The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance

Identifying latent classes of suicidal ambivalence: Associations with suicide risk correlates and outcomes

INTRODUCTION

Research has largely conceptualized suicidal ambivalence as the difference between one's wish to live and wish to die without fully considering other suicide ideation (SI) experiences included on measures like the Beck Scale for Suicide Ideation (BSS). We utilized BSS items to identify SI latent classes and examined relevant correlates and outcomes.

METHODS

We collected self-report data from two samples of US adults who: (1) self-identified as LGBTQ+ (N = 349; cross-sectional) and (2) self-reported past-week SI (BSS score ≥ 11; N = 133; 3 timepoints).

RESULTS

Latent class analyses supported three-class (Sample 1) and four-class solutions (Sample 2), which included ambivalent classes. In Sample 1, sexual orientation, gender, depression, anxiety, SI, and suicide-specific rumination were concurrently associated with class membership. In Sample 2, depression, SI, suicide-specific rumination, and physical/psychological distance from suicide methods were concurrently associated with class membership. In Sample 2, at both follow-ups, suicide plans/preparations and Acute Suicidal Affective Disturbance symptom frequencies were provided by class membership, and suicidal intent significantly differed by class membership.

CONCLUSIONS

SI classes differed by sample and evidenced nuances in SI and suicidal ambivalence. Risk factors and suicide-related outcomes also differed by class membership. Implications and limitations are discussed.

Facets of Suicidal Ideation

According to SAMHSA (2023), approximately 16,600,000 American adults and teens reported having serious thoughts of suicide in 2022. While suicide prevention has primarily focused on suicide deaths and attempts, we contend that suicidal ideation (SI) deserves more in-depth investigation and should be an essential intervention target on its own. In support of this point, we provide three examples of ways to improve specificity in understanding of SI through the study of controllability of SI, the language used to assess SI, and measuring SI in real time. We also consider qualitative work on the content of SI, its treatment, and definitional considerations. We thus call for an increased general focus on SI within research, clinical care, and policy.

Conceptual Model of and Intervention Development for Unplanned Suicide Attempts

INTRODUCTION

More than half of those who die by suicide do not communicate about suicide prior to their death. This project describes the emotional state and decision-making among "unplanned" attempt survivors to inform a conceptual model and suicide prevention interventions.

METHODS

This qualitative study purposefully sampled patients who reported having no suicidal thoughts on a standardized mental health questionnaire within 60 days (about 2 months) prior to a nonfatal suicide attempt documented in the health record. Participants verbally consented to telephone interview participation. Semistructured audio-recorded interviews elicited suicide attempt survivor descriptions of their emotional state and experiences in the days, hours, and minutes leading up to their suicide attempt. Interviews were transcribed and analyzed using grounded theory. The biopsychosocial theory of emotion regulation informed conceptual model development.

RESULTS

Participants (N = 26) described 2 distinct "phases" prior to the attempt. First, a phase of increasing life stressors, transitory and nonspecific suicidal thoughts, and a reluctance to disclose experiences. Second, an overwhelming emotional state led to a sudden suicide attempt and nondisclosure due to the rapidity and intensity of the experience. These results informed the conceptual model and intervention development to manage unplanned and overwhelming urges to attempt suicide.

DISCUSSION

Qualitative analysis informed the development of an intervention for the high-intensity "hot" period preceding an attempt, including specific steps to manage a highly intense emotional state in combination with overwhelming urges to kill oneself.

CONCLUSION

Future research is needed to evaluate whether and how this intervention helps support people with a chance of "unplanned" suicide attempts.

Modeling the associations between emotion regulation, suicide crisis syndrome and suicidal behavior: Results in community and clinical samples

BACKGROUND

Emotion Regulation (ER) and Suicide Crisis Syndrome (SCS) are psychological processes involved in suicide. Within ER, both the use of rumination and dysfunctional emotion beliefs are associated with suicide. SCS, a pre-suicidal mental state involving cognitive and affective dysregulation, is related to short-term suicide risk.

AIMS

Here, we first examined associations between ER (beliefs about the uncontrollability of emotions and rumination), SCS and suicide behavior, and second, we test a multistep model in which ER factors are linked to suicide behavior through SCS.

MATERIALS & METHODS

We conducted two cross-sectional studies to address this issue by self-reports. Study 1 used a community sample (N = 421). Study 2 used a clinical sample (N = 70).

RESULTS

Results from both studies showed that beliefs about the uncontrollability of emotions and rumination were associated with higher levels of SCS symptoms and suicide behavior, and that SCS was associated with suicide behavior. In addition, path analyses showed that uncontrollability beliefs were linked to rumination, which in turn was associated with SCS, and this variable mediated the association between ER factors and suicide ideation (in both community and clinical samples) and suicide attempts (in the community sample).

