Uncontrollability of suicidal ideation adds incremental explanatory power in prediction of later suicidal ideation

OBJECTIVE

Suicidal ideation and suicidal behaviors are major public health concerns in the United States and are difficult to treat and predict. Risk factors that are incrementally informative are needed to improve prediction and inform prevention of suicidal thoughts and behaviors. Uncontrollability of suicidal ideation, one parameter of suicidal ideation, is one such candidate.

METHOD

In the current study, we assessed the predictive power of uncontrollability of suicidal ideation, over and above overall suicidal ideation, for future suicidal ideation in a large sample of active-duty service members. A total of 1044 suicidal military service members completed baseline assessments, of whom 664 (63.6%) completed 3-month follow-up assessments.

RESULTS

While baseline overall suicidal ideation itself was the strongest predictor of future suicidal ideation, uncontrollability of suicidal ideation added some incremental explanatory power.

CONCLUSION

Further study of uncontrollability of suicidal thought is needed to elucidate its impact on suicidal outcomes.

Three-year follow-up of suicide prevention-focused group therapy for veterans

The purpose of this study was to determine the long-term effects of a suicide prevention-focused group therapy for veterans recently discharged from an inpatient psychiatry setting following a suicidal crisis. There was interest in examining the impact of mechanisms of change identified in previous research on the group, including group cohesion, working alliance, and group sessions attended. Data were abstracted from the electronic medical record 3 years following completion of a previous study that involved the group therapy. A series of generalized linear and logistic mixed models were conducted to measure the associations between group cohesion, working alliance, session attendance, and health service utilization and suicide attempts. Thirty randomly selected veterans from the original sample completed a semistructured interview to discuss their experience in the group therapy. Study team members reviewed each transcription to identify themes related to veterans' experiences in the suicide prevention-focused group therapy. No suicides were observed in the 3-year follow-up period. When examining the full sample (N = 134), session attendance and inpatient hospitalization were not significantly associated but were positively associated after removing subjects who attended zero sessions (N = 93). Higher group cohesion was associated with a reduced likelihood of inpatient psychiatric hospitalization and greater engagement in outpatient mental health services. Four themes emerged regarding veterans' experience in the group through an analysis of the semistructured interviews. Suicide prevention-focused group therapy among veteran service members was not associated with an elevated risk of mortality. Future research is needed to further elucidate mechanisms of change and moderators of response. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Optimizing the Beck Scale for Suicide Ideation: An Item Response Theory Approach Among U.S. Military Personnel

The Beck Scale for Suicide Ideation (BSS) is one of the most used and empirically supported suicide risk assessment measures for behavioral health clinicians and researchers. However, the 19-item BSS is a relatively long measure and can take 5 to 10 minutes to administer. This study used Item Response Theory (IRT) techniques across two samples of mostly U.S. military service members to first identify (n₁ = 1,899) and then validate (n₂ = 757) an optimized set of the most informative BSS items. Results indicated that Items 1, 2, 4, 6, and 15 provided a similar-shaped test information curve across the same range of the latent trait as the full-length BSS and showed reliable item functioning across participant characteristics. The sum score of these five items showed a linear score linkage with the full-scale score, ρ > 0.87, and was equally as sensitive as the full scale for prospectively predicting near-term suicidal behavior at 74% with a cut score ≥1 (equivalent to full-scale score ≥6). Results are consistent with those from civilian samples. In time- or length-limited assessments, using these five BSS items may improve administration efficiency over the full BSS, while maintaining classification sensitivity.This study suggests that summing Items 1, 2, 4, 6, and 15 of the Beck Scale for Suicide Ideation (BSS) is an acceptable approach for shortening the full-length measure.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group

INTRODUCTION

Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative.

METHODS

Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6 months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion.

RESULTS

Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster.

CONCLUSION

This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

Past Levels of Mental Health Intervention and Current Nondisclosure of Suicide Risk Among Men Older Than Age 50

Suicide risk screening depends heavily on accurate patient self-report. However, past negative experiences with mental health care may contribute to intentional nondisclosure of suicide risk during screening. This study investigated among 282 men older than age 50 whether likelihood for current explicit risk nondisclosure was associated with previous highest level of mental health care received. This sample was selected post hoc out of a larger sample of participants from higher risk and lower help-seeking populations (i.e., military service members and veterans, men older than age 50, and lesbian gay bisexual, transgender, and queer young adults), however, the other groups were underpowered for analysis. Among these men, history of psychiatric hospitalization was significantly associated with likelihood for explicit nondisclosure of current suicide risk, while history of receiving only outpatient therapy for suicidal thoughts or behaviors was significantly associated with likelihood for full reporting of suicide risk. Severity of suicidal ideation and internalized stigma against mental illness were significant indirect contributors to the effect. Although causality could not be determined, results suggest that a potential cost to consider for psychiatric hospitalization may be future nondisclosure of suicide risk. Conversely, outpatient interventions that appropriately manage suicidal thoughts or behaviors may encourage future full reporting of suicide risk and improve screening detection.

The Role of Past Suicidal Behavior on Current Suicidality: A Retrospective Study in the Israeli Military

Past suicide attempts are a significant risk factor for future suicidality. Therefore, the present military-based study examined the past suicidal behavior of soldiers who recently made a severe suicide attempt. Our sample consisted of 65 active-duty soldiers (61.5% males), between the ages of 18 and 28 years old (M = 20.4, SD ± 1.3). The inclusion criterion was a recent severe suicide attempt, requiring at least a 24 h hospitalization. This sample was divided into two groups, according to previous suicidal behavior, namely whether their first suicide attempt was before or after enlistment (n = 25; 38.5% and n = 40; 61.5%, respectively). We then examined the lethality and intent of the recent event in regard to this division. Four measures were used to assess the subjects' suicidal characteristics: the Columbia Suicide Severity Rating Scale, the Self-Harm Behavior Questionnaire, the Suicidal Behaviors Questionnaire-Revised, and the Beck Scale for Suicide Ideation. No significant difference in the severity of the suicide attempts (either actual or potential severity) were found between those who had suicide attempts before enlistment and those who had their first attempt in the service. As a matter of fact, most of the suicide attempts that occurred for the first time during military service had used a violent method (58.3%, n = 21). Finally, using multivariate analyses, we found that current thoughts and behavior, rather than past suicidality, was the strongest predictor for the lethality of suicide attempts.

