[Utilization of Outpatient Psychotherapy and Outpatient Psychiatric Treatment by Men and Women after Inpatient Treatment due to Suicide Attempt or Acute Suicidal Crisis]

OBJECTIVE

The strongest predictor of suicide attempts is a previous suicide attempt. Individuals hospitalized for suicidal ideation and behavior face an increased risk of suicide following discharge. This study investigates the extent to which outpatient treatment services are utilized the first 6 months after discharge and whether men and women differ in this regard.

METHOD

The study examines data of 124 individuals (with suicide attempts (lifetime), 59.7% female) on the use of outpatient treatment services in the 6 months after inpatient treatment.

RESULTS

37.9% (N=47) of individuals reported not having used any treatment services at all. Men were significantly less likely to make use of the services.

CONCLUSION

Members of a group with an increased risk of suicide, to a large extent, fail to make use of outpatient treatment services. Discharge management should increasingly focus on (gender-specific) barriers and pave the way for treatment in outpatient.

Understanding suicidal ideation-a network analysis of the Interpersonal Needs Questionnaire

INTRODUCTION

Identifying various interacting risk factors for suicidality is important to develop preventive measures. The Interpersonal-Psychological Theory of Suicidal Behavior (IPTS) postulates suicidal ideation resulting from the occurrence of Perceived Burdensomeness (PB) and Thwarted Belongingness (TB). Suicidal behavior ultimately occurs if people have a Capability for Suicide. In past studies, the validity of TB was often not empirically confirmed, questioning which of the aspects of TB are central and related to suicidal ideation and whether applied measurement methods adequately capture the construct.

METHOD

Using a sample of 3,404 individuals from different clinical and nonclinical settings, 30% (1,023) of whom reported suicidal ideation, two network analyses were conducted on the Interpersonal Needs Questionnaire (INQ) and a variable mapping suicidal ideation.

RESULTS

Analyses revealed that some items of the INQ were not related to suicidal ideation and the most central items did not have the strongest associations to suicidal ideation.

CONCLUSION

Based on these results, a shortened version of the INQ with the four items that showed the strongest associations with suicidal ideation in the network analyses was suggested.

Phenotyping suicidal ideation and behavior: Comparing clinical characteristics and future suicide attempts between suicidal subtypes in two clinical samples

OBJECTIVES

To further validate the concept of suicidal subtypes distinguished by indicators of suicidal thinking and behavior with regard to clinical characteristics and past and future suicide attempts.

METHODS

Psychiatric inpatients were assessed (study 1: ecological momentary assessments in 74 depressed inpatients with suicidal ideation; study 2: clinical assessments in 224 inpatients after a suicide attempt and over a 12-month follow-up period). Subtypes were identified using latent profile analysis (based on indicators of real-time suicide ideation) and latent class analysis (based on features of past suicide ideation and suicide attempt characteristics). Comparisons between subtypes included clinical characteristics (depression, suicidal ideation, trait impulsivity, childhood trauma) as well as past (study 1) and future (study 2) suicide attempts.

RESULTS

Suicidal subtypes emerged that are characterized by suicidal ideation means and stability and features of past suicidal behavior (four in study 1, three in study 2). The subtypes differed in terms of depression/suicidal ideation, but not in terms of trait impulsivity/childhood trauma. Although not significant, the subtypes "high-stable" and "low-moderate stable" reported multiple re-attempts more frequently during follow-up than the "low-stable" subtype in study 2.

CONCLUSION

Differences in clinical variables (and by trend in future suicide attempts) clearly point to the clinical relevance of suicidal subtypes (with variability of suicidal thoughts playing a particularly important role).

Defeat, entrapment, and suicidal ideation: Twelve-month trajectories

BACKGROUND

Defeat and entrapment have been highlighted in the development of suicidal ideation within the Integrated Motivational-Volitional model of suicidal behavior. Research suggests that entrapment has to be differentiated into internal and external entrapment. The aim of this study was to investigate the associations between defeat, internal, external entrapment, and suicidal ideation within and prospectively over measurements.

