Article

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

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Abstract

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 χ(2)(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.

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... 15 Many existing tools suited to the ED environment that target suicidality lack supporting evidence or, worse, are counterproductive. 22,23 One such intervention is the safety contract or no-suicide agreement. While at one time the gold standard for ED anti-suicidal interventions, the safety contract has been shown to produce worse outcomes than no intervention at all. ...
... 47 Finally, a study of the Crisis Response Plan (CRP) intervention conducted by Bryan and colleagues in a military ED met inclusion criteria. 22 The CRP pairs a brief historical interview with a collaborative identification and documentation of coping strategies and resources available to patients. 22 ...
... 22 The CRP pairs a brief historical interview with a collaborative identification and documentation of coping strategies and resources available to patients. 22 ...
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Introduction: Suicidality is a growing problem in the US, and the emergency department (ED) is often the front line for the management and effective treatment of acutely suicidal patients. There is a dearth of interventions that emergency physicians may use to manage and effectively treat acutely suicidal patients. To the extent that recently described interventions are available for ED personnel, no review has been conducted to identify them. This scoping review is intended to fill this gap by systematically reviewing the literature to identify recently described interventions that can be administered in the ED to reduce symptoms and stabilize patients. Methods: We conducted a search of PubMed, SCOPUS, and CINAHL in January 2024 to identify papers published between 2013–2023 for original research trialing recent interventions for the effective treatment of suicidality in the ED. We assessed 16 full-text articles for eligibility, and nine met inclusion criteria. Included studies were evaluated for features and characteristics, the fit of the intervention to the ED environment, and interventional efficacy. Results: Four studies assessed the efficacy of a single dose of the anesthetic/analgesic agent ketamine. Three studies assessed the efficacy of a brief psychosocial intervention delivered in the ED, two of which paired this intervention with the provision of follow-up care (postcard contact and referral assistance/case management, respectively). The remaining two studies trialed a brief, motivational interviewing-based intervention. Included studies had strong experimental designs (randomized controlled trials) but small sample sizes (average 57). Among the interventions represented across these nine studies, a single dose of ketamine and the brief psychosocial intervention Crisis Response Planning (CRP) show promise as ED-appropriate interventions for suicidality. Ketamine and CRP demonstrated the strongest fit to the ED environment and most robust efficacy findings. Conclusion: This review identified one drug (ketamine) and four unique psychological/behavioral interventions that have been used to treat acute suicidality in the ED. There is currently insufficient evidence to suggest that these interventions will prove efficacious and well-suited to be delivered in the ED environment. Future studies should continue to test these interventions in the ED setting to determine their feasibility and efficacy.
... Importantly, deficits in self-regulatory abilities, leading to emotion dysregulation, are linked with suicide ideation and transition of ideation to attempts [33]. Moreover, BCBT impacts on reduced suicidal behavior has been theorized to be a function of training in emotion regulation, cognitive reappraisal, and problem-solving skills [34]. ...
... The study is powered to detect a non-inferiority minimal clinical difference in means between groups of 4.5 points on the SSI. This metric is based on prior military suicide intervention clinical trials suggesting an anticipated difference in means between groups of 1.5 points [7,34] on the SSI over the study period for two equal-sized independent samples (i.e., G-BCBT and DBT) with an equal standard deviation of 6 [7,34] for participants in each group. ...
... The study is powered to detect a non-inferiority minimal clinical difference in means between groups of 4.5 points on the SSI. This metric is based on prior military suicide intervention clinical trials suggesting an anticipated difference in means between groups of 1.5 points [7,34] on the SSI over the study period for two equal-sized independent samples (i.e., G-BCBT and DBT) with an equal standard deviation of 6 [7,34] for participants in each group. ...
