Suicide Models and Treatment Models Are Separate Entities. What Does It Mean for Clinical Suicide Prevention?

A systematic review of psychosocial protective factors against suicide and suicidality among older adults

BACKGROUND

Research on suicide rarely focuses on protective factors. The goal of this systematic review was to assess the evidence of the associations between protective factors and reduced suicidality among older adults.

METHOD

First, a scoping review was conducted to identify pertinent terms that refer to various protective factors against suicidality. A systematic review, following the PRISMA guidelines, was then conducted on a selection of 15 protective factors (e.g., perceived control, well-being and quality of life, life satisfaction, purpose-in-life, resilience, coping, religiosity, hope, self-regulation, sense of belonging, mattering, positive relationship, social support, social connectedness, and social participation), with separate searches performed on each factor in five databases. Empirical studies were eligible if participants were adults aged 60 years and over, and if the studies reported predictive statistical analysis.

RESULTS

A total of 70 studies were retained for the review. Suicidal ideation was the main outcome measure (91%). Significant associations were consistently observed between all protective factors and reduced suicidal ideations or behaviors, particularly for purpose-in-life, resilience, and positive relationships, indicating that these are solid components for suicide prevention. Using scales, instead of a single item, to measure protective factors (e.g. life satisfaction) was more efficient to capture the associations. On the other hand, results were similar whether studies used subjective (e.g., sense of belonging) or objective (e.g., social connectedness) measures.

CONCLUSION

Protective factors were inversely associated with suicidal ideation. Improving protective factors is essential for the development of late-life suicide prevention and interventions, instead of merely focusing on risk factors.

Factor Structure and Measurement Invariance of the Suicide Status Form-IV

The Suicide Status Form-IV (SSF-IV) is the measure used in the Collaborative Assessment and Management of Suicidality (CAMS). The SSF-IV Core Assessment measures various domains of suicide risk. Previous studies established a two-factor solution in small, homogeneous samples; no investigations have assessed measurement invariance. The current investigation sought to replicate previous factor analyses and used measurement invariance to identify differences in the Core Assessment by race and gender. Adults (N = 731) were referred for a CAMS consultation after exhibiting risk for suicide. Confirmatory factor analyses indicated good fit for both one- and two-factor solutions while the two-factor solution is potentially redundant. Configural, metric, and scalar invariance held across race and gender. Ordinal logistic regression models indicated that neither race nor gender significantly moderated the relationship between the Core Assessment total score and clinical outcomes. Findings support a measurement invariant, one-factor solution for the SSF-IV Core Assessment.

Can clinician's risk assessments distinguish those who disclose suicidal ideation from those who attempt suicide?

Participants were 85 individuals who made suicide attempts within two years of their Improving Access to Psychological Therapies (IAPT) assessment, identified using record linkage. Two comparison groups, non-suicidal controls (n = 1416) and (ideators, n = 743) were compared on variables extracted from the standardized IAPT risk assessment interview. Disclosure of a historical suicide attempt or non-suicidal self-injury (NSSI) distinguished those making an attempt from those with suicidal ideation only, but suicidal intent did not. A third of the participants concealed a historical suicide attempt. The IAPT Phobia Scale classified 49.30% of attempters with 100% specificity. The IAPT Phobia Scale may have clinical value in assessing risk but requires validation. Past suicide attempt and NSSI have better clinical risk assessment utility than current suicidal ideation intensity. Risk assessment relying on disclosure is likely to be flawed and risks support being withheld from those assumed to be at lower risk.

Effectiveness of a localised and systematically developed gatekeeper training program in preventing suicide among Chinese adolescents

To combat the pressing issue of contemporary suicide rates, an effective Life Gatekeeper training program was developed to educate school teachers in identifying and intervening with at-risk students. Two single-arm sequential studies evaluated the program's effectiveness, spanning implementation science stages from design to refinement. The initial study employed face-to-face training (FTF), followed by a standardized video-based 'Train-the-trainer' (TTT) approach. In Study 1, post-intervention and one-month follow-up results showed improved suicide literacy, reduced stigma, and increased willingness to intervene among gatekeepers. The revised TTT program (study 2) also yielded reduced stigmatization and improved intervention competence. In addition, six out of twenty teachers exhibited gatekeeper behaviors. In conclusion, both delivery methods proved effective, particularly the practical application of the TTT version, although further research is warranted to examine long-term effectiveness of the program.