A test of the interpersonal theory of suicide in a large, representative, retrospective and prospective study: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

The interpersonal theory of suicide hypothesizes that perceived burdensomeness, thwarted belongingness, and hopelessness lead to active suicidal thoughts and individuals with active suicidal thoughts and elevated capability for suicide are most likely to attempt suicide. We retrospectively and prospectively tested this theory in a large sample of 7677 U.S. Army soldiers followed post-deployment for up to nine months. The interaction of perceived burdensomeness and hopelessness (OR = 2.59) was significantly associated with lifetime suicidal thoughts; however, the interactions of thwarted belongingness and perceived burdensomeness and of thwarted belongingness and hopelessness were not. Consistent with the theory, capability for suicide prospectively predicted suicide attempts during and following deployment (OR = 1.22); however, among soldiers reporting lifetime suicidal thoughts, capability did not predict attempts, only perceived burdensomeness did (OR = 1.36). Results supported some, but not all, theory hypotheses, suggesting that additional constructs may be needed to better identify the psychological factors that lead soldiers to attempt suicide.

Military Suicide Research Consortium common data elements: Bifactor analysis and longitudinal predictive ability of suicidal ideation and suicide attempts within a clinical sample

To enhance and standardize the assessment of suicidal self-directed violence (SDV) in military populations, the Military Suicide Research Consortium developed the Common Data Elements (CDEs). Previous research supported the CDEs as assessing a higher-order factor of suicidal SDV in military populations. The present study had two aims: 1) confirm the bifactor structure of the CDEs in a high-risk sample, and 2) assess the ability of the factorially derived suicidal SDV factor to predict suicide attempts and return to care for suicidal ideation over 3-month follow-up. Utilizing a sample of service members referred for a psychiatric evaluation (N = 1,044), the CDE structure was assessed with confirmatory bifactor modeling. Logistic regressions and receiver operating characteristic (ROC) analyses were used to assess the suicidal SDV risk factor's prediction of suicide attempts and return to care for suicidal ideation during follow-up (n = 758). Bifactor modeling suggested adequate fit for the overarching suicidal SDV risk factor. Logistic regressions supported the overarching suicidal SDV risk factor as a predictor of suicide attempts (OR = 4.07, p < .001) and return to care for suicidal ideation (OR = 2.81, p < .001) over follow-up. However, ROC analyses suggested that the model including the suicidal SDV risk factor was only significantly better at classifying suicide attempts over follow-up (not return to care for suicidal ideation) than the model that did not include it (AUC difference = 0.15, p < .001). Findings suggest that the shared variance assessed across CDEs better predicts future suicide attempts beyond any individual suicide-related constructs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers

IMPORTANCE

Brief cognitive behavioral therapy (BCBT) is a clinically effective intervention for reducing risk of suicide attempts among suicidal US Army soldiers. However, because specialized treatments can be resource intensive, more information is needed on costs and benefits of BCBT compared with existing treatments.

OBJECTIVE

To evaluate the cost-effectiveness of BCBT compared with treatment as usual for suicidal soldiers in the US Army.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytic model compared effects and costs of BCBT vs treatment as usual from a US Department of Defense (DoD) perspective. Model input data were drawn from epidemiologic data sets and a clinical trial among suicidal soldiers conducted from January 31, 2011, to April 3, 2014. Data were analyzed from July 3, 2018, to March 25, 2019.

INTERVENTIONS

The strategies compared were treatment as usual alone vs treatment as usual plus 12 individual BCBT sessions. Treatment as usual could include a range of pharmacologic and psychological treatment options.

MAIN OUTCOMES AND MEASURES

Costs in 2017 US dollars, suicide attempts averted (self-directed behavior with intent to die, but with nonfatal outcome), suicide deaths averted, and incremental cost-effectiveness ratios, assuming a 2-year time horizon for treatment differences but including lifetime costs.

RESULTS

In the base-case analysis, BCBT was expected to avert approximately 23 to 25 more suicide attempts and 1 to 3 more suicide deaths per 100 patients treated than treatment as usual. Sensitivity analyses assuming a range of treatment effects showed BCBT to be cost saving in most scenarios. Using the federal discount rate, the DoD was estimated to save from $15 000 to $16 630 per patient with BCBT vs treatment as usual. In a worst-case scenario (ie, assuming the weakest plausible BCBT effect sizes), BCBT cost an additional $1910 to $2250 per patient compared with treatment as usual.

CONCLUSIONS AND RELEVANCE

Results suggest BCBT may be a cost-saving intervention for suicidal active-duty soldiers. The costs of ensuring treatment fidelity would also need to be considered when assessing the implications of disseminating BCBT across the entire DoD.

Autism-related traits and suicide risk among active duty U.S. military service members

Suicide rates within the U.S. military are elevated. The interpersonal theory of suicide, supported within military samples, suggests that social disconnectedness confers risk for suicide. Autism spectrum disorder (ASD) is characterized by symptoms-difficulties in social communication/interaction (SCI) and restricted and repetitive behaviors (RRBs)-that contribute to social disconnectedness. To our knowledge, no study has examined ASD-related traits and suicide risk among active duty U.S. military service members. Participants included 292 active duty U.S. military service members (M [SD] age = 28.67 [7.40] years, 68.5% male, 78.1% White). The Autism Spectrum Quotient, Repetitive Behaviours Questionnaire-2 for Adults, Self-Injurious Thoughts and Behaviors Interview-Short Form, and Interpersonal Needs Questionnaire assessed for SCI difficulties, RRBs, suicidal symptoms, and interpersonal theory of suicide constructs (i.e., perceived burdensomeness, thwarted belongingness), respectively. Elevated levels of SCI difficulties and RRBs were associated with increased odds of reporting suicidal thoughts and behaviors occurring since joining the military, controlling for the number of years of service and suicidal symptoms occurring prior to joining the military. Perceived burdensomeness and thwarted belongingness statistically accounted for the relationship between ASD-related traits and suicidal ideation occurring since joining the military; a rival mediator, emotion dysregulation, was not a significant mediator. Among active duty U.S. military service members, greater ASD-related traits were associated with an increased likelihood of reporting suicidal thoughts and behaviors occurring since joining the military. Clinical efforts targeting perceived burdensomeness and thwarted belongingness might reduce suicide risk among military service members with elevated ASD-related traits. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Pre-deployment predictors of suicide attempt during and after combat deployment: Results from the Army Study to Assess Risk and Resilience in Servicemembers

BACKGROUND

Deployment-related experiences might be risk factors for soldier suicides, in which case identification of vulnerable soldiers before deployment could inform preventive efforts. We investigated this possibility by using pre-deployment survey and administrative data in a sample of US Army soldiers to develop a risk model for suicide attempt (SA) during and shortly after deployment.