Article
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Background Suicide is a pressing matter for the military. Not only does it pose a health risk, but suicide also compromises operational readiness. Despite provision of suicide prevention clinical best practices, the Department of Defense suffers several challenges (e.g., clinician shortages) limiting the agency’s ability to effectively respond to service member suicide. Implementation of evidence-based suicide-specific group therapy is a possible solution to service member well-being needs and system challenges. Service members can also gain coping skills useful beyond managing suicidal thoughts and behaviors. Methods This 2-arm non-inferiority randomized controlled trial compares a group therapy format of Brief Cognitive Behavioral Therapy (i.e., G-BCBT) with Dialectical Behavior Therapy (DBT) Skills Group. Both therapies are delivered in-person at a United States Naval Medical Center. Participants (N = 136) are active-duty service members with recent suicidal thoughts or suicidal behavior. Evaluation features electronically delivered questionnaires at baseline, after each treatment session, and at 3- and 6-month follow-up. Discussion The primary outcome concerns G-BCBT impacts on suicidal ideation. Secondary outcomes of interest are suicide attempt, psychological distress (e.g., symptoms of depression, anxiety), and self-regulatory skills (e.g., emotion regulation). We also examine self-regulatory skills as treatment moderators. Clinical trial strengths and limitations are reviewed. Trial registration This study was registered at Clinicaltrials.gov (protocol NCT05401838).
... Conflicting effects have been reported for brief suicide interventions targeting critical high-risk periods. While some interventions resulted in statistically significantly reduced risk of suicide attempt [21][22][23][24][25][26], others did not find this [27][28][29][30]. Most of the previously conducted interventions included same elements as examined here, such as interview before discharge with a focus on suicide warning signs and safety planning as well as follow-up contact after discharge (either by phone or post cards). ...
... Most of the previously conducted interventions included same elements as examined here, such as interview before discharge with a focus on suicide warning signs and safety planning as well as follow-up contact after discharge (either by phone or post cards). Except for two interventions [23,24], most have been conducted as randomized controlled trials (RCT) [21,22,[25][26][27][28][29][30][31]. All RCTs had small sample sizes and, consequently, only few events of suicide attempt were observed during follow-up; implying that they might not have been sufficiently powered to detect a statistical difference. ...
... One reason for this might be differences in study populations; the SAFE intervention was offered to all discharged inpatients whether they had suicidal tendencies or not, while participants in the other studies either experienced current suicidal ideations or had recently presented with a suicide attempt. [21,22,[24][25][26]. Targeting all patients, as we did may dilute the effectiveness of the intervention, however we choose to offer the intervention to all discharged patients because we know from previous studies that only focusing on those who already had displayed suicidality, we risk bypassing many who will be at suicidal risk after discharge [32]. ...
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Objectives The risk of suicidal behavior after discharge from psychiatric admission is high. The aim of this study was to examine whether the SAFE intervention, an implementation of a systematic safer discharge procedure, was associated with a reduction in suicidal behavior after discharge. Methods The SAFE intervention was implemented at Mental Health Center Copenhagen in March 2018 and consisted of three systematic discharge procedures: (1) A face-to-face meeting between patient and outpatient staff prior to discharge, (2) A face-to-face meeting within the first week after discharge, and (3) Involvement of relatives. Risk of suicide attempt at six-month post-discharge among patients discharged from the SAFE intervention was compared with patients discharged from comparison mental health centers using propensity score matching. Results 7604 discharges took place at the intervention site, which were 1:1 matched with discharges from comparison sites. During the six months of follow-up, a total of 570 suicide attempts and 25 suicides occurred. The rate of suicide attempt was 11,652 per 100,000 person-years at the SAFE site, while it was 10,530 at comparisons sites. No observable difference in suicide attempt 1.10 (95% CI: 0.89–1.35) or death by suicide (OR = 1.27; 95% CI:0.58–2.81) was found between sites at 6-month follow-up. Conclusion No difference in suicidal behavior between the sites was found in this pragmatic study. High rates of suicidal behavior were found during the 6-months discharge period, which could suggest that a preventive intervention should include support over a longer post-discharge period than the one-week follow-up offered in the SAFE intervention.
... Importantly, de cits in self-regulatory abilities, leading to emotion dysregulation, are linked with suicide ideation and transition of ideation to attempts [33]. Moreover, BCBT impacts on reduced suicidal behavior has been theorized to be a function of training in emotion regulation, cognitive reappraisal, and problem-solving skills [34]. ...
