Borderline Personality Traits Do Not Moderate the Relationship Between Depression, Beliefs, and Suicidal Thoughts and Behaviors

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

Uncovering the role of substance use in suicide attempts using a mixed-methods approach

INTRODUCTION

Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts.

METHODS

Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD.

RESULTS

In Study 1, patients with co-occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method.

CONCLUSIONS

Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans.

Targeting Perceived Burdensomeness to Reduce Suicide Risk

Perceived burdensomeness (PB), defined by an intractable perception of burdening others, often reflects a false mental calculation that one's death is worth more than one's life and has been supported as a significant risk factor for suicide. Because PB often reflects a distorted cognition, it may serve as a corrective and promising target for the intervention of suicide. More work on PB is needed in clinically severe and in military populations. Sixty-nine (Study 1) and 181 (Study 2) military participants at high baseline suicide risk engaged in interventions targeting constructs relating to PB. Baseline and follow-up measures (at 1, 6, 12, 18, and 24 months) of suicidal ideation were administered, and various statistical approaches-including repeated-measures ANOVA, mediation analyses, and correlating standardized residuals-explored whether suicidal ideation decreased specifically by way of PB. In addition to utilizing a larger sample size, Study 2 included an active PB-intervention arm (N = 181) and a control arm (N = 121), who received robust care as usual. In both studies, participants improved considerably regarding baseline to follow-up suicidal ideation. The results of Study 2 mirrored those of Study 1, corroborating a potential mediational role for PB in treatment-related improvements in suicidal ideation in military participants. Effect sizes ranged from .07-.25. Interventions tailored at decreasing levels of perceived burdensomeness may be uniquely and significantly effective in reducing suicidal thoughts.

Finding Effective and Efficient Ways to Integrate Research Advances Into the Clinical Suicide Risk Assessment Interview

Research in clinical suicidology continues to rapidly expand, much of it with implications for day-to-day clinical practice. Clinicians routinely wrestle with how best to integrate recent advances into practice and how to do so in efficient and effective fashion. This article identifies five critical domains of recent research findings and offers examples of simple questions that can easily be integrated into a clinician's existing suicide risk assessment interview and related protocol helping inform the risk formulation process.

A Standard Protocol for the Clinical Management of Suicidal Thoughts and Behavior: Implications for the Suicide Prevention Narrative

The last several decades have witnessed growing and converging evidence from randomized controlled trials (RCT's) that an identifiable set of simple clinical management strategies are effective for those at risk for suicidal thinking and/or suicide attempts. The current article offers a brief review of clinical strategies supported by RCT's targeting suicidality as "commonalities of treatments that work" and related recommendations for use in the delivery of care for suicidal individuals in generic fashion, regardless of any particular treatment, theoretical orientation, or intervention perspective. The article includes eight recommendations that can be easily adapted across the full range of clinical contexts, institutional settings, and delivery systems, recommendations that help frame a broader clinical narrative for suicide prevention. Recommendations cut across five identifiable domains or clinical strategies for the delivery of care: (1) informed consent discussion that identifies risks of opting out of care and emphasizes the importance of shared responsibility and a collaborative process, (2) an explanatory model that emphasizes the importance of individual self-management skills and targeting the causes of suicide rather than describing suicidality as a function of mental illness, (3) the importance of proactively identifying barriers to care and engaging in targeted problem-solving to facilitate treatment adherence, (4) a proactive and specific plan for management of future suicidal episodes, and (5) reinforcing the importance of taking steps to safeguard lethal means and facilitate safe storage of firearms.

Commentary on the Special Issue on Posttraumatic Stress and Suicide: Recognizing that simple things save lives

This article offers commentary on the special issue of the Journal of Traumatic Stress dedicated to posttraumatic stress and suicide, with a specific focus on practical recommendations that can be integrated into day-to-day clinical practice. Given the complexity of the myriad associations among posttraumatic stress symptoms, the nature of trauma, and suicidality demonstrated in the articles in this issue, it is important for practitioners to utilize evidence-based approaches to clinical practice in order to be effective. The articles in this special issue offer findings that do just that, providing a foundation rich in practical applications to clinical work, including an understanding of potential mechanisms of action and related targeted interventions.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

The Brief Suicide Cognitions Scale: Development and Clinical Application

The study explored the development of the Brief Suicide Cognitions Scale (B-SCS), a simple and brief measure of suicide risk. The B-SCS provides a brief measure that captures critical aspects of suicide risk embedded in core beliefs about the self as unlovable, one's emotional experience as unbearable, and life problems as unsolvable (i.e., the suicidal belief system), resulting in chronic or enduring suicide risk and heightened vulnerability for acute episodes secondary to internal and external triggers. Data were analyzed from three diverse samples, including a student sample (N = 349), an inpatient psychiatric sample (N = 160), and a sample of emergency department (ED) patients presenting secondary to a suicidal crisis (N = 94). Those in the student and inpatient samples completed additional symptom measures (hopelessness, anxiety, depression) and the ED sample provided 6-month follow-up data for suicide attempts. Reliability (internal consistency, test-retest), concurrent validity, construct (divergent, convergent) validity, factorial, incremental, and predictive validity were evaluated, along with calculation of predictive value of negative and positive tests, sensitivity, and specificity estimates. The B-SCS demonstrated good reliability and validity, a unidimensional factor structure across samples, along with good predictive validity and value in real-world clinical settings. The B-SCS is a brief, reliable and valid measure of suicide risk, with good ability to identify those with enduring risk for subsequent suicide attempts. The B-SCS offers a unique contribution to understanding and assessing the nature of suicide risk over time targeting the suicidal belief system, with easy application across inpatient and outpatient clinical settings, and good predictive value.