METHODS

A sample of 308 psychiatric inpatients (53% female) aged 18 to 81 years (M = 36.92, SD = 14.30) was assessed for the four constructs after admission to a psychiatric ward and six, nine, and twelve months later. Multilevel analyses were conducted to examine associations.

RESULTS

Defeat was associated with (a change in) internal and external entrapment. Defeat predicted a change in internal entrapment over time. Defeat and internal, but not external, entrapment were associated with (a change in) suicidal ideation. Internal entrapment was able to predict suicidal ideation. Internal entrapment and defeat predicted a change in suicidal ideation over time.

CONCLUSION

Results highlight the importance to distinguish between internal and external entrapment, and their specific association with suicidal ideation. Perceptions of internal entrapment are of central relevance when experiencing suicidal ideation and should be considered in clinical practice.

Suicidal behavior in the social environment: Does exposure moderate the relationship between an individual's own suicidal ideation and behavior?

INTRODUCTION

Suicidal behavior still cannot be sufficiently predicted. Exposure to suicidal behavior in the personal social environment is assumed to moderate the individual's transition from suicidal ideation to suicidal behavior within the Integrated Motivational-Volitional Model of Suicidal Behavior (IMV-model). This study aimed to investigate this moderating effect in a German high-risk sample.

METHODS

We interviewed 308 psychiatric inpatients (53% female) aged 18 to 81 years (M = 36.9, SD = 14.30) admitted after attempted suicide (53%) or due to an acute suicidal crisis (47%) regarding exposure events in their social environment. Four types of exposure events were analyzed using moderation analyses: familial suicides/suicide attempts, non-familial suicides/suicide attempts. Additionally, the numbers of reported exposure events were compared between patients with and without a recent suicide attempt as well as between patients with lifetime suicide attempts and lifetime suicidal ideation.

RESULTS

Neither moderating effects of exposure events on the relationship between lifetime suicidal ideation and recent suicidal behavior nor group differences between suicidal ideators and suicide attempters regarding the exposure events were found.

CONCLUSIONS

Exposure events might have differential and possibly protective effects on suicidal behavior - depending on type and quality (intensity, personal relevance, and recency) of event - and on the outcome (suicide vs. suicide attempt).

Predicting suicidal ideation in a longitudinal high-risk sample: Multilevel analyses and 12-month trajectories

BACKGROUND

The Interpersonal Theory of Suicide states that suicidal ideation (SI) results from perceived burdensomeness (PB) and thwarted belongingness (TB). Cross-sectional studies found associations with SI. This study examined the prospective prediction of SI.

METHODS

Three hundred and eight inpatients reporting severe SI or a recent suicide attempt were assessed four times within 12 months. The prediction of SI was examined using multilevel analyses, group comparisons, and logistic regression analyses.

RESULTS

Cross-sectionally, PB and TB were associated with SI. Prospectively, neither PB nor TB predicted SI. We found no autocorrelation of SI over time. Patients with persistent and fluctuating SI reported higher PB at T0. PB predicted the persistence of SI over 12 months.

CONCLUSION

Results emphasize cross-sectional associations between PB, TB, and SI. PB and TB could not predict the intensity of SI over time. SI did not predict itself over time. PB was associated with a persistent trajectory of SI over 12 months.

Child abuse and suicidality in the context of the Interpersonal Psychological Theory of Suicide: A network analysis

OBJECTIVES

While there is evidence for an association of child abuse with suicidality in the course of life, the underlying mechanisms remain unclear. The Interpersonal Psychological Theory of Suicide (IPTS) provides a theoretical framework to investigate this relationship. The present study examines how different subtypes of child abuse are related to suicidal ideation and to attempts in the context of the IPTS.