... The study is powered to detect a non-inferiority minimal clinical difference in means between groups of 4.5 points on the SSI. This metric is based on prior military suicide intervention clinical trials suggesting an anticipated difference in means between groups of 1.5 points [7,34] on the SSI over the study period for two equal-sized independent samples (i.e., G-BCBT and DBT) with an equal standard deviation of 6 [7,34] for participants in each group. ...
... The study is powered to detect a non-inferiority minimal clinical difference in means between groups of 4.5 points on the SSI. This metric is based on prior military suicide intervention clinical trials suggesting an anticipated difference in means between groups of 1.5 points [7,34] on the SSI over the study period for two equal-sized independent samples (i.e., G-BCBT and DBT) with an equal standard deviation of 6 [7,34] for participants in each group. ...
Preprint
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Background Suicide is a pressing matter for the military. Not only does it pose a health risk, but suicide also compromises operational readiness. Despite provision of suicide prevention clinical best practices, the Department of Defense suffers several challenges (e.g., clinician shortages) limiting the agency’s ability to effectively respond to service member suicide. Implementation of evidence-based suicide-specific group therapy is a possible solution to service member well-being needs and system challenges. Service members can also gain coping skills useful beyond managing suicidal thoughts and behaviors. Methods This 2-arm non-inferiority randomized controlled trial compares a group therapy format of Brief Cognitive Behavioral Therapy (i.e., G-BCBT) with Dialectical Behavior Therapy (DBT) Skills Group. Both therapies are delivered in-person at a United States Naval Medical Center. Participants (N = 136) are active-duty service members with recent suicidal thoughts or suicidal behavior. Evaluation features electronically delivered questionnaires at baseline, after each treatment session, and at 3- and 6-month follow-up. Discussion The primary outcome concerns G-BCBT impacts on suicidal ideation. Secondary outcomes of interest are suicide attempt, psychological distress (e.g., symptoms of depression, anxiety), and self-regulatory skills (e.g., emotion regulation). We also examine self-regulatory skills as treatment moderators. Clinical trial strengths and limitations are reviewed. Trial registration This study was registered at Clinicaltrials.gov (protocol NCT05401838).
... The most commonly known SSP has been developed by Stanley and Brown (2012) and includes six primary elements: (1) identifying warning signs of a suicide crisis; (2) internal coping strategies; (3) social supports that can distract from the current crisis; (4) contact information for these social supports; (5) contact information for health care services; and (6) reducing access to lethal means (Stanley & Brown, 2012). SSP was developed as a response to growing recognition that "contracting for safety," an approach involving a verbal contract in which a service user agrees to avoid attempting suicide before reaching out for professional support, was largely ineffective for mitigating suicide risk (Bryan et al., 2017;Egan, 1997;Rudd et al., 2006). SSP is closely aligned with the values and culture of occupational therapy through its emphasis on collaboration and person-centered care (ACOTRO et al., 2021;Egan & Restall, 2022). ...
... (m = 68.2) representing moderate-high quality evidence. See Table 2. S-SSP and E-SSP interventions included in this category were called "crisis response plans" (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019) and "safety plans" (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020. S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. ...
... S-SSPs included identification of warning signs, self-management and coping strategies, and social supports and healthcare professionals who could help during a suicide crisis. Four of these plans also included identifying crisis services (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019), three included a component of reducing access to lethal means (Green et al., 2018;Stanley et al., 2015Stanley et al., , 2020, and one included a component of identifying places that could serve as a distraction (Green et al., 2018). E-SSPs included the components included in S-SSPs, while also including verbal contracts for safety and identifying reasons for living (Bryan et al., 2017(Bryan et al., , 2018a(Bryan et al., , 2018bRozek et al., 2019). ...