Using Machine Learning to Predict Suicide Attempts in Military Personnel

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.

Longitudinal suicide ideation trajectories in a clinical trial of brief CBT for U.S. military personnel recently discharged from psychiatric hospitalization

Research among adolescent samples has suggested patterns of change in suicidal ideation (SI) following psychiatric hospitalization discharge are heterogenous and predictive of subsequent suicide attempts. However, no studies have examined SI trajectories following discharge among adult samples or the effect of treatment on trajectories. We used growth mixture modeling to examine trajectories of SI among 152 active duty military personnel in a randomized controlled trial comparing brief cognitive-behavioral therapy (CBT) for suicide prevention to treatment as usual following discharge from inpatient psychiatric hospitalization for a suicide risk. Analyses of SI at baseline, 3-, 6-, and 12-months post-discharge among the full sample randomized to both conditions revealed two trajectories: rapid improvers (59.21%) and gradual improvers (40.79%). Gradual improvers were more than twice as likely to attempt suicide in the two years following discharge. Exploratory analyses suggested that, relative to those in the treatment as usual condition, those randomized to brief CBT in both trajectories may be less likely to make a suicide attempt during the follow-up period. Results replicate and extend prior research in identifying distinct ideation trajectories following psychiatric inpatient hospitalization for suicide risk to active-duty personnel in a treatment trial and linking these trajectories to suicide attempts during follow-up.

The role of depression and suicidal cognitions as contributors to suicide risk among active duty soldiers reporting symptoms of posttraumatic stress disorder

BACKGROUND

Military suicide rates have risen across all service branches, with the overall rate surpassing that of the general population for the first time in history in 2008. Service members with posttraumatic stress disorder (PTSD) are at a substantially higher risk for suicidal ideation, suicide attempts, and death by suicide than their peers without PTSD. While the link between PTSD and suicide is well established in the literature, less is known about the precise nature of that connection. Several constructs have been implicated as potential mediators of this relation, such as depression, alcohol use, suicidal cognitions, and sleep disturbance. Yet, to our knowledge, these constructs have never been examined simultaneously in a single model to determine mediational influence for suicide risk among soldiers with PTSD.

METHODS

A sample of 172 active duty Army soldiers completed a series of measures targeting the aforementioned constructs. Data were analyzed using mediation model analyses.

RESULTS

Suicidal cognitions fully mediated the relation between PTSD symptoms and current suicide risk severity. The indirect effect for suicidal cognitions was significantly larger than indirect effects for alcohol use, depression, and sleep disturbance. Exploratory analyses suggest serial mediation of the relation between PTSD and current suicide risk by depression and suicidal cognitions.

LIMITATIONS

These results should be interpreted within the context of study limitations, to include use of self-report data and inability to firmly establish temporal sequencing assumed in mediation.

CONCLUSIONS

Implications of this study include the improvement of suicide risk assessment and individualized treatment planning for suicidal military personnel with PTSD.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

The Relationship between Post-Battle Experiences and Thwarted Belongingness and Perceived Burdensomeness in Three United States Military Samples

Suicide rates within the military are elevated relative to the general population; however, research suggests that many of the suicide risk factors for military personnel are similar to the suicide risk factors for civilians. Given that many military specific experiences (e.g., number of deployments) are not considered robust predictors of either suicidal ideation or behavior, it has been posited that deployment specific experiences (e.g., post-battle experiences) may be better able to explain the increased rates of suicide among military personnel. Therefore, the current study aimed to examine the relationship between post-battle experiences and perceived burdensomeness (PB), thwarted belongingness (TB), and suicidal ideation within 3 different military samples: a non-clinical sample of Army National Guard personnel, a non-clinical sample of active duty U.S. Air Force Security Forces personnel, and a clinical sample of U.S. Army personnel receiving outpatient treatment. Post-battle experiences were found to be significantly associated with TB in both non-clinical samples; however, the association between post-battle experiences and TB was non-significant within the clinical sample. Furthermore, results indicated that post-battle experiences were not significantly associated with either PB or suicidal ideation in any of the samples. These findings suggest that in non-clinical samples, post-battle experiences impact a soldier's ability to feel connected to others. Within clinical samples, results indicate that post-battle experiences may not be a direct contributor to either PB or TB. These results indicate a need for universal intervention promoting interpersonal support of military personnel and their families prior to development of further need for psychological interventions. This upstream approach may decrease further development of TB and potentially prevent suicidal desire.

