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Characteristics of Impulsive Suicide Attempts and Attempters
Abstract
Suicide attempts often are impulsive, yet little is known about the characteristics of impulsive suicide. We examined impulsive suicide attempts within a population-based, case-control study of nearly lethal suicide attempts among people 13–34 years of age. Attempts were considered impulsive if the respondent reported spending less than 5 minutes between the decision to attempt suicide and the actual attempt. Among the 153 case-subjects, 24% attempted impulsively. Impulsive attempts were more likely among those who had been in a physical fight and less likely among those who were depressed. Relative to control subjects, male sex, fighting, and hopelessness distinguished impulsive cases but depression did not. Our findings suggest that inadequate control of aggressive impulses might be a greater indicator of risk for impulsive suicide attempts than depression.
... First, interviews with survivors have shown that the decision to attempt suicide is often impulsive, with the time between the decision and attempt often being a matter of minutes or hours (Deisenhammer et al. 2009;Paashaus et al. 2021). Therefore a waiting period law may induce a "cooling-off" period, resulting in individuals changing their minds (Simon et al. 2001). Second, firearms are the most lethal of attempted suicides; therefore, even if all suicide attempts with a firearm switched to other methods, overall suicides might still decrease. ...
We study the impact of gun‐purchase waiting periods on suicide rates using county‐level mortality data from 1991–2019. We find that waiting periods are associated with a reduction in both firearm and overall suicide rates of approximately 5% and 2%, respectively. Novelly, we find that counties that are within 50 miles from a state without a waiting period experience no statistically significant reduction in suicides. Our findings reveal that the decrease in suicides under a waiting period is driven by counties that are more than 50 miles from a non‐restricted neighboring state.
... In fact, research consistently shows that a considerable number of suicides move from thought to action without prior planning [9][10][11][12], and some individuals attempt suicide without experiencing suicidal thoughts beforehand [13]. Moreover, the intensity and onset of suicidal ideation can vary significantly over time [14]. ...
Suicide rates have increased in the US over the last decades. Schools often deliver suicide prevention trainings and there is growing evidence that these trainings in schools are effective. The current study examined a new upstream approach, CODE RED in which trainees complete their own safety plan prior to a mental health emergency. Participants were adult school personnel (n = 201) who completed CODE RED trainings and were surveyed using three validated 4-item measures: acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). Open-ended questions were analyzed using a thematic approach. Of 201 participants who completed the survey, acceptability (18.0), appropriateness (17.9) and feasibility (18.0) were high as assessed by standardized implementation measures (each out of 20). Open-ended responses further indicated a great deal of satisfaction with the training. As a first step in determining acceptability and feasibility, CODE RED was found to be highly acceptable to adult school employees who found it applicable, appealing as an intervention, and easy to use. Most staff are hopeful that it will be useful with youth as well. It will be important to determine how this activity is used by youth and if it can be used in mental health crises to decrease symptoms.
... 2,[6][7][8][9][10][11][12][13] It is important to acknowledge that the conceptualization of "failure to disclose" holds significance only in the presence of information that warrants disclosure. Indeed, extant research consistently indicates that a large proportion of suicides occur without prior planning [14][15][16][17][18][19] and some individuals who attempt suicide do not experience suicide-related thoughts. 20 Additionally, the onset and intensity of suicidal ideation and intent can fluctuate greatly over time. ...
Introduction
More than half of those who die by suicide do not communicate about suicide prior to their death. This project describes the emotional state and decision-making among “unplanned” attempt survivors to inform a conceptual model and suicide prevention interventions.
Methods
This qualitative study purposefully sampled patients who reported having no suicidal thoughts on a standardized mental health questionnaire within 60 days (about 2 months) prior to a nonfatal suicide attempt documented in the health record. Participants verbally consented to telephone interview participation. Semistructured audio-recorded interviews elicited suicide attempt survivor descriptions of their emotional state and experiences in the days, hours, and minutes leading up to their suicide attempt. Interviews were transcribed and analyzed using grounded theory. The biopsychosocial theory of emotion regulation informed conceptual model development.
Results
Participants (N = 26) described 2 distinct “phases” prior to the attempt. First, a phase of increasing life stressors, transitory and nonspecific suicidal thoughts, and a reluctance to disclose experiences. Second, an overwhelming emotional state led to a sudden suicide attempt and nondisclosure due to the rapidity and intensity of the experience. These results informed the conceptual model and intervention development to manage unplanned and overwhelming urges to attempt suicide.
Discussion
Qualitative analysis informed the development of an intervention for the high-intensity “hot” period preceding an attempt, including specific steps to manage a highly intense emotional state in combination with overwhelming urges to kill oneself.
Conclusion
Future research is needed to evaluate whether and how this intervention helps support people with a chance of “unplanned” suicide attempts.
... We also found that the impulsivity facet of sensationseeking was related to the likelihood of jumping in the scenario. While those who attempt suicide by jumping tend to make more impulsive attempts (measured by the less than five minutes between thoughts and action of an attempt; Simon et al., 2002), the impulsivity facet of sensation seeking has not been previously found to be related to likelihood of engaging in suicidal behavior (Klonsky & May, 2010). As the nature of our task (safely jumping from a height) could be similar to other safe and non-suicide related jumping activities that people high on sensation-seeking tend to partake in (e.g. ...
The study of suicide is complex and often relies on proxy measures of suicidal thoughts and behaviors, which have significant limitations. Virtual Reality (VR) has recently been used to study processes associated with suicidal behavior without the associated risk. However, other mechanisms may explain the decision to engage in virtual suicide, other than suicide-related processes. One such confounder, impulsivity, may impact this decision as it relates to other safe recreational jumping activities (e.g., base jumping, bungee jumping, skydiving). This study examined likelihood of jumping (“Virtual Suicide”) in a VR suicide scenario in a sample of 145 undergraduates. Specifically, we examined impulsivity facets, suicidal ideation, and history of suicide attempt to determine which factors predicted jumping likelihood. We found that suicidal ideation and only the impulsivity facet of sensation-seeking were related to the likelihood that someone jumped during the VR suicide scenario, while history of suicide attempt was not. More research needs to be done on using suicide-related VR to better understand its relationship with real life suicidal behavior, however it has promise for the future of suicide research after further study.
... between 25 % and 60 % of suicide attempts are considered "impulsive," further limiting the predictive value of participants' momentary responses with respect to future STBs (Simon et al., 2001;Wojnar et al., 2009;Wyder and De Leo, 2007). Hence, solely relying on participants' responses to individual items and self-assessment questionnaires for tailoring NE management may not be effective (Franklin et al., 2017;Steeg et al., 2018) and it is necessary to explore and incorporate additional clarification options. ...
Background
Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.
Aims
This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.
Methods
Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.
Results
In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.
Conclusion
This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.
The existing models for understanding suicidal ideation and behavior do not provide satisfactory orientation for clinical-therapeutic work with suicidal clients. Based on the observation that ambivalence accompanies the entire suicidal process and building on the empirical knowledge about suicidal ambivalence, this article presents the ambivalence model of suicidality (ABS model), a new clinical working model that aims to provide a framework for risk assessment, case conceptualization and treatment planning in the treatment of suicidal individuals. The model divides the suicidal process into three phases (uncertainty phase, transition phase and action phase), describes the psychological state within the different phases, and identifies phase-specific therapeutic interventions. The ABS model is a descriptive model that can be used to structure and organize crisis intervention and psychotherapy with suicidal patients.
Suicide is a major public health concern in the United States. Veterans are among those at higher risk for death by suicide. Firearm ownership is one factor that contributes to veterans’ elevated suicide risk. The current study sought to determine the effectiveness of an evidence-based, multi-media advertising campaign with a specific focus on veterans related to secure storage of firearms and general help-seeking attitudes during a mental health crisis. Results indicated positive changes in (a) attitudes toward seeking help from a health care provider or a friend/loved one during a mental health crisis, (b) attitudes toward firearm storage during a crisis, and (c) self-reported secure firearm storage behaviors post-advertising, particularly among veterans. Implications for future advertising campaigns, clinical interventions, and research investigations are discussed.
