Suicide Intent Scale in the prediction of suicide

Developing a risk prediction model for death at first suicide attempt-Identifying risk factors from Thailand's national suicide surveillance system data

More than 60% of suicides globally are estimated to take place in low- and middle-income nations. Prior research on suicide has indicated that over 50% of those who die by suicide do so on their first attempt. Nevertheless, there is a dearth of knowledge on the attributes of individuals who die on their first attempt and the factors that can predict mortality on the first attempt in these regions. The objective of this study was to create an individual-level risk-prediction model for mortality on the first suicide attempt. We analyzed records of individuals' first suicide attempts that occurred between May 1, 2017, and April 30, 2018, from the national suicide surveillance system, which includes all of the provinces of Thailand. Subsequently, a risk-prediction model for mortality on the first suicide attempt was constructed utilizing multivariable logistic regression and presented through a web-based application. The model's performance was assessed by calculating the area under the receiver operating curve (AUC), as well as measuring its sensitivity, specificity, and accuracy. Out of the 3,324 individuals who made their first suicide attempt, 50.5% of them died as a result of that effort. Nine out of the 21 potential predictors demonstrated the greatest predictive capability. These included male sex, age over 50 years old, unemployment, having a depressive disorder, having a psychotic illness, experiencing interpersonal problems such as being aggressively criticized or desiring plentiful attention, having suicidal intent, and displaying suicidal warning signals. The model demonstrated a good predictive capability, with an AUC of 0.902, a sensitivity of 84.65%, a specificity of 82.66%, and an accuracy of 83.63%. The implementation of this predictive model can assist physicians in conducting comprehensive evaluations of suicide risk in clinical settings and devising treatment plans for preventive intervention.

Profiles, Transitions, and Resilience Factors of Suicide Risk in Early Chinese Adolescents

As a severe public health concern directly endangering life safety, adolescent suicide has been extensively investigated in variable-centered studies. However, gaps remain in the knowledge of heterogeneous suicide risk patterns and their developmental nature. Additionally, little is known about protective factors associated with suicide risk patterns and changes. This study applied person-centered approaches to explore suicide risk profiles and transitions over time in early Chinese adolescents, along with their protective factors. A total of 1518 junior high school students (49.6% girls, Mage = 13.57, SD = 0.75) participated in two surveys within a 12-month interval. Latent Profile Analysis and Latent Transition Analysis were used to model the profiles and transitions of suicide risk. Three risk profiles were identified at both time points: low risk profile (73.9, 78.3%), medium risk-high threat profile (16.2, 10.2%), and high risk profile (9.9, 10.2%). Low risk profile was stable, while medium risk-high threat and high risk profiles showed great transitions over 12 months. Sense of control, meaning in life, and regulatory emotional self-efficacy served as protective factors against suicide risk profiles and transitions. Findings underscore the importance of comprehensively illustrating suicide risk states from multiple aspects, as well as understanding the fluid nature of transitions between different risk states. Prevention and intervention strategies aimed at enhancing resilience, such as increasing sense of control, perceived meaningfulness, and belief in emotional regulation, may contribute to reducing the risk of suicide among adolescents.

Relationship of stress-reactive cortisol to suicidal intent of prior attempts in major depression

Higher intent suicide attempts carry elevated risk of future suicidal behavior. Abnormal functioning of the hypothalamic-pituitary-adrenal (HPA) axis is both linked to nonfatal suicidal behavior and suicide deaths in major depressive disorder. Few studies, however, have identified biological markers of a high-intent suicidal subgroup. We examined HPA axis output and reactivity to the Trier Social Stress Test (TSST) via salivary cortisol in depressed individuals (N=68) with a suicide attempt (SA) history. A median split of higher and lower suicidal intent scores was used to define groups. Individuals with high intent SA had attenuated total cortisol output (AUCg), F(1,60)=10.04, SE=5.095, p=.003, and lower HPA-axis stress responsivity to the TSST (AUCi), F(1,60)=4.50, SE=4.604, p=.039, compared with the low intent SA group. The high intent group also reported more pronounced negative affect than the low intent group (F[1,61]=6.413, SE=10.55, p=.014) both at baseline (meandiff=22.32, p=.038) and in response to the stressor task (meandiff=37.62, p=.003). Vulnerability to suicidal behavior in high-intent individuals may be related to the combined profile of impaired physiological responses to stress and greater negative affectivity. This clinical and biologic subgroup may benefit from targeted suicide prevention interventions.

Maladaptive Personality Traits of Inpatients with Self-Harm Behavior and Its Association with Suicide Intent Severity

Introduction: Inpatients with self-harm behavior utilize a high proportion of health care resources, and determining their suicide risk may be challenging. This study examines how maladaptive personality traits in people who self-harm are associated with suicide intent severity. Methods: This was a 5-month cross-sectional study. The International Personality Disorders Examination (IPDE) ICD-10 questionnaire, Beck's Suicide Intent Scale (SIS), and the Depression Anxiety Stress Scale (DASS) 21 were administered. Sociodemographic and clinical data were recorded with STATA version 10.1 for statistical analyses. Results: Thirty-seven out of 40 (92.50%) inpatients participated in this study. About two-thirds (n = 24, 64.86%) were first-time self-harmers, with self-poisoning (n = 33, 89.19%) being the most common method. About two-thirds (n = 24, 64.86%) had low to moderate suicide intent. The most common diagnosis was adjustment disorder (n = 21, 56.76%). Around one-third had at least severe ratings for depressive, anxiety, and stress symptoms. All screened positive for at least one class of maladaptive personality traits, with the majority (n = 33, 89.19%) having more than one class of maladaptive personality traits. The three most prevalent classes of maladaptive personality traits were anankastic (n = 28, 75.68%), schizoid (n = 25, 67.57%), and paranoid (n = 23, 62.16%). Only dissocial traits were positively correlated with suicide intent severity (regression coefficient = 1.37, p = .017) following adjustment for the most important confounder, DASS 21. Discussion: Maladaptive personality traits were common in inpatients with self-harm behavior, with dissocial traits being positively correlated with suicide intent severity. This finding may inform suicide prevention strategies for patients who self-harm.

Epigenetic changes in the CYP2D6 gene are related to severity of suicide attempt: A cross-sectional study of suicide attempters

BACKGROUND

The ability to accurately estimate risk of suicide deaths on an individual level remains elusive.

METHODS

This study reports on a case-control study set-up from a well-characterized cohort of 88 predominantly female suicide attempters (SA), stratified into low- (n = 57) and high-risk groups (n = 31) based on reports of later death by suicide, as well as degree of intent-to-die and lethality of SA method. We perform an unbiased analysis of 12,930 whole-blood derived CpG-sites (Illumina Infinium EPIC BeadChip) previously demonstrated to be more conciliable with brain-derived variations. The candidate site was validated by pyrosequencing. External replication was performed in (1) relation to age at index suicide attempt in 97 women with emotionally unstable personality disorder (whole-blood) and (2) death by suicide in a mixed group of 183 prefrontal-cortex (PFC) derived samples who died by suicide or from non-psychiatric etiologies.

RESULTS

CYP2D6-coupled CpG-site cg07016288 was hypomethylated in severe suicidal behavior (p < 10E-06). Results were validated by pyrosequencing (p < 0.01). Replication analyses demonstrate hypomethylation of cg07016288 in relation to age at index SA in females (p < 0.05) and hypermethylation in PFC of male suicide completers (p < 0.05).

LIMITATIONS

Genotyping of CYP2D6 was not performed and CpG-site associations to gene expression were not explored.

