RECENT AND NEEDED ADVANCES IN THE UNDERSTANDING, PREDICTION, AND PREVENTION OF SUICIDAL BEHAVIOR

Impairment in personality functioning predicts young adult suicidal ideation and suicide attempt above and beyond depressive symptoms

Interpersonal factors and depression are believed to be some of the main drivers of suicidal thoughts and behaviors, but other factors may be equally or more important. Drawing on psychodynamic (mentalization) theory, we propose that personality functioning, in particular an incoherent sense of self, may be an important driver of suicidal thoughts and behaviors over and above factors of interpersonal functioning and depression. To evaluate this, we examined associations between personality functioning and suicidal ideation and suicide attempt in young adults. Participants (N=153; Mage=20.93) were recruited from a college sample (N=90) and a clinical sample with borderline personality disorder (N=63). Personality functioning (self and interpersonal components) was measured with the Level of Personality Functioning Scale - Brief Form 2.0. Suicidal ideation was measured with the Personality Assessment Inventory. Suicide attempt history was assessed with the Columbia-Suicide Severity Rating Scale. Depression symptoms were measured with the Symptom Checklist 90. Regressions examined relationships between personality functioning, depression symptoms, and suicidal ideation or attempt while controlling for age and gender. Overall personality functioning was significantly associated with suicidal ideation (β=.584, p<.001) and suicide attempt (β=.384, p<.001). Overall personality functioning was a stronger predictor than depression symptoms, age, and gender when included in the same model predicting suicidal ideation or attempt. Both the self and interpersonal components of personality functioning were significantly associated with suicidal ideation and attempt, with larger effect sizes for self-functioning. Findings underscore the importance of considering personality functioning, especially self-functioning, in suicide risk assessment and treatment.

Prevalence of suicidal ideation and associated factors among pregnant women attending ANC follow-up clinic in Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, 2022

Suicide is a worldwide concern and ranks as the third leading cause of death among individuals of reproductive age. According to many findings, Ethiopia remains to suffer with a considerable number of suicide deaths and attempts, so more research on the prevalence of suicidal ideation is necessary. Since there is limited research available about suicide ideation/attempts specifically from the study area, evidence-based and solution-oriented research is necessary. This study sought to determine the prevalence of suicidal ideation and its contributing factors among pregnant women visited ante-natal care (ANC) at the University of Gondar Specialized Compressive Hospital. Institutional based cross-sectional study was conducted among 174 pregnant women who visit ante-natal care (ANC) at the University of Gondar Specialized Compressive Hospital, from June 01 to August 30, 2022. Participants were selected by using a systematic random sampling method. The World Mental Health (WMH) survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) was used to measure suicidal ideation and attempt. The data was entered into SPSS version 25 for analysis, and descriptive and inferential statistics were done. Bivariable and multivariable binary logistic regression analyses were done to identify factors associated with suicidal ideation and attempt among pregnant women. Variables with a P value less than 0.05 were considered statistically significant with 95% CI. In the current study 174 pregnant women were screened, and 168 volunteered to participate with a response rate of 96.5%. The finding showed that the prevalence of suicidal ideation and a suicidal attempt was 5.4% (95% CI: 1.8-8.9) and 4.8% (95% CI: 1.8-8.9) respectively. Unplanned pregnancy [AOR: 1.9(1.22-0.88)], history of abortion [AOR: 2.5(1.5-12.6)], history of stillbirth [AOR: 2.32(1.7-13.2)], HIV status of seropositive [AOR: 1.5(01.2-16.0)] and history of lifetime substance use [AOR: 1.6(1.3-12.0)] were significant positive predictors of prevalence of suicidal ideation. The study finding shows that the prevalence of suicidal ideation and attempt among pregnant women was low. Unplanned pregnancy, history of abortion, history of stillbirth, HIV status of seropositive, and history of lifetime substance use were variables significantly associated with suicidal ideation among pregnant women.

Examining contemporaneous and temporal associations of real-time suicidal ideation using network analysis

BACKGROUND

Suicidal ideation arises from a complex interplay of multiple interacting risk factors over time. Recently, ecological momentary assessment (EMA) has increased our understanding of factors associated with real-time suicidal ideation, as well as those predicting ideation at the level of hours and days. Here we used statistical network methods to investigate which cognitive-affective risk and protective factors are associated with the temporal dynamics of suicidal ideation.

METHODS

The SAFE study is a longitudinal cohort study of 82 participants with current suicidal ideation who completed 4×/day EMA over 21 days. We modeled contemporaneous (t) and temporal (t + 1) associations of three suicidal ideation components (passive ideation, active ideation, and acquired capability) and their predictors (positive and negative affect, anxiety, hopelessness, loneliness, burdensomeness, and optimism) using multilevel vector auto-regression models.

RESULTS

Contemporaneously, passive suicidal ideation was positively associated with sadness, hopelessness, loneliness, and burdensomeness, and negatively with happiness, calmness, and optimism; active suicidal ideation was positively associated with passive suicidal ideation, sadness, and shame; and acquired capability only with passive and active suicidal ideation. Acquired capability and hopelessness positively predicted passive ideation at t + 1, which in turn predicted active ideation; acquired capability was positively predicted at t + 1 by shame, and negatively by burdensomeness.

CONCLUSIONS

Our findings show that systematic real-time associations exist between suicidal ideation and its predictors, and that different factors may uniquely influence distinct components of ideation. These factors may represent important targets for safety planning and risk detection.