Patterns of change in suicide ideation signal the recurrence of suicide attempts among high-risk psychiatric outpatients

Suicide ideation is an inherently dynamic construct. Previous research implicates different temporal patterns in suicide ideation among individuals who have made multiple suicide attempts as compared to individuals who have not. Temporal patterns among first-time attempters might therefore distinguish those who eventually make a second suicide attempt. To test this possibility, the present study used a dynamical systems approach to model change patterns in suicide ideation over the course of brief cognitive behavioral therapy for suicide prevention (12 sessions total) among 33 treatment-seeking active duty Soldiers with one prior suicide attempt. Variable-centered models were constructed to determine if change patterns differed between those with and without a follow-up suicide whereas person-centered models were constructed to determine if within-person change patterns were associated with eventual suicide attempts. Severity of suicide ideation was not associated with the occurrence of suicide attempts during follow-up, but person-centered temporal patterns were. Among those who made an attempt during follow-up, suicide ideation demonstrated greater within-person variability across treatment. Results suggest certain change processes in suicide ideation may characterize vulnerability to recurrent suicide attempt among first-time attempters receiving outpatient behavioral treatment. Nonlinear dynamic models may provide advantages for suicide risk assessment and treatment monitoring in clinical settings.

Variables associated with reductions in insomnia severity among acutely suicidal patients receiving brief cognitive behavioral therapy for suicide prevention

INTRODUCTION

This study compared changes in sleep disturbance over time across brief cognitive behavioral therapy for suicide prevention and treatment as usual and examined the mechanisms that link sleep disturbance with several suicide risk factors.

METHOD

Active duty U.S. Army soldiers (N = 152) completed a randomized controlled trial to test the efficacy of brief cognitive behavioral therapy (n = 76) or treatment as usual (n = 76). Six assessments of insomnia symptoms, hopelessness, coping, and suicide beliefs were tracked over 24 months.

RESULTS

Brief cognitive behavioral therapy patients reported a significant decrease in sleep disturbance symptoms over time while treatment as usual patients did not. These improvements were initially observed during treatment and carried over through 12-months. Changes in sleep disturbance predicted changes in suicide risk. Longitudinal growth modeling was used to assess potential mechanisms of this effect. Results suggested that changes in cognitive flexibility, as defined by measures of hopelessness and suicide beliefs, predicted change in sleep disturbance symptoms. These relationships did not differ across treatment groups.

LIMITATIONS

The participants were active duty military personnel. Therefore, the results may not generalize to other patient populations. A greater number of assessment periods in closer proximity as well as additional measures of constructs of interest would have improved the internal validity of this study.

CONCLUSIONS

Brief cognitive behavioral therapy significantly reduces sleep disturbance and suicide risk. Changes in cognitive flexibility, in part, explain change in sleep disturbance across both treatments.

Associations of patient-rated emotional bond and vocally encoded emotional arousal among clinicians and acutely suicidal military personnel

OBJECTIVE

To determine if synchrony in emotional arousal and affective regulation between patients and clinicians reflect emotional bonding during emergency behavioral health appointments.

METHOD

Audio recordings of suicide risk assessment interviews and crisis intervention planning with 54 suicidal active duty soldiers presenting to an emergency department or behavioral health clinic were analyzed. Emotional arousal was assessed using mean fundamental frequency. Patient-rated emotional bond was assessed with the Working Alliance Inventory, Short Form (Hatcher & Gillaspy, 2014). Actor-partner interdependence modeling was used to identify moment-to-moment patterns of covariance among clinician and patient emotional arousal.

RESULTS

Greater synchrony in clinician and patient emotional arousal was positively associated with higher emotional bond ratings during the crisis intervention but not the risk assessment interview. During the risk assessment interview, higher emotional bond was associated with a dysregulating effect of the clinician on the patient's emotional arousal (i.e., larger fluctuations in the patient's emotional arousal). The reverse pattern was seen during the intervention: Higher emotional bond was associated with a regulating effect of the clinician on the patient's emotional arousal (i.e., smaller fluctuations in the patient's emotional arousal). Emotional bond during the intervention was also positively associated with a regulating effect of the patient on the clinician's emotional arousal.

CONCLUSION

Emotional bonding during emergency clinical encounters is associated with patient-clinician synchrony in emotional states. During crisis interventions, emotional bonding is also associated with mutual down-regulation of emotional arousal among patients and clinicians. (PsycINFO Database Record

Nonlinear Change Processes During Psychotherapy Characterize Patients Who Have Made Multiple Suicide Attempts

Research suggests that multiple suicide attempters experience considerable variability in suicide ideation and longer-duration suicidal crises, which suggests the possibility of two states of stability (one low risk and one high risk). To date, however, few studies have examined nonlinear change processes in suicide ideation among patients. In a sample of 76 active duty U.S. Army soldiers receiving brief cognitive behavioral therapy for acute suicide risk, we examined differences in the ebb and flow of suicide ideation among multiple attempters, first-time attempters, and ideators. Results indicated that multiple attempters were characterized by two states of stability corresponding to low and high intensity suicide ideation; these states were separated by a region of instability corresponding to moderate intensity suicide ideation. In contrast, ideators and first-time attempters were characterized by only a single state of stability corresponding to low intensity suicide ideation. Among patients who have made multiple suicide attempts, suicide ideation may function as a bimodal rather than a continuous construct.