CONCLUSIONS

CYP2D6-coupled epigenetic markers are hypomethylated in females in dependency of features known to confer increased risk of suicide deaths and hypermethylated in PFC of male suicide completers. Further elucidating the role of CYP2D6 in severe suicidality or suicide deaths hold promise to deduce clinically meaningful results.

Assessing suicidality during the SARS-CoV-2 pandemic: Lessons learned from adaptation and implementation of a telephone-based suicide risk assessment and response protocol in Malawi

The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.

The Psychological Impact of Rhino-Orbital Mucormycosis During the Second Wave of COVID-19 Pandemic From South East Asian Country

AIM

The present study addressed overcoming the lacunae in the literature of psychiatric manifestations associated with rhino-orbital mucormycosis. The current study aimed to assess the symptoms of depression, anxiety, stress, coping measures, suicidal intent, and visual disability in patients of rhino-orbital mucormycosis (ROM) during the epidemic of the disease at the nodal tertiary care center in North India.

METHODS

Fifty-four inpatients of laboratory-proven rhino-orbital mucor-mycosis (ROM) were included for an observational, cross-sectional study at nodal, designated COVID-19, and mucormycosis treating tertiary care hospital. Patients with Hindi Mini-Mental State Examination score <24, prior psychiatric illness, and severely ill requiring ventilator support were excluded. The psychological variables were assessed using Depression, Anxiety, and Stress Scale 21 (DASS 21), Beck's Suicide intent Scale, Coping Scale Questionnaire, and Visual disability scale (IND-VFQ33). Their socioeconomic status was assessed using the Modified Kuppuswamy Scale.

RESULTS

Ninety percent of patients with ROM had diabetes mellitus. The majority (44%) of patients belonged to lower socioeconomic strata. Higher frequencies of severe depression (28%), extremely severe anxiety (26%), and mild stress (17%) were noted in the study participants. On the Tukey test, depression score was higher in patients of ROM compared to COVID (with ROM) (p-value= 0.016). On Tukey analysis, anxiety score was significantly higher in ROM patients compared to COVID (with ROM) patients (p-value = 0.018). Coping scores were significantly higher in COVID (with ROM) patients compared to ROM patients (p value = 0.035). Mild to moderate visual disability was noted in the study participants.  Conclusion: The current study reflects the association of higher depression and anxiety scores in cases with ROM that indicated higher mental health needs. Early assessment, early detection, and early intervention for psychological help, along with the multidisciplinary team, helped to improve the overall psychological outcome of the affected patients.

A one-year follow-up study of treatment-compliant suicide attempt survivors: relationship of CYP2D6-CYP2C19 and polypharmacy with suicide reattempts

This study of a cohort of 1-year treatment-compliant survivors of a suicide attempt examined for the first time whether a high CYP2D6-CYP2C19 metabolic capacity (pharmacogenes related to psychopathology, suicide, and attempt severity) and/or polypharmacy treatments predicted repeat suicide attempts, adjusting for sociodemographic and clinical factors as confounders. Of the 461 (63% women) consecutively hospitalized patients who attempted suicide and were evaluated and treated after an index attempt, 191 (67.5% women) attended their 6- and 12-month follow-up sessions. Clinicians were blinded to the activity scores (AS) of their genotypes, which were calculated as the sum of the values assigned to each allele (CYP2C19 *2, *17; CYP2D6 *3, *4, *4xN, *5, *6, *10, wtxN). No differences were found in polypharmacy prescription patterns and the variability of CYP2D6 and CYP2C19 genotypes between adherents and dropouts, but the formers were older, with a higher frequency of anxiety and bipolar disorders and fewer alcohol and substance use disorders. The risk of reattempts was higher for CYP2D6 ultrarapid (AS > 2) metabolizers (β = 0.561, p = 0.005) and violent suicide survivors (β = -0.219, p = 0.042) if the attempt occurred during the first 6-month period, individuals with an increased number of MINI DSM-IV Axis I mental disorders (β = 0.092, p = 0.032) during the second 6-month period and individuals with a combined high CYP2D6-CYP2C19 metabolic capacity (AS > 4) (β = 0.345, p = 0.024) and an increased use of drugs other than antidepressants, anxiolytics-depressants and antipsychotics-lithium (β = 0.088, p = 0.005) in multiple repeaters during both periods. CYP2D6 and CYP2C19 rapid metabolism and polypharmacy treatment for somatic comorbidities must be considered to prevent the severe side effects of short-term multiple suicide reattempts after a previous attempt.

The clinical characterization of the adult patient with bipolar disorder aimed at personalization of management

Bipolar disorder is heterogeneous in phenomenology, illness trajectory, and response to treatment. Despite evidence for the efficacy of multimodal-ity interventions, the majority of persons affected by this disorder do not achieve and sustain full syndromal recovery. It is eagerly anticipated that combining datasets across various information sources (e.g., hierarchical "multi-omic" measures, electronic health records), analyzed using advanced computational methods (e.g., machine learning), will inform future diagnosis and treatment selection. In the interim, identifying clinically meaningful subgroups of persons with the disorder having differential response to specific treatments at point-of-care is an empirical priority. This paper endeavours to synthesize salient domains in the clinical characterization of the adult patient with bipolar disorder, with the overarching aim to improve health outcomes by informing patient management and treatment considerations. Extant data indicate that characterizing select domains in bipolar disorder provides actionable information and guides shared decision making. For example, it is robustly established that the presence of mixed features - especially during depressive episodes - and of physical and psychiatric comorbidities informs illness trajectory, response to treatment, and suicide risk. In addition, early environmental exposures (e.g., sexual and physical abuse, emotional neglect) are highly associated with more complicated illness presentations, inviting the need for developmentally-oriented and integrated treatment approaches. There have been significant advances in validating subtypes of bipolar disorder (e.g., bipolar I vs. II disorder), particularly in regard to pharmacological interventions. As with other severe mental disorders, social functioning, interpersonal/family relationships and internalized stigma are domains highly relevant to relapse risk, health outcomes, and quality of life. The elevated standardized mortality ratio for completed suicide and suicidal behaviour in bipolar disorder invites the need for characterization of this domain in all patients. The framework of this paper is to describe all the above salient domains, providing a synthesis of extant literature and recommendations for decision support tools and clinical metrics that can be implemented at point-of-care.

A machine learning approach for predicting suicidal ideation in post stroke patients

Currently, the identification of stroke patients with an increased suicide risk is mainly based on self‐report questionnaires, and this method suffers from a lack of objectivity. This study developed and validated a suicide ideation (SI) prediction model using clinical data and identified SI predictors. Significant variables were selected through traditional statistical analysis based on retrospective data of 385 stroke patients; the data were collected from October 2012 to March 2014. The data were then applied to three boosting models (Xgboost, CatBoost, and LGBM) to identify the comparative and best performing models. Demographic variables that showed significant differences between the two groups were age, onset, type, socioeconomic, and education level. Additionally, functional variables also showed a significant difference with regard to ADL and emotion (p < 0.05). The CatBoost model (0.900) showed higher performance than the other two models; and depression, anxiety, self-efficacy, and rehabilitation motivation were found to have high importance. Negative emotions such as depression and anxiety showed a positive relationship with SI and rehabilitation motivation and self-efficacy displayed an inverse relationship with SI. Machine learning-based SI models could augment SI prevention by helping rehabilitation and medical professionals identify high-risk stroke patients in need of SI prevention intervention.

