk and 661 controls from 12 Crisis Response Centers and 5 university counseling centers were recruited to complete SSQ-OR, Beck Scale for Suicide Ideation (BSSI) and Patient Health Questionnaire-9 (PHQ-9). In a 6 months follow-up, we reached out to 176 participants to ask whether they had experienced a suicidal thought, plan, or attempt since the baseline assessment. Cronbach's α, Mann-Whitney U test, Spearman's correlation, factor analyses, Receiver operating characteristic (ROC) analysis and logistic regression analysis were used to verify the SSQ-OR.

RESULTS

Structural validity was supported by a two-factor solution using exploratory and confirmatory factor analyses. Excellent model fit indices for the two-factor structure using exploratory factor analysis were confirmed (RMSEA = 0.033, TLI = 0.980, CFI = 0.983). The SSQ-OR demonstrated strong internal consistency. The concurrent validity based on the correlations with other self-reported indicators of suicidal potential-BSSI and PHQ-9- revealed substantial relationships. The high-risk group was effectively characterized by a cut-off point of 4, with a sensitivity of 0.73 and a specificity of 0.79. The SSQ-OR scores were significant predictors of suicidal thoughts and behaviors within 6 months.

CONCLUSIONS

The SSQ-OR exhibits sound psychometric properties, and could be used as a complement to a self-report or clinical-administered scale to screen suicide risk comprehensively.

Adherence to childhood religious affiliation and suicide intentions in women exposed to the violence of the 1994 Genocide against the Tutsi in Rwanda

PURPOSE

To examine the association between adherence to childhood religious affiliations and serious suicide intentions in 371 women exposed to the 1994 Genocide against the Tutsi in Rwanda.

METHODS

Participants were randomly sampled in 2011 from households in the Southern Province of Rwanda. Trained interviewers gathered information on socio-economic background, genocide-related trauma exposure, Major Depressive Episode (MDE) and suicide intentions (assessed with the Mini International Neuropsychiatric Interview), and Posttraumatic Stress Disorder (PTSD) (assessed with the PTSD Checklist-Civilian version).

RESULTS

In this predominantly Christian sample, 62.8% (233/371) had adhered to their childhood religious affiliation. Adherence was associated with lower odds of serious suicide intentions (OR 0.321, 95% CI 0.13-0.78, P < 0.01) independent of socio-economic factors, court-designated victim status, trauma exposure, MDE, and PTSD; that association held following consideration of specific denomination.

CONCLUSION

Women who adhere to their childhood religious affiliation may be less likely to have serious suicide intentions following major catastrophes. Whether that association is attributable to stronger connections with lost and remaining family and friends, or greater faith in the church as a facilitator of reconciliation and coping, requires further study.

The death-implicit association test and suicide attempts: a systematic review and meta-analysis of discriminative and prospective utility

Suicide risk assessment involves integrating patient disclosure of suicidal ideation and non-specific risk factors such as family history, past suicidal behaviour, and psychiatric symptoms. A death version of the implicit association test (D-IAT) has been developed to provide an objective measure of the degree to which the self is affiliated with life or death. However, this has inconsistently been associated with past and future suicidal behaviour. Here, we systematically review and quantitatively synthesize the literature examining the D-IAT and suicide attempts. We searched psychINFO, Medline, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until 9 February 2021 to identify publications reporting D-IAT scores and suicide attempts (PROSPERO; CRD42020194394). Using random-effects models, we calculated standardized mean differences (SMD) and odds ratios (ORs) for retrospective suicide attempts. We then calculated ORs for future suicide attempts. ORs were dichotomized using a cutoff of zero representing equipoise between self-association with life and death. Eighteen studies met our inclusion criteria (n = 9551). The pooled SMD revealed higher D-IAT scores in individuals with a history of suicide attempt (SMD = 0.25, 95% CI 0.15 to 0.35); however, subgroup analyses demonstrated heterogeneity with acute care settings having lower effect sizes than community settings. Dichotomized D-IAT scores discriminated those with a history of suicide attempt from those without (OR 1.38 95% CI 1.01 to 1.89) and predicted suicide attempt over a six-month follow-up period (OR 2.99 95% CI 1.45 to 6.18; six studies, n = 781). The D-IAT may have a supplementary role in suicide risk assessment; however, determination of acute suicide risk and related clinical decisions should not be based solely on D-IAT performance.