Differential Effects of Brief CBT Versus Treatment as Usual on Posttreatment Suicide Attempts Among Groups of Suicidal Patients

OBJECTIVE

The purpose of this study was to examine variability in outcomes (suicide attempt rates) across subgroups of patients who were randomly enrolled in brief cognitive-behavioral therapy (CBT) and treatment as usual.

METHODS

A secondary analysis was conducted of data collected during a randomized clinical trial of brief CBT for suicide prevention in a sample of 176 U.S. military personnel who reported active suicide ideation in the past week or a suicide attempt in the past month. Latent-class analysis was used to identify empirically distinct and clinically meaningful patient subgroups. Rates of suicide attempts during a two-year follow-up period were compared across classes and treatment groups.

RESULTS

Three latent classes corresponding to low (N=55), moderate (N=40), and high (N=57) suicide risk were identified. The classes significantly differed with respect to psychiatric symptom severity but not demographic or historical variables. Rates of suicide attempts during the two-year follow-up significantly varied across classes in treatment as usual but did not vary across classes in brief CBT (21% versus 10%, respectively, in the low-severity class, 8% versus 13% in the moderate-severity class, and 41% versus 10% in the high-severity class). Differences between treatment conditions in suicide attempt rates were statistically significant for the high-severity class.

CONCLUSIONS

Treatment as usual was associated with variable rates of suicidal behavior, depending on suicide risk severity. Brief CBT contributed to consistently low rates of suicidal behavior regardless of patient severity.

Mechanisms of Action Contributing to Reductions in Suicide Attempts Following Brief Cognitive Behavioral Therapy for Military Personnel: A Test of the Interpersonal-Psychological Theory of Suicide

Brief cognitive behavioral therapy (BCBT) is associated with significant reductions in suicide attempts among military personnel. However, the underlying mechanisms of action contributing to reductions in suicide attempts in effective psychological treatments remain largely unknown. The present study conducted a secondary analysis of a randomized controlled trial of BCBT versus treatment as usual (TAU) to examine the mechanisms of action hypothesized by the interpersonal-psychological theory of suicide (IPT): perceived burdensomeness, thwarted belongingness, and fearlessness about death. In a sample of 152 active duty U.S. Army personnel with recent suicide ideation or attempts, there were significantly fewer suicide attempts in BCBT, but there were no differences between treatment groups from baseline to 6 months postbaseline on any of the 3 IPT constructs or their interactions. Tests of the moderated mediation failed to support an indirect effect for the IPT model, regardless of which IPT variables were specified as mediators or moderators. Results suggest that the IPT's hypothesized mechanisms of action do not account for reductions in suicide attempts in BCBT. Implications for clinical practice and research are discussed.

Is the Higher Number of Suicide Attempts in Bipolar Disorder vs. Major Depressive Disorder Attributable to Illness Severity?

The present study represents an early stage investigation into the phenomenon whereby those with bipolar disorder attempt suicide more frequently than those with unipolar depression, but do not tend to attempt suicide during mania. Data for this study were obtained from baseline measurements collected in a randomized treatment study at a major southwestern United States military medical center. We demonstrated the rarity of suicide attempts during mania, the higher frequency of suicide attempts in those with bipolar disorder compared to those with depression, and the persistence of effects after accounting for severity of illness. These results provide the impetus for the development and testing of theoretical explanations.

Effect of Crisis Response Planning on Patient Mood and Clinician Decision Making: A Clinical Trial With Suicidal U.S. Soldiers

OBJECTIVE

The study examined the immediate effect of crisis interventions on the emotional state of acutely suicidal soldiers and clinician decision making.

METHODS

Soldiers (N=97) presenting to a military emergency department or behavioral health clinic were randomly assigned to receive a contract for safety (N=32), standard crisis response plan (S-CRP; N=32), or enhanced crisis response plan (E-CRP; N=33). Soldiers completed self-report scales before and after the intervention. Clinicians blinded to treatment group assignment rated participants' suicide risk level and made a decision about inpatient psychiatric admission.

RESULTS

Larger reductions in negative emotional states occurred in S-CRP and E-CRP. Larger increases in positive emotional states occurred in E-CRP. Clinician suicide risk ratings did not differ across treatment groups. Participants in E-CRP were less likely to be psychiatrically admitted.

CONCLUSIONS

The CRP immediately reduces negative emotional states among acutely suicidal soldiers. Discussing a patient's reasons for living during a CRP also reduces the likelihood of inpatient psychiatric admission.

Perceived problem-solving deficits and suicidal ideation: Evidence for the explanatory roles of thwarted belongingness and perceived burdensomeness in five samples