Amaç: 6 Şubat 2023 tarihli Kahramanmaraş merkezli depremlerden etkilenen depremzedelerden inti-har girişimi olan grupta bulunmayı öngören dürtüsellik, psikolojik acı, depresyon ve anksiyete düzeyleri-ni incelemekti. Materyal ve Metod: Ağustos 2023 ile Şubat 2024 arasında, intihar girişiminde bulunan 36 depremzede, bir psikiyatri kliniğinde vaka grubuna dahil edilmek üzere seçildi. Aynı zamanda, vaka grubu ile yaş ve cinsiyet açısından eşleştirilen ve psikiyatrik tanı almamış 36 depremzeden oluşan bir kontrol grubu oluşturuldu. Devamında her bir depremzede yarı yapılandırılmış sosyodemografik ve klinik veri formu, Beck Depresyon Ölçeği (BDÖ), Beck Anksiyete Ölçeği (BAÖ), Psikolojik Acı Ölçeği (PAÖ) ve Barratt Dürtüsellik Ölçeğini (BDÖ) doldurdu. Bulgular: İntihar girişiminde bulunan hastaların %63.9'u kadındı. Vaka grubundaki bireyler, kontrol gru-buna göre depremde daha fazla akraba kaybı yaşadı (p=0,002). Vaka grubunda, plan yapmama alt ölçeği ile BDÖ ve PAÖ arasında pozitif bir korelasyon vardı (sırasıyla r=0,691, p<0,001, r=0,370 p=0,026). İnti-har eyleminin depremle ilgili olup olmadığı açısından analiz edildiğinde, depremle ilgili intiharlarda daha az intihar geçmişi ve yöntem farkı olduğu gözlemlendi (sırasıyla p=0,006, p=0,029). Lojistik regres-yon analizine göre, yüksek PAÖ şiddeti, depremzedelerin intihar girişimi geçmişine sahip olma grubunda yer alacağını öngörmektedir (OR = 1,50, %95 CI: 1,17-1,94, p=0,01). Sonuç: Depresyon, dürtüsellik, anksiyete ve psikolojik acı belirtileri gösteren deprem sonrası hayatta kalanlar, intihar riski açısından yakından izlenmeli ve psikososyal müdahaleler sağlanmalıdır.
Introduction
The transition from suicidal thoughts to behaviors often involves considering the consequences of suicide as part of the decision‐making process. This study explored the relationship between this consideration process and the decision to either abort or carry out a suicide attempt.
Methods
Among inpatients with a suicide‐related event in the past 2 weeks (suicide attempt n = 30 or aborted attempt n = 16), we assessed the degree to which they considered six domains of consequences, the impact of these considerations on their inclination to attempt suicide, and the duration of their decision‐making.
Results
All the participants who aborted and 87% of those who attempted considered consequences of suicide. Participants who aborted took longer to progress through decision‐making stages and considered more suicide‐hindering factors, especially interpersonal ones, though these differences were no longer significant after correction. Group status moderated the relationship between the balance of suicide‐facilitating and suicide‐hindering considerations and decision‐making duration. Considering the consequences of suicide more favorably was related to a shorter ideation‐to‐action period before a suicide attempt and a longer ideation period before aborting an attempt.
Conclusion
This study highlights the complexity of suicide decision‐making and its role in better understanding the progression from ideation to action.
b> Einleitung: Suizidales Erleben und Verhalten weist eine erhebliche Dynamik auf und ist sehr heterogen motiviert. Ein genaues Verständnis der individuellen Funktionsweise suizidalen Erlebens und Verhaltens stellt die Voraussetzung einer therapeutischen Aufarbeitung suizidaler Krisen dar. Methode: Ausgehend von der Feststellung, dass ambivalentes Erleben den gesamten suizidalen Prozess begleitet, wird im vorliegenden Artikel das Ambivalenzmodell der Suizidalität (ABS-Modell) als Verstehens- und Orientierungsmodell für die klinische Praxis vorgestellt. Ergebnisse: In dem Modell wird der suizidale Prozess in drei Phasen unterteilt (Unsicherheits-, Transitions- und Handlungsphase), es wird die psychische Befindlichkeit innerhalb der verschiedenen Phasen beschrieben und es werden phasenspezifische therapeutische Ansatzpunkte benannt. Diskussion/Schlussfolgerung: Beim ABS-Modell handelt es sich um ein deskriptives Modell, anhand dessen die Krisenintervention und Psychotherapie suizidaler Personen strukturiert und gestaltet werden kann.
Importance
Suicide is a leading cause of death among US youths, and mental health disorders are a known factor associated with increased suicide risk. Knowledge about potential sociodemographic differences in documented mental health diagnoses may guide prevention efforts.
Objective
To examine the association of documented mental health diagnosis with (1) sociodemographic and clinical characteristics, (2) precipitating circumstances, and (3) mechanism among youth suicide decedents.
Design, Setting, and Participants
This retrospective, cross-sectional study of youth suicide decedents aged 10 to 24 years used data from the Centers for Disease Control and Prevention National Violent Death Reporting System from 2010 to 2021. Data analysis was conducted from January to November 2023.
Exposures
Sociodemographic characteristics, clinical characteristics, precipitating circumstances, and suicide mechanism.
Main Outcomes and Measures
The primary outcome was previously documented presence of a mental health diagnosis. Associations were evaluated by multivariable logistic regression.
Results
Among 40 618 youth suicide decedents (23 602 aged 20 to 24 years [58.1%]; 32 167 male [79.2%]; 1190 American Indian or Alaska Native [2.9%]; 1680 Asian, Native Hawaiian, or Other Pacific Islander [4.2%]; 5118 Black [12.7%]; 5334 Hispanic [13.2%]; 35 034 non-Hispanic; 30 756 White [76.1%]), 16 426 (40.4%) had a documented mental health diagnosis and 19 027 (46.8%) died by firearms. The adjusted odds of having a mental health diagnosis were lower among youths who were American Indian or Alaska Native (adjusted odds ratio [aOR], 0.45; 95% CI, 0.39-0.51); Asian, Native Hawaiian, or Other Pacific Islander (aOR, 0.58; 95% CI, 0.52-0.64); and Black (aOR, 0.62; 95% CI, 0.58-0.66) compared with White youths; lower among Hispanic youths (aOR, 0.76; 95% CI, 0.72-0.82) compared with non-Hispanic youths; lower among youths aged 10 to 14 years (aOR, 0.70; 95% CI, 0.65-0.76) compared with youths aged 20 to 24 years; and higher for females (aOR, 1.64; 95% CI, 1.56-1.73) than males. A mental health diagnosis was documented for 6308 of 19 027 youths who died by firearms (33.2%); 1691 of 2743 youths who died by poisonings (61.6%); 7017 of 15 331 youths who died by hanging, strangulation, or suffocation (45.8%); and 1407 of 3181 youths who died by other mechanisms (44.2%). Compared with firearm suicides, the adjusted odds of having a documented mental health diagnosis were higher for suicides by poisoning (aOR, 1.70; 95% CI, 1.62-1.78); hanging, strangulation, and suffocation (aOR, 2.78; 95% CI, 2.55-3.03); and other mechanisms (aOR, 1.59; 95% CI, 1.47-1.72).
Conclusions and Relevance
In this cross-sectional study, 3 of 5 youth suicide decedents did not have a documented preceding mental health diagnosis; the odds of having a mental health diagnosis were lower among racially and ethnically minoritized youths than White youths and among firearm suicides compared with other mechanisms. These findings underscore the need for equitable identification of mental health needs and universal lethal means counseling as strategies to prevent youth suicide.
Background: Prevention strategies for suicide emphasize restrictions on firearm access. These restrictions may lose efficacy if individuals substitute other lethal suicide methods. Aims: The objective of this study is to determine the extent to which individuals who die by suicide in the United States substitute hanging for firearm injury. Methods: This study is a repeated cross-sectional analysis of suicide deaths in the United States from 2003 to 2021. Multiple regression was used to estimate the effect of firearm access proxies on individual suicide methods (hanging vs. firearm injury). Results: The probability of death by hanging was significantly and negatively associated with proxies of firearm access. Limitations: This study does not compare crude rates of suicide by state, which rise on average with rates of firearm ownership. The National Violent Death Reporting System expanded over the sample period, so early years have incomplete ascertainment. Rates of gun ownership and gun safety law scales are measured as proxies. Conclusions: Although means restriction around firearm access is a critical tool for suicide prevention, complementary strategies for prevention around hanging merit further study.