Article
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Date Presented 04/22/2023 Suicide is a leading cause of mortality worldwide. OTs regularly encounter persons who are at risk of suicide in their practice, and they need to be aware of strategies to mitigate risk. Suicide safety planning is an evidence-based intervention designed for this purpose. We conducted this systematic review to synthesize effectiveness studies to determine the outcomes and components of safety planning interventions to direct future OT research and practice. Primary Author and Speaker: Carrie Anne Marshall Contributing Authors: Pavlina Crowley, Dave Carmichael, Suliman Aryobi, Rebecca A. Goldszmidt, Roxanne Isard, Corinna Easton, Julia Holmes, Susanne Murphy
... The first SR (Bosse Chartier et al. 2023) narratively summarized trials testing whether SSIs delivered in emergency departments, offered to people admitted for suicide-related thoughts and behavior, could (a) increase rates of linkage to outpatient mental health services following emergency department discharge, and (b) reduce rates of re-hospitalization following discharge. Across 7 trials that assessed effects on outpatient service attendance, all of them suggested that emergency-department based SSIs (e.g., Safety Planning Intervention, Stanley et al. 2018; Contract for Safety, Bryan et al. 2017) significantly increased youths' and adults' attendance at future outpatient mental health services, compared to controls. Additionally, some trials suggested that SSIs significantly reduced rates of re-hospitalization (e.g., a family-based narrative intervention for suicide prevention, Wharff et al. (2019); Crisis Response Plan, Bryan et al. 2017), but others did not (e.g., Family Intervention for Suicide Prevention; Asarnow et al. 2011). ...
... Across 7 trials that assessed effects on outpatient service attendance, all of them suggested that emergency-department based SSIs (e.g., Safety Planning Intervention, Stanley et al. 2018; Contract for Safety, Bryan et al. 2017) significantly increased youths' and adults' attendance at future outpatient mental health services, compared to controls. Additionally, some trials suggested that SSIs significantly reduced rates of re-hospitalization (e.g., a family-based narrative intervention for suicide prevention, Wharff et al. (2019); Crisis Response Plan, Bryan et al. 2017), but others did not (e.g., Family Intervention for Suicide Prevention; Asarnow et al. 2011). The other SR that reported SSI effects on service use (McGinnes et al. 2016) found no evidence that SSIs (defined as < 10 minute, provider-delivered, feedback-based interventions) reduced rates of hospital re-admission among youth and adults at-risk for alcohol-related harm. ...
Preprint
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Most people with mental health needs cannot access treatment; among those who do, many access services only once. Accordingly, single-session interventions (SSIs) may help bridge the treatment gap. We conducted the first umbrella review synthesizing research on SSIs for mental health problems and service engagement in youth and adults. Our search yielded 24 systematic reviews of SSIs including 415 unique trials. Twenty reviews (83.33%) reported significant, positive effects of SSIs for >1 outcomes (anxiety; depression; externalizing problems; eating problems; substance use; treatment engagement or uptake). Across 12 reviews that meta-analytically examined SSIs’ effectiveness relative to controls, SSIs showed a positive effect across outcomes and age groups, SMD=-0.25, I2 = 43.17%. Per AMSTAR-2, some methodological concerns emerged across reviews, such low rates of pre-registration. Overall, findings support the clinical utility of SSIs for certain psychological problems and populations. Implementation research is needed to integrate effective SSIs into systems of care.
... Highlighting the need for innovative crisis services are the rising cost of traditional hospital-based crisis care (Hargraves & Kennedy, 2019;United Healthcare, 2019) and evidence of limited effectiveness and lower client satisfaction associated with traditional hospital-based crisis services (i.e., patient presentation to an emergency department (ED), with possible subsequent transfer to an inpatient psychiatric unit) (Agar-Jacomb & Read, 2009;Garriga et al., 2016;Lyons et al., 2009;Olfson et al. 2016;Shattell & Andes, 2011;Tuttle, 2008;Weiss et al., 2012). Accordingly, there is growing David L. Roberts robertsd5@uthscsa.edu in outpatient care and which are known to decrease suicide risk (e.g., Bryan et al., 2017). ...
... Interns receive approximately 20 h of informational, modeling-based and practice-based training in the LR's evidence-based crisis counseling model. Training integrates three content areas: (1) Crisis Response Planning (Bryan et al., 2017) for suicide risk assessment and safety planning; ...