Perceived social problem-solving deficits are associated with suicide risk; however, little research has examined the mechanisms underlying this relationship. The interpersonal theory of suicide proposes 2 mechanisms in the pathogenesis of suicidal desire: intractable feelings of thwarted belongingness (TB) and perceived burdensomeness (PB). This study tested whether TB and PB serve as explanatory links in the relationship between perceived social problem-solving (SPS) deficits and suicidal thoughts and behaviors cross-sectionally and longitudinally. The specificity of TB and PB was evaluated by testing depression as a rival mediator. Self-report measures of perceived SPS deficits, TB, PB, suicidal ideation, and depression were administered in 5 adult samples: 336 and 105 undergraduates from 2 universities, 53 homeless individuals, 222 primary care patients, and 329 military members. Bias-corrected bootstrap mediation and meta-analyses were conducted to examine the magnitude of the direct and indirect effects, and the proposed mediation paths were tested using zero-inflated negative binomial regressions. Cross-sectionally, TB and PB were significant parallel mediators of the relationship between perceived SPS deficits and ideation, beyond depression. Longitudinally and beyond depression, in 1 study, both TB and PB emerged as significant explanatory factors, and in the other, only PB was a significant mediator. Findings supported the specificity of TB and PB: Depression and SPS deficits were not significant mediators. The relationship between perceived SPS deficits and ideation was explained by interpersonal theory variables, particularly PB. Findings support a novel application of the interpersonal theory, and bolster a growing compendium of literature implicating perceived SPS deficits in suicide risk. (PsycINFO Database Record

Effect of crisis response planning vs. contracts for safety on suicide risk in U.S. Army Soldiers: A randomized clinical trial

OBJECTIVE

To evaluate the effectiveness of crisis response planning for the prevention of suicide attempts.

METHOD

Randomized clinical trial of active duty Army Soldiers (N=97) at Fort Carson, Colorado, presenting for an emergency behavioral health appointment. Participants were randomly assigned to receive a contract for safety, a standard crisis response plan, or an enhanced crisis response plan. Incidence of suicide attempts during follow-up was assessed with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation during the past week and/or a lifetime history of suicide attempt. Exclusion criteria were the presence of a medical condition that precluded informed consent (e.g., active psychosis, mania). Survival curve analyses were used to determine efficacy on time to first suicide attempt. Longitudinal mixed effects models were used to determine efficacy on severity of suicide ideation and follow-up mental health care utilization.

RESULTS

From baseline to the 6-month follow-up, 3 participants receiving a crisis response plan (estimated proportion: 5%) and 5 participants receiving a contract for safety (estimated proportion: 19%) attempted suicide (log-rank χ²(1)=4.85, p=0.028; hazard ratio=0.24, 95% CI=0.06-0.96), suggesting a 76% reduction in suicide attempts. Crisis response planning was associated with significantly faster decline in suicide ideation (F(3,195)=18.64, p<0.001) and fewer inpatient hospitalization days (F(1,82)=7.41, p<0.001). There were no differences between the enhanced and standard crisis response plan conditions.

CONCLUSION

Crisis response planning was more effective than a contract for safety in preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.

Personality Disorder Symptoms and Suicidality: Low Desire and High Plans for Suicide in Military Inpatients and Outpatients

This study characterizes the personality disorder (PD) symptoms of patients who endorse a perplexing combination of low desire and high plans for suicide. Five PD (antisocial, narcissistic, borderline, dependent, avoidant) symptoms were examined at the junction of two suicide risk factors: (a) suicidal desire/ideation and (b) resolved plans/preparations. Participants (N = 250) were recruited from U.S. Army Medical Center affiliated sites, including two outpatient clinics, an inpatient facility, and an emergency room. Self-report measures of PD and suicide symptoms were administered. The interaction of desire and plans was entered into multiple regression equations predicting PD symptoms. Patients endorsing low desire and high plans for suicide reported significantly more antisocial and narcissistic symptoms and fewer borderline, avoidant, and dependent PD symptoms. These findings support the existence of patients who endorse suicide plans in the absence of strong suicidal desire and suggest that they display antisocial and narcissistic personality characteristics. Future directions and clinical implications are discussed.

The ebb and flow of the wish to live and the wish to die among suicidal military personnel

BACKGROUND

The relative balance between the wish to live and the wish to die (i.e., suicidal ambivalence) is a robust predictor of suicidal behavior and may be a mechanism underlying the effectiveness of treatments that reduce suicidal behaviors. To date, however, few studies have explored possible mechanisms of action in these treatments.

METHOD

Active duty Soldiers (N=152) with a recent suicide attempt and/or active suicide ideation were randomized to receive brief cognitive behavioral therapy (BCBT) or treatment as usual (TAU). The Suicide Attempt Self-Injury Inventory (Linehan et al., 2006a) was used to assess the incidence of suicide attempts during the 2-year follow-up. The wish to live and the wish to die were assessed with items 1 and 2, respectively, of the Beck Scale for Suicide Ideation (Beck and Steer, 1991).

RESULTS

Across both treatments, the wish to live was significantly weaker among patients who attempted suicide but the wish to die was stronger only among patients who attempted suicide in TAU. Among nonattempters, the wish to die stabilized the wish to live, but among attempters the wish to live and the wish to die were not associated with each other. In BCBT the wish to live destabilized the wish to die among nonattempters.

LIMITATIONS

Self-report methodology, predominantly male sample.

CONCLUSIONS

The emergence of suicidal behavior is driven primarily by the absence of the wish to live. BCBT is associated with a unique coupling of an ambivalent wish to live and wish to die, which may suggest an underlying mechanism of action.