Subtypes of Depressed Youth Admitted for Inpatient Psychiatric Care: A Latent Profile Analysis

Depressed youth frequently present with comorbid symptoms. Comorbidity is related to a poorer prognosis, including treatment resistance, academic problems, risk of suicide, and overall impairment. Studies examining the latent structure of depression support the notion of multiple presentations of depressed youth; however, it is unclear how these presentations are represented among acutely impaired youth. Participants (n = 457) in this naturalistic study were admitted to a psychiatric inpatient unit (Mean age = 14.33 years, SD = 1.94;76% female;46.6% Black/African-American). Selected subscales from the parent-report Behavior Assessment System for Children, Second Edition, were utilized as indicators in a latent profile analysis. Subgroups were validated based on their relationships with meaningful clinical correlates (e.g., family factors, discharge diagnosis) and further described by their associations with demographic variables. A five-class model provided the best balance of fit and parsimony. Subtypes of depressed youth included Predominantly Depressed (39.1%), Oppositional (28.2%), Severely Disruptive (12.3%), Anxious-Oppositional (11.6%), and Anxious-Withdrawn (8.8%). Comorbid symptoms were present in four of the five classes (60.9% of sample). High levels of externalizing symptoms were a prominent clinical feature associated with three classes (52.1% of the sample). Construct validity of the respective classes was demonstrated by differential association with clinical correlates, family characteristics, and demographics. Findings suggest that depressed youth presenting for acute inpatient psychiatric care displayed varied clinical presentations. The identified latent groups aligned with existing research reflecting comorbidity with anxiety, inattention, and externalizing disorders. Findings underscore the need for an increased clinical appreciation of comorbidity and encourage more targeted and effective prevention and treatment strategies.

Relations between discrimination, rejection sensitivity, negative affect, and decrements in problem-solving ability following social rejection: An experimental investigation

INTRODUCTION

While negative affect and problem-solving deficits have been consistently linked to suicidal thoughts and behaviors, the latter are often conceptualized and studied as time- and/or context-invariant. Though requiring additional empirical support, theory suggests that discrimination may strengthen the relation between rejection sensitivity and increases in negative affect as well as declines in problem-solving abilities following rejection. The aim of the current study was to test this claim using a social rejection paradigm (i.e., Cyberball) with young adults experiencing past-month suicidal ideation.

METHODS

The sample consisted of 50 participants. Lifetime discrimination and rejection sensitivity were assessed prior to Cyberball. Negative affect and problem-solving abilities were assessed pre- and post-Cyberball. SPSS and the PROCESS macro were used to test relations among variables of interest.

RESULTS

Rejection sensitivity predicted greater problem-solving decrements, but not negative affect, following rejection among individuals who had experienced higher (vs. lower) levels of lifetime discrimination.

CONCLUSION

Addressing rejection sensitivity and sources of discrimination within the context of treatment may reduce the impact of social rejection on problem-solving abilities among young adults at risk for suicide.

EEG wakefulness regulation in transdiagnostic patients after a recent suicide attempt

OBJECTIVE

Decades of research have not yet produced statistically reliable predictors of preparatory behavior eventually leading to suicide attempts or deaths by suicide. As the nature of suicidal behavior is complex, it is best investigated in a transdiagnostic approach, while assessing objective markers, as proposed by the Research Domain Criteria (Cuthbert, 2013).

METHODS

A 15-min resting-state EEG was recorded in 45 healthy controls, and 49 transdiagnostic in-patients with a recent (<6 months) suicide attempt. Brain arousal regulation in eyes-closed condition was assessed with the Vigilance Algorithm Leipzig (VIGALL) (Sander et al., 2015).

RESULTS

A significant incline of median vigilance and vigilance slope was observed in patients within the first 3-min of the EEG recording. Additionally, a significant positive correlation of self-reported suicidal ideation with the vigilance slope over 15-min recording time, as well as a significant negative correlation with EEG vigilance stage A1 during the first 3-min was found.

CONCLUSIONS

Transdiagnostic patients with a recent suicide attempt show a distinct vigilance regulation pattern. Further studies including a control group consisting of patients without life-time suicide attempts are needed to increase the clinical utility of the findings.

SIGNIFICANCE

These findings might serve as potential objective markers of suicidal behavior.

Content and Process of Adolescent Suicide Ideation: Implications for Risk Assessment

This study examined differences in the content and process of suicide ideation between adolescents presenting with recent suicide ideation or a suicide attempt in clinical settings. Across two combined study samples, adolescents (N = 229; 79% female; 73% Hispanic/Latine), ages 12-19, presenting with a recent suicide attempt, recent suicide ideation with a past suicide attempt history, or recent suicide ideation with no past suicide attempt history were interviewed in detail about the process and content of their suicide ideation. The group with suicide ideation and a past suicide attempt more often reported that their recent ideation lasted greater than 4 h compared to those with suicide ideation but no past suicide attempt history. The suicide attempt group more often considered ingestion as their first method of attempt, compared to the other two suicide ideation groups, and less often considered "other" methods (e.g., jumping from a height or onto train/traffic, hanging). Wish to die was lower in the ideation-only group, compared to both other groups. Separate analyses from Study 2 suggested that the majority of adolescents' suicide ideation contained imagery; however, a higher proportion of adolescents with suicide ideation and a past suicide attempt reported imagery in their ideation than those with ideation but no past attempt. Understanding what adolescents think about when they consider suicide and how they think about it may be informative about risk of a suicide attempt.

Social connectedness and suicidal ideation: the roles of perceived burdensomeness and thwarted belongingness in the distress to suicidal ideation pathway

BACKGROUND

Suicide is a serious public health issue. Distress has been identified as a common risk factor, with research also suggesting that a lack of social connectedness is involved.

METHODS

This quantitative, cross-sectional study investigated the role of perceived burdensomeness and thwarted belongingness in the psychological distress/suicidal ideation pathway in a community sample of 480 Australian adults.