DISCUSSION

As we expected, in both samples, uncontrollability of emotions and rumination were positively related with SCS and suicide behavior.

CONCLUSION

We emphasize the importance of addressing uncontrollability beliefs and rumination in suicide prevention.

Perseveration on suicidal thoughts and images in daily life: An examination of the cognitive model of suicide through a dynamic systems lens

According to the cognitive model of suicide, interactions between hopelessness and attentional biases toward suicidal information create a narrowed attentional focus on suicide as a viable solution, particularly in the presence of life stress, leading to increased suicide risk. This study used a dynamic systems approach to examine the short-term temporal patterns between stress, hopelessness, suicide-specific rumination, and suicidal intent. Adults (N = 237; M = 27.12 years; 62% cisgender women; 87% White/European American) with elevated suicidal ideation completed ecological momentary assessments six times a day for 14 days. A multilevel model approach informed by dynamic systems theory was used to simultaneously assess stable and dynamic temporal processes underlying perceived stress, hopelessness, suicide-specific rumination, and suicidal intent. Each variable demonstrated temporal stability. In support of the cognitive model of suicide, we observed (1) a reciprocal relationship between stress and hopelessness such that stress and hopelessness amplified each other (early-stage processes), and (2) reinforcing loops such that hopelessness, suicide-specific rumination, and suicidal intent amplified each other (later-stage processes). A dynamic systems modeling approach underscored the negative impact of a perpetuating cycle of suicide-specific rumination, deepening hopelessness, and escalating suicidal intent on increasing suicide risk, which may be targets for intervention.

Machine learning approach for the development of a crucial tool in suicide prevention: The Suicide Crisis Inventory-2 (SCI-2) Short Form

The Suicide Crisis Syndrome (SCS) describes a suicidal mental state marked by entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal that has predictive capacity for near-term suicidal behavior. The Suicide Crisis Inventory-2 (SCI-2), a reliable clinical tool that assesses SCS, lacks a short form for use in clinical settings which we sought to address with statistical analysis. To address this need, a community sample of 10,357 participants responded to an anonymous survey after which predictive performance for suicidal ideation (SI) and SI with preparatory behavior (SI-P) was measured using logistic regression, random forest, and gradient boosting algorithms. Four-fold cross-validation was used to split the dataset in 1,000 iterations. We compared rankings to the SCI-Short Form to inform the short form of the SCI-2. Logistic regression performed best in every analysis. The SI results were used to build the SCI-2-Short Form (SCI-2-SF) utilizing the two top ranking items from each SCS criterion. SHAP analysis of the SCI-2 resulted in meaningful rankings of its items. The SCI-2-SF, derived from these rankings, will be tested for predictive validity and utility in future studies.

Psychometric properties and factor structure of the suicidal narrative inventory in major depression: A multicentric evaluation

BACKGROUND

The Suicidal Narrative Inventory (SNI) is a 38-item self-report measure developed to assess elements of the suicidal narrative, a subacute, predominantly cognitive, presuicidal construct. Our objectives were to assess the factor structure, validity, and reliability of the SNI-38 among adults with major depressive disorder (MDD).

METHODS

Using a cross-sectional design, we administered the Hindi version of the SNI along with other self-report measures to adults with MDD, recruited from 24 tertiary care hospitals across India. Confirmatory factor analysis (CFA) was performed to assess the factor structure of SNI-38. Reliability (internal consistency) was assessed using Cronbach's alpha (α). Convergent, discriminant, and criterion validity of the SNI-38 were tested by comparing it against other appropriate measures.

RESULTS

We collected usable responses from 654 Hindi-speaking participants (Mean age = 36.9 ± 11.9 years, 50.2% female). The eight-factor solution of the SNI showed good model fit indices (χ2[637] = 3345.58, p <.001, CFI =.98, and RMSEA =.08). Internal consistencies for the SNI subscale scores were good to excellent, α ranging from .73 to.92. While most subscales significantly converged with other measures, associations were comparatively weaker and inconsistent for the 'thwarted belongingness' and 'goal reengagement' subscales.

CONCLUSION

Consistent with prior data, our study confirmed an eight-factor solution and demonstrated adequate psychometric properties for the Hindi version of the SNI-38 in our sample. These findings provide empirical support for the use of SNI to assess the suicidal narrative among Indian adults with MDD.