METHODS

146 psychiatric inpatients (M = 37.9 years, 62% female) with an acute suicidal crisis (n = 71) or a recent suicide attempt (n = 74) were examined at baseline (T0) and six (T1) months later. We measured emotional, physical, and sexual abuse, the constructs of the IPTS (thwarted belongingness, perceived burdensomeness, and capability for suicide) and suicidal ideation as well as suicide attempts. Using the statistics program R, a network analysis of all named constructs was conducted. Centrality measures were computed.

RESULTS

Emotional abuse was the most central kind of abuse in the network and had a direct relationship with suicide attempts and an indirect relationship with suicidal ideation via perceived burdensomeness. Physical and sexual abuse showed no significant relations with the different constructs of the IPTS.

CONCLUSION

The major limitation of this study was the modest sample size which reduced the number of variables able to be included in the network. Regarding child abuse, the results underline that emotional abuse plays a central role in this network and may be important for suicide risk assessment. Future research should address this topic in a larger sample.

PRACTITIONER POINTS

Emotional abuse was the most central kind of abuse in this network analysis. Sexual abuse was the only kind of abuse with a direct relation to suicidal ideation. Capability for suicide had just a marginal position in the network analysis. Early interventions addressing the effects of child abuse are recommended. Replications in larger samples and with more relevant variables are needed.

Testing the Four Main Predictions of the Interpersonal-Psychological Theory of Suicidal Behavior in an Inpatient Sample Admitted Due to Severe Suicidality

This study aimed to evaluate four main predictions of the Interpersonal Psychological Theory of Suicide (IPTS): the importance of perceived burdensomeness (PB), thwarted belongingness (TB), hopelessness (H), and capability for suicide (CS) for (passive/active) suicide ideation, suicide intent and suicide attempts. N = 308 psychiatric inpatients admitted due to severe suicidality (53.6% female: n = 165; age: M = 36.82, SD = 14.30, range: 18-81) completed self-report measures of TB, PB, H, CS and suicide ideation as well as interviews on suicide intent and suicide attempts. TB and PB were associated with (passive/active) suicidal ideation, whereas the three-way interaction PB, TB, and H was not associated with active suicide ideation. Fearlessness about death in conjunction with active suicidal ideation was not associated with suicide intent and the interaction of PB, TB, and CS was neither predictive of recent suicide attempt status nor lifetime number of suicide attempts. Given the cross-sectional nature of the data, conclusions on causality should be handled carefully. The results challenge the theoretical validity of the IPTS and its clinical utility-at least within the methodological limitations of the current study. Yet, findings underscore the importance of PB in understanding suicidality.

From decision to action: Suicidal history and time between decision to die and actual suicide attempt

A substantial proportion of suicide attempts seem to be realized in a sudden manner. However, it is unclear how suicide attempters showing a rapid transition from the decision to die to acting differ from suicide attempters showing a slower transition regarding their suicidal history. The main aim of this study was to determine the proportion of suicide attempters, who reported a rapid transition (≤5, ≤10, ≤180 min) between their decision to die and their actual attempt. Furthermore, attempter groups (≤ vs. >5, ≤ vs. >10 and ≤ vs. >180 min) were compared regarding suicidal history (ideation, plans, and number of lifetime as well as 12 month suicide attempts) as well as depression, hopelessness and trait impulsivity. In total, 118 inpatients (62.7% female; age: M = 38.71, SD = 14.71) hospitalized due to a recent suicide attempt were assessed using structured clinical interview measures assessing suicidal history and self-report instruments. Thirty-six percent reported a time period of ≤5 min, 44% a time period of ≤10 min and 73% a time period of ≤180 min between their decision to die and their attempt. Participants with a rapid transition (≤5, ≤10, ≤180 min) did not differ from participants with a slower transition (>5, >10, >180 min) regarding suicidal history, depression, hopelessness and trait impulsivity. Taken together, a rapid transition seems common, but nevertheless, rapidly realized suicide attempts cannot necessarily be characterized as impulsive.