Accelerated epigenetic aging in suicide attempters uninfluenced by high intent-to-die and choice of lethal methods

Suicide attempts (SA) are associated with excess non-suicidal mortality, putatively mediated in part by premature cellular senescence. Epigenetic age (EA) estimators of biological age have been previously demonstrated to strongly predict physiological dysregulation and mortality risk. Herein, we investigate if violent SA with high intent-to-die is predictive of epigenetics-derived estimates of biological aging. The genome-wide methylation pattern was measured using the Illumina Infinium Methylation EPIC BeadChip in whole blood of 88 suicide attempters. Subjects were stratified into two groups based on the putative risk of later committed suicide (low- [n = 58] and high-risk [n = 30]) in dependency of SA method (violent or non-violent) and/or intent-to-die (high/low). Estimators of intrinsic and extrinsic EA acceleration, one marker optimized to predict physiological dysregulation (DNAmPhenoAge/AgeAccelPheno) and one optimized to predict lifespan (DNAmGrimAge/AgeAccelGrim) were investigated for associations to severity of SA, by univariate and multivariate analyses. The study was adequately powered to detect differences of 2.2 years in AgeAccelGrim in relation to SA severity. Baseline DNAmGrimAge exceeded chronological age by 7.3 years on average across all samples, conferring a mean 24.6% increase in relation to actual age. No individual EA acceleration marker was differentiated by suicidal risk group (p > 0.1). Thus, SA per se but not severity of SA is related to EA, implicating that excess non-suicidal mortality in SA is unrelated to risk of committed suicide. Preventative healthcare efforts aimed at curtailing excess mortality after SA may benefit from acting equally powerful to recognize somatic comorbidities irrespective of the severity inherent in the act itself.

Excess mortality by suicide in high-risk subgroups of suicide attempters: a prospective study of standardised mortality rates in suicide attempters examined at a medical emergency inpatient unit

OBJECTIVES

The primary aim of the present study was to investigate the putative excess mortality by suicide in suicide attempters. As a secondary aim, we investigate excess mortality in specific, clinically relevant subgroups: individuals with repeated suicide attempts (RA); individuals who used violent method at the attempt (VA); and those who scored high on the Suicide Intent Scale (HS) at the time of the baseline attempt. Finally, we investigate excess mortality in men and women separately and within 5 years and over 5 years after hospital admission for attempted suicide.

DESIGN

Prospective register-based follow-up for 21-32 years. Standardised mortality ratio (SMR) was calculated for suicide using national census data. Clinically relevant subgroups were investigated separately.

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

1039 individuals who were psychiatrically assessed at admission to medical inpatient care for attempted suicide between 1987 and 1998.

OUTCOME MEASURE

Suicide.

RESULTS

The overall SMR for suicide was 23.50 (95% CI 18.68 to 29.56); significantly higher (p<0.001) among women (30.49 (95% CI 22.27 to 41.72)) than men (18.61 (95% CI 13.30 to 26.05)). Mortality was highest within the first 5 years after the index suicide attempt (48.79 (95% CI 35.64 to 66.77)) compared with those who died after 5 years (p<0.001) (14.74 (10.53 to 20.63)). The highest independent SMR was found for VA (70.22 (95% CI 38.89 to 126.80)). In a regression model including RA, VA and HS all contributed significantly to excess suicide mortality.

CONCLUSIONS

An elevated risk of premature death by suicide was found in suicide attempters compared with the general population. Assessment of previous suicide attempts is important, even though the attempt/s may have occurred decades ago. When assessing suicide risk, clinicians should consider repeated attempts and whether the attempts involved high suicidal intent and violent method. Healthcare interventions may benefit from targeting identified subgroups of attempters.

Hopelessness and shame in relation to suicide attempts by Cuban adolescents

Youth suicide rates in Cuba are very high compared with most other countries, despite considerable improvement in recent years. The purpose of our study was to determine whether hopelessness and shame distinguish adolescent suicide attempters from non-attempters, over and above the effects of depression and suicidal ideation. Participants were 844 Cuban adolescents from the province of Holguin in Eastern Cuba. The attempter groups included 38 participants being treated for suicide attempts in a day hospital and 82 participants in the community who self-reported a previous suicide attempt. The other participants were non-attempter controls. All participants were asked to complete measures of depression, hopelessness, shame and suicidal ideation. As expected, attempters scored higher than non-attempters on the control variables of depression and suicidal ideation. In addition, attempters self-reported greater shame, especially behavioral and characterological shame, than non-attempters. Contrary to our hypothesis, there was no significant difference in hopelessness between attempters and non-attempters. The results are inconsistent with the considerable narrative lore about hopelessness as a reason for suicide in Cuba and other socialist countries. However, some collective socialization practices may lead to shame.

Risk Assessment on Suicide Death and Attempt among Chinese Rural Youths Aged 15-34 Years

Background: Although many suicide risk assessment tools are available in the world, their validity is not adequately assessed. In this study, we aimed to develop and evaluate a suicide risk assessment model among Chinese rural youths aged 15–34 years. Method: Subjects were 373 suicide deaths and 507 suicide attempters aged 15–34 years in three Chinese provinces (Shandong, Liaoning, and Hunan). Information about the community residents was also collected as the control groups. Social-demographic, social and psychological variables were examined for the suicides, suicide attempters, and community residents. Logistic regressions based on subjects from Shandong and Liaoning provinces were conducted to establish the suicide risk assessment models. Receiver operating characteristic (ROC) curves were drawn, and area under the ROC curves (AUC) were calculated to show how well the models separated the group being tested into those with and without suicide attempt or suicide. Results: The assessment model for suicide death included education years (OR = 0.773, p < 0.001), agricultural worker (OR = 2.091, p < 0.05), physical health (OR = 0.445, p < 0.05), family suicide history (OR = 6.858, p < 0.001), negative life events (OR = 1.340, p < 0.001), hopelessness (OR = 1.171, p < 0.001), impulsivity (OR = 1.151, p < 0.001), and mental disorder (OR = 8.384, p < 0.001). All these factors were also supported in the assessment model for suicide attempt, with an extension of very poor economic status (OR = 1.941, p < 0.01) and social interaction (OR = 0.855, p < 0.001). The AUC was 0.950 and 0.857 for the sample used to establish the assessment models of suicide death and attempt, respectively. The AUC was 0.967 and 0.942 for the sample used to verify the established assessment models of suicide death and attempt, respectively. Conclusions: Compared with some other assessment tools, the models for suicide death and attempt in the current study performed well among Chinese rural youths aged 15–34 years. A reliable suicide risk assessment approach, which includes multiple risk factors, should be evaluated in various cultures and populations.

Looking for Razors and Needles in a Haystack: Multifaceted Analysis of Suicidal Declarations on Social Media-A Pragmalinguistic Approach

In this paper, we study language used by suicidal users on Reddit social media platform. To do that, we firstly collect a large-scale dataset of Reddit posts and annotate it with highly trained and expert annotators under a rigorous annotation scheme. Next, we perform a multifaceted analysis of the dataset, including: (1) the analysis of user activity before and after posting a suicidal message, and (2) a pragmalinguistic study on the vocabulary used by suicidal users. In the second part of the analysis, we apply LIWC, a dictionary-based toolset widely used in psychology and linguistic research, which provides a wide range of linguistic category annotations on text. However, since raw LIWC scores are not sufficiently reliable, or informative, we propose a procedure to decrease the possibility of unreliable and misleading LIWC scores leading to misleading conclusions by analyzing not each category separately, but in pairs with other categories. The analysis of the results supported the validity of the proposed approach by revealing a number of valuable information on the vocabulary used by suicidal users and helped to pin-point false predictors. For example, we were able to specify that death-related words, typically associated with suicidal posts in the majority of the literature, become false predictors, when they co-occur with apostrophes, even in high-risk subreddits. On the other hand, the category-pair based disambiguation helped to specify that death becomes a predictor only when co-occurring with future-focused language, informal language, discrepancy, or 1st person pronouns. The promising applicability of the approach was additionally analyzed for its limitations, where we found out that although LIWC is a useful and easily applicable tool, the lack of any contextual processing makes it unsuitable for application in psychological and linguistic studies. We conclude that disadvantages of LIWC can be easily overcome by creating a number of high-performance AI-based classifiers trained for annotation of similar categories as LIWC, which we plan to pursue in future work.