Self-burdensomeness, other-burdensomeness, and suicidal ideation

Perceiving oneself as a burden to others (other-burdensomeness), as well as perceiving one's selfhood as a burden (self-burdensomeness), have been proposed as risk factors for suicidal ideation. Yet, it is unclear whether the altruistic motive of being a burden to others or the self-oriented motive of being a burden on oneself is more relevant to suicidal ideation. Given this background, two rival mediation models were tested. Data from N = 228 outpatients (64% female; age: M(SD) = 38.69 (12.27), range:17-65) undergoing psychotherapy were collected at two measurement time points over a three-month period (first measurement = T1, second measurement = T2). The significant positive association between other-burdensomeness (T1) and suicidal ideation (T2) was partially mediated by self-burdensomeness (T1). Furthermore, the significant positive association between self-burdensomeness (T1) and suicidal ideation (T2) was partially mediated by other-burdensomeness (T1). Results suggest that suicidal ideation can develop from both an altruistic, self-sacrificial perception of being a burden to others, as well as from a more self-oriented perception of being a burden to oneself. There is no indication that either self-burdensomeness or other-burdensomeness is a stronger indicator in the development of suicidal ideation.

Intensive Longitudinal Assessment of Adolescents to Predict Suicidal Thoughts and Behaviors

OBJECTIVE

Suicide is a leading cause of death among adolescents. However, there are no clinical tools to detect proximal risk for suicide.

METHOD

Participants included 13- to 18-year-old adolescents (N = 103) reporting a current depressive, anxiety, and/or substance use disorder who owned a smartphone; 62% reported current suicidal ideation, with 25% indicating a past-year attempt. At baseline, participants were administered clinical interviews to assess lifetime disorders and suicidal thoughts and behaviors (STBs). Self-reports assessing symptoms and suicide risk factors also were obtained. In addition, the Effortless Assessment of Risk States (EARS) app was installed on adolescent smartphones to acquire daily mood and weekly suicidal ideation severity during the 6-month follow-up period. Adolescents completed STB and psychiatric service use interviews at the 1-, 3-, and 6-month follow-up assessments.

RESULTS

K-means clustering based on aggregates of weekly suicidal ideation scores resulted in a 3-group solution reflecting high-risk (n = 26), medium-risk (n = 47), and low-risk (n = 30) groups. Of the high-risk group, 58% reported suicidal events (ie, suicide attempts, psychiatric hospitalizations, emergency department visits, ideation severity requiring an intervention) during the 6-month follow-up period. For participants in the high-risk and medium-risk groups (n = 73), mood disturbances in the preceding 7 days predicted clinically significant ideation, with a 1-SD decrease in mood doubling participants' likelihood of reporting clinically significant ideation on a given week.

CONCLUSION

Intensive longitudinal assessment through use of personal smartphones offers a feasible method to assess variability in adolescents' emotional experiences and suicide risk. Translating these tools into clinical practice may help to reduce the needless loss of life among adolescents.

The use of advanced technology and statistical methods to predict and prevent suicide

In the past decade, two themes have emerged across suicide research. First, according to meta-analyses, the ability to predict and prevent suicidal thoughts and behaviours is weaker than would be expected for the size of the field. Second, review and commentary papers propose that technological and statistical methods (such as smartphones, wearables, digital phenotyping and machine learning) might become solutions to this problem. In this Review, we aim to strike a balance between the pessimistic picture presented by these meta-analyses and the optimistic picture presented by review and commentary papers about the promise of advanced technological and statistical methods to improve the ability to understand, predict and prevent suicide. We divide our discussion into two broad categories. First, we discuss the research aimed at assessment, with the goal of better understanding or more accurately predicting suicidal thoughts and behaviours. Second, we discuss the literature that focuses on prevention of suicidal thoughts and behaviours. Ecological momentary assessment, wearables and other technological and statistical advances hold great promise for predicting and preventing suicide, but there is much yet to do.

A test of invariance of the construct of suicidal ideation across three diverse samples

BACKGROUND

Suicide treatment research has placed major emphasis on preventing behavior, an observable phenomenon. Suicidal ideation (SI), however, is a distressing experience that annually impacts >15 million Americans; yet the construct validity of SI has not been well established, limiting empirical attention.

METHOD

We compared the coherence of three SI items (diminished wish to live, urge to die/controllability, suicide intent/expectations) and four related items across three adult samples (N = 314) that differed based on current SI severity and assessment time-scales (retrospective versus momentary).

RESULTS

A measurement model with scalar invariance had acceptable fit (CFI = 0.969, RMSEA = 0.076), indicating that the SI items consistently loaded onto one construct across samples. The structural model with metric invariance also had acceptable fit (CFI = 0.956, RMSEA = 0.063) and three of four related items (burdensome, hopelessness, and fatigue, but not agitation) were associated with SI across samples.

LIMITATIONS

Use of existing data limited the items considered.

CONCLUSIONS

Suicidal ideation is a coherent construct independent of the items used to assess it, the assessment's time-scale (retrospective versus momentary), or the severity of thoughts, and is worthy of greater empirical, clinical, and policy attention.