METHODS

Data came from the Army Study to Assess Risk and Resilience in Servicemembers Pre-Post Deployment Survey (PPDS). Soldiers completed a baseline survey shortly before deploying to Afghanistan in 2011-2012. Survey measures were used to predict SAs, defined using administrative and subsequent survey data, through 30 months after deployment. Models were built using penalized regression and ensemble machine learning methods.

RESULTS

Significant pre-deployment risk factors were history of traumatic brain injury, 9 + mental health treatment visits in the 12 months before deployment, young age, female, previously married, and low relationship quality. Cross-validated AUC of the best penalized and ensemble models were .75-.77. 21.3-40.4% of SAs occurred among the 5-10% of soldiers with highest predicted risk and positive predictive value (PPV) among these high-risk soldiers was 4.4-5.7%.

CONCLUSIONS

SA can be predicted significantly from pre-deployment data, but intervention planning needs to take PPV into consideration.

Psychological Problems among 12th-Grade Students Predicting Military Enlistment: Findings from the Monitoring the Future Survey

Objective: Rates of some psychological disorders are higher among enlisted U.S. military personnel than socio-demographically matched civilians. Indirect evidence suggests some internalizing and externalizing psychological problems among enlistees onset prior to enlistment. However, the consistency and strength of the associations between pre-enlistment psychological problems and enlistment over time is unknown. We address this uncertainty by examining whether internalizing and externalizing problems in high school predicted subsequent military enlistment using a large cohort-sequential panel study. Method: The Monitoring the Future study administered baseline surveys from 1989-2014 and biennial follow-up surveys two and four years later to national samples of high-school seniors (N = 20,823). Validated self-report scales assessed internalizing (depression, low self-esteem) and externalizing (risk-taking, school misbehavior, conduct disorder, interpersonal violence, alcohol, and drug use) problems in each survey. Follow-up surveys assessed military enlistment. Logistic regression models were used to estimate associations of problems scales with subsequent enlistment. Results: School misbehavior in 12th grade, and risk-taking in 12th grade and two years after graduation were associated with significantly elevated odds of enlistment at follow-up. Although modest, these associations were linear and invariant across respondent sex and baseline survey year. Conclusions: School misbehavior and risk-taking predicted subsequent enlistment and there was no evidence of historical changes in these associations over the course of 25 years; these pre-enlistment psychological problems do not fully explain the high rates of psychological disorders among enlisted military personnel. Further research is needed to determine whether these predictors are associated with negative outcomes during or after military service.

An Examination of the Psychometric Properties of the Reasons for Living Inventory within a Male Veteran Clinical Sample

Elevated suicide risk among veteran populations remains a significant public health concern. However, few suicide assessment measures have been validated for veterans. The current study evaluated the reliability and validity of the Reasons for Living Inventory (RFL) scores among veteran populations. The participants included male veterans (N = 421) from a broad range of ages, combat exposures, and history of suicide attempts. Participants completed the RFL and a set of additional self-report measures of relevant constructs in a cross-sectional design. Estimates of internal consistency reliability were adequate for scores on all the original RFL subscale scores. Exploratory factor analysis (EFA) and exploratory bifactor (bi-factor EFA) analyses provided detailed information regarding the 6-factor solution from the original validation studies with the RFL. Additional analyses identified potential correlates for the RFL total and subscale scores. Secondary analyses showed support for evidence of known-groups validity for the RFL total scale score. Overall, this study provides initial support for the RFL as a reliable and valid measure of protective factors in veterans. Future studies may wish to consider further validation of the current findings.

Perceptions of belongingness and social support attenuate PTSD symptom severity among firefighters: A multistudy investigation

Firefighters experience high rates of posttraumatic stress disorder (PTSD). It is imperative to identify malleable factors that protect against the development of PTSD symptoms among this population. We examined whether perceptions of belongingness broadly (Study 1) and social support from supervisors, coworkers, and family/friends specifically (Study 2) are associated with lower PTSD symptom severity among firefighters. Study 1 included 840 U.S. firefighters (91.1% male); participants completed the Interpersonal Needs Questionnaire and PTSD Checklist-Civilian Version. Study 2 included 200 U.S. women firefighters exposed to a Criterion A traumatic event; participants completed the Generic Job Stress Questionnaire, Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders-5, and PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Linear regression analyses were conducted, adjusting for the number of years participants served as firefighters. Greater belongingness broadly (Study 1; b = -0.740, p < .001) as well as social support specifically (Study 2) from supervisors (b = -4.615, p < .001), coworkers (b = -4.465, p = .001), and family/friends (b = -3.206, p = .021) were associated with less severe PTSD symptoms. When all sources of social support were entered into a single model, only support from supervisors was significantly associated with lower overall PTSD symptom severity (b = -4.222, p = .004). Belongingness and social support may protect against the development of PTSD among firefighters. Supervisor social support may be particularly salubrious, suggesting that top-down mental wellness promotion within the fire service may be indicated to protect firefighters against PTSD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining the link between prior suicidality and subsequent suicidal ideation among high-risk US military service members

BACKGROUND

Research is needed to identify the factors that explain the link between prior and future suicidality. This study evaluated possible mediators of the relationship between: (1) the severity of prior suicidality and (2) suicidal ideation severity at 3-month follow-up among a sample of high-risk military personnel.

METHODS

US military service members referred to or seeking care for suicide risk (N = 624) completed self-report psychiatric domain measures and a clinician interview assessing prior suicidality severity at baseline. Three months later, participants completed a self-report measure of suicidal ideation severity. Three separate percentile bootstrap mediation models were used to examine psychiatric factors (i.e. alcohol abuse, anxiety sensitivity, hopelessness, insomnia, posttraumatic stress symptoms, suicidal ideation, and thwarted belongingness) as parallel mediators of the relationship between prior suicidality severity (specifically, suicidal ideation, suicide attempt, and overall suicidality - i.e. ideation/attempt severity combined) at baseline and suicidal ideation severity at follow-up.