Background
Suicide remains a major public health problem, and firearms are used in approximately half of all such incidents. This study sought to predict the occurrence of suicide specifically by firearm, as opposed to any other means of suicide, in order to help inform possible life-saving interventions.
Methods
This study involved data from the Minnesota Violent Death Reporting System. Models evaluated whether data beyond basic demographics generated increased prediction accuracy. Models were built using random forests, logistic regression and data imputation. Models were evaluated for prediction accuracy using the area under the curve analysis and for proper calibration.
Results
Results showed that models constructed with social determinants and personal history data led to increased prediction accuracy in comparison to models constructed with basic demographic information only. The study identified an optimised ‘top 20’ variables model with a 73% chance of correctly discerning relative incident risk for a pair of individuals. Age, height/weight, employment industry/occupation, sex and education level were found to be most highly predictive of firearm suicide in the study’s ‘top 20’ model.
Conclusions
The study demonstrated that the use of a firearm in a death by suicide, as opposed to any other means of suicide, can be reasonably well predicted when an individual’s social determinants and personal history are considered. These predictive models could help inform many prevention strategies, such as safe storage practices, background checks for firearm purchases or red flag laws.
Background
The Collaborative Care Model (CoCM) increases access to mental health treatment and improves outcomes among patients with mild to moderate psychopathology; however, it is unclear how effective CoCM is for patients with elevated suicide risk.
Methods
We examined data from the Penn Integrated Care program, a CoCM program including an intake and referral management center plus traditional CoCM services implemented in primary care clinics within a large, diverse academic medical system. In this community setting, we examined: (1) characteristics of patients with and without suicidal ideation who initiated CoCM, (2) changes in suicidal ideation (Patient Health Questionnaire-9 [PHQ-9] item 9), depression (PHQ-9 total scores), and anxiety (Generalized Anxiety Disorder Scale-7 scores) from the first to last CoCM visit overall and across demographic subgroups, and (3) the relationship between amount of CoCM services provided and degree of symptom reduction.
Results
From 2018 to 2022, 3,487 patients were referred to CoCM, initiated treatment for at least 15 days, and had completed symptom measures at the first and last visit. Patients were 74% female, 45% Black/African American, and 45% White. The percentage of patients reporting suicidal ideation declined 11%-7% from the first to last visit. Suicidal ideation severity typically improved, and very rarely worsened, during CoCM. Depression and anxiety declined significantly among patients with and without suicidal ideation and across demographic subgroups; however, the magnitude of these declines differed across race, ethnicity, and age. Patients with suicidal ideation at the start of CoCM had higher depression scores than patients without suicidal ideation at the start and end of treatment. Longer CoCM episodes were associated with greater reductions in depression severity.
Conclusions
Suicidal ideation, depression, and anxiety declined following CoCM among individuals with suicidal ideation in a community setting. Findings are consistent with emerging evidence from clinical trials suggesting CoCM’s potential for increasing access to mental healthcare and improving outcomes among patients at risk for suicide.
Background
Self-injurious thoughts and behaviors (SITBs) are a major problem worldwide and continue to be a serious public health concern. Research investigating risk factors for suicide has shown that reward processes, such as the inability to feel pleasure, may confer risk for SITBs. However, less work has examined how different dimensions of trait reward relate to SITBs. Accordingly, the present study investigated the unique and interactive effects of trait anticipatory and consummatory reward for explaining SITBs.
Methods
260 community adults ages 18–55 (M/SD = 32.79/10.54, females = 49.6 %, males = 50.4 %) completed an interview, neuropsychological tests, and questionnaires. We used hierarchical multivariate multiple regression analysis to assess cross-sectional associations between trait anticipatory and consummatory reward and different types of SITBs [self-injurious thoughts, nonsuicidal self-injury (NSSI), and suicide attempts] from the Risky, Impulsive, and Self-destructive Behavior Questionnaire.
Results
The unique variance associated with anticipatory and consummatory reward were differentially related to self-injurious thoughts but unrelated to self-injurious behaviors (NSSI/suicide attempts). The interaction of anticipatory and consummatory reward was associated with self-injurious behavior, such that the inability to experience both anticipatory and consummatory reward was associated with higher frequency of NSSI.
Limitations
Limitations of the study include its cross-sectional nature and reliance on self-reported measures.
Conclusions
Low anticipatory reward and high consummatory reward may confer risk for self-injurious thoughts. Low levels of both trait anticipatory and consummatory reward may confer risk for NSSI. Findings suggest reward sensitivity may be an understudied risk factor for a range of SITBs.
Background
In emergency psychiatry high levels of suicidality are encountered. However, empirical studies about the extent of suicidal ideation remain scarce, and data are often gathered retrospectively via medical records. The present observational study aims to assess suicidal ideation, planning, and actions experienced by patients presenting with psychiatric emergencies.
Methods
In a consecutive sample of 136 patients, a standard psychiatric examination including the Chronological Assessment of Suicide Events (CASE Approach) was completed. An evaluative monitoring form for the CASE Approach was designed to record and quantify the garnered information.
Results
Almost 60% of the patients reported suicidal ideation with some planning. Approximately 25% had experienced over 10 hours of suicidal ideation on their worst days in the past 2 months; 27% had procured their method of choice, and another 27% had practiced a small, moderate, or serious suicide attempt.
Conclusion
Findings suggest more intense suicidality in emergency psychiatry than has been reported in previous empirical studies.
The Suicide Crisis Syndrome (SCS) describes a suicidal mental state marked by entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal that has predictive capacity for near-term suicidal behavior. The Suicide Crisis Inventory-2 (SCI-2), a reliable clinical tool that assesses SCS, lacks a short form for use in clinical settings which we sought to address with statistical analysis. To address this need, a community sample of 10,357 participants responded to an anonymous survey after which predictive performance for suicidal ideation (SI) and SI with preparatory behavior (SI-P) was measured using logistic regression, random forest, and gradient boosting algorithms. Four-fold cross-validation was used to split the dataset in 1,000 iterations. We compared rankings to the SCI–Short Form to inform the short form of the SCI-2. Logistic regression performed best in every analysis. The SI results were used to build the SCI-2-Short Form (SCI-2-SF) utilizing the two top ranking items from each SCS criterion. SHAP analysis of the SCI-2 resulted in meaningful rankings of its items. The SCI-2-SF, derived from these rankings, will be tested for predictive validity and utility in future studies.
The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life‐sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients’ level of decisional capacitation—among other relevant information—in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs—the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness .
Suicide is a leading cause of death among youth, and emergency departments (EDs) play an important role in caring for youth with suicidality. Shortages in outpatient and inpatient mental and behavioral health capacity combined with a surge in ED visits for youth with suicidal ideation (SI) and self‐harm challenge many EDs in the United States. This review highlights currently identified best practices that all EDs can implement in suicide screening, assessment of youth with self‐harm and SI, care for patients awaiting inpatient psychiatric care, and discharge planning for youth determined not to require inpatient treatment. We will also highlight several controversies and challenges in implementation of these best practices in the ED. An enhanced continuum of care model recommended for youth with mental and behavioral health crises utilizes crisis lines, mobile crisis units, crisis receiving and stabilization units, and also maximizes interventions in home‐ and community‐based settings. However, while local systems work to enhance continuum capacity, EDs remain a critical part of crisis care. Currently, EDs face barriers to providing optimal treatment for youth in crisis due to inadequate resources including the ability to obtain emergent mental health consultations via on‐site professionals, telepsychiatry, and ED transfer agreements. To reduce ED utilization and better facilitate safe dispositions from EDs, the expansion of community‐ and home‐based services, pediatric‐receiving crisis stabilization units, inpatient psychiatric services, among other innovative solutions, is necessary.
Suicide risk assessment and management is a core psychiatric competency that is important for both the proper treatment of patients and for medicolegal reasons. The standard of care for suicide risk assessment and management has progressed a great deal in recent years and points toward an approach that is patient-centered and that affirms the therapeutic relationship. Principally, a therapeutic suicide risk assessment should inform treatment. Key components of a clinical risk assessment include conducting and documenting a psychiatric assessment, augmenting the psychiatric assessment with structured instruments, stratifying risk in terms of severity and temporality and engaging in safety planning. To mitigate risk, individualized safety plans that are created in collaboration between clinician and patient should address access to lethal means and should outline a series of steps that the patient can engage in to manage a suicidal crisis.