Were suicide deceased more determined to die than attempters? A comparison study based on two psychological autopsy studies

The reason that some victims of suicide behaviors survived while the others died is unknown, and few studies have been conducted for Chinese populations. We aimed to analyze the effect of suicide intent on outcomes of suicide behaviors, and to explore the impact of psychological strain on suicide intent. Data for this study was derived from two psychological autopsy research projects conducted in China. The same interview procedure and instruments were used in the two projects. Suicide intent was measured by Beck's Suicidal Intention Scale. Information on psychological strain was obtained. A total of 274 suicide deaths and 507 suicide attempters were included in the study. After controlling for socio-demographic variables, suicide intent was significantly associated with suicide death among people having suicide behaviors. Aspiration strain and coping strain were significantly associated with suicide intent. Significant intent-death association and psychological strain-suicide intent association were found in this study. Suicide intent might be an intermediate variable in the pathway from psychological strain to suicide death. Therefore, suicides might be more determined or motivated to die than those attempters who did not die of the act. Future research should continue to explore the mechanism of the psychological strain-suicide intent association, and more efforts on suicide prevention should be made from the perspective of psychological strain.

Comparison Between Inflammatory Biomarkers (High-Sensitivity C-Reactive Protein and Neutrophil-Lymphocyte Ratio) and Psychological Morbidity in Suicide Attempt Survivors Brought to Medicine Emergency

Objectives: This study aimed to compare inflammatory biomarkers (high-sensitivity {hs} C-reactive protein, neutrophil-lymphocyte ratio) and psychological morbidity in suicide attempt survivors.

Methods: One hundred ninety-eight poisoning cases screened, 40 age-matched suicide attempt survivors (SAS), 40 healthy controls (HC) between the age of 18 years and 60 years were included. Complete hemogram, neutrophil-lymphocyte ratio (NLR), hsCRP values obtained, compared with Hospital Anxiety and Depression Scale (HADS), suicide intent scale, presumptive stressful life events scale (PSLES), general health questionnaire 12-item (GHQ-12) (Hindi version), and Hindi Mental State Examination (HMSE).

Results: A statistically significant difference was observed in hsCRP (p=0.016) and NLR (p=0.029) of depressed-suicidal participants vs healthy controls. hsCRP values of anxious-suicidal subjects vs healthy controls showed a statistically significant difference (p=0.001). There was a statistically significant difference between patients, healthy controls in HADS anxiety and HADS depression mean scores (p<0.001). The PSLES items were ranked according to the mean stress scores of all the items (mean±SD), highest four were excessive alcohol use by the family member 47.50 (±27.03), conflicts with in-laws 50 (±27.73), family conflict 50 (±29.42), marital conflict 50.63 (±32.76). There was a statistically significant difference in hemoglobin (p<0.001), red blood cells count (p<0.001), hematocrit (p<0.001) between suicide attempt survivors and healthy controls.

Conclusion: Both hsCRP and NLR have emerged as potential inflammatory biomarkers for depressive patients with suicidal attempts. Additionally, there may be a link between anemia and suicide risk in patients with depression.

A Systematic Review of Neuromodulation Treatment Effects on Suicidality

Introduction: Neuromodulation is an important group of therapeutic modalities for neuropsychiatric disorders. Prior studies have focused on efficacy and adverse events associated with neuromodulation. Less is known regarding the influence of neuromodulation treatments on suicidality. This systematic review sought to examine the effects of various neuromodulation techniques on suicidality. Methods: A systematic review of the literature from 1940 to 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was conducted. Any reported suicide-related outcome, including suicidal ideation, suicide intent, suicide attempt, completed suicide in reports were considered as a putative measure of treatment effect on suicidality. Results: The review identified 129 relevant studies. An exploratory analysis of a randomized controlled trial comparing the effects of sertraline and transcranial direct-current stimulation (tDCS) for treating depression reported a decrease in suicidal ideation favoring tDCS vs. placebo and tDCS combined with sertraline vs. placebo. Several studies reported an association between repetitive transcranial magnetic stimulation and improvements in suicidal ideation. In 12 of the studies, suicidality was the primary outcome, ten of which showed a significant improvement in suicidal ideation. Electroconvulsive therapy (ECT) and magnetic seizure therapy was also shown to be associated with lower suicidal ideation and completed suicide rates. There were 11 studies which suicidality was the primary outcome and seven of these showed an improvement in suicidal ideation or suicide intent and fewer suicide attempts or completed suicides in patients treated with ECT. There was limited literature focused on the potential protective effect of vagal nerve stimulation with respect to suicidal ideation. Data were mixed regarding the potential effects of deep brain stimulation on suicidality. Conclusions: Future prospective studies of neuromodulation that focus on the primary outcome of suicidality are urgently needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=125599, identifier: CRD42019125599.

Neighborhood Disorder, Social Support, and Outcomes Among Violence-Exposed African American Women

Intimate partner violence (IPV) against women, particularly those living in poverty who have multiple marginalized identities, is a significant public health issue. IPV is associated with numerous mental health concerns including depression, hopelessness, and suicidal behavior. The present study examined the ecological determinants of these mental health outcomes in a high-risk sample of 67 low-income, African American women survivors of IPV. Based on an ecological framework that conceptualizes individuals as nested in multiple, interactive systems, we examined, longitudinally, the main and interactive effects of self-reported neighborhood disorder and social support from family members and friends on participants' mental health (i.e., self-reported depressive symptoms, hopelessness, and suicide intent). In multiple regression analyses, neighborhood disorder interacted with social support from family members to predict depressive symptoms and hopelessness over time. Neighborhood disorder also interacted with social support from friends to predict hopelessness and suicide intent over time. High levels of social support buffered against the dangerous effects of neighborhood disorder on depressive symptoms, hopelessness, and suicide intent; at low levels of social support, there was no significant association between neighborhood disorder and those mental health outcomes. Neighborhood disorder and social support did not yield significant main effects. These findings underscore the importance of interventions that target individuals, families, and communities (e.g., community empowerment programs). Group interventions may also be important for low-income, African American women survivors of IPV, as they can help survivors establish and strengthen relationships and social support.

Depressed adolescents' exposure to suicide attempts and suicide loss

This study explored depressed adolescent inpatients' (N = 158) experiences of exposure to friends' and family members' suicidal behaviors. Most of the participants (n = 102, 64.6%) reported exposure to suicide-related behavior. Teens exposed to suicide were more likely than non-exposed peers to report experiencing physical abuse, sexual abuse, and suicide attempts. No differences were observed between those exposed to only suicide attempts and those exposed to both suicide attempts and deaths in clinical characteristics or suicidal behaviors. Exposure to any form of suicide-related behavior may be associated with multiple forms of adversity in childhood.