Two sides of the same coin? Empirical examination of two proposed characterizations of acute suicidal crises: Suicide crisis syndrome and acute suicidal affective disturbance

Two proposed suicide-specific diagnoses, with accumulating research support, characterize the phenomenology of acute suicidal crises: Suicide Crisis Syndrome (SCS) and Acute Suicidal Affective Disturbance (ASAD). Despite conceptual overlap and some similar criteria, the two syndromes have never been compared empirically. The present study addressed this gap by examining SCS and ASAD utilizing a network analysis approach. A sample of 1568 community-based adults (87.6% cisgender women, 90.7% White, M_age = 25.60 years, SD = 6.59) in the United States completed an online battery of self-report measures. SCS and ASAD were first examined in individual network models, followed by a combined network to determine changes in network structure, as well as identify bridge symptoms that connected SCS and ASAD. The proposed criteria of SCS and ASAD formed sparse network structures that were largely unaffected by the influence of the other syndrome in a combined network. Social disconnection/withdrawal and manifestations of overarousal-particularly agitation, insomnia, and irritability-emerged as bridge symptoms that may connect SCS and ASAD. Our findings indicate the network structures of SCS and ASAD exhibit patterns of independence, alongside interdependence between overlapping symptom domains (i.e., social withdrawal, overarousal). Future work should examine SCS and ASAD prospectively to better understand their temporal dynamics and predictive utility in relation to imminent suicide risk.

Acute suicidal affective disturbance and borderline personality disorder symptoms: Distinct yet correlated constructs

OBJECTIVE

Acute Suicidal Affective Disturbance (ASAD) has been proposed to address the need for a suicide-specific diagnostic entity that better accounts for the psychological symptoms that may emerge during an acute suicidal crisis and that may precede imminent suicidal behaviors. However, additional research is needed to establish ASAD's delimitation from preexisting psychological disorders, especially disorders that include suicidal thoughts and behaviors in their diagnostic criteria such as borderline personality disorder (BPD).

METHODS

We estimated two Gaussian graphical models (GGMs), exploratory factor analysis (EFA) models, and confirmatory factor analysis models in a sample of psychiatric outpatients (N = 460) to examine the structure of ASAD and BPD symptoms.

RESULTS

Our estimated models showed while most ASAD and BPD symptoms largely shared associations with other symptoms belonging to their respective disorder construct, strong associations connected some ASAD symptoms with BPD symptoms, which, in a network model, emerged in the form of nonzero edges among those symptoms, and in EFA models, as factors that featured both ASAD and BPD symptoms as indicators.

CONCLUSIONS

Our findings suggest the network structure of the proposed criteria of ASAD features symptoms that are largely distinct to ASAD but do include symptoms that share meaningful correlations with BPD symptoms that suggest ASAD and BPD are correlated constructs.

Unsound sleep, wound-up mind: a longitudinal examination of acute suicidal affective disturbance features among an eating disorder sample

BACKGROUND

Suicide is one of the most commonly reported causes of death in individuals with eating disorders. However, the mechanisms underlying the suicide and disordered eating link are largely unknown, and current assessments are still unable to accurately predict future suicidal thoughts and behaviors. The purpose of this study is to test the utility of two promising proximal risk factors, sleep quality and agitation, in predicting suicidal ideation in a sample of individuals with elevated suicidal thoughts and behaviors, namely those with eating disorders.

METHODS

Women (N = 97) receiving treatment at an eating disorder treatment center completed weekly questionnaires assessing suicidal ideation, agitation, and sleep. General linear mixed models examined whether agitation and/or sleep quality were concurrently or prospectively associated with suicidal ideation across 12 weeks of treatment.

RESULTS

There was a significant interaction between within-person agitation and sleep quality on suicidal ideation [B(s.e.) = -0.02(0.01), p < 0.05], such that on weeks when an individual experienced both higher than their average agitation and lower than their average sleep quality, they also experienced their highest levels of suicidal ideation. However, neither agitation nor sleep quality prospectively predicted suicidal ideation.

CONCLUSIONS

This study was the first to examine dynamic associations between interpersonal constructs and suicidal ideation in individuals with eating disorders. Results suggest that ongoing assessment for overarousal symptoms, such as agitation and poor sleep quality, in individuals with eating disorders may be warranted in order to manage suicidal ideation among this vulnerable population.

Revised Attentional Fixation on Suicide Experiences Questionnaire and its relationship with suicidal ideation and behavior: A cross-sectional study

INTRODUCTION

The Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) was developed to measure attentional fixation on suicide, a cognitive process characterized by a preoccupation with suicide as a solution. This study investigated a revised version (AFSEQ-R) and examined differences between those who made a recent suicide attempt and those with suicidal ideation (SI).

METHOD

Participants were 57 inpatients who attempted suicide within 14 days of study participation and 57 inpatients who presented with SI but no suicidal behavior within the past year. Analyses examined the internal reliability, multidimensionality, and construct validity of the AFSEQ-R, and whether attentional fixation moderated the correlation between SI and attempt status.