The purpose of this study is to address a significant gap in knowledge on firearm ownership rates and storage characteristics in a national sample of college students. We used 2021–2022 survey data from the Healthy Minds Study, which included approximately 88,500 students at over 100 US colleges and universities. We conducted analyses using descriptive statistics and two-sample proportion tests. About 4% of respondents reported having a firearm on or around campus. Among firearm owners, 68.8% reported storing firearms at their permanent address within an hour’s drive from campus, and 43.1% reported storing their firearms unloaded and locked. Firearm ownership rates were significantly higher for respondents who were positive for specific risk factors (i.e., in a relationship, suicide ideation, recent binge drinking, and having been physically assaulted) versus those who were negative. These findings support the need for targeted messaging and firearm safety training for college students to reduce firearm-related risks.
Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75–99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients’ values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07–1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.
ClinicalTrials.gov: NCT05288517.
Gambling problems have consistently been linked to suicidality, including suicidal ideation, attempts, and suicide. However, the magnitude of the relationship has varied significantly across studies and the potential causal link between gambling problems and suicidality is currently unclear. A meta-analytic literature review was conducted to (a) synthesize pooled prevalence rates of suicidality among individuals with gambling problems; (b) determine if individuals with gambling problems had an increased likelihood of reporting suicidality compared to individuals without gambling problems; and (c) review evidence on causality and directionality. A search in Web of Science, APA PsycInfo, APA PsycNet, Medline, CINAHL, ProQuest, Embase, and Google Scholar electronic databases identified 107 unique studies (N = 4,691,899) that were included for review. Studies were included if they were available in any European language and provided sufficient data for the calculation of prevalence rates or effect sizes. Two researchers extracted the data independently using a predefined coding schema that included the Newcastle–Ottawa Quality Assessment Scale. Random-effects meta-analyses yielded pooled prevalence rates of 31.6% (95% CI [29.1%, 34.3%]) for lifetime suicidal ideation and 13.2% (95% CI [11.3%, 15.5%]) for lifetime suicide attempts. Individuals with gambling problems had significantly increased odds of reporting lifetime suicidal ideation (OR = 2.17, 95% CI [1.90, 2.48]) and lifetime suicide attempts (OR = 2.81, 95% CI [2.23, 3.54]) compared to individuals without gambling problems. Two studies reported that individuals with pathological gambling had an increased risk of dying by suicide. Metaregression analyses suggested that the risk of study bias was positively related to the prevalence rates of suicidal ideation. Sex proportions were found to moderate the odds of suicidal ideation, but the direction of the effect was inconsistent. For suicide attempts, psychiatric comorbidity and sample size were positively and inversely, respectively, associated with prevalence rates. The synthesis indicates that suicidality is common among individuals with gambling problems and hence should be addressed by help agencies. Inferences on causality and directionality are hampered by a lack of longitudinal studies.
Niniejszy artykuł stanowi próbę podsumowania badań na temat zagrożeń samobójczych w kontekście dostępu do środków letalnych. Przyjęto, że kwestie te należą do tematów, które warto analizować, m.in. ze względu na tragiczne w skutkach znaczenie aktów autodestrukcyjnych. W zaprezentowanych rozważaniach odwołano się do najważniejszych pojęć badawczych, nawiązano do stosowanych paradygmatów oraz ujęć w obecnych w literaturze przedmiotu. Podkreślono, że suicydologia należy do kategorii nauk interdyscyplinarnych, gdyż łączy takie dziedziny jak: psychologia, pedagogika, medycyna, prawo, bezpieczeństwo wewnętrzne i inne. Wskazano na skomplikowane przyczyny prób samobójczych oraz możliwości przeciwdziałania kryzysom. Wyróżniono różne środki, narzędzia, substancje, które determinują to, że niektóre próby samobójcze są zakończone zgonem. Podkreślono, że niejednokrotnie samobójstwom można zapobiec, szczególnie wtedy, jeśli korzysta się z odpowiedniej profilaktyki. W zaprezentowanych analizach skorzystano z ustaleń obecnych w literaturze przedmiotu, które skonfrontowano z wynikami badań własnych.
Military conflicts are ubiquitous. There are a lot of combat veterans around the world. Suicidality in combat veterans is a large and important issue. In this article, the author discusses some aspects of this issue. The combat environment is characterized by violence, physical strains, separation from loved ones and other hardships. Combat deployment may lead to multiple emotional, cognitive, psychosomatic symptoms, suicidal ideation and behavior. Pre-deployment, deployment and post-deployment adversities may increase suicide risk in combat veterans. The act of killing in combat is a stressor which may raise suicide risk. Combat-related injuries are associated with increased suicide risk. Post-deployment difficulties of reintegrating into civilian life may lead to depression and suicidality. Studies suggest that suicidal behavior in combat veterans may have a neurobiological basis. Prevention of suicide among combat veterans should include pre-deployment screening to exclude individuals with psychiatric disorders; psychological support and prevention of harassment and/or abuse during deployment; psychosocial support after deployment; diagnosing and treating psychiatric and medical disorders including neurological disorders; frequent suicide screening; education of mental and non-mental health clinicians, war veterans, their families and friends regarding signs/symptoms of suicidality; and restriction of access to lethal means. We need to study the specific psychobiology of combat veterans to understand how to develop effective suicide prevention interventions for this population.
This paper summarises themes that have emerged from 14 years of study of suicide and work with those bereaved. It is based on a talk given in many clinical settings over the past 10 years. I describe my own emotional journey following impactful deaths and summarise personal ‘truths’ about suicide that have emerged over time. Case studies used for illustration are composites taken from clinical practice; accounts of relatives and other survivors of suicide; and data taken from many sources including suicide audits in mental health organisations, the police and transport services, and from the examination of coroners’ records. The intention is to assist open dialogue about the nature of suicide, to contribute to the understanding of the impact on those bereaved and to encourage open-hearted clinical engagement with those who are suicidal.
Background
Understanding the neural mechanism underlying the transition from suicidal ideation to action is crucial but remains unclear. To explore this mechanism, we combined resting-state functional connectivity (rsFC) and computational modeling to investigate differences between those who attempted suicide(SA) and those who hold only high levels of suicidal ideation(HSI).
Methods
A total of 120 MDD patients were categorized into SA group (n=47) and HSI group (n=73). All participants completed a resting-state functional MRI scan, with three subregions of the insula and the dorsal anterior cingulate cortex (dACC) being chosen as the region of interest (ROI) in seed-to-voxel analyses. Additionally, 86 participants completed the balloon analogue risk task (BART), and a five-parameter Bayesian modeling of BART was estimated.
Results
In the SA group, the FC between the ventral anterior insula (vAI) and the superior/middle frontal gyrus (vAI-SFG, vAI-MFG), as well as the FC between posterior insula (pI) and MFG (pI-MFG), were lower than those in HSI group. The correlation analysis showed a negative correlation between the FC of vAI-SFG and psychological pain avoidance in SA group, whereas a positive correlation in HSI group. Furthermore, the FC of vAI-MFG displayed a negative correlation with loss aversion in SA group, while a positive correlation was found with psychological pain avoidance in HSI group.
Conclusion
In current study, two distinct neural mechanisms were identified in the insula which involving in the progression from suicidal ideation to action. Dysfunction in vAI FCs may gradually stabilize as individuals experience heightened psychological pain, and a shift from positive to negative correlation patterns of vAI-MFC may indicate a transition from state to trait impairment. Additionally, the dysfunction in PI FC may lead to a lowered threshold for suicide by blunting the perception of physical harm.
Introduction:
Suicide premeditation is a critical factor to consider when assessing suicide risk. Understanding which individuals are more or less likely to plan their suicidal behavior can shed light on how suicidal thoughts turn into actions.
Method:
The present study used psychological autopsy data to identify factors associated with level of premeditation among 131 adults who died by suicide.
Results:
Logistic regression analyses indicated that suicide decedents with higher premeditation scores had higher odds of being diagnosed with a depressive disorder and choosing a violent suicide method, specifically a firearm. Individuals with lower premeditation scores had higher odds of being diagnosed with a polysubstance use disorder.
Conclusion:
Suicide decedents exhibiting greater premeditation before their deaths were different in several ways from suicide decedents exhibiting less premeditation. A better understanding of suicide premeditation can ultimately aid in the development of improved risk assessments and targeted safety interventions for those struggling with suicidal thoughts.