RESULTS

Hopelessness, specifically, and the total effect of all mediators, each significantly accounted for the relationship between prior suicidality severity and subsequent ideation severity across models. In the models with attempt severity and overall suicidality severity as predictors, thwarted belongingness was also a significant mediator.

CONCLUSIONS

Hopelessness, thwarted belongingness, and overall severity of psychiatric indices may explain the relationship between prior suicidality severity and future suicidal ideation severity among service members at elevated suicide risk. Research is needed to replicate these findings and examine other possible mediators.

The Relationship between Suicidal Responses and Traumatic Brain Injury and Severe Insomnia in Active Duty, Veteran, and Civilian Populations

This study examined how a positive traumatic brain injury (TBI) screening and insomnia severity relate to suicidal outcomes across active duty, veteran, and civilian samples. Data were used from 3,993 participants from 19 studies. We conducted a series of analyses by group to identify which significantly differed on the variables of interest. TBI and insomnia each had independent relationships with outcomes over and above the impact of the other factor. Veterans presented as clinically worse across the outcomes. However, the relationship between insomnia and suicidal responses was stronger for active duty military compared to veterans. Continued research on TBIs and insomnia severity across groups will improve quality of care for those at risk of suicide.

Investigating the reliability of suicide attempt history reporting across five measures: A study of US military service members at risk of suicide

OBJECTIVE

Utilizing a sample of military service members at risk of suicide, this study aimed to: (a) identify patterns of suicide attempt (SA) history reporting across five measures and (b) evaluate whether consistent SA reporters (i.e., individuals who consistently report an SA history across measures) differ from inconsistent SA reporters on other clinical severity indices.

METHOD

Participants (N = 984) completed five validated SA history measures and self-report psychiatric symptom measures.

RESULTS

Of the sample, 35.4% inconsistently responded to SA history measures. Inconsistent reporters disclosed more severe suicide threat histories than consistent reporters. On all other clinical severity indices, inconsistent reporters evinced either less severe or comparable symptom levels.

CONCLUSIONS

A nontrivial portion of service members may respond inconsistently to different assessments of SA history. Research is needed to identify factors that account for inconsistent SA history reporting and to improve the accuracy of SA history assessments among military personnel.

Assessment of a Risk Index for Suicide Attempts Among US Army Soldiers With Suicide Ideation: Analysis of Data From the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

IMPORTANCE

The Department of Veterans Affairs recently began requiring annual suicide ideation (SI) screening of all patients and additional structured questions for patients reporting SI. Related changes are under consideration at the Department of Defense. These changes will presumably lead to higher SI detection, which will require hiring additional clinical staff and/or developing a clinical decision support system to focus in-depth suicide risk assessments on patients considered high risk.

OBJECTIVE

To carry out a proof-of-concept study for whether a brief structured question battery from a survey of US Army soldiers can help target in-depth suicide risk assessments by identifying soldiers with self-reported lifetime SI who are at highest risk of subsequent administratively recorded nonfatal suicide attempts (SAs).

DESIGN, SETTING, AND PARTICIPANTS

Cohort study with prospective observational design. Data were collected from May 2011 to February 2013. Participants were followed up through December 2014. Analyses were conducted from March to November 2018. A logistic regression model was used to assess risk for subsequent administratively recorded nonfatal SAs. A total of 3649 Regular Army soldiers in 3 Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) surveys who reported lifetime SI were followed up for 18 to 45 months from baseline to assess administratively reported nonfatal SAs.

MAIN OUTCOMES AND MEASURES

Outcome was administratively recorded nonfatal SAs between survey response and December 2014. Predictors were survey variables.

RESULTS

The 3649 survey respondents were 80.5% male and had a median (interquartile range) age of 29 (25-36) years (range, 18-55 years); 69.4% were white non-Hispanic, 14.6% were black, 9.0% were Hispanic, 7.0% were another racial/ethnic group. Sixty-five respondents had administratively recorded nonfatal SAs between survey response and December 2014. One additional respondent died by suicide without making a nonfatal SA but was excluded from analysis based on previous evidence that predictors are different for suicide death and nonfatal SAs. Significant risk factors were SI recency (odds ratio [OR], 7.2; 95% CI, 2.9-18.0) and persistence (OR, 2.6; 95% CI, 1.0-6.8), positive screens for mental disorders (OR, 26.2; 95% CI, 6.1-112.0), and Army career characteristics (OR for junior enlisted rank, 30.0; 95% CI, 3.3-272.5 and OR for senior enlisted rank, 6.7; 95% CI, 0.8-54.9). Cross-validated area under the curve was 0.78. The 10% of respondents with highest estimated risk accounted for 39.2% of subsequent SAs.

CONCLUSIONS AND RELEVANCE

Results suggest the feasibility of developing a clinically useful risk index for SA among soldiers with SI using a small number of self-report questions. If implemented, a continuous quality improvement approach should be taken to refine the structured question series.

Evaluation of Structured Assessment and Mediating Factors of Suicide-Focused Group Therapy for Veterans Recently Discharged from Inpatient Psychiatry

The current study investigated the impact of adding the Suicide Status Form (SSF) to a suicide-focused group therapy for veterans recently discharged from an inpatient psychiatry setting. A sample of 141 veterans was enrolled and randomized into a Usual Assessment Group Therapy or SSF-Assessment Group Therapy. Participants completed interviews at baseline, 1, and 3 months. No significant differences were observed between groups regarding group attendance (IRR = 1.01, Std. Err = 0.08, 95% CI = 0.87, 1.18) or client satisfaction (β = 0.23, Std. Err = 0.66, p = 0.73, d = -.25). No main effects were observed across the study on secondary outcomes of interest for suicidal ideation and overall symptom distress, although participants in both treatment conditions reported significant improvements on these outcomes over the course of the study. Patients in the Usual Assessment Group Therapy demonstrated greater reductions in overall symptom distress across the 3-month follow-up window (β = 6.08, Std. Err = 2.04, p = 0.003; f² = 0.05). Follow-up path analyses revealed that more frequent session attendance was significantly related to less suicidal ideation at 1-month, higher working alliance between individual members and group facilitators was associated with greater suicidal ideation at 1-month, and higher group cohesion among group members at 1-month was significantly associated with less thwarted belongingness at 1-month. Although the SSF did not improve the impact of an existing suicide-focused group therapy, the study findings support future research on group treatments for suicidal veterans.