The role of the 5-HTTLPR polymorphism in acquired capability for suicide

OBJECTIVE

According to the Interpersonal Psychological Theory of Suicide, capability for suicide comprises two dimensions: fearlessness about death and elevated pain tolerance. The short (S) allelic variant of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) has repeatedly been associated with more violent and lethal suicide methods and lethality of suicide attempts. The current study aimed to investigate whether 5-HTTLPR allelic variants are associated with fearlessness about death and pain tolerance/persistence and whether it moderates the relationship between childhood maltreatment and acquired capability for suicide.

METHOD

A cohort of 208 inpatients hospitalized due to a recent suicide attempt or severe suicidal ideation was genotyped for the 5-HTTLPR and assessed for childhood maltreatment. Subjective pain tolerance and fearlessness about death as well as objective pain persistence was assessed using a pressure algometer.

RESULTS

Fearlessness about death, pain tolerance, and pain persistence did not differ between 5-HTTLPR genotypes. However, there was a significant correlation between self-reported childhood maltreatment and fearlessness about death that emerged exclusively in homozygous S-allele carriers.

CONCLUSION

Results suggest that there are no "high-risk"-alleles that generally increase capability for suicide. However, in terms of future suicide-related behaviors exposure to childhood maltreatment events could exert a particularly negative influence on homozygous S-allele carriers by increasing their fearlessness about death.

Interpersonal theory of suicide: prospective examination

BACKGROUND

The interpersonal theory of suicide (IPTS) is one of the most intensively researched contemporary theories on the development of suicidal ideation and behaviour. However, there is a lack of carefully conducted prospective studies.

AIMS

To evaluate the main predictions of the IPTS regarding the importance of perceived burdensomeness, thwarted belongingness and capability for suicide in predicting future suicide attempts in a prospective design.

METHOD

Psychiatric in-patients (n = 308; 53.6% (n = 165) female; mean age 36.82 years, s.d. = 14.30, range 18-81) admitted for severe suicidal ideation (n = 145, 47.1%) or a suicide attempt completed self-report measures of thwarted belongingness, perceived burdensomeness, capability for suicide, hopelessness, depression and suicidal ideation as well as interviews on suicide intent and suicide attempts and were followed up for 12 months. Logistic regression and receiver operating characteristics (ROC) analysis were conducted.

RESULTS

The interaction of perceived burdensomeness, thwarted belongingness and capability for suicide was not predictive of future suicide attempts, but perceived burdensomeness showed a significant main effect (z = 3.49, P < 0.01; OR = 2.34, 95% CI 1.59-3.58) and moderate performance in screening for future suicide attempts (area under the curve AUC = 0.729, P < 0.01).

CONCLUSIONS

The results challenge the theoretical validity of the IPTS and its clinical utility - at least within the methodological limitations of the current study. Yet, findings underscore the importance of perceived burdensomeness in understanding suicidal ideation and behaviour.

Validation of the motivational phase of the integrated motivational-volitional model of suicidal behavior in a German high-risk sample

BACKGROUND

The Integrated Motivational-Volitional (IMV) model of suicidal behavior proposes in its motivational phase that perceptions of defeat and entrapment (total, internal and external entrapment) lead to the development of suicidal ideation and that thwarted belongingness and perceived burdensomeness moderate this process. The aim of this study was to test the motivational phase of the IMV model cross-sectionally in a German sample of psychiatric inpatients.

METHODS

A total of 308 psychiatric inpatients (53% female) aged 18 to 81 years (M = 36.92, SD = 14.30) were included in the study and investigated within 14 days after psychiatric admission due to suicide attempt (53%) or acute suicidal crisis (47%). Statistical analyses included a mediation analysis and moderation analyses.

RESULTS

Results demonstrate a simple mediation of defeat via entrapment (total, internal and external entrapment) on suicidal ideation. The interaction between thwarted belongingness and perceived burdensomeness was confirmed as a motivational moderator.

LIMITATIONS

Limiting factors of the present study are the cross-sectional design and the retrospective assessment of suicidal ideation.