Educational attainment reduces the risk of suicide attempt among individuals with and without psychiatric disorders independent of cognition: a bidirectional and multivariable Mendelian randomization study with more than 815,000 participants

Rates of suicidal behavior are increasing in the United States and identifying causal risk factors continues to be a public health priority. Observational literature has shown that educational attainment (EA) and cognitive performance (CP) influence suicide attempt risk; however, the causal nature of these relationships is unknown. Using summary statistics from genome-wide association studies (GWAS) of EA, CP, and suicide attempt risk with > 815,000 combined white participants of European ancestry, we performed multivariable Mendelian randomization (MR) to disentangle the effects of EA and CP on attempted suicide. In single-variable MR (SVMR), EA and CP appeared to reduce suicide attempt risk (EA odds ratio (OR) per standard deviation (SD) increase in EA (4.2 years), 0.524, 95% CI, 0.412-0.666, P = 1.07 × 10-7; CP OR per SD increase in standardized score, 0.714, 95% CI, 0.577-0.885, P = 0.002). Conversely, bidirectional analyses found no effect of a suicide attempt on EA or CP. Using various multivariable MR (MVMR) models, EA seems to be the predominant risk factor for suicide attempt risk with the independent effect (OR, 0.342, 95% CI, 0.206-0.568, P = 1.61 × 10-4), while CP had no effect (OR, 1.182, 95% CI, 0.842-1.659, P = 0.333). In additional MVMR analyses accounting simultaneously for potential behavioral and psychiatric mediators (tobacco smoking; alcohol consumption; and self-reported nerves, tension, anxiety, or depression), the effect of EA was little changed (OR, 0.541, 95% CI, 0.421-0.696, P = 3.33 × 10-6). Consistency of results across complementary MR methods accommodating different assumptions about genetic pleiotropy strengthened causal inference. Our results show that even after accounting for psychiatric disorders and behavioral mediators, EA, but not CP, may causally influence suicide attempt risk among white individuals of European ancestry, which could have important implications for health policy and programs aimed at reducing the increasing rates of suicide. Future work is necessary to examine the EA-suicide relationship populations of different ethnicities.

Serum β-endorphin levels are associated with addiction to suicidal behavior: A pilot study

The literature provides partial support for the hypothesis that some suicide attempters develop a behavioral addiction to suicidal behavior (SB). We hypothesized that major suicide repeaters (MR) (≥5 lifetime suicide attempts) are addicted to suicide attempts as measured by modified DSM-IV criteria for substance dependence. In this cross-sectional study with 13 psychiatric controls (PC), 55 non-major suicide attempters (NMR), and 9 MR we found that MR are characterized by emotional abuse and neglect, as well as higher scores on the Personality and Life Event scale (short version). The levels of 8 AM serum ACTH, cortisol and β-endorphin were elevated in all three groups. Serum β-endorphin (pg/mL) was particularly high in PC diagnosed with schizophrenia 220.34 (±56.30). The level of 8 AM serum β-endorphin rose with increased numbers of criteria met for addiction to SB from 130.31 (±88.16) (≥ 3 criteria met for addiction to SB) to 174.84 (±114.93) (≥ 6 criteria met for addiction to SB) whereas serum ACTH and cortisol did not change. SB addicts (≥ 6 criteria) displayed higher serum β-endorphin concentrations than non-addicts (174.84 ± 114.93 vs. 116.93 ± 61.70, FET p = 0.09). The present study brings some support to the addictive hypothesis of SB. Our results delineate β-endorphin as a promising biomarker of SB addiction, and offer a good basis for future studies that test whether buprenorphine can be used to prevent repetitive suicide attempts, non-suicidal-self-injury (NSSI), and the development of an addiction to SB.

Long-term risk factors for suicide in suicide attempters examined at a medical emergency in patient unit: results from a 32-year follow-up study

OBJECTIVES

The overall aim of this study is to gain greater knowledge about the risk of suicide among suicide attempters in a very long-term perspective. Specifically, to investigate possible differences in clinical risk factors at short (≤5 years) versus long term (>5 years), with the hypothesis that risk factors differ in the shorter and longer perspective.

DESIGN

Prospective study with register-based follow-up for 21-32 years.

SETTING

Medical emergency inpatient unit in the south of Sweden.

PARTICIPANTS

1044 individuals assessed by psychiatric consultation when admitted to medical inpatient care for attempted suicide during 1987-1998.

OUTCOME MEASURES

Suicide and all-cause mortality.

RESULTS

At follow-up, 37.6% of the participants had died, 7.2% by suicide and 53% of these within 5 years of the suicide attempt. A diagnosis of psychosis at baseline represented the risk factor with the highest HR at long-term follow-up, that is, >5 years, followed by major depression and a history of attempted suicide before the index attempt. The severity of a suicide attempt as measured by SIS (Suicide Intent Scale) showed a non-proportional association with the hazard for suicide over time and was a relevant risk factor for suicide only within the first 5 years after an attempted suicide.

CONCLUSIONS

The risk of suicide after a suicide attempt persists for up to 32 years after the index attempt. A baseline diagnosis of psychosis or major depression or earlier suicide attempts continued to be relevant risk factors in the very long term. The SIS score is a better predictor of suicide risk at short term, that is, within 5 years than at long term. This should be considered in the assessment of suicide risk and the implementation of care for these individuals.

Ketamine for acute suicidal ideation. An emergency department intervention: A randomized, double-blind, placebo-controlled, proof-of-concept trial

BACKGROUND

Depressed patients presenting to emergency departments with acute suicidal ideation are a major public health concern. Ketamine, a rapidly acting antidepressant with antisuicidal properties, might offer relief.

METHODS

In a randomized, double-blind, placebo-controlled, proof-of-concept trial, 18 depressed subjects with acute suicidal ideation, who required hospitalization, were randomized to either an intravenous ketamine 0.2 mg/kg group or a saline placebo group. Safety and efficacy evaluations were scheduled for 15, 30, 60, 90, 120, 180, and 240 min, and on Days 1, 2, 3, 7, and 14 after infusion. The main outcome measure was suicidal ideation with secondary measures of depression.

RESULTS

Nine subjects were randomized to each group. There were no differences between groups at baseline in any demographic or assessment scales. A reduction in suicidal ideation was noted at 90-180 min (p < .05). Ninety minutes after infusion, 88% of the ketamine group had achieved remission of suicidal ideation compared with 33% in the placebo group (p < .05). No serious adverse events were noted.

CONCLUSIONS

Ketamine was safe and effective for rapid reduction in suicidal ideation in depressed, highly suicidal subjects presenting to the emergency department. Our results support further study of ketamine for acute suicidal ideation.

Group ("Project Life Force") versus individual suicide safety planning: A randomized clinical trial

One in five suicide deaths is a Veteran and in spite of enhanced suicide prevention services in the Veterans Health Administration (VHA), twenty Veterans die by suicide each day. One component of the VHA's coordinated effort to treat high-risk suicidal Veterans, and diminish suicide risk, is the use of the safety plan. The current study aims to examine a novel intervention integrating skills training and social support with safety planning for Veterans at high-risk for suicide, "Project Life Force" (PLF). A randomized clinical trial (RCT) will be conducted examining if Veterans who are at high-risk for suicide will benefit from the novel group intervention, PLF, compared to Veterans who receive treatment as usual (TAU). We plan to randomize 265 Veterans over the course of the study. The primary outcome variable is the incidence of suicidal behavior, during follow-up, established using a rigorous, multi-method assessment. Secondary outcomes include depression, hopelessness, suicide coping and treatment utilization. Exploratory analyses include safety plan quality and belongingness for those in both arms as well as group cohesion for those in the PLF intervention. Strengths and limitations of this protocol are discussed.

Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale

BACKGROUND

How suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent.

METHODS

Prospective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated.

RESULTS

Of 479 participants, 329 (68.7%) were women. The age range was 18-95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%.

LIMITATIONS

The clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis.