Patterns and predictors of persistence of suicide ideation: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Persistent suicide ideation (SI) is known to be a risk factor for subsequent suicidal behaviors. Reducing SI persistence among people with a history of SI consequently might be a useful target for preventive intervention; however, basic information is lacking about patterns and predictors of SI persistence. We report preliminary retrospective data on annual SI persistence in a representative sample of 3,501 U.S. Army soldiers with lifetime SI from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Reports about age-of-onset and number of years with SI were used to estimate two definitions of persistence: persistence beyond year-of-onset and proportional annual persistence (i.e., percentage of years with SI since year-of-onset). Results revealed that for 47.8% of respondents with lifetime SI, their SI did not persist beyond the year-of-onset. For the 52.2% whose SI did persist beyond the year-of-onset, the median (interquartile range) proportional annual persistence was 33% (17-67%). Significant predictors of increased persistence were different for respondents with preenlistment SI onset (prior histories of attention-deficit/hyperactivity disorder [ADHD], bipolar disorder, and panic disorder) and postenlistment SI onset (male, combat support military occupation specialty, prior histories of ADHD, panic disorder, and posttraumatic stress disorder). These predictors of persistence are different from the predictors of SI onset, suggesting that secondary preventive interventions to reduce SI persistence may need to focus on different factors than primary preventive interventions to reduce SI onset. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Risk factors for the transition from suicide ideation to suicide attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Prior research has shown that most known risk factors for suicide attempts in the general population actually predict suicide ideation rather than attempts among ideators. Yet clinical interest in predicting suicide attempts often involves the evaluation of risk among patients with ideation. We examined a number of characteristics of suicidal thoughts hypothesized to predict incident attempts in a retrospective analysis of lifetime ideators (N = 3,916) drawn from a large (N = 29,982), representative sample of United States Army soldiers. The most powerful predictors of first nonfatal lifetime suicide attempt in a multivariate model controlling for previously known predictors (e.g., demographics, mental disorders) were: recent onset of ideation, presence and recent onset of a suicide plan, low controllability of suicidal thoughts, extreme risk-taking or "tempting fate," and failure to answer questions about the characteristics of one's suicidal thoughts. A predictive model using these risk factors had strong accuracy (area under the curve [AUC] = .93), with 66.2% of all incident suicide attempts occurring among the 5% of soldiers with highest composite predicted risk. This high concentration of risk in this retrospective study suggests that a useful clinical decision support model could be constructed from prospective data to identify those with highest risk of subsequent suicide attempt. (PsycINFO Database Record

Predicting suicide attempts among soldiers who deny suicidal ideation in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

Most nonfatal suicide attempts and suicide deaths occur among patients who deny suicidal ideation (SI) during suicide risk screenings. Little is known about risk factors for suicidal behaviors among such patients. We investigated this in a representative sample of U.S. Army soldiers who denied lifetime SI in a survey and were then followed through administrative records for up to 45 months to learn of administratively-recorded suicide attempts (SA). A novel two-stage risk assessment approach was used that combined first-stage prediction from administrative records to find the subsample of SI deniers with highest subsequent SA risk and then used survey reports to estimate a second-stage model identifying the subset of individuals in the high-risk subsample at highest SA risk. 70% of survey respondents denied lifetime SI. Administrative data identified 30% of this 70% who accounted for 81.2% of subsequent administratively-recorded SAs. A relatively small number of self-report survey variables were then used to create a prediction model that identified 10% of the first-stage high-risk sample (i.e., 3% of all soldiers) at highest SA risk (accounting for 45% of SAs in the total sample). We close by discussing potential applications of this approach for identifying future SI deniers at highest SA risk.

Assessing the Reliability of the CAMS Rating Scale Using a Generalizability Study

Background: An important consideration when conducting randomized controlled trials is treatment differentiation. Direct observation helps ensure that providers in different treatment groups are delivering distinct interventions. One direct observation method is the use of a measure to rate clinician performance when delivering an intervention. Aims: This generalizability study evaluated the reliability of the CAMS Rating Scale (CRS), a measure used to assess delivery of the Collaborative Assessment and Management of Suicidality (CAMS). Method: Digitally recorded tapes of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were coded using the CRS. Sessions (N = 36) were each coded by two raters, and encompassed four clinicians, four time points, and 34 unique patients across two treatment groups. A reliability coefficient (i.e., G coefficient) and the percentages of variance contributed by each component of the measurement model were obtained. Results: The CRS reliably differentiates CAMS from E-CAU, minimizes measurement error relative to expected variance sources, and continues to demonstrate high inter-rater reliability. Limitations: The absence of blind raters, a formal training protocol for the rating team, and ratings from all clinician-patient dyads at all time points was a limitation. Conclusion: The CRS is a reliable treatment differentiation measure that can play an integral role in studies evaluating CAMS.

PTSD symptom clusters and suicide attempts among high-risk military service members: A three-month prospective investigation

OBJECTIVE

Suicide rates within the U.S. military are elevated, and the assessment and treatment of posttraumatic stress disorder (PTSD) has been identified as one potential conduit for suicide risk reduction. Despite increased interest in examining whether PTSD symptom clusters differentially predict suicide-related outcomes, to our knowledge no study has examined this question utilizing a prospective design for which suicide attempts is the outcome. Thus, the present study assessed whether PTSD symptom clusters differentially predict suicide attempts at 3-month follow-up and examined the moderating role of combat exposure.

METHOD

Participants were 758 military service members referred for psychiatric evaluation for suicide-related concerns and who provided both baseline and follow-up data (76.8% male, M_age = 25.20 y [SD_age = 6.22 y], 61.6% White/Caucasian, 28.2% combat-exposed). Baseline PTSD symptom clusters scores were derived from an abbreviated version of the PTSD Checklist-Military Version (PCL-M). Suicide attempts occurring from baseline to follow-up were assessed with the Suicide Attempt Self-Injury Interview (SASII). Logistic regression models were utilized, controlling for baseline suicide risk severity (i.e., frequency of suicidal ideation, levels of suicidal intent, past suicide plans and attempts) and sociodemographic characteristics.

RESULTS

The hyperarousal symptom cluster was the only significant predictor of subsequent suicide attempts and, moreover, this association was significant for combat-exposed service members but not for non-combat-exposed service members.