RESULTS

As expected, distress was found to be a strong predictor of suicidal ideation. Perceived burdensomeness and thwarted belongingness both moderated and mediated the relationship between distress and suicidal ideation. Specifically, distress was more strongly linked to suicide ideation when burdensomeness or thwarted belongingness were also high. This moderating effect was stronger for thwarted belongingness than it was for burdensomeness. These variables also mediated the pathway, in that higher distress related to higher burdensomeness and thwarted belonging, which in turn related to higher suicide ideation. This mediating effect was stronger for burdensomeness than for thwarted belonging.

CONCLUSIONS

Overall, the findings confirm the importance of our social relatedness in suicide. Increasing belongingness and reducing the perception of being a burden on others may be an important intervention strategy for weakening the link between distress and suicide ideation.

Deficits in psychological resilience and problem-solving ability in adolescents with suicidal ideation

OBJECTIVES

This study aimed to explore differences between psychological resilience and problem-solving ability in grade one junior middle school adolescents with and without suicidal ideation, focusing on the relationship between these factors and suicidal ideation.

METHODS

Ninety-nine adolescents (aged 10 to 14) were divided into Suicidal Ideation (SI, n = 49) and Non-Suicidal Ideation (NSI, n = 50) grouped by the Self-rating Idea of Suicide Scale (SIOSS). The Psychological Resilience Scale (PRS) and Tower of Hanoi task (TOH) were applied to assess psychological resilience and problem-solving ability, respectively.

RESULTS

The SI group scored significantly lower than the NSI group on PRS (p < 0.001) and performed more poorly on TOH than the NSI group, with more mistakes in the number of errors index (p < 0.001) and requiring a longer time in the task completion time index (p < 0.05). Among all the participants in this study, a significant negative correlation was observed between PRS and SIOSS (r = - 0.413, p < 0.01). The sub-dimensions of PRS including emotional control, family support, and interpersonal assistance were significantly negatively correlated with the SIOSS total score (r = - 0.361, - 0.360, - 0.382; p < 0.01).

CONCLUSIONS

This study profiled the characteristics and differences in psychological resilience and problem-solving ability between adolescents with and without suicidal ideation. The data suggested adolescents with SI might have deficits in psychological resilience and problem-solving ability, which may serve as potential targets for suicide intervention.

Understanding Suicide over the Life Course Using Data Science Tools within a Triangulation Framework

Suicide and suicidal behaviors are important global health concerns. Preventing suicide requires a nuanced understanding of the nature of suicide risk, both acutely during periods of crisis and broader variation over the lifespan. However, current knowledge of the sources of variation in suicide risk is limited due to methodological and conceptual challenges. New methodological approaches are needed to close the gap between research and clinical practice. This review describes the life course framework as a conceptual model for organizing the scientific study of suicide risk across in four major domains: social relationships, health, housing, and employment. In addition, this review discusses the utility of data science tools as a means of identifying novel, modifiable risk factors for suicide, and triangulation as an overarching approach to ensuring rigor in suicide research as means of addressing existing knowledge gaps and strengthening future research.

Don't Miss the Moment: A Systematic Review of Ecological Momentary Assessment in Suicide Research

Suicide and suicide-related behaviors are prevalent yet notoriously difficult to predict. Specifically, short-term predictors and correlates of suicide risk remain largely unknown. Ecological momentary assessment (EMA) may be used to assess how suicidal thoughts and behaviors (STBs) unfold in real-world contexts. We conducted a systematic literature review of EMA studies in suicide research to assess (1) how EMA has been utilized in the study of STBs (i.e., methodology, findings), and (2) the feasibility, validity and safety of EMA in the study of STBs. We identified 45 articles, detailing 23 studies. Studies mainly focused on examining how known longitudinal predictors of suicidal ideation perform within shorter (hourly, daily) time frames. Recent studies have explored the prospects of digital phenotyping of individuals with suicidal ideation. The results indicate that suicidal ideation fluctuates substantially over time (hours, days), and that individuals with higher mean ideation also have more fluctuations. Higher suicidal ideation instability may represent a phenotypic indicator for increased suicide risk. Few studies succeeded in establishing prospective predictors of suicidal ideation beyond prior ideation itself. Some studies show negative affect, hopelessness and burdensomeness to predict increased ideation within-day, and sleep characteristics to impact next-day ideation. The feasibility of EMA is encouraging: agreement to participate in EMA research was moderate to high (median = 77%), and compliance rates similar to those in other clinical samples (median response rate = 70%). More individuals reported suicidal ideation through EMA than traditional (retrospective) self-report measures. Regarding safety, no evidence was found of systematic reactivity of mood or suicidal ideation to repeated assessments of STBs. In conclusion, suicidal ideation can fluctuate substantially over short periods of time, and EMA is a suitable method for capturing these fluctuations. Some specific predictors of subsequent ideation have been identified, but these findings warrant further replication. While repeated EMA assessments do not appear to result in systematic reactivity in STBs, participant burden and safety remains a consideration when studying high-risk populations. Considerations for designing and reporting on EMA studies in suicide research are discussed.

Role of thwarted belongingness, perceived burdensomeness and psychological distress in the association between adverse childhood experiences and suicidal ideation in college students

BACKGROUND

Adverse childhood experiences (ACEs) have a detrimental impact on short- and long-term mental and physical health. A growing body of research has indicated that the prevalence of suicidal phenomena is significantly higher among individuals with a history of ACEs. However, there is a lack of understanding about processes that result in ACEs leading to suicidal ideation when testing within a theoretical framework.

AIMS

To develop and test a multidimensional model that would explain the association between ACEs and suicidal ideation in college students.