CONCLUSION

Predictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.

PTSD from a suicide attempt: An empirical investigation among suicide attempt survivors

OBJECTIVES

Suicide attempts (SAs), by definition, represent a risk for serious injury or death; thus, one's SA may contribute to the development of posttraumatic stress disorder (PTSD). Yet, empirical data on this topic are lacking. This study aimed to characterize the phenomenology, rate, and associated features of PTSD following one's SA.

METHOD

A total of 386 adult SA survivors recruited from web-based sources participated.

RESULTS

Overall, 27.5% (95% confidence interval = 23.1-31.9%) of SA survivors screened positive for a probable SA-related PTSD diagnosis. Individuals with a probable SA-related PTSD diagnosis reported greater current suicidal intent than those without this probable diagnosis; this association was significant at low, but not high, levels of depression symptoms.

CONCLUSIONS

A substantial proportion of SA survivors may experience SA-related PTSD. SA-related PTSD may be a viable assessment and intervention target to improve the quality of life and to reduce future suicide risk among SA survivors.

Predicting Planned Suicide Attempts With the Columbia-Suicide Severity Rating Scale: A Subanalysis of the 2013 Korea National Suicide Survey on Emergency Department Visitors

Identifying predictors of planned suicide attempts (PSA) is critical because these are associated with grave consequences. Using data of suicide attempters visiting emergency departments, we investigated whether the Columbia-Suicide Severity Rating Scale (C-SSRS) subscales, by retrospectively evaluating ideation before an attempt, could predict the occurrence of PSA versus unplanned suicide attempts using logistic regression analyses. The severity subscale was used as a continuous (model A) and a categorical (model B) variable. In model A, higher scores on each subscale were associated with increased risk of PSA. In model B, the highest score on the severity subscale and a higher intensity subscale score predicted PSA. The severity and intensity subscales had areas under receiver operating curves of 0.712 and 0.688 with optimum cutoff points of 4/5 and 15/16, respectively. In addition, being aged 30 to 49 and 50 to 69 years, being male, interpersonal stress, and depressive and adjustment disorders increased PSA risk. The C-SSRS subscales, along with sociodemographic and clinical risk factors, can predict PSA.

A Comparison of Attitudes Toward Suicide Among Individuals With and Without Suicidal Thoughts and Suicide Attempts in South Korea

Abstract. Background: A suicidal person can go through different stages that include suicidal thoughts and suicide attempts. For a few individuals, these can end up with suicide. However, there have been no studies investigating any differences in attitudes toward suicides among individuals with no suicidal thoughts, those with suicidal thoughts, and those with suicide attempts. Aims: This study was carried out to compare attitudes toward suicide among three different groups: individuals with a history of no suicidal thoughts, those with a history of suicidal thoughts, and those with a history of suicide attempts. Method: To examine Koreans' attitudes toward suicide, we analyzed the data from the 2013 National Suicide Survey involving 1,500 participants aged between 19 and 75 years. Results: Different attitudes toward suicide were found among the three groups. Persons reporting that they had made a suicide attempt in their life showed the most permissive attitudes toward suicide. Limitations: Since this research is based on cross-sectional data, it is difficult to eliminate the possibility of changes in attitude toward suicide completely after having a suicidal thought and suicide attempt. Conclusion: These results can be a useful source for constructing effective messages for suicide prevention campaigns and can ultimately contribute to an improvement in the public's perceptions of suicide in the future.

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior: Study rationale, methodology, and baseline sample characteristics of a long-term, large-scale, multi-center, prospective, naturalistic, observational cohort study

BACKGROUND

The Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior (K-COMPASS) study is a prospective, naturalistic, observational cohort study, aiming to identify predictors of suicide attempt and suicide characteristics in the Korean suicidal population. The findings intend to contribute to a thorough understanding of suicidal phenomena and development of suicide prevention guidelines. The present cross-section study examines the study rationale, methodology, and baseline characteristics of the participants.

METHODS

Participants were enrolled via the hospital and community gateways, establishing the hospital-based cohort (HC) and community-based cohort (CC), respectively. Baseline assessment was conducted on sociodemographic, clinical, diagnostic, and psychopathological aspects. The Columbia-Suicide Severity Rating Scale was used to investigate suicidality.

RESULTS

A total of 800 suicidal people aged 15 years or older were enrolled from 8 university hospitals and 8 community mental health welfare centers (CMHWCs), among whom 480 (60%) were suicidal ideators and 320 (40%) were attempters. The ideators comprised 207 CC and 273 HC participants, whereas the attempters, 34 CC and 286 HC participants. Despite their lower severity in some measures, including suicidal ideation, compared with their HC counterparts, the CC participants within each group of ideators or attempters presented clinically significant psychopathology. Moreover, alcohol use problems and past suicide attempt were more likely to be found in CC participants. Only 11.1% to 21.6% of the participants in each of the four groups (defined by the cohorts and the ideators/attempters) were on any type of psychiatric treatment.

CONCLUSIONS

Suicidal visitors to CMHWCs need to be as closely monitored as suicidal patients in university hospitals, especially considering their association with problem drinking and past suicide attempt. A cautious assumption is that the high suicide rate in Korea might be partly attributable to the low proportion of patients receiving psychiatric services.

Difficulties in emotion regulation and suicide ideation and attempt in adolescent inpatients

This study aimed to examine the concurrent relation between six dimensions of emotion dysregulation, proposed by Gratz and Roemer (2004), and suicide ideation and attempt in a large sample of psychiatric adolescent inpatients. A sample of 547 adolescent inpatients completed measures on dimensions of emotion dysregulation, psychiatric diagnoses, and suicidal ideation and attempt. Binary logistic regression analyses revealed that limited access to emotion regulation strategies, difficulties in impulse control, and mood disorder diagnosis, were significantly associated with past year suicidal ideation, covarying for other emotion dysregulation subscales, anxiety and externalizing diagnoses, sex, and age. However, difficulties in impulse control was not significantly related to suicide ideation when analyses were conducted separately by sex. Binary logistic regressions also revealed that past year suicidal ideation uniquely and significantly associated with lifetime attempt, covarying for sociodemographics, psychiatric diagnoses, and all emotion dysregulation subscales; these results held when analyses were also conducted separately by sex. Results indicating an association between perceived limited emotion regulation strategies and suicide ideation are consistent with existing research and suicide-focused theory. This finding may have some tentative benefit to informing clinical assessment and treatment of suicidal thoughts. Other findings are discussed.

Characteristics of a suicide attempt predict who makes another attempt after hospital discharge: A decision-tree investigation

The year following discharge from psychiatric hospitalization is a high-risk period for suicidal behavior, particularly among patients initially hospitalized after a suicide attempt. Demographic and clinical correlates have been identified; however, characteristics of the initial attempt may provide insight into risk for subsequent attempts as well. This investigation examined whether individual or a combination of suicide attempt characteristics predicted future attempts. Two hundred and eighteen psychiatric inpatients from the MacArthur Violence Risk Assessment Study with a recent suicide attempt were administered items from the Suicide Intent Scale and followed one year after discharge. Sixty-nine (31.65%) made a subsequent attempt. Data were analyzed by a stepwise logistic regression, followed by an iterative receiver operator curve (IROC) analysis, a recursive partitioning classification tree. The cross-validated IROC, but not logistic regression, predicted subsequent suicide attempts. Furthermore, the IROC found that participants who made definite plans and underwent extensive preparation were at highest risk for subsequent attempts. These findings suggest that suicide attempt characteristics preceding psychiatric hospitalization can help identify patients at elevated risk for another attempt post-discharge.