CONCLUSIONS

PTSD hyperarousal symptoms, characterized in part by overarousal (e.g., agitation), should be considered in military suicide risk assessment and prevention efforts, particularly for combat-exposed service members. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Access to Psychotropic Medication via Prescription Is Associated With Choice of Psychotropic Medication as Suicide Method: A Retrospective Study of 27,876 Suicide Attempts

OBJECTIVE

Whether physical access to psychotropic medication via prescription (ie, prescribed access) is associated with use of psychotropic medication as a means of subsequent suicide attempt remains unclear. In a population of suicide attempters, we investigated whether prescribed access to any psychotropic medication increased the likelihood of using any psychotropic drug in a suicide attempt and whether prescribed access to a specific psychotropic drug type increased the likelihood of using that specific psychotropic drug type in an attempt.

METHODS

Case-control study design was used. We identified individuals receiving care for a suicide attempt (fatal or nonfatal) in emergency department and inpatient settings from a US insurance claims dataset (2006-2013) using relevant ICD-9-CM codes. Cases used a psychotropic drug in their suicide attempt, while controls used another method. Exposed individuals filled a psychotropic drug prescription within 90 days prior to the attempt. Multivariable logistic regression estimated odds ratios.

RESULTS

A population of 27,876 (cases = 10,158, controls = 17,718) was included. Anxiolytics were used most in attempts (n = 6,037, 59.4%), followed by antidepressants (n = 3,573, 35.2%), antipsychotics or mood stabilizers (n = 1,168, 11.5%), and stimulants (n = 368, 3.6%). Thirteen percent (n = 1,316) used more than 1 type of psychotropic drug in the attempt. Across all psychotropic drug groups evaluated, individuals using psychotropic medication in a suicide attempt were significantly more likely to have had prescribed access (adjusted odds ratio [aOR] = 1.7; 95% CI, 1.6-1.9), with the highest drug type-specific odds ratios for antipsychotics or mood stabilizers (aOR = 6.5; 95% CI, 5.4-7.7) and stimulants (aOR = 7.6; 95% CI, 5.5-10.5).

CONCLUSIONS

Individuals at high risk for suicide with prescribed access to any psychotropic medication should be targeted for means safety interventions.

The psychometric properties of the Collaborative Assessment and Management of Suicidality rating scale

OBJECTIVE

The CAMS Rating Scale (CRS) is an adherence measure for the Collaborative Assessment and Management of Suicidality (CAMS), a suicide-specific clinical intervention. This study examined the ability of the CRS to assess adherence to CAMS.

METHODS

Video-recorded therapy sessions of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were rated with the CRS. These ratings (N = 98) were used to evaluate criterion validity, internal consistency, and factor structure.

RESULTS

Criterion validity and factor analyses did not support the organization of the CRS into its current subscales. Furthermore, the identified factor model and item-level statistics revealed weak CRS items. Finally, internal consistency was higher among CAMS clinicians than among clinicians delivering E-CAU.

CONCLUSION

These results establish the CRS as a measure that can effectively assess the adherence to CAMS in its current form. Potential revisions to future iterations of the CRS are discussed.

The Military Suicide Research Consortium Common Data Elements: An Examination of Measurement Invariance Across Current Service Members and Veterans

Suicide rates within the U.S. military are elevated, necessitating greater efforts to identify those at increased risk. This study utilized a multigroup confirmatory factor analysis to examine measurement invariance of the Military Suicide Research Consortium Common Data Elements (CDEs) across current service members ( n = 2,015), younger veterans (<35 years; n = 377), and older veterans (≥35 years; n = 1,001). Strong factorial invariance was supported with adequate model fit observed for current service members, younger veterans, and older veterans. The structures of all models were generally comparable with few exceptions. The Military Suicide Research Consortium CDEs demonstrate at least adequate model fit for current military service members and veterans, regardless of age. Thus, the CDEs can be validly used across military and veteran populations. Given similar latent structures, research findings in one group may inform clinical and policy decision making for the other.

Improving risk prediction accuracy for new soldiers in the U.S. Army by adding self-report survey data to administrative data

BACKGROUND

High rates of mental disorders, suicidality, and interpersonal violence early in the military career have raised interest in implementing preventive interventions with high-risk new enlistees. The Army Study to Assess Risk and Resilience in Servicemembers (STARRS) developed risk-targeting systems for these outcomes based on machine learning methods using administrative data predictors. However, administrative data omit many risk factors, raising the question whether risk targeting could be improved by adding self-report survey data to prediction models. If so, the Army may gain from routinely administering surveys that assess additional risk factors.

METHODS

The STARRS New Soldier Survey was administered to 21,790 Regular Army soldiers who agreed to have survey data linked to administrative records. As reported previously, machine learning models using administrative data as predictors found that small proportions of high-risk soldiers accounted for high proportions of negative outcomes. Other machine learning models using self-report survey data as predictors were developed previously for three of these outcomes: major physical violence and sexual violence perpetration among men and sexual violence victimization among women. Here we examined the extent to which this survey information increases prediction accuracy, over models based solely on administrative data, for those three outcomes. We used discrete-time survival analysis to estimate a series of models predicting first occurrence, assessing how model fit improved and concentration of risk increased when adding the predicted risk score based on survey data to the predicted risk score based on administrative data.

RESULTS

The addition of survey data improved prediction significantly for all outcomes. In the most extreme case, the percentage of reported sexual violence victimization among the 5% of female soldiers with highest predicted risk increased from 17.5% using only administrative predictors to 29.4% adding survey predictors, a 67.9% proportional increase in prediction accuracy. Other proportional increases in concentration of risk ranged from 4.8% to 49.5% (median = 26.0%).

CONCLUSIONS

Data from an ongoing New Soldier Survey could substantially improve accuracy of risk models compared to models based exclusively on administrative predictors. Depending upon the characteristics of interventions used, the increase in targeting accuracy from survey data might offset survey administration costs.

Non-suicidal self-injury and suicidal thoughts and behaviors: A study of the explanatory roles of the interpersonal theory variables among military service members and veterans

OBJECTIVE

Research has identified non-suicidal self-injury (NSSI) as a robust correlate of suicidal thoughts and behaviors; however, little is known regarding why these constructs may be related. Consistent with the interpersonal theory of suicide, this study investigated thwarted belongingness (TB), perceived burdensomeness (PB), and capability for suicide (CS) as explanatory links in the association between NSSI, ideation, and suicide attempt history.