Individual and environmental contingencies associated with multiple suicide attempts among U.S. military personnel

Suicidal behavior among U.S. military personnel persists as a significant public health issue. Previous research indicates the primary motive for suicide attempts among military personnel is the desire to reduce or alleviate emotional distress, a finding that converges with studies in nonmilitary samples. Much less is understood about the consequences of a first suicide attempt that could influence the occurrence of additional suicide attempts. In order to identify these contingencies, 134 active duty Soldiers who had attempted suicide (n=69 first-time attempters, n=65 multiple attempters) participated in structured interviews focused on their experiences immediately following their first attempt. Soldiers were more likely to have made multiple suicide attempts if they were younger at the time of their first attempt, were not admitted to a hospital or treatment program after their first attempt, or experienced emotional and psychological relief immediately afterwards. Results suggest that Soldiers who experience emotional and/or psychological relief immediately after their first suicide attempt or do not receive treatment are more likely to make additional suicide attempts.

From impulse to action among military personnel hospitalized for suicide risk: alcohol consumption and the reported transition from suicidal thought to behavior

OBJECTIVE

Alcohol use is associated with unplanned or impulsive suicide attempts. Although unplanned suicide attempts assume a rapid transition for suicidal impulse to action, many studies do not quantify the time elapsed from suicidal impulse to action. The current study was designed to clarify how alcohol use facilitates the transition from suicidal impulse to action among U.S. Army personnel. We hypothesized that alcohol consumption during the 24 h preceding a suicide attempt would be associated with significantly faster transition from suicidal impulse to action but would be unrelated to medical lethality.

METHOD

A total of 119 active duty U.S. Army Soldiers who made a total of 175 suicide attempts during military service, 121 of which occurred during the preceding year, completed clinician-administered structured interviews focused on psychiatric diagnosis and the contextual characteristics of their suicide attempts.

RESULTS

Alcohol use during the 24 h prior to a suicide attempt was associated with significantly faster transition from suicidal impulse to action. Among suicide attempts in the past year, lethality significantly increased as the length of time since the last alcoholic drink increased. Drug use during the 24 h prior to a suicide attempt was unrelated to speed of transition or attempt lethality.

CONCLUSIONS

Soldiers acted upon their suicidal impulses more quickly when they had been drinking on the day of their suicide attempts. This rapid transition may contribute to the selection of less lethal suicide methods during periods of active drinking as compared to methods selected after the discontinuation of alcohol consumption.

DEPRESSION MEDIATES THE RELATION OF INSOMNIA SEVERITY WITH SUICIDE RISK IN THREE CLINICAL SAMPLES OF U.S. MILITARY PERSONNEL

BACKGROUND

A growing body of empirical research suggests insomnia severity is directly related to suicide ideation, attempts, and death in nonmilitary samples, even when controlling for depression and other suicide risk factors. Few studies have explored this relationship in U.S. military personnel.

METHODS

The present study entailed secondary data analyses examining the associations of insomnia severity with suicide ideation and attempts in three clinical samples: Air Force psychiatric outpatients (n = 158), recently discharged Army psychiatric inpatients (n = 168), and Army psychiatric outpatients (n = 54). Participants completed the Beck Scale for Suicide Ideation, the Beck Depression Inventory-II or Patient Health Questionnaire-9, the Insomnia Severity Index, and the Posttraumatic Stress Disorder Checklist at baseline; two samples also completed these measures during follow-up.

RESULTS

Sleep disturbance was associated with concurrent (β's > 0.21; P's < 0.059) and prospective (β's > 0.39; P's < 0.001) suicide ideation in all three samples. When adjusting for age, gender, depression, and posttraumatic stress, insomnia severity was no longer directly associated with suicide ideation either concurrently (β's < 0.19; P's > 0.200) or prospectively (β's < 0.26; P's > 0.063), but depression was (β's > 0.22; P's < 0.012). Results of a latent difference score mediation model indicated that depression mediated the relation of insomnia severity with suicide ideation.

CONCLUSIONS

Across three clinical samples of military personnel, depression explained the relationship between insomnia severity and suicide risk.

Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up

OBJECTIVE

The authors evaluated the effectiveness of brief cognitive-behavioral therapy (CBT) for the prevention of suicide attempts in military personnel.

METHOD

In a randomized controlled trial, active-duty Army soldiers at Fort Carson, Colo., who either attempted suicide or experienced suicidal ideation with intent, were randomly assigned to treatment as usual (N=76) or treatment as usual plus brief CBT (N=76). Assessment of incidence of suicide attempts during the follow-up period was conducted with the Suicide Attempt Self-Injury Interview. Inclusion criteria were the presence of suicidal ideation with intent to die during the past week and/or a suicide attempt within the past month. Soldiers were excluded if they had a medical or psychiatric condition that would prevent informed consent or participation in outpatient treatment, such as active psychosis or mania. To determine treatment efficacy with regard to incidence and time to suicide attempt, survival curve analyses were conducted. Differences in psychiatric symptoms were evaluated using longitudinal random-effects models.

RESULTS

From baseline to the 24-month follow-up assessment, eight participants in brief CBT (13.8%) and 18 participants in treatment as usual (40.2%) made at least one suicide attempt (hazard ratio=0.38, 95% CI=0.16-0.87, number needed to treat=3.88), suggesting that soldiers in brief CBT were approximately 60% less likely to make a suicide attempt during follow-up than soldiers in treatment as usual. There were no between-group differences in severity of psychiatric symptoms.