CONCLUSION

The main assumptions of the motivational phase of the IMV model could empirically be confirmed. Perceptions of defeat, internal and external entrapment, thwarted belongingness, and perceived burdensomeness should be taken into account with regard to prevention, risk assessment and interventions of suicidal ideation and attempts. However, future investigations based on prospective data are warranted.

Validation of the German capability for suicide questionnaire (GCSQ) in a high-risk sample of suicidal inpatients

BACKGROUND

The German Capability for Suicide Questionnaire (GCSQ) was developed to measure fearlessness of death and pain tolerance - two constructs central to the Interpersonal Theory of Suicide. Initial scale development, definition of the factor structure and confirmation of the two-dimensional factor structure was performed in samples suffering from relatively low levels of suicide ideation/behavior. The present study aimed to validate the German Capability for Suicide Questionnaire (GCSQ) in a high-risk sample of suicidal inpatients.

METHODS

Factor structure, reliability and validity were investigated in a sample of inpatients (N = 296; 53.0% female; age in years: M = 36.81, SD = 14.27) admitted to a hospital due to a recent suicide attempt or an acute suicidal crisis (in immediate need of inpatient treatment). To establish convergent validity, interview-based assessments of lifetime suicide attempts and non-suicidal self-injury as well as questionnaire-based assessments of painful and provocative events were used. Finally, stability of GCSQ-scores over a follow-up period of 12 months was assessed.

RESULTS

Results indicated good psychometric properties, and provided additional evidence for construct validity and stability of the subscales over a one-year period, and demonstrated adequate fit of the data with respect to the original factor structure.

CONCLUSIONS

Results suggest that the GCSQ is a brief, reliable, and valid measure of capability for suicide that can be used in clinic assessment and research.

Psychometrische Eigenschaften und Faktorstruktur der deutschen Version der Beck-Suizidgedanken-Skala (BSS): Validierung an einer Stichprobe psychiatrischer Patienten

Ziel der Studie Dimensionalität, Reliabilität und konvergente Validität der deutschsprachigen Beck Scale for Suicidal Ideation (BSS) sollen erstmalig in einer klinischen Stichprobe untersucht warden.

Methodik 308 stationäre Patienten nach Suizidversuch/mit akuter Suizidalität wurden rekrutiert (53,6% weiblich); 224 füllten die vollständige BSS sowie weitere Fragebögen für Depression (DESC), Hoffnungslosigkeit (BHS), interpersonale Variablen (INQ) und Defeat (DS-d)/Entrapment (ES-d) aus. Neben konfirmatorischen Faktoranalysen (CFA, Prüfung von Modellen mit 1, 2, 3 und 5 Faktoren) zur Dimensionalitätsprüfung wurden Pearson-Korrelationen zur Bestimmung der konvergenten Validität berechnet.

Ergebnisse Insgesamt erzielt das 5-Faktoren-Modell den besten Fit; ohne Berücksichtigung des RMSEA-Wertes ist der Modell-Fit zwischen den verschiedenen Modellen allerdings vergleichbar. Im Rahmen der mehrfaktoriellen Modelle entstehen inhaltlich vergleichbare Subskalen. Akzeptable interne Konsistenzen zeigen sich nur für die Subskalen, die passive Todeswünsche (α>0,80), aktive Suizidgedanken (α>0,73) und suizidhandlungsbezogene Items (α>0,70) erfassen. Der BSS-Summenscore sowie die Subskalen, die passive bzw. aktive Suizidgedanken abbilden, korrelieren moderat mit DESC, BHS, INQ und DS-d/ ES-d (r zwischen 0,25 und 0,66), während die handlungsbezogene Subskala keine (INQ, Thwarted Belongingness) bzw. geringe Assoziationen zeigt (r zwischen 0,14 und 0,27).

Schlussfolgerung Die CFAs liefern keinen eindeutigen Hinweis für eine ein- oder mehrdimensionale Struktur der BSS. So ist die Auswertung über den BSS-Summenwert trotz Hinweisen auf dessen Reliabilität und konvergente Validität aus empirischer Sicht kritisch zu bewerten.