METHOD

Data were obtained from a cross-sectional survey completed by 321 college students primarily recruited from universities in Ireland. Participants were aged 18-21 (n = 176) and 22-25 years (n = 145). An ACEs questionnaire, the Interpersonal Needs Questionnaire, which assessed thwarted belongingness and perceived burdensomeness, the CORE-10, which assessed psychological distress, and the Suicide Ideation Scale (SIS) were administered.

RESULTS

After controlling for gender and sexual orientation, results revealed a significant direct effect of ACEs on suicidal ideation such that more accumulated ACEs were associated with higher suicidal ideation (effect size 0.30; 95% CI 0.047-0.538). A significant indirect effect of ACEs on suicidal ideation through perceived burdensomeness and psychological distress, and thwarted belongingness and psychological distress, was observed (effect size 0.90; 95% CI 0.558-1.270).

CONCLUSIONS

Findings suggest that ACEs have a detrimental impact on college students' mental health. Results highlight the potential benefits of ACE-informed interventions that target thwarted belongingness and perceived burdensomeness to countervail suicidal ideation in college students.

Multi-informant reports of depressive symptoms and suicidal ideation among adolescent inpatients

OBJECTIVE

Suicide is a leading cause of death among adolescents, and suicidal thoughts represent key predictors to suicidal behavior. Yet, suicidal thoughts can be challenging to accurately assess. Symptoms that commonly co-occur with suicidal thoughts, such as depressive symptoms, may provide valuable information for predicting these thoughts. Although clinicians commonly collect multi-informant reports about adolescent depressive symptoms, these reports often yield discrepant findings as individual predictors of adolescents' suicidal thoughts.

METHOD

We tested the ability of specific patterns of multi-informant reports to predict adolescents' suicidal thoughts. Ninety adolescent inpatients and their parents (i.e., "dyads") reported on adolescent depressive symptoms, and adolescents completed self-report assessments of suicidal thoughts at baseline and three-month follow-up.

RESULTS

Dyads displayed variability in reporting patterns, and these patterns uniquely predicted suicidal thoughts. Adolescents reporting elevated depressive symptoms displayed increased concurrent suicidal thoughts relative to adolescents reporting subthreshold depressive symptoms, regardless of parent report. Yet, only adolescents who reported elevated depressive symptoms and whose parents reported subthreshold adolescent depressive symptoms displayed increased future suicidal thoughts.

CONCLUSIONS

Identifying patterns of multiple informants' reports about adolescent depressive symptoms may improve the prediction of suicidal thoughts. These findings have important implications for assessing adolescents at risk for suicide.

Instability of Suicidal Ideation in Patients Hospitalized for Depression: An Exploratory Study Using Smartphone Ecological Momentary Assessment

This study used ecological momentary assessment (EMA) to explore the correlates of suicidal ideation (SI) instability in patients hospitalized for depression and SI. Thirty-nine adult inpatients were given smartphones with visual analogue scales to rate current depressed mood, anger/irritability, feeling socially connected, and SI three times a day throughout hospitalization. Affective Lability Scales (ALS) were also completed at baseline. SI instability was correlated with SI intensity, depressed mood instability, and social connection instability. Social connection instability was not associated with SI instability after controlling for depressed mood instability. ALS scores were not associated with EMA-derived SI instability. Participants with multiple past suicide attempts experienced greater SI instability. More research examining the clinical significance of SI instability is warranted.

Informing the study of suicidal thoughts and behaviors in distressed young adults: The use of a machine learning approach to identify neuroimaging, psychiatric, behavioral, and demographic correlates

Young adults are at high risk for suicide, yet there is limited ability to predict suicidal thoughts and behaviors. Machine learning approaches are better able to examine a large number of variables simultaneously to identify combinations of factors associated with suicidal thoughts and behaviors. The current study used LASSO regression to investigate extent to which a number of demographic, psychiatric, behavioral, and functional neuroimaging variables are associated with suicidal thoughts and behaviors during young adulthood. 78 treatment seeking young adults (ages 18-25) completed demographic, psychiatric, behavioral, and suicidality measures. Participants also completed an implicit emotion regulation functional neuroimaging paradigm. Report of recent suicidal thoughts and behaviors served as the dependent variable. Five variables were identified by the LASSO regression: Two were demographic variables (age and level of education), two were psychiatric variables (depression and general psychiatric distress), and one was a neuroimaging variable (left amygdala activity during sad faces). Amygdala function was significantly associated with suicidal thoughts and behaviors above and beyond the other factors. Findings inform the study of suicidal thoughts and behaviors among treatment seeking young adults, and also highlight the importance of investigating neurobiological markers.

Suicide and suicidality in contemporary serving and ex-serving Australian Defence Force personnel

OBJECTIVE

The risk of suicide in contemporary serving and ex-serving Australian Defence Force personnel is an area of significant concern, driving government-directed inquiries, community campaigns and most recently, the establishment of a permanent National Commissioner for Defence and Veteran Suicide Prevention. This concern is mirrored in international militaries and despite investment in prevention programmes, suicide is a leading cause of death in military populations. This review seeks to summarise recent findings from Australian research regarding the magnitude and factors associated with suicide and suicidality in contemporary serving and ex-serving Australian Defence Force populations and discusses research findings, implications and future opportunities.

METHODS

Initial review of the prevalence of suicide and suicidality in the general community and military populations is presented, followed by review of recent research findings pertaining to suicides and suicidal thoughts, plans and attempts in contemporary serving and ex-serving Australian Defence Force personnel. Key findings are presented from the 2010 Australian Defence Force Mental Health and Wellbeing Prevalence Study and the 2015 Transition and Wellbeing Research Programme.