Personal, Criminal and Social Predictors of Suicide Attempts in Prison

Previous epidemiological analyses indicate that specific demographic and criminal factors might be associated with suicide attempts during incarceration. However, there is a relative lack of research examining the role of social variables such as perceived social support. Data from 943 male inmates enrolled from three correctional facilities in Spain were collected. Participants completed self-report measures of the demographic, penitentiary and sentence-related, social support and suicide attempts variables. Approximately 1 in 11 inmates indicated that they had attempted suicide during incarceration. Inmates who were 50 years or above and who were serving longer sentences were significantly more likely to attempt suicide. Perceived social support was not associated with suicide attempts. These characteristics might be included in the development of intervention programs for incarcerated individuals.

Childhood maltreatment, psychiatric symptoms, and suicidal thoughts among adolescents receiving substance use treatment services

INTRODUCTION

Childhood maltreatment experiences are associated with future suicidal thoughts and suicide attempts, yet the roles of specific psychiatric symptoms mediating this relation remain to be clarified. To clarify these relations, we tested a model incorporating multiple forms of childhood maltreatment (sexual abuse, physical punishment, emotional neglect), past year psychiatric disorder symptoms during adolescence (anxiety, mood, and conduct disorders) and recent suicidal thoughts.

METHODS

We administered structured interviews to 394 adolescents receiving outpatient substance use treatment services in the Southeastern United States (280 males; Mage = 16.33; SDage = 1.15). Structural equation models (SEMs) were used to evaluate the degree to which relations between childhood maltreatment and suicidal thoughts were mediated by specific past-year psychiatric symptoms.

RESULTS

Mood disorder symptoms significantly mediated the relation between neglect/negative home environment and suicidal thoughts. This path of influence did not vary by gender.

CONCLUSIONS

Childhood maltreatment and subsequent psychopathology influence suicidal thoughts among adolescents receiving substance use treatment services. The findings of the present study have implications for the adaptation and delivery of substance use treatment services to adolescents to enhance treatment engagement and outcomes.

A Naturalistic, European Multi-Center Clinical Study of Electrodermal Reactivity and Suicide Risk Among Patients With Depression

Background: Electrodermal hyporeactivity has been proposed as a marker of suicidal risk. The EUDOR-A study investigated the prevalence of electrodermal hyporeactivity among patients with depression and its association with attempted and completed suicide. Methods: Between August 2014 and March 2016, 1,573 in- and outpatients with a primary diagnosis of depression (active or remission phase) were recruited at 15 European psychiatric centers. Each patient was followed-up for 1 year. Electrodermal activity was assessed at baseline with the ElectroDermal Orienting Reactivity Test. Data on the sociodemographic characteristics, clinical diagnoses, and treatment of the subjects were also collected. The severity of the depressive symptoms was assessed through the Montgomery-Asberg Depression Rating Scale. Information regarding number, time, and method of suicide attempts was gathered at baseline and at the end of the 1-year follow-up. The same data were collected in case of completed suicide. Results: Hyporeactive patients were shown to be significantly more at risk of suicide attempt compared to reactive patients, both at baseline and follow-up. A sensitivity of 29.86% and a positive predictive value (PPV) of 46.77% were found for attempted suicide at baseline, while a sensitivity of 35.36% and a PPV of 8.92% were found for attempted suicide at follow-up. The sensitivity and PPV for completed suicide were 25.00 and 0.61%, respectively. However, when controlled for suicide attempt at baseline, the association between hyporeactivity and follow-up suicide attempt was no longer significant. The low number of completed suicides did not allow any analysis.

A Review of Suicide Risk Assessment Tools and Their Measured Psychometric Properties in Korea

While there has been a slew of review studies on suicide measurement tools until now, there were not any reviews focusing on suicide assessment tools available in Korea. This review aimed to examine the psychometric properties of tools developed in Korea or the translated versions from the original tools in their foreign language and to identify potential improvements and supplements for these tools. A literature search was done using the Korean academic information search service, Research Information Service System, to identify the suicide measures to be included in this review. Abstracts were screened to identify which measures were used to assess suicide-related factors. Based on the established inclusion and exclusion criteria, 18 tools remained and we assessed their psychometric properties. The current review indicated several major findings. First, many of the tools did not report predictive validity and even those with predictive validity were based on past suicide attempts. Second, some of the tools overlooked the interactive component for the cause of suicide. In addition, information to supplement the self-reported and clinician-administered reports by collecting reports from the subjects' families and acquaintances is needed. It is also important to develop a screening tool that examines other aspects of an individual's personal life, including unemployment, bereavement, divorce, and childhood trauma. Moreover, tools that have been studied in more diverse groups of the population are needed to increase external validity. Finally, the linguistic translation of the tools into Korean needs to consider other cultural, social, and psychological factors of the sample of interest.