Objectives
Impulsivity is one factor that is associated with increased risk for suicide ideation and suicidal risk. However, limited studies have examined the association between impulsivity and suicidal risk, or clinically relevant protective factors, for Black Americans. While mindfulness is a robust coping mechanism and facilitator of psychological well-being, few studies have examined its role in the context of impulsivity and suicidal risk for Black Americans. The purpose of this study was to examine the mediating role of mindfulness on the association between impulsivity and suicidal risk within a university sample of Black emerging adults.
Method
Data from 332 Black emerging adults (79.2% female; mean age = 22.4, SD = 5.6) were used to examine the indirect effect of impulsivity on suicide ideation and elevated suicide risk through mindfulness. Participants completed an online questionnaire battery that included measures of impulsivity, mindfulness, suicide ideation, and elevated suicide risk.
Results
After controlling for age and gender, mediation analyses revealed that impulsivity was directly and indirectly associated with suicide ideation and elevated suicide risk via lower levels of mindfulness.
Conclusions
This study provides preliminary insight into novel risk and protective factors that influence suicide ideation and elevated suicide risk among Black emerging adults. Further, these findings support the clinical utility of mindfulness as a potential buffer to the negative consequences of impulsivity for Black Americans.
Preregistration
This study is not preregistered.
Objective:
Native American adolescents are disproportionately burdened by suicidality. Here, we examine patterns of reporting of suicide ideation and suicide attempt among Native American youth compared to those from other ethnoracial backgrounds, as this data is important for grounding commonly subscribed to frameworks of suicide risk (e.g., ideation-to-action).
Method:
Data are from the Youth Risk Behavior Surveillance Survey (N = 54,243; grades 9-12; 51.0% female) and Minnesota Student Survey (N = 335,151; grades 8, 9, 11; 50.7% female). Comparing Native American youth to peers from other ethnoracial backgrounds, we examined two suicide reporting patterns: 1) odds of reporting suicide attempt among those who reported ideation and 2) odds of reporting suicide ideation among those who reported an attempt.
Results:
Across both samples, when reporting suicide ideation, youth from other ethnoracial backgrounds were 20-55% less likely than Native American youth to also report attempt. While few consistent differences were observed between Native American youth and those from other racial minority backgrounds in patterns of co-reporting suicide ideation and attempt across samples, White youth were between 37% and 63% less likely than Native American youth to report a suicide attempt without also reporting ideation.
Conclusions:
The increased odds of engaging in a suicide attempt with or without reporting ideation question the generalizability of widely held frameworks of suicide risk to Native American youth and have important implications for suicide risk monitoring. Future research is needed to illuminate how these behaviors unfold over time and the potential mechanisms of risk for engaging in suicide attempts in this disproportionately burdened group.Abbreviations: YRBSS: Youth Risk Behavior Surveillance Survey; MSS: Minnesota Student Survey.
Background and objectives:
Limiting firearm access is essential to decreasing teen suicide. Previous efforts have focused on household firearms; however, less is known about firearm access and possession among teens at increased suicide risk. Our objective was to estimate prevalence of firearm possession and access among high school-aged teens with recent depression and/or lifetime history of suicidality (DLHS).
Methods:
We conducted a probability-based, cross-sectional Web survey of 1914 parent-teen dyads between June 24, 2020, and July 22, 2020, with data weighted to generate a nationally representative sample of US teenagers (aged 14-18). Logistic regression analyses examined the difference between teens with and without DLHS for: (1) personal firearm possession, (2) perceived firearm access, and (3) method of firearm attainment.
Results:
Among high school-aged teens, 22.6% (95% confidence interval [CI], 19.4-25.8) reported DLHS, 11.5% (95% CI, 8.7-14.3) reported personal firearm possession, and 44.2% (95% CI, 40.2-48.2) endorsed firearm access. Teens experiencing DLHS had increased perceived access (adjusted odds ratio, 1.56; 95% CI, 1.07-2.28) compared with non-DLHS peers. There was no association between DLHS and personal firearm possession (adjusted odds ratio, 0.97; 95% CI, 0.47-2.00). Among teens reporting firearm possession, those with DLHS were more likely to have acquired it by buying/trading for it (odds ratio, 5.66; 95% CI, 1.17-27.37) and less likely receiving it as a gift (odds ratio, 0.06; 95% CI, 0.01-0.36).
Conclusions:
High school-aged teens experiencing DLHS have higher perceived firearm access compared with lower-risk peers. Providers should speak directly to high school-aged teens at increased suicide risk about firearm access, in addition to counseling parents.
The pupillary light reflex (PLR) is a method for measuring dynamic responses within the autonomic nervous system, and would have potential value as a point of care test in a psychiatry clinic if reproducible results could be obtained in a short period of time. We collected PLR from adult community volunteers and depressed outpatients with the purpose of demonstrating (1) that valid data could be obtained >90% of the time from both the community volunteers and the patients, and (2) that reproducible results could be obtained with repeated measurement over short periods of time. Valid data were captured for 90.3% of 76 participants, allowing for two attempts of the PLR per participant. Success rates were similar for depressed patients and community volunteers. Eighteen of these 76 participants provided repeated paired measurements after 5 and 10 minutes of dark adaptation, producing high correlations for maximal constriction velocity (MCV) between assay 1 and 2 (Pearson's r=0.71, p<0.001), but there was a significant 8% increase in velocity for MCV between assay 1 and 2 (∆=0.34+0.59 mm/sec, p<0.05). In contrast, PLR measurements were stable when tested in a separate cohort of 21 additional participants at 10 and 15 minutes of dark adaptation with a MCV Pearson's correlation of r=0.84, p<0.001, with a non-significant 1% difference between the two time points. These findings indicate an acceptable rate of collecting valid and reproducible PLR data when contrasting 2 measurements of PLR after 10 or 15 minutes of dark adaptation in depressed and suicidal patients. This article is protected by copyright. All rights reserved.
Unlabelled:
Chronic pain in youth is often associated with social conflict, depression, and suicidality. The Interpersonal Theory of Suicide posits that there are psychosocial factors, such as peer victimization and lack of fear of pain, that may also influence suicidality.
Objectives:
The objective of this study was to determine if depressive symptoms, peer victimization, and lack of fear of pain predict suicidality in adolescents with chronic pain. It was hypothesized that higher levels of depressive symptoms and peer victimization, and lower levels of fear of pain, would predict higher lifetime prevalence of suicidality.
Methods:
Participants consisted of 184 youth with primary chronic pain conditions (10-18 y, M=14.27 y). Measures included diagnostic clinical interviews assessing suicidality and self-report questionnaires assessing depressive symptoms, peer victimization, and fear of pain.
Results:
Forty-two (22.8%) participants reported suicidality. Regression analyses demonstrated that the occurrence of suicidality was associated with higher rates of depressive symptoms (β=1.03, P=0.020, 95% CI [1.01, 1.06]) and peer victimization (β=2.23, P<0.05, 95% CI [1.07, 4.63]), though there was no association between lower fear of pain and suicidality.
Discussion:
These results suggest that depressive symptoms and peer victimization are significant predictors of suicidality in adolescents with chronic pain; however, lower fear of pain was not shown to be a significant predictor. Given these findings, depression and peer victimization should be further explored and considered in the design and implementation of prevention and early intervention strategies that target chronic pain and suicidality in youth.
Suicide is the culmination of the interaction of a number of factors with the critical component being distress. The contribution of mental illness as a vulnerability factor in an individual case of suicide by a prisoner may be significant, marginal or non-existent. Because of the high prevalence in prison populations of all risk factors for suicide, relying solely on those factors is of little use in elaborating the risk of suicide for a given prisoner. Whilst a current mental illness or past history of a suicide attempt are two factors that appear to be strongly associated with completed suicide, no screening or risk assessment tool has any proven efficacy in predicting suicide in prison populations. The stress–vulnerability model offers a more sophisticated and comprehensive assessment and also informs a more individualised needs-based management of the risk of suicide with an emphasis on detecting and responding to a prisoner’s distress.
Background:
Suicide prevention is limited by the frequent non-planned or impulsive nature of suicidal behavior. For instance, 25-62 % of suicide attempts, occur within 30 min of the onset of suicidal ideation. We aimed to examine frontal brain activity in depressed patients following a suicide attempt and its relationship with the duration of the suicidal process.