RESULTS

Differences between serving and ex-serving Australian Defence Force cohorts were observed, with rates of completed suicide in ex-serving Australian Defence Force males more than double that of serving Australian Defence Force males, and increased risk for suicidality observed among those who had recently transitioned out of full-time Australian Defence Force service. Risk for increased suicidality and completed suicide is particularly evident for younger males of lower ranks, and those who have been medically discharged.

CONCLUSIONS

The findings provide insight into career phases and groups that should be followed-up and targeted for prevention and early intervention programmes, including prior to and several years following transition out of full-time military service. Further research to better understand the factors that influence those who develop suicidal ideation, and those who progress to plans and attempts, will inform a more sophisticated approach to suicide prevention programmes.

Is Emotion Dysregulation Associated With Suicidal Ideation in Post 9/11 Veterans?

Emotion dysregulation, a risk factor for suicide ideation and attempts, has not been studied in U.S. veterans of Operations Enduring and Iraqi Freedom and New Dawn (OEF/OIF/OND). Data were collected through standardized telephone interviews and computer-based surveys from 278 OEF/OIF/OND veterans (70.6% male, 29.4% female). Bivariate analyses indicated that emotion dysregulation was associated with suicidal ideation during the past-three-months (r = 0.30, p < 0.05) and lifetime suicide attempts (r = 0.21, p < 0.05). When PTSD and depression symptoms were added to a sequential logistic regression model, emotion dysregulation was no longer significantly associated with ideation or attempt. Emotion dysregulation was associated with suicidal ideation and attempt; however, current distress had greater associations. Dysregulation is one of several factors in veteran suicide risk.

Perceived burdensomeness is a curvilinear, short-term predictor of suicide ideation in a community sample of adults

OBJECTIVE

Our primary aim was to test the Interpersonal Theory of Suicide's synergy hypothesis (i.e., the interaction between perceived burdensomeness and thwarted belongingness) in the proximal prediction of suicide ideation, while accounting for quadratic effects.

METHOD

We used MTurk to recruit participants (N = 478) with a lifetime history of suicidal thoughts and behaviors; they completed two batteries of self-report questionnaires three days apart.

RESULTS

Contrary to the synergy hypothesis, only suicide ideation and the quadratic effect of perceived burdensomeness at Time 1 were significant predictors of suicide ideation at Time 2. The quadratic effect of perceived burdensomeness indicated a u-shaped function, whereby scores at or above the 80^th percentile on perceived burdensomeness at Time 1 had increasingly strong, positive associations with suicide ideation at Time 2, while scores under the 80^th percentile were not predictive of suicide ideation at Time 2. Also, thwarted belongingness and suicide ideation at Time 1 were significant predictors of perceived burdensomeness at Time 2.

CONCLUSIONS

These findings add to a growing literature that does not support the synergy hypothesis and suggests the importance of including nonlinear terms when examining the Interpersonal Theory of Suicide's constructs.

Classification trees identify shared and distinct correlates of nonsuicidal self-injury and suicidal ideation across gender identities in emerging adults

College students have an elevated risk for self-injurious thoughts and behaviours (SITBs), and there are robust differences in prevalence rates for SITBs across gender identities. Although numerous constructs have been implicated as risk factors, researchers have not significantly improved at predicting SITBs, possibly owing to constraints of confirmatory analyses. Classification trees are exploratory, person-centred analyses that enable joint examination of numerous correlates and their interactions. Thus, classification trees may discern previously unstudied risk factors and identify distinct subpopulations with elevated risk for SITBs. We tested classification trees that evaluated 298 potential correlates of nonsuicidal self-injury and suicidal ideation across self-identified women and men. Data came from 5,131 college students who completed the National College Health Assessment, which assesses a wide range of health-related constructs. Models produced parsimonious decision trees that accounted for a substantial amount of outcome variability (38.3-51.5%). Psychopathology, poorer psychological well-being, and other SITBs emerged as important correlates for all participants. Trauma, disordered eating, and heavy alcohol use were salient among women, whereas alcohol use norms were important correlates among men. Importantly, models identified several constructs that may be amenable to intervention. Results support the use of exploratory analyses to explicate heterogeneity among individuals who engage in SITBs and suggest that gender identity is an important moderator for certain risk factors.

Parent-Youth Divergence (and Convergence) in Reports of Youth Internalizing Problems in Psychiatric Inpatient Care

When compared to one another, multiple informants' reports of adolescent internalizing problems often reveal low convergence. This creates challenges in the delivery of clinical services, particularly for severe outcomes linked to internalizing problems, namely suicidal thoughts and behaviors. Clinicians would benefit from methods that facilitate interpretation of multi-informant reports, particularly in inpatient settings typified by high-cost care and high-stakes decision-making. 765 adolescent inpatients (70.3% female; M_age = 14.7) and their parents completed measures of adolescent internalizing problems. We obtained baseline clinical and treatment characteristics from electronic medical records. Latent class analysis revealed four reporting patterns: Parent-Adolescent Low (LL; 49.0%), Parent Low-Adolescent High (PL-AH; 11.5%), Parent High-Adolescent Low (PH-AL; 21.8%), Parent-Adolescent High (HH; 17.6%). Relative to the LL class, adolescents in the PH-AL and PL-AH classes were more likely to be admitted with suicidality. In terms of treatment characteristics and relative to the LL class, HH and PH-AL adolescents were more likely to receive standing antipsychotics, PH-AL adolescents were more likely to be in seclusion, and HH adolescents had longer hospital stays. At discharge and relative to the LL class, HH, PH-AL, and PL-AH adolescents were more likely to receive an anxiety disorder diagnosis. Further, HH, PH-AL, and PL-AH adolescents were more likely to receive partial hospitalization or care in another restrictive environment after inpatient treatment, relative to the LL class. This naturalistic study informs clinical decision-making by aiding our understanding of how multi-informant reports facilitate interpretations of adolescents' clinical presentations as well as predictions about treatment characteristics.