How to save a life: From neurobiological underpinnings to psychopharmacotherapies in the prevention of suicide

The impact of suicide on our societies, mental healthcare, and public health is beyond questionable. Every year approximately 700 000 lives are lost due to suicide around the world (WHO, 2021); more people die by suicide than by homicide and war. Although suicide is a key issue and reducing suicide mortality is a global imperative, suicide is a highly complex biopsychosocial phenomenon, and in spite of several suicidal models developed in recent years and a high number of suicide risk factors identified, we still have neither a sufficient understanding of underpinnings of suicide nor adequate management strategies to reduce its prevalence. The present paper first overviews the background of suicidal behavior including its epidemiology, prevalence, age and gender correlations and its association with neuropsychiatric disorders as well as its clinical assessment. Then we give an overview of the etiological background, including its biopsychosocial contexts, genetics and neurobiology. Based on the above, we then provide a critical overview of the currently available intervention options to manage and reduce risk of suicide, including psychotherapeutic modalities, traditional medication classes also providing an up-to-date overview on the antisuicidal effects of lithium, as well as novel molecules such as esketamine and emerging medications and further molecules in development. Finally we give a critical overview on our current knowledge on using neuromodulatory and biological therapies, such as ECT, rTMS, tDCS and other options.

Living with suicidal thoughts: A scoping review

BACKGROUND

There is a significantly higher number of people experiencing severe levels of suicidal thoughts compared to that of suicidal deaths and suicide attempts. In suicide prevention research, there is a shift towards greater emphasis on people's experiences of living with suicidal thoughts. This can expand the existing evidence base, which is dominated by a biomedical approach. The aim of this review was to summarise and disseminate existing research on the lived experiences of living with suicidal thoughts.

METHODS

A scoping review by Arksey & O'Malley consisting of six stages: (1) formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4) mapping data, (5) summarising the results and (6) consulting stakeholders. PubMed, PsycINFO and CINAHL were searched for studies in English, Danish, Swedish and Norwegian. Peer-reviewed articles examining people's experiences of living with suicidal thoughts using qualitative methods were included. The search was supplemented with a citation pearl search in the Web of Science database. Twenty-eight studies were included.

RESULTS

The findings were organised under two thematic headings: (a) the significance of social connections and (b) a loss of the personal self.

CONCLUSION

There is a need for further qualitative research of people's experiences of living with suicidal thoughts from an everyday life perspective. Awareness about social connections and attachment in mental health prevention and governance is crucial. Trauma-informed care could be a useful approach to prevent suicidal thoughts as the review found that many participants had traumatic experiences in both childhood and adulthood. As part of the treatment of suicidal thoughts, it might be useful to have a focus on narrative and communicative methods and their clinical application.

Association of sociodemographic, proximal, and distal clinical factors with current suicidal ideation: Findings from a nonclinical sample of young adults

BACKGROUND

Accumulating evidence indicates that a variety of distal and proximal factors might impact a risk of suicide. However, the association between both groups of factors remains unknown. Therefore, in the present study, we aimed to investigate the interplay between distal and proximal correlates of the current suicidal ideation.

METHODS

A total of 3,000 individuals (aged 18-35 years, 41.7% males), who had reported a negative history of psychiatric treatment, were enrolled through an online computer-assisted web interview. Self-reports were administered to measure: (a) distal factors: a history of childhood trauma (CT), reading disabilities (RDs), symptoms of attention-deficit/hyperactivity disorder (ADHD), lifetime history of non-suicidal self-injury (NSSI), lifetime problematic substance use as well as family history of schizophrenia and mood disorders; (b) proximal factors: depressive symptoms, psychotic-like experiences (PLEs), and insomnia; and (c) sociodemographic characteristics.

RESULTS

Suicidal ideation was directly associated with unemployment, being single, higher level of RD, lifetime history of NSSI as well as higher severity of PLEs, depression, and insomnia. The association of distal factors with suicidal ideation was fully (a history of CT and symptoms of ADHD) or partially (a history of NSSI and RD) mediated by proximal factors (PLEs, depression, and insomnia).

CONCLUSIONS

Main findings from this study posit the role of distal factors related to neurodevelopmental disorders, CT and NSSI in shaping suicide risk. Their effects might be partially or fully mediated by depression, PLEs, and insomnia.