Suicidality Among Children and Youth With and Without Autism Spectrum Disorder: A Systematic Review of Existing Risk Assessment Tools

Individuals with autism are at heightened risk for experiencing suicidality compared to those without autism. Despite this, it is unknown what tools are used to assess suicide risk in research and clinical practice among children and youth with autism. This systematic review examined tools commonly used to measure suicidality in children and youth with and without autism spectrum disorder. Four databases were searched. We identified five tools (C-SSRS, PSS, SITBI, SIQ-JR, BSS) commonly used with youth in the general population; however, we did not identify any tools that were commonly used autistic children and youth. Results highlight the lack of available tools utilized to measure suicidality in autistic children and youth. We propose a framework to facilitate research to fill this gap.

Multi-informant prediction of near-term suicidal behavior independent of suicidal ideation

BACKGROUND

Both the Suicide Crisis Syndrome (SCS) and clinicians' emotional responses to suicidal patients are predictive of near-term suicidal behaviors. Thus, we tested predictive validity of a combination of the proposed Diagnostic and Statistical Manual SCS criteria and the Therapist Response Questionnaire Suicide Form (TRQ-SF) for near-term suicidal behavior.

METHODS

The presence of SCS in adult psychiatric outpatients (N=451) was assessed using relevant items from validated psychometric assessments. Clinicians completed the TRQ-SF immediately after patient intake. Suicide attempts (SA) and a combination of suicide plans and attempts (SPA) were measured at one month follow-up (N=359).

RESULTS

At follow-up nine patients reported having SPA and seven reported SA. Meeting the SCS criteria were associated with near-term SA (χ2=5.987, p<0.01), while high TRQ-SF scores were associated with both near-term SA (χ2=5.971, p<0.05) and SPA (χ2=7.069, p<0.01). Meeting either the SCS or having high TRQ-SF scores, but not both, was associated with near-term SA (χ2=11.893, p<0.01) and SPA (χ2=11.449, p<0.01). Incremental predictive validity over standard suicide risk factors and individual scales was demonstrated in logistic regressions.

CONCLUSIONS

Multi-informant risk assessment not reliant on patient self-reported ideation appear to enhance predictive power of traditional risk assessments in identifying imminent suicide risk.

Brain grey matter abnormalities in first episode non-affective psychosis patients with suicidal behaviours: The role of neurocognitive functioning

BACKGROUND

Suicide is one of the leading causes of premature death in first-episode psychosis (FEP) patients. The understanding of suicidal behaviour (SB) is limited, and new and integrative approaches focusing on the likely relationship of the biological and cognitive features of SB in the early phases of psychosis are warranted. We aimed to study the relationship of brain grey matter anomalies and cognitive functioning with SB or suicidal risk in a large sample of non-affective FEP patients.

METHODS

We used a voxel-based morphometry analysis in 145 FEP patients to investigate the pattern of structural brain abnormalities related to SB. In addition, bivariate and multivariate analyses were performed to explore the relationship between cognitive functioning and SB.

RESULTS

A reduction in grey matter volume in the frontal area, temporal gyrus, precuneus, uncus, amygdala, left cuneus and subcallosal gyrus as well as a marked regional volume reduction in the right hemisphere was linked with the presence of SB. Additionally, worse global cognitive functioning and living in urban areas were identified as suicide risk factors.

CONCLUSIONS

This study provides some insights about the brain abnormalities associated with SB in FEP patients. Specifically, the areas reported are involved in important functions related to SB, such as impulsivity, problem solving or responses to pain. Thus, the results confirm the relevant role of cognitive functioning on SB.

Prisoners with neurodevelopmental difficulties: Vulnerabilities for mental illness and self-harm

BACKGROUND

Research into neurodevelopmental disorders in adult offenders has tended to be disorder specific, so hindering service planning for a group of offenders with similar vulnerabilities.