Decomposing implicit associations about life and death improves our understanding of suicidal behavior

The Death/Suicide Implicit Association Test (IAT) is effective at detecting and prospectively predicting suicidal thoughts and behaviors. However, traditional IAT scoring procedures used in all prior studies (i.e., D-scores) provide an aggregate score that is inherently relative, obfuscating the separate associations (i.e., "Me = Death/Suicide," "Me = Life") that might be most relevant for understanding suicide-related implicit cognition. Here, we decompose the D-scores and validate a new analytic technique called the Decomposed D-scores ("DD-scores") that creates separate scores for each category ("Me," "Not Me") in the IAT. Across large online volunteer samples (N > 12,000), results consistently showed that a weakened association between "Me = Life" is more strongly predictive of having a history of suicidal attempts than is a stronger association between "Me = Death/Suicide." These findings replicated across three different versions of the IAT and were observed when calculated using both reaction times and error rates. However, among those who previously attempted suicide, a strengthened association between "Me = Death" is more strongly predictive of the recency of a suicide attempt. These results suggest that decomposing traditional IAT D-scores can offer new insights into the mental associations that may underlie clinical phenomena and may help to improve the prediction, and ultimately the prevention, of these clinical outcomes.

Diminished responses to bodily threat and blunted interoception in suicide attempters

Psychological theories of suicide suggest that certain traits may reduce aversion to physical threat and increase the probability of transitioning from suicidal ideation to action. Here, we investigated whether blunted sensitivity to bodily signals is associated with suicidal action by comparing individuals with a history of attempted suicide to a matched psychiatric reference sample without suicide attempts. We examined interoceptive processing across a panel of tasks: breath-hold challenge, cold-pressor challenge, and heartbeat perception during and outside of functional magnetic resonance imaging. Suicide attempters tolerated the breath-hold and cold-pressor challenges for significantly longer and displayed lower heartbeat perception accuracy than non-attempters. These differences were mirrored by reduced activation of the mid/posterior insula during attention to heartbeat sensations. Our findings suggest that suicide attempters exhibit an 'interoceptive numbing' characterized by increased tolerance for aversive sensations and decreased awareness of non-aversive sensations. We conclude that blunted interoception may be implicated in suicidal behavior.

Suicidal Ideation Among Anxious Youth: A Preliminary Investigation of the Role of Neural Processing of Social Rejection in Interaction with Real World Negative Social Experiences

Suicidal ideation increases in adolescence, especially for anxious youth, and is a frequent precursor to suicide. This study examined whether neural processing of social rejection interacted with negative social experiences to predict suicidal ideation. Thus, to our knowledge this is the first study to examine how brain function may interact with the environment to contribute to suicidal ideation in youth, consistent with a developmental psychopathology perspective. Thirty-six anxious youth (ages 11 to 16) completed diagnostic interviews and questionnaires, an ecological momentary assessment (EMA) protocol, and a functional magnetic resonance imaging paradigm. Results showed that youth experienced greater severity of suicidal ideation when they exhibited heightened activation to social rejection in the right anterior insula and also experienced high levels of peer victimization or EMA-measured daily negative social experiences. Findings provide preliminary evidence that alterations in neural processing of social rejection interacts with exposure to negative social experiences to contribute to suicidal ideation.

Non-suicidal self-injury prevalence, course, and association with suicidal thoughts and behaviors in two large, representative samples of US Army soldiers

BACKGROUND

Non-suicidal self-injury (NSSI) prospectively predicts suicidal thoughts and behaviors in civilian populations. Despite high rates of suicide among US military members, little is known about the prevalence and course of NSSI, or how NSSI relates to suicidal thoughts and behaviors, in military personnel.

METHODS

We conducted secondary analyses of two representative surveys of active-duty soldiers (N = 21 449) and newly enlisted soldiers (N = 38 507) from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

RESULTS

The lifetime prevalence of NSSI is 6.3% (1.2% 12-month prevalence) in active-duty soldiers and 7.9% (1.3% 12-month prevalence) in new soldiers. Demographic risk factors for lifetime NSSI include female sex, younger age, non-Hispanic white ethnicity, never having married, and lower educational attainment. The association of NSSI with temporally primary internalizing and externalizing disorders varies by service history (new v. active-duty soldiers) and gender (men v. women). In both active-duty and new soldiers, NSSI is associated with increased odds of subsequent onset of suicidal ideation [adjusted odds ratio (OR) = 1.66-1.81] and suicide attempts (adjusted OR = 2.02-2.43), although not with the transition from ideation to attempt (adjusted OR = 0.92-1.36). Soldiers with a history of NSSI are more likely to have made multiple suicide attempts, compared with soldiers without NSSI.

CONCLUSIONS

NSSI is prevalent among US Army soldiers and is associated with significantly increased odds of later suicidal thoughts and behaviors, even after NSSI has resolved. Suicide risk assessments in military populations should screen for history of NSSI.

Rethinking suicides as mental accidents: Towards a new paradigm

BACKGROUND

Since its beginnings, suicide research has made great progress in terms of empirical findings. However, in contrast to empirical knowledge, the theoretical understanding of suicides has shown only minimal progress. Missing interdisciplinary bridges and the lack of a unifying paradigm have been major obstacles. This paper examines the starting points for a rethink.