Short defeat and entrapment scale: A psychometric investigation in three German samples

BACKGROUND

The present study aimed to validate the German version of the Short Defeat and Entrapment Scale (SDES).

METHODS

Validity and reliability were established in an online (N = 480), an outpatient (N = 277) and an inpatient sample (N = 296). Statistical analyses included confirmatory factor analyses (CFA) and group differences in defeat and entrapment.

RESULTS

For the online and the inpatient sample, the CFA indicated a two-factor solution, whereas for the outpatient sample both one- and two-factor solutions fitted the data equally well. Scale properties for the two-factor solution (defeat and entrapment subscale) were excellent. Thus, further analyses were based on this solution. For the online and the outpatient sample, suicidal ideators and suicide attempters scored significantly higher in defeat and entrapment than non-ideators and non-attempters.

LIMITATIONS

Limiting factors of the study were the different measures across the samples and the cross-sectional design of the study.

CONCLUSION

Though results were partly mixed, we found support for a two-factor solution of the instrument showing excellent psychometric properties in all three samples. The two-factor solution is further expected to have higher clinical utility than a one-factor solution. Suicidal ideators and suicide attempters in the online and outpatient sample showed higher scores in defeat and entrapment than non-ideators and non-attempters, emphasizing these two concepts as predictors for suicidal ideation. All in all, the present study supports the general validity and reliability of the SDES. However, future investigations based on prospective data are warranted.

Suicide Attempters, Suicide Ideators, and Non-Ideators

Abstract. Background: Suicide ideation is a prerequisite for suicide attempts. However, the majority of ideators will never act on their thoughts. It is therefore crucial to understand factors that differentiate those who consider suicide from those who make suicide attempts. Aim: Our aim was to investigate the role of protective factors in differentiating non-ideators, suicide ideators, and suicide attempters. Method: Inpatients without suicide ideation ( n = 32) were compared with inpatients with current suicide ideation ( n = 37) and with inpatients with current suicide ideation and a lifetime history of suicide attempts ( n = 26) regarding positive mental health, self-esteem, trust in higher guidance, social support, and reasons for living. Results: Non-ideators reported more positive mental health, social support, reasons for living, and self-esteem than suicide ideators and suicide attempters did. No group differences were found regarding trust in higher guidance. Suicide ideators and suicide attempters did not differ regarding any of the study variables. Limitations: Results stem from a cross-sectional study of suicide attempts; thus, neither directionality nor generalizability to fatal suicide attempts can be determined. Conclusion: Various protective factors are best characterized to distinguish ideators from nonsuicidal inpatients. However, the same variables seem to offer no information about the difference between ideators and attempters.

Do suicide attempters and suicide ideators differ in capability for suicide?

Suicide ideation is a prerequisite for suicide attempts. However, the majority of ideators will never act on their thoughts. It is therefore crucial to understand what differentiates those who consider suicide from those who attempt suicide. The aim of this study was to investigate the role of different aspects of capability for suicide (fearlessness about death, subjective pain tolerance, objective pain persistence) in differentiating suicide ideators from suicide attempters, single attempters from multiple attempters and recent attempters from distant attempters. A total of 308 psychiatric inpatients (53.6% female; age: M=36.92, SD=14.30) suffering from suicide ideation with or without lifetime suicide attempts were compared regarding fearlessness about death, subjective pain tolerance and objective pain persistence (assessed with a pressure algometer). No differences in fearlessness about death, subjective pain tolerance and objective pain persistence were found in suicide ideators vs. attempters, single vs. multiple attempters and recent vs. distant attempters. It might be presumed that fearlessness about death, subjective pain tolerance and objective pain persistence do not offer useful information for the differentiation between suicide ideators and attempters, however, there are several limitations to take into account. Further effort is needed to understand more clearly what differentiates suicide ideators from suicide attempters.