AIM

To examine vulnerabilities for mental illness and self-harming behaviours among male prisoners screening positive for a range of neurodevelopmental difficulties-including but not confined to disorders of intellectual ability, attention deficit hyperactivity, and in the autistic spectrum.

METHOD

In a cross-sectional study, prisoners who screened positive for neurodevelopmental difficulties were compared to prisoners who screened negative for the same on indicators of suicide-related and self-harm behaviours, mental illness, and substance misuse using the Mini International Neuropsychiatric Interview (MINI).

RESULTS

Of 87 prisoners who screened positive for neurodevelopmental difficulties, 69 had full MINI mental health data. In comparison with 69 neurotypical men in the same prison, the neurodevelopmental difficulties group was significantly more likely to have thought about self-harm and suicide in the last month and to have significantly higher rates of concurrent mental disorders including psychosis, anxiety, depression, personality disorder, and substance dependency disorders.

CONCLUSIONS

This is one of the first studies to examine the mental health of adults with neurodevelopmental difficulties in a prison setting. This group, unlike those who meet diagnostic threshold, is not routinely considered by mental health or correctional services. The study found prisoners with neurodevelopmental difficulties showed greater vulnerability to mental disorder and thoughts of suicide and suicide-related behaviours than other prisoners. Accordingly, we recommend routine early screening across the criminal justice system for any neurodevelopmental difficulties to inform decision-making on the most appropriate disposal and support.

Evaluation of a Suicide Risk Assessment Tool in a Large Sample of Detained Youth

OBJECTIVES

We evaluated the six-item Inmate Security Assessment (ISA) tool used among detained youth in Manitoba, Canada.

METHOD

Two hundred and forty-one recorded self-harm incidents among all incarcerated youth occurred between January 1, 2005 and December 31, 2010 (N=5102). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR) and negative likelihood ratio (NLR) for three categories of suicide risk (high, medium, and low) as well as each of the six suicide risk evaluation indicators were determined. Receiver operating characteristic (ROC) curves and area under the curve (AUC) calculations for the three suicide risk levels and the six indicators were created.

RESULTS

Having at least a low suicide risk level (93.8%) or at least one suicide risk factor (94.6%) provided high sensitivity. Specificity was high if an individual had at least a medium suicide risk level (94.2%) or at least three suicide risk indicators (96.7%). The PPV was low (8.9-16.2%) and the NPV was high (94.9-99.3%) for all suicide risk levels. The most sensitive risk factor for self-harm was a prior history of suicidal behavior or a family history of suicide (94.6%). All risk indicators had a low PPV (7.4-23.1%) and a high NPV (95.4-99.5%). A very low NLR was found for those without prior suicidal behavior or a family history of suicide (0.107). The AUC was 0.719 (95%CI = 0.692-0.746), indicating a fair test.

CONCLUSION

The ISA is a moderately accurate tool for identifying risk for self-harm in detained youth.

Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

Suicide risk and social support in Australian resource sector employees: A cross-sectional study

This study examines the association between suicide risk and social support in Australian resource sector employees. We included 150 participants, who completed the Beck Hopelessness Scale and MOS-Social Support Survey. Data were analyzed using smallest space analysis and multidimensional scalogram analysis. The analysis identified four distinct regions, which were conceptualized as "confiding," "affection," "companionship," and "practical help." All of these components of social support were associated with hopelessness, which has important clinical implications as hopelessness is related to suicide risk. The results of this study also demonstrated that lower levels of social support, and greater sense of perceived hopelessness tended to lead to Australian resource workers seeking assistance from mental health professionals in the previous year. Attention should turn towards providing interventions that promote social support for employees in Australian resource industry.

Long noncoding RNA expression in peripheral blood mononuclear cells and suicide risk in Chinese patients with major depressive disorder

BACKGROUND

WHO stated that nearly one million people commit suicide every year worldly, and 40% of the suicide completer suffered from depression. The primary aim of this study was to explore the association between long noncoding RNAs (lncRNAs) expression in peripheral blood mononuclear cells (PBMCs) and suicide risk of patients with major depressive disorder (MDD).