METHODS

In the first step, we identified major challenges in suicide research, which have been obstructing a better understanding. In the second step, we determined a new concept of suicide that is highly compatible with epidemiological results and meets the requirements of interdisciplinary usability. In the third step, the implications of this paradigm were explored by relating it to two process typologies, the one characterizing the temporal dynamics of suicide processes, and the other representing risk mechanisms / factors occurring at different stages of suicide processes.

RESULTS

Since suicides are rare events and often appear to be "rash acts", they can be conceived of as mental accidents or, more precisely, as failures to withstand temporary suicide impulses. This paradigm is suitable for synchronously implementing different personal, psychopathological, societal and situational perspectives. It applies to a high proportion of suicides and works well when being exposed to different typologies of suicide processes.

CONCLUSIONS

The mental accident paradigm provides an interdisciplinary starting point in suicidology that offers new perspectives in research, prediction and prevention.

The influence of family factors on time to suicidal ideation onsets during the adolescent developmental period

Family factors are associated with suicidal behavior in youth, but little is known about how the joint influence of multiple family factors prospectively predicts onsets of suicidal ideation (SI) in adolescence, a developmental period characterized by increases in SI and risk for suicide. This study investigated whether parent history of SI interacted with either positive or negative parent-child relationship quality to longitudinally predict time to SI onsets during the transition into and across adolescence. Specifically, we used a longitudinal, multi-wave design and survival analyses to examine whether the interaction between these family factors prospectively predicted time to emergence of SI onsets (assessed at 6 month intervals over 3 years) in a community sample of youth ages 8 to 15 (N = 238; 57% girls). Results supported an interaction effect, such that more negative relationship quality with parents predicted earlier emergence of SI among those youth whose parents had no history of SI. However, negative parent relationship quality did not amplify risk among youth with parent history of SI; all youth with a parent history of SI were more likely to experience earlier emergence of SI regardless of level of negative relationship quality. Findings did not support an interaction between low levels of parent-child positive relationship quality and parent history of ideation. Implications for the role of family factors in the etiology and prevention of SI are discussed.

A longitudinal study of risk factors for suicide attempts among Operation Enduring Freedom and Operation Iraqi Freedom veterans

BACKGROUND

Suicide rates among veterans have increased markedly since the onset of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF; LeardMann et al., 2013). Identification of factors with the greatest contribution to suicide risk among veterans is needed to inform risk assessment and to identify intervention targets.

METHODS

This study examined predictors of suicide attempts among participants in the Veterans After-Discharge Longitudinal Registry; a nationwide cohort of OEF/OIF veterans enrolled in Department of Veterans Affairs (VA) services. Veterans with and without probable posttraumatic stress disorder (PTSD) were sampled at a 3:1 ratio, and male and female veterans were sampled at a 1:1 ratio. Participants (N = 1,649) were assessed at two time points, roughly 2 years apart (M = 28.74 months, SD = 8.72).

RESULTS

Seventy-four participants (4.49%) attempted suicide during the follow-up period. The strongest predictors of suicide attempts among the full sample were suicidal intent, attempt history, suicide ideation, PTSD symptoms, alcohol use disorder (AUD) symptoms, and depression. Veterans with multiple risk factors were particularly vulnerable; of veterans with 0, ≥1, ≥2, ≥3, or ≥ 4 of these risk factors, 0%, 7.81%, 10.31%, 18.45%, and 20.51% made a suicide attempt, respectively.

CONCLUSIONS

This prospective study identified several strong predictors of suicide attempts among OEF/OIF veterans which may be important targets for suicide prevention efforts. Further, co-occurrence of multiple risk factors was associated with markedly greater risk for suicide attempts; veterans with multiple risk factors appear to be at the highest risk among OEF/OIF veterans enrolled in VA care.

Mind full of life: Does mindfulness confer resilience to suicide by increasing zest for life?

BACKGROUND

Mindfulness is a trainable skill that may enhance resilience to suicidality among vulnerable groups such as young people. The current study examined whether mindfulness protects against suicidal desire in the face of heightened risk and adversity by increasing zest for life in a sample of university students.

METHODS

In a prospective design, participants (N = 233) were assessed at two time points over eight weeks. Online surveys included the Mindful Attention and Awareness Scale, Zest for Life Scale, Interpersonal Needs Questionnaire, Kessler Psychological Distress Scale, and items assessing suicidal ideation and suicidal intent.

RESULTS

Baseline mindfulness was associated with lower suicidal ideation and intent at follow-up. Moderated mediation analyses confirmed the effects of mindfulness on ideation and intent were mediated by zest for life and these indirect effects were stronger at higher versus lower levels of general (psychological distress) and suicide-specific (perceived burdensomeness and thwarted belongingness) risk.

LIMITATIONS

Single item assessments of suicidal desire.

CONCLUSIONS

Findings suggest that mindfulness protects against suicidal desire in conditions of heightened risk and adversity by enhancing one's orientation towards a life worth living. Theories of suicide should consider the dynamic interplay between risk and life-sustaining resilience, while clinicians treating suicidality could use mindfulness strategies to strengthen the desire to (re)engage with life, thereby complementing direct amelioration of suicide risk factors.