Methods:
We recruited 35 adult patients within three days of a suicide attempt of at least moderate lethality. Duration of the suicidal process was recorded in a semi-structured interview, including suicide contemplation (time from onset of suicidal ideation to decision to kill oneself) and suicide action intervals (time from the decision to kill oneself to suicide attempt). Resting state EEG data from AF7, AF8, TP9 and TP10 leads was collected with a portable MUSE 2 headband system. The average frequency values throughout a 5-minute portable EEG recording were extracted for delta (1-4 Hz), theta (4-8 Hz), alpha (8-13 Hz), and beta (13-30 Hz) waves.
Results:
Delta (r = 0.450, p = 0.021) and theta power (r = 0.395, p = 0.044) were positively correlated with the duration of the suicide action interval. There were no significant correlations of the suicide contemplation interval with clinical or EEG measures. Patients with suicide action interval shorter than 30 min showed lower delta power (U = 113, p = 0.049) compared with those with longer duration.
Conclusions:
Lower theta and delta activity may reflect hindered cognitive control and inhibition in impulsive suicide attempters. Portable EEG may provide a valuable tool for clinical research and in the management of acutely suicidal patients.
BACKGROUND: Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969–2018 with particular regard to different methods of suicide used in different subgroups of the resident population.
METHODS: We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10–29, 30–64, >64 years), and nationality (Swiss vs other citizenship).
RESULTS: There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58–2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97–2.07), and in older residents (>64 years) than in the age groups 30–64 years (IRR 1.35, 95% CI 1.32–1.37) and 10–29 years (IRR 2.37, 95% CI 2.32–2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.
CONCLUSIONS: Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.
Background
Medically serious suicide attempts (MSSA) represent a subgroup of clinically heterogeneous suicidal behaviours very close to deaths by suicide. A simple definition of an MSSA is a suicide attempt with life-threatening consequences, regardless of the severity of the attempter’s mental disorder. Few studies have specifically analysed the heterogeneity of MSSA. Therefore, the aim of this study is to describe the profile of individuals who made a highly severe MSSA and to compare those admitted to Intensive Care Units (ICU) – including Burn Units– with other MSSA admitted to other medical and surgical units.
Methods
The study sample consisted of 168 patients consecutively admitted to non-psychiatric wards from two public hospitals in Barcelona after an MSSA during a 3-year period. In order to select more severe MSSA, the minimum hospital stay was expanded from Beautrais’ definition of ≥ 24 h to ≥ 48 h. Mean hospital stay was 23.68 (SD = 41.14) days. Patients needing ICU treatment ( n = 99) were compared to other MSSArs ( n = 69) that were admitted to other medical and surgical units, not requiring intensive care treatment, with an initial bivariant analysis followed by a logistic regression analysis using conditional entrance.
Results
Medically serious suicide attempters (MSSArs) spent more time hospitalized, more frequently reported recent stressful life events, were more likely to have at least one prior suicide attempt (SA) and their current attempt was more frequently non-planned, compared to the profile of MSSArs reported in previous studies. The most frequent method was medication overdose (67.3%) and jumping from heights (23.2%). Among those who chose more than one method (37.6%), the most frequent combination was medication overdose and drug use. Affective disorders and personality disorders were the most frequent diagnoses. Higher educational level, history of previous mental disorders and prior lifetime suicide attempts were significantly more frequent among those admitted to ICU compared to other MSSArs. Patients needing admission to ICU less frequently used self-poisoning and cuts.
Conclusions
MSSA needing ICU admission can be regarded clinically as similar to attempts resulting in suicide. More research on this type of highly severe suicide behaviour is needed due to its serious implications both from a clinical and public health perspective.
Suicide is considered to be a conscious and intentional act that is carried out within a social and cultural context. This study examines the unique phenomenon of a cluster of suicide attempts conducted without perceived intent, ideation, plan, volition, or agency in a remote province in Central Asia. This study investigated the lived experiences of individuals who made such unintended suicide attempts and examined the differences between these experiences and those of individuals who made their suicide attempt with intent and agency. The authors conducted a secondary analysis of qualitative data originally collected for a prior grounded theory study. The present study examined a specific and unique set of participant experiences related to suicide attempts made without agency. Results found that instances of suicide attempts made without perceived intent by participants included themes of impulsivity, not knowing what happened, feeling out of control, attributing these experiences to the supernatural, and being fearful of such events occurring again. Clinical practice may need to be adapted to address experiences of such unique suicide attempt experiences. In addition, further research is warranted to understand and examine the phenomenon of suicide attempts carried out without perceived intent, ideation, plan, volition, or agency.
Suicide is an important cause of death in patients with mental health disorders, but little is known about the occurrence of suicidal ideation and attempts in outpatient psychotherapy patients. The aim of this study was to identify the proportion of patients with and correlates of suicidal ideation and attempts in community-based psychotherapy practices. Using 983 applications for reimbursement of psychotherapy from individual patients, reports about suicidal thoughts and suicide attempts were extracted along with demographic, biographic, and clinical data. Multivariate logistic regression analysis was used to identify correlates of suicidal ideation and attempts by calculating odds ratios (OR). Among the patients, 19% presented with suicidal thoughts (11% currently and 8% in the past) and 6% with suicide attempts. Important correlates of suicidal thoughts were male gender (OR 1.7), lower education (OR 1.8), early retirement (OR 2.9), death of a parent when younger than 5 years old (OR 3.3), violence experienced from various people (OR 2.1), self-harm behavior (OR 7.9), and alcohol misuse (OR 1.7). Suicide attempts were associated with male gender (OR 5.6), lower education (OR 4.2), violence experienced from partner (OR 2.5) or from various people (OR 9.5), and self-harm behavior (OR 15.0). These results show that the proportion of suicidal patients seeking outpatient psychotherapy is high. It should therefore be a central topic in clinical training. Biographic data such as the loss of a parent at an early age or experiencing violence are associated with who is at increased risk and should be explored in detail.
This study's purpose was to develop a reliable and valid self-report questionnaire, the Child–Adolescent Suicidal Potential Index (CASPI), to screen for risk for suicidal behavior in children and adolescents. Four hundred twenty-five child and adolescent psychiatric patients and nonpatients completed the CASPI and other research instruments to rate suicidal and assaultive behavior and symptoms of depression, anxiety, and hopelessness. The 30-item CASPI involves 3 factors (anxious–impulsive depression, suicidal ideation or acts, family distress) that contributed to a unidimensional 2nd-order factor accounting for 59% of the total variance. Internal consistency (alpha) for the total score was .90, and test–retest reliability (ICC) for the total score was .76. Total score distinguished between children and adolescents with different severity of psychopathology and different levels of suicidal and assaultive behavior. Each of the 3 factors had different contributions to discriminating between levels of suicidal status. CASPI total score of 11 distinguished suicidal ideation or acts from nonsuicidal behavior, with sensitivity 70% and specificity 65%. CASPI total score positively correlated with symptom severity of depression, anxiety, and hopelessness.
The article which follows this introduction was originally published as a Special (Cover) Article in the American Journal of Psychiatry in the November, 1985 issue, the same month in which the First International Drug Symposium, sponsored by The Bahamas Ministry of Health and The Embassy of the United States of America, was convened to discuss the rock-cocaine epidemic in the Bahamas and other Caribbean Islands. Based on my article, I was invited to participate in the Symposium and to speak about some of my views on the psychological predispositions for drug dependence in general, and in particular, on the psychological predisposition for cocaine dependence. At first, I did not grasp the seriousness and scope of the cocaine problem, but I accepted the invitation, believing I might make a contribution to the Symposium. I was not long in attendance at the Symposium before I realized that the Bahamian citizens, professionals, and health care leaders were facing a major crisis as a consequence of the cocaine epidemic.
Recent clinical observations and psychiatric diagnostic findings of drug-dependent individuals suggest that they are predisposed to addiction because they suffer with painful affect states and related psychiatric disorders. The drugs that addicts select are not chosen randomly. Their drug of choice is the result of an interaction between the psychopharmacologic action of the drug and the dominant painful feelings with which they struggle. Narcotic addicts prefer opiates because of their powerful muting action on the disorganizing and threatening affects of rage and aggression. Cocaine has its appeal because of its ability to relieve distress associated with depression, hypomania, and hyperactivity.