METHODS

Using Human LncRNA 3.0 microarray profiling which includes 30,586 human lncRNAs and RT-PCR, six down-regulated lncRNAs were identified differentially expressed in MDD patients. According to suicidal ideation and suicidal attempt, the suicide risk of MDD patients was classified into suicidal ideation versus no suicidal ideation groups, and past attempt versus no past attempt groups, respectively. The expression of six lncRNAs in MDD patients and controls were examined by RT-PCR.

RESULTS

The expression of six lncRNAs had significant differences between no suicidal ideation, suicidal ideation, and controls; corresponding lncRNAs associated with suicidal attempt had remarkable differences between no past attempt, past attempt, and controls. Additionally, only the expression of lncRNAs in suicidal ideation group and past attempt group markedly declined compared with controls.

CONCLUSIONS

This study indicated that the expression of six down-regulated lncRNAs had a negative association with suicide risk in MDD patients, and the expression of lncRNAs in PBMCs could have the potential to help clinician judge the suicide risk of MDD patients to provide timely treatment and prevent suicide.

Suicide risk among prisoners in French Guiana: prevalence and predictive factors

BACKGROUND

Suicide rates in prison are high and their risk factors are incompletely understood. The objective of the present study is to measure the risk of suicide and its predictors in the only prison of multicultural French Guiana.

METHODS

All new prisoners arriving between September 2013 and December 2014 were included. The Mini International Neuropsychiatric Interview (MINI) was used and socio-demographic data was collected. In order to identify the predictors of suicide risk multivariate logistic regression was used.

RESULTS

Of the 707 prisoners included 13.2% had a suicidal risk, 14.0% of whom had a high risk, 15.1% a moderate risk and 41.9% a low risk. Predictive factors were depression (OR 7.44, 95% CI: 3.50-15.87), dysthymia (OR 4.22, 95% CI: 1.34-13.36), panic disorder (OR 3.47, 95% CI: 1.33-8.99), general anxiety disorder (GAD) (OR 2.19, 95% CI: 1.13-4.22), men having been abused during childhood (OR 21.01, 95%, CI: 3.26-135.48), having been sentenced for sexual assault (OR 7.12, 95% CI: 1.98-25.99) and smoking (OR 2.93, 95%, CI 1.30-6.63).

CONCLUSION

The suicide risk was lower than in mainland France, possibly reflecting the differences in the social stigma attached to incarceration because of migrant populations and the importance and trivialization of drug trafficking among detainees. However, there were no differences between nationalities. The results reemphasize the importance of promptly identifying and treating psychiatric disorders, which were the main suicide risk factors.

EUDOR-A multi-centre research program: A naturalistic, European Multi-centre Clinical study of EDOR Test in adult patients with primary depression

BACKGROUND

Electrodermal reactivity has been successfully used as indicator of interest, curiosity as well as depressive states. The measured reactivity depends on the quantity of sweat secreted by those eccrine sweat glands that are located in the hypodermis of palmar and plantar regions. Electrodermal hyporeactive individuals are those who show an unusual rapid habituation to identical non-significant stimuli. Previous findings suggested that electrodermal hyporeactivity has a high sensitivity and a high specificity for suicide. The aims of the present study are to test the effectiveness and the usefulness of the EDOR (ElectroDermal Orienting Reactivity) Test as a support in the suicide risk assessment of depressed patients and to assess the predictive value of electrodermal hyporeactivity, measured through the EDOR Test, for suicide and suicide attempt in adult patients with a primary diagnosis of depression.

METHODS AND DESIGN

1573 patients with a primary diagnosis of depression, whether currently depressed or in remission, have been recruited at 15 centres in 9 different European countries. Depressive symptomatology was evaluated through the Montgomery-Asberg Depression Scale. Previous suicide attempts were registered and the suicide intent of the worst attempt was rated according to the first eight items of the Beck Suicide Intent Scale. The suicide risk was also assessed according to rules and traditions at the centre. The EDOR Test was finally performed. During the EDOR Test, two fingers are put on gold electrodes and direct current of 0.5 V is passed through the epidermis of the fingers according to standards. A moderately strong tone is presented through headphones now and then during the test. The electrodermal responses to the stimuli represent an increase in the conductance due to the increased number of filled sweat ducts that act as conductors through the electrically highly resistant epidermis. Each patient is followed up for one year in order to assess the occurrence of intentional self-harm.