An examination of suicide research and funding in New Zealand 2006–16: implications for new research and policies

Objective Suicide is a significant public health problem in New Zealand, with the youth suicide rate being one of the highest among developed countries. Increased suicide rates in recent years suggest that the evidence base and research priorities for New Zealand suicide prevention need to be reassessed. To inform policy development, the aim of the present study was to evaluate all peer-reviewed New Zealand published suicide research and major grant allocations from 2006 to 2016. Methods The methodology duplicated a recent Australian review of suicide prevention research and funding. Publications and grant funding allocations were assessed independently. Key research databases were searched in April 2016 for all suicide-related publications. Identified papers were then classified by research type, population focus and type of self-injurious behaviour. Citation indices were obtained for each publication. Annual reports, newsletters and summary data from four major New Zealand funding bodies (the Health Research Council of New Zealand, Marsden Fund, Lottery Health Research and the Ministry of Health) were reviewed for funding allocations. Identified grants were coded for type of project, type of self-injurious behaviour and target population. Descriptive analyses were performed. Results In all, 104 published articles and 27 grants met review criteria. Total funding was NZ$12 677 261.62. Most published articles were epidemiological in nature and the most common type of grant was for an intervention. Conclusions In the past decade, a substantial number of articles has been published and significant funding was invested in New Zealand’s suicide research. The present review suggests that future research investments should focus on effective translation of research findings into suicide prevention programs. Several pragmatic recommendations are proposed to help improve the evidence base and reduce New Zealand’s suicide rates. What is known about the topic? Suicide prevention continues to be a national public health priority for New Zealand. Although much is known about the prevalence of suicidal behaviours in New Zealand, less is known about how well suicide research has addressed prevention priorities and specific target populations. Australian research found that research funding and publications were dominated by epidemiological studies rather than evaluation or intervention studies. It is yet to be determined whether these research and funding trends also apply for New Zealand. What does this paper add? This study examined all peer-reviewed and published suicide research and all major suicide prevention projects that have been funded in New Zealand between 2006 and 2016. The purpose of the review was to summarise the evidence base, evaluate funding and determine the ability of the evidence base to inform policy development. The findings demonstrate that the New Zealand research trends are similar to those found in Australia, with most studies being epidemiological and few representative of interventions. What are the implications for practitioners? This review highlights that there were few intervention and evaluation studies. Partnerships between practitioners and/or community organisations implementing interventions and researchers to systematically evaluate existing interventions and develop new evidence-based interventions would help improve the evidence base for New Zealand suicide prevention.

Real-time assessment of suicidal thoughts and behaviors

One of the greatest challenges to understanding, predicting, and preventing suicide is that we have never had the ability to observe and intervene upon them as they unfold in real-time. Recently developed real-time monitoring methods are creating new opportunities for scientific and clinical advances. For instance, recent real-time monitoring studies of suicidal thoughts show that they typically are episodic, with quick onset and short duration. Many known risk factors that predict changes in suicidal thoughts over months/years (e.g. hopelessness) do not predict changes over hours/days-highlighting the gap in our abilities for short-term prediction. Current and future studies using newer streams of data from smartphone sensors (e.g. GPS) and wearables (e.g. heart rate) are further expanding knowledge and clinical possibilities.

Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory

BACKGROUND

We have developed the Suicide Crisis Inventory (SCI) to evaluate the intensity of the Suicidal Crisis Syndrome, an acute state hypothesized to precede suicide attempt. The psychometric properties of the SCI, including predictive validity for suicidal behavior (SB), were assessed.

METHODS

Adult psychiatric patients (n = 201) hospitalized for high suicide risk were assessed. Logistic regression models assessed the SCI's predictive validity for SB in the 4-8 weeks following hospital discharge and its incremental predictive validity over traditional risk factors (n = 137, 64% f/u rate). Internal structure, reliability, convergent and discriminant validity, and state versus trait properties were also assessed.

RESULTS

The SCI had excellent internal consistency (Cronbach's α 0.970). The SCI total score at discharge predicted short-term SB with 64% sensitivity 88% specificity (OR = 13, P = .003) at its optimal cut score. In a test of its incremental predictive validity, SCI total score at discharge improved prediction of SB over traditional risk factors (Chi-squared 5.597, P = .024, model P = .001), with AOR 2.02 (P = .030). The SCI admission versus discharge test-retest reliability and score distributions showed it to be an acute state measure.

CONCLUSION

The SCI was predictive of future SB in high-risk psychiatric inpatients during the crucial weeks following their hospital discharge. Further validation in diverse patient populations is needed.

First onset of suicidal thoughts and behaviours in college

BACKGROUND

College students are a worldwide increasing group of young people at risk for suicidal thoughts and behaviours (STB). However, no previous studies have prospectively investigated the first onset of STB during the college period.

METHODS

Using longitudinal data from the Leuven College Surveys, 2337 (response rate [RR]=66.6%) incoming freshmen provided baseline data on STB, parental psychopathology, childhood-adolescent traumatic experiences, 12-month risk for mental disorders, and 12-month stressful experiences. A total of 1253 baseline respondents provided data on 12-month STB in a two-year annual follow-up survey (conditional RR=53.6%; college dropout adjusted conditional RR=70.2%).

RESULTS

One-year incidence of first-onset STB was 4.8-6.4%. Effect sizes of the included risk factors varied considerably whether viewed from individual-level (ORs=1.91-17.58) or population-level perspective (PARPs=3.4-34.3%). Dating violence prior to the age of 17, physical abuse prior to the age of 17, and 12-month betrayal by someone else than the partner were most strong predictors for first-onset suicidal ideation (ORs=4.23-12.25; PARPs=8.7-27.1%) and plans (ORs=6.57-17.58; PARPs=15.2-34.3%). Multivariate prediction (AUC=0.84-0.91) revealed that 50.7-65.7% of first-onset STB cases were concentrated in the 10% at highest predicted risk.

LIMITATIONS

As this is a first investigation of STB onset in college, future studies should use validation samples to test the accuracy of our multivariate prediction model.

CONCLUSIONS

The first onset of STB in college appears to be higher than in the general population. Screening at college entrance is a promising strategy to identify those students at highest prospective risk, enabling the cost-efficient clinical assessment of young adults in college.