RESULTS

Exploratory factor analysis revealed a two-factor structure, and subscale and total scores demonstrated excellent internal consistency. Cognitive Stuckness (and total score) correlated with SI, anxiety, impulsivity, and specific problem-solving deficits, while Cognitive Dysfunction correlated with anxiety and acted as a moderator of the correlation between Stuckness and SI. AFSEQ-R scores did not moderate the relationship between SI and attempt status.

CONCLUSION

AFSEQ-R is a psychometrically sound and valid measure of attentional fixation. Attentional fixation on suicide is correlated with SI, and prospective studies are needed to uncover its directional effect on suicidal crises.

Suicide plan prevalence, recurrence, and longitudinal association with nonfatal suicide attempt

BACKGROUND

Each year, millions of people develop suicide plans. These plans are assumed to indicate imminent suicide risk, yet this has rarely been tested. The present study seeks to address two questions: (1) how prevalent are specific thoughts of suicide plans among individuals with a history of suicidal thoughts and behaviors and (2) do suicide plans confer risk of future suicide attempts in the short term?

METHODS

Secondary data analysis was performed on a longitudinal dataset (N = 1021). Prevalence and frequencies of suicide planning features (i.e., method, time, place) at baseline and 3, 14, and 28 days post-baseline were calculated. Logistic regressions were conducted to assess whether suicide plans confer risk of suicide attempts across a 28-day follow-up period.

RESULTS

Suicide planning more commonly involved thoughts of method than place and/or time. High variability in suicide planning was evident and thoughts of suicide plans frequently recurred. Contrary to assumptions, suicide plans displayed weak associations with nonfatal suicide attempt across the 28-day follow-up period.

CONCLUSIONS

Suicide plans appear heterogeneous in nature. They do not appear to play a strong role in predicting nonfatal suicide attempts. Re-evaluation of the central role that suicide plans occupy within clinical risk assessments may be warranted.

Predictive validity and symptom configuration of proposed diagnostic criteria for the Suicide Crisis Syndrome: A replication study

OBJECTIVE

The Suicide Crisis Syndrome (SCS) is a new proposed suicide-specific diagnosis. In the present large replication study, we examine SCS diagnostic criteria to determine which configuration of symptoms demonstrates the strongest convergent and predictive validity for near-term suicidal behaviour.

METHODS

We conducted confirmatory factor analysis (CFA) to examine the factor structure of the proxy-SCS variables derived from an extensive self-report test battery and administered to 903 psychiatric patients (age (M = 36.70, SD = 13.91); gender (64.0% female)) at intake and 4-8-week follow-up assessments. Convergent and predictive validity of five configurations of the proposed SCS diagnostic criteria for suicidal ideation (SI) and attempts (SA) were examined using regression analyses. The new clinician-rated SCS-Checklist was piloted with 68 participants.

RESULTS

Both the one-factor and the five-factor models of proxy-SCS variables exhibited strong model fit, supporting the uni-dimensionality as well as the five-criteria structure of the SCS. All four configurations were uniquely related to the presence of a suicide attempt at follow-up when controlling for intake SI, lifetime SA, age, and gender, but none were significantly associated with intake SA when controlling for intake SI, age, and gender. All bivariate correlations between proxy-assessed and checklist-assessed SCS symptom configurations were significant and positive.

CONCLUSION

The proposed five-symptom structure of the SCS diagnostic criteria was supported and appears to describe a clinically meaningful syndrome specifically related to near-term suicidal behaviour. SCS assessment may significantly improve clinical evaluation of imminent suicide risk. Future studies are needed to assess the utility of the syndrome in clinical settings.

Assessment of acute and non-acute suicide crisis symptoms: Validation of the Korean version of the acute suicidal affective disturbance inventory

Suicide risk assessment is predominantly based on assessing current/recent suicidal ideation and past suicidal behavior. However, suicidal ideation and lifetime suicide attempt are poor predictors of imminent suicide risk or crisis. The acute suicidal affective disturbance inventory-lifetime (ASADI-L) was developed to assess symptoms of acute suicidal affective disturbance, which includes a drastic increase in suicidal intent, perceptions of social and/or self-alienation, hopelessness, and overarousal. However, the ASADI-L has not yet been validated in a Korean population. Also, the ASADI-L has only been validated for people who experience a drastic increase in suicidal intention over the course of hours or days (i.e., the acute suicidal intention group) and not validated for those who experience suicidal intention for a longer period (i.e., the non-acute suicidal intention group). Thus, the aims of this study were to (1) validate the ASADI-L in a sample of Korean community adults; and (2) compare clinical characteristics of the acute and non-acute suicidal intention groups. Among 1,675 community adults, data from 682 participants who reported a lifetime drastic increase in suicidal intent were analyzed. Results indicated that the ASADI-L has relevant reliability, validity, and a unidimensional factor structure. The acute suicidal intention group had higher ASAD symptoms as well as clinical symptoms than the non-acute group, but the two groups did not differ in history of suicide attempt. Overall, these findings suggest that the ASADI-L is a valid measure of acute and non-acute suicidal affective disturbance among Korean adults. Further investigation of the differences in acute and non-acute suicide risk is warranted.