DISCUSSION

Based on previous studies, expected results would be that patients realizing a suicide attempt with a strong intent or committing suicide should be electrodermally hyporeactive in most cases and non-hyporeactive patients should show only few indications of death intent or suicides.

TRIAL REGISTRATION

The German Clinical Trials Register, DRKS00010082 . Registered May 31^st, 2016. Retrospectively registered.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk

BACKGROUND

To date, no diagnostic tool has demonstrated clinical value for the assessment of short-term suicide risk among high-risk individuals. To this end we have developed the Modular Assessment of Risk for Imminent Suicide (MARIS), a modular patient and clinician informed risk evaluation instrument. Here we assess its predictive validity for suicidal behavior (SB) in psychiatric patients following discharge from an inpatient unit.

METHODS

The MARIS and a psychological test battery were administered to 136 adult psychiatric patients hospitalized for high risk of suicide. Eighty-six participants had complete data at discharge and 59 (69.8%) were reached for follow-up. Logistic regressions were used to assess the predictive validity of the MARIS for SB over the 4-8weeks following hospital discharge and its incremental predictive validity over standard risk factors.

RESULTS

Patients who exhibited SB in the period between initial assessment and follow-up had significantly higher MARIS scores. ROC analysis indicated good sensitivity and specificity of MARIS in identifying risk (OR=19). Further, MARIS total score significantly improved predictive validity by the standard risk factors when added to a model comprising global depression severity, hopelessness, and lifetime number of suicide attempts, and was the only factor that approached independent significance.

CONCLUSION

The MARIS appears to be a practical and effective tool for detecting short-term suicide risk following hospital discharge, supporting the validity of modular multi-informant approach to suicide risk evaluation. Replication of these findings and further investigation of the applications of such an approach are warranted.

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.

Male depression and suicide: What NPs should know

The discordant relationship between men's low rates of diagnosed depression and high male suicide rates continues to prevail in North America. NPs are in a unique position to prevent suicide through recognizing and addressing the gendered nature of men's depression.

Attitudes of acceptability and lack of condemnation toward suicide may be predictive of post-discharge suicide attempts

BACKGROUND

Suicide attempts (SA) after psychiatric hospitalization continue to be a major cause of morbidity. Implicit measures may enhance our ability to assess suicide risk. In this context, we describe the first use of the Suicide Opinion Questionnaire (SOQ) to identify post-discharge suicide attempters.

METHODS

Adult psychiatric inpatients admitted for suicidality (N = 91) were administered a battery of measures including the SOQ, and forty were reached and reassessed for SA at two months post-discharge. Exploratory factor analysis (EFA) on items associated with suicidality was performed to identify latent constructs. Linear discriminant analysis (LDA) was used to optimize factor combination for suicide identification. Results were compared with explicit measures of suicidality, and logistic regression was used to control for other risk factors. Finally, a simplified 9-item scale was derived from the results and its performance compared to that of the linear discriminant function.

RESULTS

Twenty items differed between patients with and without SA at intake or follow-up. EFA on these identified two factors: suicide attempters indicated greater acceptability and less moral condemnation of suicide. The LDA-derived discriminant function and 9-item scale was significantly sensitive and specific for post-discharge SA.

CONCLUSIONS

Attitudes of acceptability and lack of condemnation toward suicide may constitute an implicit measure of suicidality that could contribute to risk assessment in a high-risk population.

The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: a review

We reviewed research on the relationship between (a) exposure to psychological trauma and (b) nonsuicidal self-injury (NSSI) and suicidality (suicidal ideation [SI] and suicide attempts [SA]) in individuals with dissociative disorders and posttraumatic stress disorder (PTSD). The review provides a context for the special issue of the Journal of Trauma & Dissociation on these topics. Exposure to childhood sexual abuse is the most consistent traumatic antecedent of self-harm, although traumatic violence in childhood (particularly physical abuse) and adulthood (particularly domestic violence) and exposure to multiple types of traumatic stressors also are associated with NSSI and SI/SA. Dissociative disorders and PTSD are consistently associated with increased NSSI and SA/SI. There is preliminary cross-sectional evidence that dissociation and posttraumatic stress disorders may mediate the relationship between psychological trauma and NSSI and SI/SA. Research on emotion dysregulation as a potential cross-cutting mechanism linking dissociation, PTSD, and self-harm is also reviewed. We conclude with a discussion of implications for clinical practice and future directions for scientific research.