CONCLUSIONS

Brief CBT was effective in preventing follow-up suicide attempts among active-duty military service members with current suicidal ideation and/or a recent suicide attempt.

Nonsuicidal self-injury as a prospective predictor of suicide attempts in a clinical sample of military personnel

BACKGROUND

Nonsuicidal self-injury (NSSI) is a risk factor for suicide attempts, but it has received little attention in military populations, for whom suicide rates have doubled over the past decade. In the current study, the relationship of NSSI with future suicide attempts was prospectively examined in a sample of active duty Soldiers receiving outpatient psychiatric treatment for suicide ideation and/or a recent suicide attempt.

METHODS

Data were collected as part of a two-year prospective study of 152 active duty Soldiers (87% male, 71% Caucasian, mean age=27.53) in outpatient mental health care who reported current suicide ideation and/or a suicide attempt during the month preceding intake. Suicide attempts and NSSI were assessed using the Suicide Attempt Self Injury Interview.

RESULTS

Forty percent of Soldiers with a history of nonsuicidal self-injury and 25% of Soldiers with a history of suicide attempt made a suicide attempt during the 2-year follow-up. Soldiers with a history of nonsuicidal self-injury were more than twice as likely to make a subsequent suicide attempt (hazard ratio [HR]=2.25, P=.045). Soldiers with a history of suicide attempt were no more likely to make a subsequent suicide attempt than Soldiers without a previous suicide attempt (HR=.88, P=.787). Thirty percent of Soldiers with a history of suicide attempt had also engaged in nonsuicidal self-injury. Forty-two percent of Soldiers with histories of both nonsuicidal self-injury and suicide attempt made a subsequent suicide attempt and were more likely to make a suicide attempt during follow-up than Soldiers with a history of suicide attempt only. Number of NSSI episodes, but not number of suicide attempts, was significantly associated with increased risk for future suicide attempt. Results were unchanged when adjusting for baseline symptom severity.

LIMITATIONS

Predominantly male, active duty Army sample.

CONCLUSIONS

Among Soldiers in outpatient mental health care, a history of NSSI is a stronger predictor of future suicide attempts than a history of suicide attempts. Soldiers with a history of both NSSI and suicide attempt are at especially increased risk.

An investigation of the interactive effects of the capability for suicide and acute agitation on suicidality in a military sample

BACKGROUND

According to the interpersonal theory of suicide (1, 2), the difficulties inherently associated with death by suicide deter many individuals from engaging in suicidal behavior. Consistent with the notion that suicide is fearsome, acute states of heightened arousal are commonly observed in individuals immediately prior to lethal and near-lethal suicidal behavior. We suggest that among individuals who possess elevated levels of the capability for suicide, the heightened state of arousal experienced during periods of acute agitation may facilitate suicidal behavior in part because it would provide the necessary energy to approach a potentially lethal stimulus. Among individuals who are low on capability, the arousal experienced during agitation may result in further avoidance.

METHODS

In the present project we examine how acute agitation may interact with the capability for suicide to predict suicidality in a large military sample (n = 1,208) using hierarchical multiple regression.

RESULTS

Results were in line with a priori hypotheses: among individuals high on capability, as agitation increases, suicidality increases whereas as agitation increases among individuals low on capability, suicidality decreases. Results held beyond the effects of thwarted belongingness, perceived burdensomeness, and suicidal cognitions.

CONCLUSIONS

Beyond further substantiating the link between agitation and suicide, findings of the present study provide evidence for the construct validity of the acquired capability as well as offer initial evidence for moderating role of capability on the effect of agitation on suicide. Limitations of the current study highlight a need for future research that improves upon the techniques used in the present study. Implications for science and practice are discussed.

Reasons for suicide attempts in a clinical sample of active duty soldiers

BACKGROUND

Self-reported reasons for suicide attempts were examined in a sample of active duty soldiers who had attempted suicide using a functional approach that classifies suicidal behaviors into four primary functions of reinforcement: automatic negative (AN-R; to reduce aversive internal experiences), automatic positive (AP-R; to generate desired internal experiences), social negative (SN-R; to avoid aversive contextual demands), and social positive (SP-R; to generate desired environmental contexts). Based on previous theory and research, the authors hypothesized that soldiers would attempt suicide primarily to reduce aversive internal experiences (i.e., AN-R).

METHODS

72 soldiers (66 male, 6 female; 65.3% Caucasian, 9.7% African-American, 2.8% Asian, 2.8% Pacific Islander, 4.2% Native American, and 9.7% "other"; age M=27.34, SD=6.50) were interviewed using the Suicide Attempt Self Injury Interview to assess suicidal intent, method, lethality, and reasons for attempting suicide.

RESULTS

Soldiers endorsed attempting suicide for both automatic and social reasons, with multiple functions being endorsed in 95% of attempts. AN-R was endorsed in 100% of suicide attempts, and was primary to other functions. Suicidal intent was weakly correlated with AN-R, AP-R, and SN-R functions (rs<.22), and medical lethality was very weakly correlated with only the SP-R function (r=.18).

LIMITATIONS

Small sample size and retrospective self-report methodology.