Suicide Risk in Young Men and Women After Substance Intoxication

This study investigates suicide and overdoses in 1,119 consecutive patients (64% women), 15 to 34 years of age, presenting at the emergency department after self-poisoning from1994 to 2000 and followed regarding death to 2006. Regression and Kaplan-Meier survival analyses were performed for suicide and other causes of death. The patients had about a 60 times higher risk (SMR = 61.95) of death due to suicide and 26 times higher (SMR = 26.47) for all-cause mortality. Men had a nearly 2 times higher risk for suicide than women and half of the suicides occurred during the first 2 years after admission. Poisoning was the most common suicide method and early prevention of self-poisoning is crucial to reducing future deaths.

Factors Affecting Suicide Method Lethality Among Suicide Attempters in the Korea National Suicide Survey

This is the first national survey study in South Korea investigating the relationship between suicide lethality and the clinical information of suicide attempters. An interview questionnaire was used to assess their sociodemographic factors, medical and psychiatric information, and two suicide scales, the Columbia-Suicide Severity Rating Scale and the Suicide Intent Scale. Suicide methods were categorized as low and high lethality; low lethality covered drug overdose or self-cutting behavior, and high lethality covered all other methods. High and low lethality suicide method groups were significantly different in demographic, medical, and psychiatric factors. The two scale score distributions differed significantly across two groups, and the difference was also valid for the subcategory analyses of the Suicide Intent Scale. Multiple factors such as older age, male sex, no previous psychiatric history, and previous suicide attempt, as well as high suicide intent by means of suicide scale, affect selection of suicide method of high lethality.

Epigenetic Changes in the CRH Gene are Related to Severity of Suicide Attempt and a General Psychiatric Risk Score in Adolescents

The aim of this study, comprising 88 suicide attempters, was to identify hypothalamic-pituitary-adrenal (HPA) -axis coupled CpG-sites showing methylation shifts linked to severity of the suicide attempt. Candidate methylation loci were further investigated as risk loci for a general psychiatric risk score in two cohorts of adolescents (cohort 1 and 2). The genome-wide methylation pattern was measured in whole blood using the Illumina Infinium Methylation EPIC BeadChip. Subjects were stratified into high-risk and low-risk groups based on the severity of the suicidal behavior. We included CpG sites located within 2000 basepairs away from transcriptional start site of the following HPA-axis coupled genes: corticotropin releasing hormone (CRH), corticotropin releasing hormone binding protein (CRHBP), corticotropin releasing hormone receptor 1 (CRHR1), corticotropin releasing hormone receptor 2 (CRHR2), FK506-binding protein 51 (FKBP5) and the glucocorticoid receptor (NR3C1). The methylation state of two corticotropin releasing hormone (CRH)-associated CpG sites were significantly hypomethylated in the high-risk group of suicide attempters (n = 31) (cg19035496 and cg23409074) (p < 0.001). Adolescent cohort 1 and 2 consisted of 129 and 93 subjects, respectively, and were stratified by the in silico generated DAWBA measurements of a general psychiatric risk score into high-risk group (>~50% risk) or controls. In adolescent cohort 2, cg19035496 was hypermethylated in subjects with a high general psychiatric risk score. Our results show epigenetic changes in the CRH gene related to severity of suicide attempt in adults and a general psychiatric risk score in adolescents.

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Two CRH-associated CpG sites were significantly hypomethylated in the high-risk group of suicide attempters.

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In adolescent cohort, cg19035496 was hypermethylated in subjects with a high general psychiatric risk score.

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Epigenetic modulatory effects on the HPA axis dysregulation are associated with psychiatric illness and suicidal behavior.

In this study, comprising 88 suicide attempters, we aimed to identify epigenetic changes in stress system linked to severity of the suicide attempt. In the next step, we investigated if the same epigenetic changes could be detected in adolescents with high risk for psychiatric illness. The methylation pattern was measured in blood and subjects were stratified into high-risk and low-risk groups based on the severity of the suicidal behavior. One corticotropin releasing hormone (CRH)-a key regulator of stress system-associated CpG site showed less methylation in the high-risk group and was hypermethylated in adolescents with a high general psychiatric risk score. Epigenetic changes in the CRH gene were related to severity of suicide attempt in adults and a general psychiatric risk score in adolescents.

Depressed Multiple-Suicide­Attempters – A High-Risk Phenotype

Abstract. Background: There is compelling evidence that suicide attempts are among the strongest predictors of suicide and future suicide attempts. Aim: This study aimed to examine psychopathology in multiple-suicide attempters. Method: We compared the demographic and clinical features of three groups: depressed patients without a history of suicide attempts (non-attempters), depressed patients with a history of one to three suicide attempts (attempters), and depressed patients with a history of four or more suicide attempts (multiple attempters). Results: We found that attempters and multiple attempters had higher levels of depression, hopelessness, aggression, hostility, and impulsivity and were more likely to have borderline personality disorder and family history of major depression or alcohol use disorder compared with non-attempters, but did not differ between each other on these measures. Multiple attempters had greater suicidal ideation at study entry and were more likely to have family history of suicide attempt compared with attempters. Importantly, multiple attempters had greater suicide intent at the time of the most medically serious suicide attempt and more serious medical consequences during their most medically serious suicide attempt compared with attempters. Limitations: The cross-sectional design of the study. Conclusion: Our data suggest that multiple-suicide attempters require careful evaluation as their behavior can have serious medical consequences.

Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence

Background

Instruments have been developed to facilitate suicide risk assessment. We aimed to evaluate the evidence for these instruments including assessment of risk of bias and diagnostic accuracy for suicide and suicide attempt.

Methods

PubMed (NLM), PsycInfo, Embase, Cinahl and the Cochrane Library databases were searched until December 2014. We assessed risk of bias with QUADAS-2. The average sensitivity and specificity of each instrument was estimated and the certainty of the evidence was assessed with GRADE. We considered instruments with a sensitivity > 80% and a specificity > 50% to have sufficient diagnostic accuracy.

Results

Thirty-five relevant studies were identified but 14 were considered to have high risk of bias, leaving 21 studies evaluating altogether 15 risk assessment instruments. We could carry out meta-analyses for five instruments. For the outcome suicide attempt SAD PERSONS Scale had a sensitivity of 15% (95% CI 8–24) and specificity of 97% (96–98), and the Manchester Self-Harm Rule (MSHR) a sensitivity of 97% (97–97) and a specificity of 20% (20–21). ReACT, which is a modification of MSHR, had a similar low specificity, as did the Sodersjukhuset Self Harm Rule. For the outcome suicide, the Beck Hopelessness Scale had a sensitivity of 89% (78–95) and specificity of 42% (40–43).

Conclusions

Most suicide risk assessment instruments were supported by too few studies to allow for evaluation of accuracy. Among those that could be evaluated, none fulfilled requirements for sufficient diagnostic accuracy.

Suicide attempters with high and low suicide intent: Different populations in rural China

This paired case-control study aimed to compare characteristics between suicide attempters with high and low suicide intent in rural China. We evaluated 409 suicide attempters and their paired controls who were matched with the same gender, age (a difference of no more than 3 years), and similar residence. Compared to paired control, suicide attempt with high and low suicide intent shared the 3 common risk factors of negative life event, high depression score, and low social support score. In addition, mental disorder was an independent risk factor of suicide attempt with high intent. Having a low education level and occupation as a farmer were risk factors of suicide attempt with low intent. Mental disorder and depression were associated with a significantly increased risk of suicide attempt with high intent compared to low intent. Depression was found to be related to suicide attempt with high intent compared to low intent in the subgroups of male or female aged 35-54 or 55-70 years. Distinct characteristics were found in the suicide attempters with different intent. These findings are important and the aim is to transform them into concrete ideas for the prevention of suicide attempt in rural China.