Recent research advances in identification and prevention of youth suicide risk

PURPOSE OF THE REVIEW

The rate of youth suicidal behaviors has gradually increased over the last 15 years and continues to grow during the COVID-19 pandemic. This trend burdens mental health services and demands significant developments in risk detection and delivery of interventions to reduce the risk. In this article we outline significant advances and recent findings in youth suicide research that may facilitate strategies for identifying and preventing suicide risk among youth at risk in general and in specific risk groups.

RECENT FINDINGS

The rise in suicide and suicidal behaviors is most likely to affect young people of racial, ethnic, sexual, and gender identity minorities and those living in poverty or experiencing maltreatment. The suicide rate in children is rising and demands special attention. Proximal risk factors for suicidal behavior compared with suicidal ideation have been suggested to identify near-term suicidal risk. Effective and scalable prevention strategies were identified, and the role of new technologies in suicide prevention among youth is to be determined.

SUMMARY

To reach broader suicide prevention in youth and reduce the pressure on mental healthcare, public health approaches and improved service access for minority youth and those living in underserved areas of the world are needed.

Differential disclosure of suicidal intent to clinicians versus researchers: Associations with concurrent suicide crisis syndrome and prospective suicidal ideation and attempts

Several patient and setting characteristics have been found to predict disclosure of suicidality to clinicians versus researchers. Less understood, however, is whether differential disclosure of suicidality predicts concurrent indirect indicators of suicide risk and future suicide-related outcomes. The present study examined differential disclosure of suicidal intent in clinical versus research settings as a predictor of (1) concurrent symptoms of the Suicide Crisis Syndrome (SCS); and (2) suicidal ideation and attempts within one month in patients (n = 1039) and their clinicians (n = 144), who completed a battery of self-report and interview measures at baseline. Patients who reported suicidal intent to anyone had higher concurrent SCS symptoms than those who denied suicidal intent, with no differences between those who reported intent to clinicians versus researchers only. Severity of suicidal ideation and rates of suicide attempts at one-month follow-up were higher among those who disclosed suicidal intent to a research assistant than among those who did not-regardless of whether suicidal intent was disclosed to their clinician. Overall, an improved understanding of the factors contributing to differential disclosure will improve both scientific inquiry and patient safety.

Can passive measurement of physiological distress help better predict suicidal thinking?

There has been growing interest in using wearable physiological monitors to passively detect the signals of distress (i.e., increases in autonomic arousal measured through increased electrodermal activity [EDA]) that may be imminently associated with suicidal thoughts. Before using these monitors in advanced applications such as creating suicide risk detection algorithms or just-in-time interventions, several preliminary questions must be answered. Specifically, we lack information about whether: (1) EDA concurrently and prospectively predicts suicidal thinking and (2) data on EDA adds to the ability to predict the presence and severity of suicidal thinking over and above self-reports of emotional distress. Participants were suicidal psychiatric inpatients (n = 25, 56% female, M age = 33.48 years) who completed six daily assessments of negative affect and suicidal thinking duration of their psychiatric inpatient stay and 28 days post-discharge, and wore on their wrist a physiological monitor (Empatica Embrace) that passively detects autonomic activity. We found that physiological data alone both concurrently and prospectively predicted periods of suicidal thinking, but models with physiological data alone had the poorest fit. Adding physiological data to self-report models improved fit when the outcome variable was severity of suicidal thinking, but worsened model fit when the outcome was presence of suicidal thinking. When predicting severity of suicidal thinking, physiological data improved model fit more for models with non-overlapping self-report data (i.e., low arousal negative affect) than for overlapping self-report data (i.e., high arousal negative affect). These findings suggest that physiological data, under certain contexts (e.g., when combined with self-report data), may be useful in better predicting-and ultimately, preventing-acute increases in suicide risk. However, some cautious optimism is warranted since physiological data do not always improve our ability to predict suicidal thinking.

The role of suicide ideation in assessing near-term suicide risk: A machine learning approach

BACKGROUND

The majority of suicide attempters do not disclose suicide ideation (SI) prior to making an attempt. When reported, SI is nevertheless associated with increased risk of suicide. This paper implemented machine learning (ML) approaches to assess the degree to which current and lifetime SI affect the predictive validity of the Suicide Crisis Syndrome (SCS), an acute condition indicative of imminent risk, for near-term suicidal behaviors (SB ).