CONCLUSIONS

Soldiers attempt suicide primarily to alleviate emotional distress. Reasons for attempting suicide do not correlate strongly with suicidal intent or medical lethality.

Stigma and suicide warning signs

The current study explored the relationship between stigma and suicide warning signs using a case vignette methodology. Three comparable vignettes were used varying only the essential warning signs, including heart attack, suicidality without specific mention of suicidal thinking, and suicidality with specific mention of suicidal thoughts and associated intent to die. After reading the vignette, participants responded to questions gauging urgency of response, along with their appraisal of the situation across six domains including: seriousness, time (how quickly should they respond), comfort 1 (how comfortable they were with the situation in general), sureness (how sure they were in their response), comfort 2 (how comfortable they were in implementing their response), and hopefulness (how hopeful they were that their response would be helpful). Consistent with study hypotheses, results indicated that participants were significantly less comfortable, less sure, and less hopeful when responding to a suicidal crisis when compared to a heart attack. In addition, participants were significantly less likely to access emergency services for a seriously suicidal individual in comparison to someone suffering a heart attack, instead choosing to talk with family and friends first. The potential moderating effects of family and individual history of psychiatric illness and treatment, along with current individual psychological symptoms, were also explored and discussed, with no significant impact uncovered. The importance of more targeted efforts to train individuals to not just recognize suicide warning signs, but on how to specifically respond, is emphasized.

Warning signs for suicide within a week of healthcare contact in Veteran decedents

OBJECTIVES

This study examined warning signs for suicide observed in the final day(s) of life in Veteran decedents who received healthcare from Veterans Health Administration (VHA) (N=381), using data obtained from detailed chart reviews.

METHODS

Veterans who died within a week (7 days) of healthcare contact (18%) were compared to those who died later (82%). Multivariate logistic regression was used to examine differences in suicidal thoughts, psychiatric symptoms, and somatic symptoms as documented at the last visit, after controlling for demographic variables. A second multivariate regression examined whether the identified warning signs were also risk factors for suicide within a month (30 days) of contact.

RESULTS

Documented suicidal ideation, OR (95% CI)=3.46 (1.15-10.38), and psychotic symptoms, OR (95% CI)=2.67 (1.11-6.42), at the last visit increased the likelihood of suicide within a week of healthcare contact. Both variables also increased the odds of suicide within a month of contact.

CONCLUSIONS

The assessment of suicidal ideation is critical to identify Veterans at immediate risk. However, recognition of psychotic symptoms may also improve identification. In addition to indicating immediate risk, some warning signs may also suggest on-going risk.

The realities of risk, the nature of hope, and the role of science: A response to Cook and VandeCreek

A response is offered to the critiques of both Cook and VandeCreek. Among the points emphasized are the simple realities of risk with suicidal patients, existing empirical research with informed consent in both clinical psychology and other health care areas, as well as the persistence of common myths in clinical practice with suicidal patients. Although empirical science provides a firm foundation to much of what is proposed, it is critical for practitioners to recognize and respond to the ethical demands for openness and transparency with high-risk clients in an effort to achieve shared responsibility in care. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Informed consent with suicidal patients: Rethinking risks in (and out of) treatment

Informed consent is uniformly accepted as essential to the treatment process. However, the relevant literature has not discussed issues of risk specific to suicidal patients, nor has such information routinely been included in the informed consent process. The implications of including suicide-specific risk information in the informed consent process is discussed and examples provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military

BACKGROUND

Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.

METHODS

Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).

RESULTS

In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.

LIMITATIONS

The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk.

CONCLUSIONS

These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Primary care providers' views regarding assessing and treating suicidal patients

Primary care providers (PCPs) usually do not explore patient suicidality during routine visits. Factors that predict PCP attitudes toward the assessment and treatment of suicidality were examined via an online survey of 195 practicing PCPs affiliated with medical schools in the United States. PCPs who perceived themselves as competent to work with suicidal patients were more willing to assess and more willing to treat suicidal patients, with the perception of competency fully explaining the relationship between training and willingness to treat. Female gender predicted lower self-perceived competency, while in-office access to professional mental health (MH) consultation predicted greater self-perceived competency. Higher self-perceived general competence predicted lower subjective valuation of access to MH consultation. Multiple linear regression analysis indicated a three-way interaction between training, gender, and valuation of MH consultation as predictors of perceived competency, with training generally being associated with greater perceived competency to treat suicidality. Relative to their male counterparts, female PCPs have lower confidence in assessing and treating suicidality. Perceived competence in risk assessment should be given more attention in medical training because of its role in PCPs' willingness to treat suicidality.

A psychometric study of the Suicide Ideation Scale

An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were conducted on the Suicide Ideation Scale (SIS) with a large military clinical sample (total N = 3,072). The EFA identified a two-factor solution with the first factor (Resolved Plans/Preparation) accounting for 17.3% of the variance and the second (Suicidal Desire) accounting 15.1% of the variance. This 2-factor solution demonstrated a good fit to the data in the CFA. SIS construct validity and internal reliability data are also reported. The results of this study provide additional psychometric data for the SIS that support use of the measure in clinical work and research. Implications for theories related to suicide assessment and clinical practice are discussed.