METHOD

Military service members and veterans (N = 973; agemean = 29.9 years, 78.8% male, 63.8% Caucasian/White) completed measures of lifetime NSSI and suicide attempts; current suicidal ideation; TB, PB, and CS; and related psychiatric symptoms. Bootstrap moderated mediation analyses were employed to examine whether (a) TB moderated the mediating effect of PB on NSSI and ideation, (b) PB moderated the mediating effect of TB on NSSI and ideation, and (c) CS moderated the mediating effect of TB and PB on NSSI and attempts.

RESULTS

TB and PB significantly accounted for the relationship between lifetime NSSI and current ideation. TB did not moderate the mediating effect of PB on NSSI and ideation, and PB did not moderate the mediating effect of TB. However, CS significantly moderated the mediating effects of TB and PB on NSSI and attempt history.

CONCLUSIONS

The interpersonal theory of suicide hypotheses were partially supported. Consistent with the theory, the interaction of TB and PB only explained NSSI and attempt history among service members with high levels of CS. TB and PB only individually explained the association between lifetime NSSI and recent suicidal ideation. Prospective studies are warranted to replicate these findings across other military samples. (PsycINFO Database Record

Initial validation of brief measures of suicide risk factors: Common data elements used by the Military Suicide Research Consortium

The Military Suicide Research Consortium (MSRC) developed a 57-item questionnaire assessing suicide risk factors, referred to as the Common Data Elements (CDEs), in order to facilitate data sharing and improve collaboration across independent studies. All studies funded by MSRC are required to include the CDEs in their assessment protocol. The CDEs include shortened measures of the following: current and past suicide risk, lethality and intent of past suicide attempts, hopelessness, thwarted belongingness, anxiety sensitivity, posttraumatic stress disorder symptoms, traumatic brain injury, insomnia, and alcohol abuse. This study aimed to evaluate the psychometric properties of the CDE items drawn from empirically validated measures. Exploratory factor analysis was used to examine the overall structure of the CDE items, and confirmatory factor analyses were used to evaluate the distinct properties of each scale. Internal consistencies of the CDE scales and correlations with full measures were also examined. Merged data from 3,140 participants (81.0% military service members, 75.6% male) across 19 MSRC-funded studies were used in analyses. Results indicated that all measures exhibited adequate internal consistency, and all CDE shortened measures were significantly correlated with the corresponding full measures with moderate to strong effect sizes. Factor analyses indicated that the shortened CDE measures performed well in comparison with the full measures. Overall, our findings suggest that the CDEs are not only brief but also provide psychometrically valid scores when assessing suicide risk and related factors that may be used in future research. (PsycINFO Database Record

Health care contact and suicide risk documentation prior to suicide death: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

OBJECTIVE

Prior research has shown that a substantial portion of suicide decedents access health care in the weeks and months before their death. We examined whether this is true among soldiers.

METHOD

The sample included the 569 Regular Army soldiers in the U.S. Army who died by suicide on active duty between 2004 and 2009 compared to 5,690 matched controls. Analyses examined the prevalence and frequency of health care contacts and documentation of suicide risk (i.e., the presence of prior suicidal thoughts and behaviors) over the year preceding suicide death. Predictors of health care contact and suicide risk documentation were also examined.

RESULTS

Approximately 50% of suicide decedents accessed health care in the month prior to their death, and over 25% of suicide decedents accessed health care in the week prior to their death. Mental health encounters were significantly more prevalent among suicide decedents (4 weeks: 27.9% vs. 7.9%, χ2 = 96.2, p < .001; 52 weeks: 59.4% vs. 33.7%, χ2 = 120.2, p < .001). Despite this, risk documentation was rare among suicide decedents (4 weeks: 13.8%; 52 weeks: 24.5%). Suicide decedents who were male, never married, and non-Hispanic Black were less likely to access care prior to death. Number of mental health encounters was the only predictor of suicide risk documentation among decedents at 4 weeks (OR = 1.14) and 52 weeks (OR = 1.05) prior to their death.

CONCLUSIONS

Many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. However, in most cases, there was no documentation of prior suicidal thoughts or behaviors, highlighting the need for improvements in risk detection and prediction. Increasing the frequency, scope, and accuracy of risk assessments, especially in mental health care settings, may be particularly useful. (PsycINFO Database Record

Thwarted belongingness as an explanatory link between insomnia symptoms and suicidal ideation: Findings from three samples of military service members and veterans

BACKGROUND

Although insomnia has been identified as a robust predictor of suicidal ideation and behaviors, little is known about the mechanisms by which sleep disturbances confer risk for suicide. We investigated thwarted belongingness as an explanatory link between insomnia symptoms and suicidal ideation across three military service member and veteran samples.

METHODS

Data were collected among United States military service members and veterans (N1=937, N2=3,386, N3=417) who completed self-report measures of insomnia symptoms, thwarted belongingness, suicidal ideation, and related psychiatric symptoms (e.g., anxiety, hopelessness). Bias-corrected bootstrap mediation analyses were utilized to examine the indirect effects of insomnia symptoms on suicidal ideation through thwarted belongingness, controlling for related psychiatric symptoms.

RESULTS

Consistent with study hypotheses, thwarted belongingness significantly accounted for the relationship between insomnia and suicidal ideation across all three samples; however, insomnia symptoms did not significantly account for the relationship between thwarted belongingness and suicidal ideation, highlighting the specificity of our findings.

LIMITATIONS

This study utilized cross-sectional self-report data.

CONCLUSIONS

Insomnia may confer suicide risk for military service members and veterans, in part, through the pathway of thwarted belongingness. Additional prospective studies are warranted to further delineate this model of risk. Our results offer a potential therapeutic target for the prevention of suicide, via the promotion of belongingness, among service members and veterans experiencing insomnia symptoms.

Ecological Momentary Assessment is a Neglected Methodology in Suicidology

Ecological momentary assessment (EMA) is a group of research methods that collect data frequently, in many contexts, and in real-world settings. EMA has been fairly neglected in suicidology. The current article provides an overview of EMA for suicidologists including definitions, data collection considerations, and different sampling strategies. Next, the benefits of EMA in suicidology (i.e., reduced recall bias, accurate tracking of fluctuating variables, testing assumptions of theories, use in interventions), participant safety considerations, and examples of published research that investigate self-directed violence variables using EMA are discussed. The article concludes with a summary and suggested directions for EMA research in suicidology with the particular aim to spur the increased use of this methodology among suicidologists.