METHODS

In a sample of 591 high-risk inpatient participants, SCS and SI were respectively assessed using the Suicide Crisis Inventory (SCI) and the Columbia Suicide Severity Rating Scale (C-SSRS). Two ML predictive algorithms, Random Forest and XGBoost, were implemented and framed using optimism adjusted bootstrapping. Metrics collected included AUPRC, AUROC, classification accuracy, balanced accuracy, precision, recall, and brier score. AUROC metrics were compared by computing a z-score.

RESULTS

The combination of current SI and SCI showed slightly higher predictive validity for near-term SB as evidenced by AUROC metrics than the SCI alone, but the difference was not significant (p<0.05). Current SI scored the highest amongst a chi square distribution in regards to predictors of near-term SB.

CONCLUSION

The addition of SI to the SCS does not materially improve the model's predictive validity for near-term SB, suggesting that patient self-reported SI should not be a requirement for the diagnosis of SCS.

Crisis Concept Re-loaded?-The Recently Described Suicide-Specific Syndromes May Help to Better Understand Suicidal Behavior and Assess Imminent Suicide Risk More Effectively

Background: Despite of the decreasing suicide rates in many countries, suicide is still a major public health concern worldwide. Traditional suicide risk factors have limited clinical predictive value, as they provide little reliable information on the acute psychological processes leading to suicide. Aims: The aim of this analysis is to describe and compare the recently introduced two suicide-specific syndromes [Acute Suicidal Affective Disturbance (ASAD) and Suicidal Crisis Syndrome (SCS)] with the classic psychological features of pre-suicidal crisis and also to assess the clinical utility of the new suicide prediction scales in contrast to classical risk factors. Method: Conceptual analysis. Results: Suicide-specific syndromes are not novel in terms of symptomatology or dynamics of symptom onset, but in their use of well-defined diagnostic criteria. In addition to symptomatic classification, they also provide an opportunity to objectively measure the current pre-suicidal emotional and mental state by validated tools. Limitations: Future studies need to be completed to prove the reliability and predictive validity of suicide-specific diagnostic categories and the related suicide risk assessment tools. Conclusion: Clinical use of suicide-specific syndromes is suggested. This transdiagnostic approach not only enables a more accurate and objective assessment of imminent suicide risk, but also facilitates research in neuroscience, which represent a major step forward in managing and complex understanding of suicidal behavior.

Akut suizidal-affektive Störung: Ein systematisches Review

<b><i>Hintergrund:</i></b> Die Arbeitsgruppe um Thomas Joiner postuliert ein als <i>acute suicidal affective disturbance</i> (ASAD) bezeichnetes Syndrom, welches durch vier Symptomgruppen (Suizidabsicht, Entfremdung, Hoffnungslosigkeit, Übererregung) definiert sein soll. Ziel des vorliegenden Artikels ist, die Literatur zum ASAD-Syndrom zusammenfassend darzustellen und eine Einschätzung vorzunehmen, inwieweit tatsächlich von einem einheitlichen Syndrom ausgegangen werden kann. <b><i>Methoden:</i></b> Im Rahmen einer Literaturrecherche konnten neun Artikel identifiziert werden, die im Zeitraum von 2016 bis 2020 zum Thema publiziert wurden. <b><i>Ergebnisse und Schlussfolgerungen:</i></b> Die Befundlage unterstützt den einheitlichen Störungscharakter und die Ab­grenzbarkeit der akut suizidal-affektiven Störung von anderen Störungsbildern. Die Aussagekraft der Befundlage ist dadurch eingeschränkt, dass bislang ausschließlich Querschnittsuntersuchungen durchgeführt wurden und keinerlei Befunde dazu vorliegen, ob ASAD tatsächlich suizidalem Verhalten vorausgeht.

Assessment of near-term risk for suicide attempts using the suicide crisis inventory

BACKGROUND

The Suicide Crisis Syndrome (SCS) describes a pre-suicidal mental state marked by entrapment accompanied by affective disturbances, loss of cognitive control, hyperarousal and social withdrawal. This study tested the consistency and validity of the Suicide Crisis Inventory (SCI), a proposed measure of SCS severity, amongst a large, heterogeneous patient sample.

METHODS

The SCI was used to assess 867 adult psychiatric inpatients and outpatients. Confirmatory factor analysis, logistic regressions and area under the curve analyses (AUC) were used to examine internal structure, construct validity and predictive validity for suicide ideation, plan and attempt one-month post-assessment.

RESULTS

The five-factor model of the SCS demonstrated good fit and excellent internal consistency. SCI scores indicated significant associations but non-redundancy with depression, anxiety, and independence from other dimensions of psychiatric distress. SCI scores specifically predicted suicide attempts with an AUC of 0.733 and odds ratio=8.62 (p<0.001) at optimal cut-off point. SCI incremental predictive validity over and beyond suicidal ideation and attempts history reported at baseline was supported for predicting suicide attempts (β= 0.012, S.E = 0.006; p=0.046).

LIMITATIONS

The SCI is subject to self-report bias and does not include the SCS social withdrawal component. Follow-up assessment retention was partial (68%, n=591).