Looking Back on Self-Poisoning: The Relationship between Depressed Mood and Reporting of Suicidal Intent in People Who Deliberately Self-Poison

Lifetime worst-point suicidality is associated with risk of subsequent death by suicide. Yet little is known about how people who deliberately self-poison (DSP) change their appraisal of suicidal intent of a single DSP episode over time. We assessed whether suicidal intent for a single index episode of DSP changed over time and factors associated with such change. We studied 202 patients admitted for DSP (66.3% female, all Caucasian), 18-85 years old (M = 37.8, SD = 14.8), using a longitudinal design (0, 3, and 12 months). The primary outcome measure was change in suicidal intent for a single index DSP episode, analyzed using multilevel modeling. Wish to die and whether the episode was considered a suicide attempt increased significantly with depressed mood. Wish to die associated with the index episode also increased over time independently of depressed mood. No association with time or depressed mood was found for perceived likelihood of dying. Depressed mood was strongly associated with appraisal of suicidal intent associated with a DSP episode. In suicide risk assessment, reports of the nature and severity of past DSP should be interpreted in light of current mood.

Life satisfaction and degree of suicide intent: A test of the strain theory of suicide

BACKGROUND

Various factors contribute to suicide. Psychological strains are hypothesized to precede suicidal thought and attempt. Life satisfaction can be a measure of relative deprivation strain and aspiration-reality strain.

AIMS

This study was to compare the suicide attempters with various levels of life satisfaction and find out how life satisfaction affects the degree of suicide intent among medically serious suicide attempters.

METHODS

Subjects for study were recruited in some rural counties in China. Interview data were from hospital emergency rooms with medically serious attempters of suicide (n=791). The subjects were aged between 15 and 54years and 293 males and 498 females. Face to face interview was conducted for each suicide attempter with a semi-structural protocol including life satisfaction, physical health, demographic, sociological, and psychological measures, as well as psychological strains.

FINDINGS

The multiple linear regression analysis showed that mental disorder, aspiration strain and relative deprivation strain were significant risk factors for high intent of suicide among suicide attempters. The interaction between the two psychological strains also indicated that both failed aspiration and self-perceived low economic status in village play an important role in suicidal intent.

CONCLUSION

Low level of life satisfaction is associated with strong intent for suicide. Lack of life satisfaction is exemplified by relative deprivation perceived by the individuals and the discrepancy between an individual's aspiration for life and his/her reality. The findings from the suicide attempt data in rural China support the Strain Theory of Suicide.

Classification of Suicide Attempts through a Machine Learning Algorithm Based on Multiple Systemic Psychiatric Scales

Classification and prediction of suicide attempts in high-risk groups is important for preventing suicide. The purpose of this study was to investigate whether the information from multiple clinical scales has classification power for identifying actual suicide attempts. Patients with depression and anxiety disorders (N = 573) were included, and each participant completed 31 self-report psychiatric scales and questionnaires about their history of suicide attempts. We then trained an artificial neural network classifier with 41 variables (31 psychiatric scales and 10 sociodemographic elements) and ranked the contribution of each variable for the classification of suicide attempts. To evaluate the clinical applicability of our model, we measured classification performance with top-ranked predictors. Our model had an overall accuracy of 93.7% in 1-month, 90.8% in 1-year, and 87.4% in lifetime suicide attempts detection. The area under the receiver operating characteristic curve (AUROC) was the highest for 1-month suicide attempts detection (0.93), followed by lifetime (0.89), and 1-year detection (0.87). Among all variables, the Emotion Regulation Questionnaire had the highest contribution, and the positive and negative characteristics of the scales similarly contributed to classification performance. Performance on suicide attempts classification was largely maintained when we only used the top five ranked variables for training (AUROC; 1-month, 0.75, 1-year, 0.85, lifetime suicide attempts detection, 0.87). Our findings indicate that information from self-report clinical scales can be useful for the classification of suicide attempts. Based on the reliable performance of the top five predictors alone, this machine learning approach could help clinicians identify high-risk patients in clinical settings.

Assessment of Suicidal Intent

BACKGROUND

Suicide and suicidal attempt are an important cause of mortality and denotes severe morbidity among the population. Successful suicide attempt is associated with previous suicide attempts. Identifying factors in suicide attempters will help in formulating a comprehensive response to these issues.

OBJECTIVE

To identify the sub group who are more vulnerable and the factors associated with this group.

SETTING AND DESIGN

A cross sectional observational study of this sub group was carried out.

MATERIAL AND METHODS

study was conducted on patients who were referred to the Psychiatry department for attempted suicide. They were assessed to identify those with high suicidal intent and study the factors associated with high suicidal intent.

STATISTICS

Epiinfo by CDC was used to analyze the results.

RESULTS

High intent was associated with history of psychiatric illness, history of previous attempts and family history of suicidal attempts.

CONCLUSIONS

A sub group was identified which had a high intent and possibly higher chance of repeating an attempt.

Predicting suicide following self-harm: systematic review of risk factors and risk scales

BACKGROUND

People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex.

AIMS

To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm.

METHOD

We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable.

RESULTS

Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38-2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91-3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16-3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70-2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%.

CONCLUSIONS

The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.

The Validity of a Brief Risk Assessment Tool for Predicting Suicidal Behavior in Veterans Utilizing VHA Mental Health Care

Suicide risk among military veterans is an important and ongoing concern. The Veterans Administration (VA) mandates suicide risk screening of all veterans seen for mental health issues, but little is known about the effectiveness of this screening. A retrospective chart review to examine all suicide risk screens at VA San Diego between October and December 2012 (n = 3,365) was conducted to assess whether results were associated with suicidal behavior over the subsequent 12 months. Patients judged to be at increased risk for suicide were 3 to 16 times more likely to attempt suicide and 7 to 25 times more likely to engage in self-directed violence over the next 12 months compared with others. The screening tool may be a useful addition to clinical practice.

Predicting Risk of Suicide Attempt Using History of Physical Illnesses From Electronic Medical Records

BACKGROUND

Although physical illnesses, routinely documented in electronic medical records (EMR), have been found to be a contributing factor to suicides, no automated systems use this information to predict suicide risk.

OBJECTIVE

The aim of this study is to quantify the impact of physical illnesses on suicide risk, and develop a predictive model that captures this relationship using EMR data.

METHODS

We used history of physical illnesses (except chapter V: Mental and behavioral disorders) from EMR data over different time-periods to build a lookup table that contains the probability of suicide risk for each chapter of the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) codes. The lookup table was then used to predict the probability of suicide risk for any new assessment. Based on the different lengths of history of physical illnesses, we developed six different models to predict suicide risk. We tested the performance of developed models to predict 90-day risk using historical data over differing time-periods ranging from 3 to 48 months. A total of 16,858 assessments from 7399 mental health patients with at least one risk assessment was used for the validation of the developed model. The performance was measured using area under the receiver operating characteristic curve (AUC).

RESULTS

The best predictive results were derived (AUC=0.71) using combined data across all time-periods, which significantly outperformed the clinical baseline derived from routine risk assessment (AUC=0.56). The proposed approach thus shows potential to be incorporated in the broader risk assessment processes used by clinicians.

CONCLUSIONS

This study provides a novel approach to exploit the history of physical illnesses extracted from EMR (ICD-10 codes without chapter V-mental and behavioral disorders) to predict suicide risk, and this model outperforms existing clinical assessments of suicide risk.