Administered a scale designed to quantify hopelessness to 294 hospitalized suicide attempters, 23 general medical outpatients, 62 additional hospitalized suicide attempters, and 59 depressed psychiatric patients. The scale had a Kuder-Richardson-20 internal consistency coefficient of .93 and correlated well with the Stuart Future Test (SFT) and the pessimism item of the Beck Depression Inventory (BDI; .60 and .63, respectively). The scale was also sensitive to changes in the patient's state of depression over time, as evidenced by a correlation of .49 with change scores on the SFT and .49 with the change scores on the BDI. Findings also indicate that depressed patients have an unrealistically negative attitude toward the future and that seriousness of suicidal intent is more highly correlated with negative expectancies than with depression. A principal-components factor analysis revealed 3 factors which tapped affective, motivational, and cognitive aspects of hopelessness. (16 ref)
Adolescent parasuicide has often has been associated with family disturbance, hopelessness and psychiatric disturbance, but little empirical work has been done to verify these clinical impressions.
The present study compares matched groups of hospitalised parasuicidal adolescents, non-psychiatric medically hospitalised adolescents and a control group on measures of family disturbance, hopelessness and psychopathology.
The findings reveal significantly higher levels of family disturbance, hopelessness and depressive symptoms in the parasuicidal group.
The results suggest that prevention and treatment of adolescent parasuicide should focus on both individual and family dynamics.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
We determined the number of children and adolescents who had a history of attempted suicide in two studies of a statewide sample of violent and assaultive youth. The incidence of attempted suicide (13.2 per hundred) in Study 1 (N = 800) was markedly greater than in the general population (0.5 to 3.0 per hundred). For this highly aggressive sample, older adolescents (14- to 17-year-olds) were more likely to have attempted suicide than younger adolescents, girls were more likely than boys, and White boys were more likely than Black boys. Study 2 (N = 520) replicated the incidence findings in an independent sample. In addition, the suicidal youth did not differ from the nonsuicidal, aggressive youth (individually matched on sex, race, and age) in terms of diagnosed psychopathology, intensity, or severity of aggressive acts or in terms of victimization of parents. The suicidal youth were typically diagnosed as having Conduct Disorder (80% of the boys, 65% of the girls). We found parallel patterns of diagnosis...
Trends in a sample of one hundred adolescent and young adult suicide attempters who presented at a psychiatric emergency unit over a period of five months were generally impulsive with high intent and no disclosure prior to the event. The preferred method of suicide attempt was an overdose. Risk factors emerging from the sample included a high incidence of psychiatric illness, with 68% of subjects suffering from an affective disorder. Risk was increased with psychiatric co-morbidity and psychosocial risk factors such as family distress, sexual abuse and physical abuse.
The Self-inflicted Injury Severity Form (SIISF) was developed as an epidemiological research tool for identifying individuals in hospital emergency departments who have life-threatening self-inflicted injuries. Data were collected from 715 patients with self-inflicted injuries in two large hospitals. In 295 of these cases, a second set of data was independently collected for assessment of interrater reliability. Validity was assessed by comparing the SIISF results with simultaneously collected Risk—Rescue Ratings. Assessment of interrater reliability found that only 2.4% of physicians disagreed on the suicide method used. The kappa statistic for method used was .94, indicating excellent agreement. The SIISF was found to distinguish between severe and less severe injuries. Thus, it appears to provide a simple method to distinguish patients who have life-threatening self-inflicted injuries.
The public health approach to health problems provides a strong framework and rationale for developing and implementing suicide prevention programs. This approach consists of health-event surveillance to describe the problem, epidemiologic analysis to identify risk factors, the design and evaluation of interventions, and the implementation of prevention programs. The application of each of these components to suicide prevention is reviewed. Suggestions for improving surveillance include encouraging the use of appropriate coding, reviewing suicide statistics at the local level, collecting more etiologically useful information, and placing greater emphasis on analysis of morbidity data. For epidemiologic analysis, greater use could be made of observational studies, and uniform definitions and measures should be developed and adopted. Efforts to develop interventions must include evaluating both the process and the outcome. Finally, community suicide prevention programs should include more than one strategy and, where appropriate, should be strongly linked with the community's mental health resources. With adequate planning, coordination, and resources, and the public health approach can help reduce the emotional and economic costs imposed on society by suicide and suicidal behavior.
The findings of a pilot study, focusing on suicidal behaviors among 313 high school students in the Midwest, are discussed. Of all the students who participated in the study, 62.6% reported some degree of suicidal ideation or action, including 8.4% who had actually made a suicide attempt. The current study provides a linchpin between the studies of adolescent suicide attempt rates and the studies reporting on percentages of adolescents who made suicide attempts. When the percentage of attempters who made attempts but did not seek medical help is taken under consideration, these two groups of studies become equivalent. Apparently, suicide is a personal concern for most high school students—a problem that warrants immediate attention.
Objective:
To determine the relative importance of aggression and depression in adolescent suicide within different diagnostic categories.
Method:
One hundred sixty-three consecutive admissions to an adolescent psychiatric inpatient unit were assessed using a semistructure diagnostic instrument, the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Scores for depression, suicidal behaviors, and violent behaviors were calculated from this assessment.
Results:
Anorexia nervosa and conduct disorder patients had the highest suicidal behavior scores. In addition, patients with conduct disorder were significantly more violent than patients with major depressive disorder, and scores on the Violent Behavior Scale correlated with suicidal symptoms but not with depressive symptoms.
Conclusion:
Aggression may be as important in some kinds of suicidal behaviors as is depression. Thus it seems that there are hypothetically at least two types of suicidal behaviors during adolescence: a wish to die (depression) and a wish not to be here for a time (impulse control). The first type of suicidal behavior characterizes that seen in disorders with prominent depression such as major depressive disorder and anorexia nervosa, and the second characterizes disorders of impulse control such as conduct disorder.
Objective:
To determine whether specific psychological factors characterize adolescents who take overdoses.
Method:
Measures of problem-solving, depression, anger, impulsivity, and self-esteem were investigated in 33 adolescents after an overdose, 30 psychiatric controls, and 30 community controls, the groups being matched for age and sex. All subjects were interviewed twice, 6 weeks apart. The first interview in the overdose group followed an overdose.
Results:
Significant differences were found between the 3 groups on all of the variables at both interviews. However, when depressive affect (Beck Depression Inventory) was controlled for, all of these differences disappeared, except for impulsivity at the second interview. Here the overdose group remained more impulsive than the other groups even when depression was considered.
Conclusions:
Depression is the most important factor in the presentation of a range of psychological characteristics of adolescents who take overdoses, and this remains true at 6-week follow-up. Impulsivity is apparently an important factor, independent of depression, in adolescent self-poisoning. Further research is required to determine the mediating role of impulsivity in this behavior and to identify treatment strategies for it.
Adolescent suicide attempts are often impulsive. It has been suggested that individuals who make nonimpulsive (premeditated) attempts have greater suicidal intent and are more hopeless than the impulsive attempters. Eighty-six adolescent suicide attempters were categorized according to the degree of premeditation of their attempt, as measured by two items of the Suicide Intent Scale. Sex, age, method of attempt, and the number of prior attempts were not useful discriminators between these groups. The nonimpulsive attempters were significantly more depressed and more hopeless than the impulsive attempters, as measured by several standardized scales. Measures of depression, hopelessness, and suicidal ideation were highly correlated in both groups. Anger turned inward and hopelessness were strongly correlated only in the premeditated group, suggesting that the nonimpulsive attempter's distress may bear a strong relationship to self anger.
Cognitive therapy research has yielded (1) a taxonomy of suicidal behaviors, (2) scales for assessing suicidal ideation and intent, and (3) a model of suicidal wishes and behavior that identifies hopelessness as a key psychological variable in suicide prediction. The establishment of hopelessness as a suicide risk factor has been supported most strongly by prospective studies of inpatients and outpatients. A cutoff score of nine on the Beck Hopelessness Scale appears to be predictive of eventual suicide. Other cognitive factors associated with suicidal wishes and behaviors are discussed.
Descriptive information on a large number of children and adolescents who had committed suicide was collected from medical examiners' records. A review of deaths of persons 19 and under from nonnatural causes identified 229 youth suicides. Characteristics of these youth were extracted from medical examiners' reports: no control groups were employed. Children and adolescents who committed suicide were most likely to be older males with a current psychiatric disorder, usually an affective disorder or alcohol or drug abuse. Suicides appeared to be impulsive and triggered by age-normative precipitants. Sex, age, and cohort differences are presented. Results are evaluated in light of previous research.