CONCLUSION

The SCI is validated as a tool for the assessment of the SCS intensity and of imminent suicidal behavior. The SCI is suggested as a tool that could aid both researchers and clinicians in comprehensive assessment of a pre-suicidal mental state within moderate to high-risk populations, regardless of self-report on suicidal intent.

Differentiating genuine from feigned suicidality in corrections: A necessary but perilous task

Feigning suicidality is common among patients in correctional settings, but there has been little discussion on the differences between genuine and feigned presentations of suicidality. Differentiating suicidality from feigned suicidality is among the riskiest diagnostic challenges. Still, some headway can be made if we compare features of genuine suicidality with those of feigned presentations. To this end, I first describe a typical profile of suicidality. Next, I contrast it with the features that correctional patients who feign suicidality display in California's prison health care system. I also outline the dangers involved in identifying feigned suicidality, and I offer some ways in which to understand feigned suicidality in corrections.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

Are the "Right" People Selected for First Disclosures About Suicidal Thoughts? Exploring What We Know About Advance Care Planning in the Context of Safety Planning

Nominating primary confidants (i.e., safety plan nominees) is central to safety planning for suicide but there is a dearth of research about such confidants-a serious oversight given their high-leverage position to affect pathways into clinical care. Informed by advance care planning (ACP) work, this study examined differences between social network members who were and were not identified as primary confidants on attributes that could impact their effectiveness in a helping role. Using social network methodology, information was collected from 41 individuals with affective disorders about the 332 people and relationships in their networks. Logistic regression analysis revealed that being perceived as capable of managing stress and prioritizing the participant's best interests over one's own increased the odds of being a primary confidant. Clinicians working with suicidal individuals may benefit from integrating ACP principles-which recognize the thoughtful selection of nominees based on specific attributes-into their safety planning procedures.

Candidate Biomarkers of Suicide Crisis Syndrome: What to Test Next? A Concept Paper

BACKGROUND

There has been increasing interest in both suicide-specific diagnoses within the psychiatric nomenclature and related biomarkers. Because the Suicide Crisis Syndrome-an emotional crescendo of several interrelated symptoms-seems to be promising for the identification of individuals at risk of suicide, the aim of the present paper is to review the putative biological underpinnings of the Suicide Crisis Syndrome symptoms (entrapment, affective disturbance, loss of cognitive control, hyperarousal, social withdrawal).

METHODS

A PubMed literature search was performed to identify studies reporting a link between each of the 5 Suicide Crisis Syndrome symptoms and biomarkers previously reported to be associated with suicidal outcomes.

RESULTS

Disturbances in the hypothalamic-pituitary-adrenal axis, with dysregulated corticotropin-releasing hormone and cortisol levels, may be linked to a sense of entrapment. Affective disturbance is likely mediated by alterations in dopaminergic circuits involved in reward and antireward systems as well as endogenous opioids. Loss of cognitive control is linked to altered neurocognitive function in the areas of executive function, attention, and decision-making. Hyperarousal is linked to autonomic dysregulation, which may be characterized by a reduction in both heart rate variability and electrodermal activity. Social withdrawal has been associated with oxytocin availability. There is also evidence that inflammatory processes may contribute to individual Suicide Crisis Syndrome symptoms.

CONCLUSION

The Suicide Crisis Syndrome is a complex syndrome that is likely the consequence of distinct changes in interconnected neural, neuroendocrine, and autonomic systems. Available clinical and research data allow for development of empirically testable hypotheses and experimental paradigms to scrutinize the biological substrates of the Suicide Crisis Syndrome.

Real-Time Monitoring of Suicide Risk among Adolescents: Potential Barriers, Possible Solutions, and Future Directions

Recent advances in real-time monitoring technology make this an exciting time to study risk for suicidal thoughts and behaviors among youth. Although there is good reason to be excited about these methods, there is also reason for caution in adopting them without first understanding their limitations. In this article, we present several broad future directions for using real-time monitoring among youth at risk for suicide focused around three broad themes: novel research questions, novel analytic methods, and novel methodological approaches. We also highlight potential technical, logistical, and ethical challenges with these methodologies, as well as possible solutions to these challenges.

Is suicidality a mental disorder? Applying DSM-5 guidelines for new diagnoses

Suicidality-specific diagnoses have been proposed recently, but suicidologists are only just beginning to evaluate their merits. To advance this discussion, I introduce the term suicidal syndrome to describe the underlying entity, present a rationale for why a formal diagnosis is necessary, define the major features of the syndrome, and show how the syndrome could meet the requirements for new diagnostic candidates used in the development of the DSM-5. Against this backdrop, I examine common objections to a suicidality-specific diagnosis. Finally, I discuss several challenges with the creation of new diagnostic entities as they apply to suicidal syndrome.