Exploring the association between exposure to suicide and suicide risk among military service members and veterans

BACKGROUND

Past research suggests that suicide has a profound impact on surviving family members and friends; yet, little is known about experiences with suicide bereavement among military populations. This study aimed to characterize experiences with suicide exposure and their associations with lifetime and current psychiatric symptoms among military service members and veterans.

METHODS

A sample of 1753 United States military service members and veterans completed self-report questionnaires assessing experiences with suicide exposure, lifetime history of suicidal thoughts and behaviors, current suicidal symptoms, and perceived likelihood of making a future suicide attempt.

RESULTS

The majority of participants (57.3%) reported knowing someone who had died by suicide, and of these individuals, most (53.1%) reported having lost a friend to suicide. Chi-square tests, one-way ANOVAs, and logistic regression analyses revealed that those who reported knowing a suicide decedent were more likely to report more severe current suicidal symptoms and a history of suicidal thoughts and behaviors compared to those who did not know a suicide decedent. Hierarchical linear regression analyses indicated that greater self-reported interpersonal closeness to a suicide decedent predicted greater self-reported likelihood of a future suicide attempt, even after controlling for current suicidal symptoms and prior suicidal thoughts and behaviors.

LIMITATIONS

This study utilized cross-sectional data, and information regarding degree of exposure to suicide was not collected.

CONCLUSIONS

Military personnel and veterans who have been bereaved by suicide may themselves be at elevated risk for suicidal thoughts and behaviors. Additional work is needed to delineate the relationship between these experiences.

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers

OBJECTIVE

This study describes a randomized controlled trial called "Operation Worth Living" (OWL) which compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced care as usual (E-CAU). We hypothesized that CAMS would be more effective than E-CAU for reducing suicidal ideation (SI) and suicide attempts (SA), along with secondary behavioral health and health care utilization markers for U.S. Army Soldier outpatients with significant SI (i.e., > 13 on Beck's Scale for Suicide Ideation).

METHOD

Study participants were 148 Soldiers who presented to a military outpatient behavioral health clinic. There were 73 Soldiers in the experimental arm of the trial who received adherent CAMS; 75 Soldiers received E-CAU. Nine a-priori treatment outcomes (SI, past year SA, suicide-related emergency department (ED) admits, behavioral health-related ED admits, suicide-related inpatient psychiatric unit (IPU) days, behavioral health-related IPU days, mental health, psychiatric distress, resiliency) were measured through assessments at Baseline and at 1, 3, 6, and 12 months post-Baseline (with a 78% retention of intent-to-treat participants at 12 months).

RESULTS

Soldiers in both arms of the trial responded to study treatments in terms of all primary and secondary outcomes (effect sizes ranged from 0.63 to 12.04). CAMS participants were significantly less likely to have any suicidal thoughts by 3 months in comparison to those in E-CAU (Cohen's d = 0.93, p=.028).

CONCLUSIONS

Soldiers receiving CAMS and E-CAU significantly improved post-treatment. Those who received CAMS were less likely to report SI at 3 months; further group differences were not otherwise seen.

Suicide Resilience Inventory–25: Development and Preliminary Psychometric Properties

This manuscript describes the development of the Suicide Resilience Inventory–25, used to assess factors that help defend against suicidal thoughts and behaviors. We used multiple sources to generate and evaluate initial items (Study 1), then conducted an iterated principal-axis factor analysis with data from a combined sample of 540 adolescents and young adults. This identified three correlated factors, named Internal Protective, Emotional Stability, and External Protective. Estimated alpha for the total inventory and scales was high (.90 to .95). In Study 1, scores on the inventory significantly differentiated between the responses of adolescents and young adults. In Study 2, the inventory scores significantly differentiated between participants who reported (a) no prior suicide thoughts or attempts (145 men and 153 women), (b) brief suicidal thoughts (55 men and 110 women), and (c) prior suicide plans or attempts (22 men and 55 women). Results of the two studies suggest the inventory is useful for assessing the construct of suicide resilience in terms of these three operationally defined dimensions.

Appropriateness of the Multi-Attitude Suicide Tendency Scale for Non-White Individuals

Analyses of data collected from 480 university students (approximately 56% White and 44% Black) challenge the utility of the Multi-Attitude Suicide Tendency Scale (MAST) for use with individuals of diverse cultural backgrounds. This size sample allowed for an examination of the psychometric properties and cultural relevance of the MAST for non-Whites. Correlations between scores on the MAST, suicide, and depression measures were in the expected directions for Whites but not for Blacks or Latinos. The White sample data fit the four-factor model of the MAST, but the model required several modifications to fit the data from the Black sample. Verification of the cultural relevance of the MAST and a revision of the scale are recommended to improve its usefulness.

Physical Activity, Suicide Risk Factors, and Suicidal Ideation in a Veteran Sample

The association between current level of suicidal ideation and physical activity was tested in a broad sample of veterans seeking care from the Veterans Health Administration. It was hypothesized that the two variables would be significantly inversely related. It was further hypothesized that the relationship would be mediated by depressive symptoms, disturbed sleep, and a measure of heart rate variability based on existing research regarding physical activity and sleep. Due to the first hypothesis not being supported, the second could not be tested. Post hoc correlation analyses did find associations between physical activity and depressive symptoms, in expected directions, and are discussed. Possible explanations for the negative findings along with recommendations for future research to continue exploring links between suicide risk and physical activity are presented. We conclude by suggesting that physical activity may have promise as a risk reduction intervention and that prospective data are more likely to yield significant results than the cross-sectional methodology employed in the current study.

Staring Down Death

Abstract. Background: Lowered eye blink rate may be a clinically useful indicator of acute, imminent, and severe suicide risk. Diminished eye blink rates are often seen among individuals engaged in heightened concentration on a specific task that requires careful planning and attention. Indeed, overcoming one’s biological instinct for survival through suicide necessitates premeditation and concentration; thus, a diminished eye blink rate may signal imminent suicidality. Aims: This article aims to spur research and clinical inquiry into the role of eye blinks as an indicator of acute suicide risk. Method: Literature relevant to the potential connection between eye blink rate and suicidality was reviewed and synthesized. Results: Anecdotal, cognitive, neurological, and conceptual support for the relationship between decreased blink rate and suicide risk is outlined. Conclusion: Given that eye blinks are a highly observable behavior, the potential clinical utility of using eye blink rate as a marker of suicide risk is immense. Research is warranted to explore the association between eye blink rate and acute suicide risk.