The relationship between the medical lethality of suicidal behavior and demographic, psychiatric, social, and familial/environmental variables was examined in chart review of a consecutive series of youthful suicide attempters presenting in a Children's Hospital over 5-year period. Correlates of the lethality of suicidal behavior included male sex, diagnosis of affective disorder and substance abuse, high suicidal intent, and the ingestion of a psychotropic agent. Patients who made medically lethal attempts appeared to have characteristics which converge with those who have completed suicide. The availability of a lethal agent may be the most significant determinant of the lethality of impulsive attempts, whereas suicidal intent and severity of spychopathology may make the most important contributions to the lethality of attempts by hopeless, dysphoric individuals. The implications of these findings for the prediction and prevention of suicide in children and adolescents are discussed.
The findings of a pilot study, focusing on suicidal behaviors among 313 high school students in the Midwest, are discussed. Of all the students who participated in the study, 62.6% reported some degree of suicidal ideation or action, including 8.4% who had actually made a suicide attempt. The current study provides a linchpin between the studies of adolescent suicide attempt rates and the studies reporting on percentages of adolescents who made suicide attempts. When the percentage of attempters who made attempts but did not seek medical help is taken under consideration, these two groups of studies become equivalent. Apparently, suicide is a personal concern for most high school students--a problem that warrants immediate attention.
The authors studied 30 patients treated at an urban trauma center for self-inflicted gunshot wounds, most or all of which would have been fatal without emergency treatment. About half the patients had used alcohol or drugs immediately before wounding themselves, and slightly more than half had experienced interpersonal conflict just before the incident. Thirteen of the 30 were women. Only nine were given diagnoses of major depressive episode or dysthymia; none of the patients had written suicide notes. These data indicate that the reported demographic and clinical characteristics of impulsive, violent self-injury must be reexamined.
It is well established that alcoholics have a very high suicide rate. The evidence is of two kinds: a) Follow up studies of alcoholics consistently reveal high suicide rates. The proportion dying by suicide varies from 8% (Kessel & Grossman, 1961) to 21% (Gabriel, 1935) depending on the length of follow up. These figures represent a risk 5080 times that of the general population. Most such studies were based on clinically identified populations of alcoholics and might not be representative of alcoholics in general. However: b) Retrospective studies of suicides consistently find that a high proportion (varying from 15% in southern England Barraclough et al., 1974 to 27% in Seattle Dorpat & Ripley, (1960) were alcoholics. The evidence of these retrospective studies is that suicide usually occurs at a late stage in the alcoholic career and is associated with things which are high risk factors for suicide in other settings e.g. divorce, a history of previous suicide attempts and increasing age. The origins of the close relationship between alcoholism and suicide have rarely been investigated, though the relationship is readily comprehended. Several elements probably contribute: 1. Alcohol dependence often leads to social decline-break up of marriage, loss of job and family ties-and the resulting social isolation is a potent cause of suicide. 2. Alcohol dependence leads to loss of self esteem and hence to depression and these psychological changes predispose to suicide. 3. Intoxication produces increased impulsiveness and a weakening of normal restraints against dangerous behavior.(ABSTRACT TRUNCATED AT 250 WORDS)
Deaths by violence (accidents, homicide, suicide) have increased significantly among Alaska Natives who have a suicide rate three times that of the general U.S. population. Self-inflicted gunshot wounds comprised 75 percent of the suicides among Alaska Natives from 1976 through 1980. A review of psychiatric consultations concerning 34 Alaska Natives who had survived a self-inflicted gunshot wound indicated some common characteristics. Of the group, 28 were male, and 20 had been using alcohol at the time of the shooting. Interpersonal conflicts were cited by most persons as partial motivation for the shooting, and most shootings were impulsive rather than premeditated. Few patients had a psychiatric history or appeared impaired at the time of the consultation. Cultural and intrapsychic factors that might contribute to this high rate of self-destructive behavior were examined. These include a proscription against verbal expression of negative affect and an increase of non-Native influences with subsequent social disorganization and cultural conflict.
Previous studies have noted that a considerable proportion of suicidal behavior is impulsive. The present study aimed to ascertain the degree to which this was so and to consider whether impulsive attempters differed from non-impulsive attempters on variables such as demographic and motivational factors and circumstances that surrounded the occurrence of the act. Based on a criterion of less than 5 minutes' premeditation, 40% of two large, consecutive series were judged to have acted impulsively. While few variables differentiated between the two groups, impulsive attempters were less depressed, motivated by the desire to reduce tension, more likely to consider that they would survive, and to report that someone saw them perform the act.
There is a dearth of information on the motivational aspects of serious suicide attempts, in particular those which involve violent methods. Clarification of the reasons which lie behind such acts may suggest appropriate preventive strategies.
Interviews were carried out with 20 individuals who had attempted suicide by jumping in front of a railway train. Demographic and psychiatric data were collected for each case and the Suicidal Intent Scale was administered.
In most cases the act had been impulsive and was characterised by an extremely high level of suicidal intent. The majority were receiving psychiatric treatment at the time of their suicide attempt. In some cases, survival and the aftermath of the attempt appeared to have a beneficial effect on mental state.
While high levels of psychiatric morbidity and high suicidal intent were common, impulsivity and improved mental state indicate that there are similarities between high and low suicide intent survivors.
A study of 100 patients who made a severe suicide attempt suggested that the managed care criteria often applied for approving admission to hospitals for potentially suicidal patients were not, in fact, predictive of features seen in patients who actually made such attempts. Severe anxiety, panic attacks, a depressed mood, a diagnosis of major affective disorder, recent loss of an interpersonal relationship, recent abuse of alcohol or illicit substances coupled with feelings of hopelessness, helplessness, worthlessness, global or partial insomnia, anhedonia, inability to maintain a job, and the recent onset of impulsive behavior were excellent predictors of suicidal behavior. The presence of a specific suicide plan or suicide note were not. Patients with managed care were overrepresented by 245% in the study.
This study's purpose was to develop a reliable and valid self-report questionnaire, the Child-Adolescent Suicidal Potential Index (CASPI), to screen for risk for suicidal behavior in children and adolescents. Four hundred twenty-five child and adolescent psychiatric patients and nonpatients completed the CASPI and other research instruments to rate suicidal and assaultive behavior and symptoms of depression, anxiety, and hopelessness. The 30-item CASPI involves 3 factors (anxious-impulsive depression, suicidal ideation or acts, family distress) that contributed to a unidimensional 2nd-order factor accounting for 59% of the total variance. Internal consistency (alpha) for the total score was .90, and test-retest reliability (ICC) for the total score was .76. Total score distinguished between children and adolescents with different severity of psychopathology and different levels of suicidal and assaultive behavior. Each of the 3 factors had different contributions to discriminating between levels of suicidal status. CASPI total score of 11 distinguished suicidal ideation or acts from nonsuicidal behavior, with sensitivity 70% and specificity 65%. CASPI total score positively correlated with symptom severity of depression, anxiety, and hopelessness.
Centers for Disease Control and Prevention Statistics compiled by the Office of Statistics and Pro-gramming, using National Center for Health Statistics, Vital Statistics System for number of deaths Ex-plaining suicide: The views of survivors of serious sui-cide attempts
- I Donnell
- R Farmer
- J Catalan
National Center for Injury Prevention and Control (2002). Centers for Disease Control and Prevention. Statistics compiled by the Office of Statistics and Pro-gramming, using National Center for Health Statistics, Vital Statistics System for number of deaths. http://www.cdc.gov/ncipc/wisqars/ O'Donnell, I., Farmer, R., & Catalan, J. (1996). Ex-plaining suicide: The views of survivors of serious sui-cide attempts. British Journal of Psychiatry, 168, 780-786.
Centers for Disease Control and Prevention. Statistics compiled by the Office of Statistics and Programming, using National Center for Health Statistics, Vital Statistics System for number of deaths
- B Kost-Grant
Kost-Grant, B. (1983). Self-inflicted gunshot wounds
among Alaska Natives. Public Health Reports, 98,
72-78.
National Center for Injury Prevention and Control
(2002). Centers for Disease Control and Prevention.
Statistics compiled by the Office of Statistics and Programming, using National Center for Health Statistics,
Vital Statistics System for number of deaths.
http://www.cdc.gov/ncipc/wisqars/