Understanding for Prevention: Qualitative and Quantitative Analyses of Suicide Notes and Forensic Reports

Suicide risk is associated with vulnerabilities and specific life events. The study's objective was to explore the relevance of data from forensic documentation on suicide deaths to the design of person-centered preventive strategies. Descriptive and thematic analyses were conducted of forensic observations of 286 deaths by suicide, including some with suicide notes. Key findings included the influence of health-and family-related adverse events, emotional states of loss and sadness, and failures of the health system to detect and act on signs of vulnerability, as confirmed by the suicide notes. Forensic documentation provides useful information to improve the targeting of preventive campaigns.

Vulnerabilities and life stressors of people presented to emergency departments with deliberate self-harm; consolidating the experiences to develop a continuum of care using a mixed-method framework

Objective

Suicide is a crucial public health concern. However, the interactions between bio psychosocial vulnerabilities and stressors leading to deliberate self-harm behavior remain unexplored, especially in the Indian context. This study examined the experiences leading to self-harm behavior among people who presented to emergency departments with suicidal attempts.

Methods

In this mixed-methods study, we enrolled 44 patients who presented with self-harm behavior at three tertiary health care facilities between October and December 2019. To collect quantitative data, we employed standardized tools: General Health Questionnaire (GHQ-28), General Help-Seeking Questionnaire, Mini International Neuropsychiatric Interview, and the Brief Resilience Scale. Further, we conducted semi-structured interviews to qualitatively explore participants' life experiences and other risk factors. Qualitative analyses were performed using thematic analysis and quantitative descriptive and inferential statistics were performed using STATA software.

Results

The mean age of subjects were 29.8 years. The mean suicidality score for the patients was 26 (±8.7). In univariate analysis, depression and anxiety were positively associated with suicidality. While help-seeking behavior and resilience were negatively associated with suicidality. Qualitative results were centered on three major themes; life stressors, family related stressors, and social support-related vulnerabilities. The subjects' lived experiences were introduced in the backdrop of the interplay of vulnerabilities and stressors.

Conclusion

The biopsychosocial vulnerabilities remain dormant until it is activated by life stressors resulting in severe self-harm behaviors. Mental health team-driven assertive engagement, positive coping, and social support interventions would help prevent reattempts in people with self-harm behaviors.

Suicidal intent disclosure among adult suicide decedents: Four age group comparisons

Research on who does/does not disclose suicidal intent (SI) and related factors has important implications for suicide risk management. In this paper based on the 2017-2019 National Violent Death Reporting System, we compared four age groups (18-24, 25-44, 45-64, and 65+ years) of suicide decedents with respect to associations between SI disclosure and (1) suicide contributing/precipitating factors, and (2) suicide means. The results shows that those age 18-44 were more likely to disclose SI than those age> =45, especially among those with relationship problems. Physical health problems and death/suicide of family/friend increased the likelihood of SI disclosure in the 65+ age group.

Lifesaving turning points: First-person accounts of recovery after suicide attempt(s)

This study explores the recovery processes of persons who had attempted suicide. Semi-structured interviews were conducted with eight persons who had attempted suicide and the data were analyzed by means of systematic text condensation. The participants described lifesaving turning points, which were connected to meaningful relationships, taking control over one's own life, and establishing a new everyday life. Suicide prevention efforts must be adapted to individual needs. First-person knowledge is important if we are to understand what is seen as helpful and should be emphasized when implementing suicide prevention work.

Utilising the Integrated Motivational Volitional (IMV) model to guide CBT practitioners in the use of their core skills to assess, formulate and reduce suicide risk factors

Cognitive behavioural therapists based in primary care are not usually expected to provide therapy to acutely suicidal individuals or work directly on suicidal thoughts. However, all practitioners should be vigilant about suicide risk and potentially help to reduce vulnerabilities to future suicide risk as part of their routine work. Many of the risk factors and processes hypothesised to play a role in the development of suicidal thinking and behaviours are likely to be evident within the usual content of standard evidence-based protocols for depression or anxiety disorders. In this paper we are suggesting that even within the current primary care remit, (i) an increased awareness of suicide risk vulnerability factors and (ii) using knowledge of a psychological model of suicidal behaviour to inform clinical care are likely to be extremely helpful in structuring clinical formulation and informing interventions.

Key learning aims

(1)