Article
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Traditional forms of psychiatric crisis treatment increasingly are being buttressed by services along the Psychiatric Crisis Continuum of Care, such as short-term crisis stabilization services and peer crisis services. The UT Health Living Room (LR) is an outpatient crisis counseling service that adds three promising elements to the Continuum: (1) it integrates outpatient treatment plans into crisis counseling, (2) provides care in a space and with staff who are familiar to patients, and (3) provides training in evidence-based crisis intervention. We examined two-year LR feasibility and outcome data. Mixed-method analyses used longitudinal clinic data and patient self-report measures. Results provide initial support for the feasibility, cost effectiveness and clinical effectiveness of the LR. Limitations include non-blinded ratings, limited experimental control, and simple cost-effectiveness methodology. The UT Living Room is feasible and offers novel elements to help patients in community clinics address emotional crises.
... The SPI has been shown to reduce suicide attempts and has other related positive mental health outcomes (Stanley et al., 2018). A second similar approach is called the Crisis Response Plan (CRP) developed by M. Rudd et al. (2001) and further studied by Bryan et al. (2017). Like the SPI, the CRP involves having the patient write down their personal warning signs, along with various problemsolving strategies, on an index card that also notes external resources should CRP coping strategies fail to resolve an acute episode. ...
... Like the SPI, the CRP involves having the patient write down their personal warning signs, along with various problemsolving strategies, on an index card that also notes external resources should CRP coping strategies fail to resolve an acute episode. In an RCT with military service members who were acutely suicidal, the CRP was shown to have a significant impact on both suicide attempts and ideation when compared to "no-harm" contracts (Bryan et al., 2017). A third similar approach is the CAMS Stabilization Plan (CSP-see This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
Article
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Suicide is a major public and mental health problem in the United States and around the world. According to recent survey research, there were 16,600,000 American adults and adolescents in 2022 who reported having serious thoughts of suicide (Substance Abuse and Mental Health Services Administration, 2023), which underscores a profound need for effective clinical care for people who are suicidal. Yet there is evidence that clinical providers may avoid patients who are suicidal (out of fear and perceived concerns about malpractice liability) and that too many rely on interventions (i.e., inpatient hospitalization and medications) that have little to no evidence for decreasing suicidal ideation and behavior (and may even increase risk). Fortunately, there is an emerging and robust evidence-based clinical literature on suicide-related assessment, acute clinical stabilization, and the actual treatment of suicide risk through psychological interventions supported by replicated randomized controlled trials. Considering the pervasiveness of suicidality, the life versus death implications, and the availability of proven approaches, it is argued that providers should embrace evidence-based practices for suicidal risk as their best possible risk management strategy. Such an embrace is entirely consistent with expert recommendations as well as professional and ethical standards. Finally, a call to action is made with a series of specific recommendations to help psychologists (and other disciplines) use evidence-based, suicide-specific, approaches to help decrease suicide-related suffering and deaths. It is argued that doing so has now become both an ethical and professional imperative. Given the challenge of this issue, it is also simply the right thing to do.
... For example, MHPs across various contexts frequently use "no-suicide contracts," despite some evidence that they are ineffective and harmful (Roush et al., 2018). Evidence highlights the increased efficacy of safety planning compared to safety contracts in preventing suicide attempts, decreasing severity of suicidal ideation, and reducing days of inpatient hospitalization (Bryan et al., 2017). However, MHPs without proper training may be unaware of the evidence-based practices that reduce suicide risk. ...
... A next logical question concerns what type of suicide prevention training to implement. Suicide prevention trainings range from lay skills (i.e., gatekeeper training) to varying levels of beginner (e.g., conducting a risk interview; Cramer et al., 2013), intermediate (e.g., crisis response planning; Bryan et al., 2017), and advanced levels (e.g., suicide-specific interventions such as dialectical behavior therapy, CAMS, BCBT). From an ethical perspective, at bare minimum, we propose MHPs should receive beginner-to-intermediate level training that precedes advanced training. ...
Article
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Suicide remains a pressing national public health issue. Suicide prevention training for current and future mental health professionals (MHPs) is a secondary prevention strategy that is a common component of comprehensive suicide prevention strategies. A policy- and ethics-focused question is raised by the ongoing need for training: Should suicide prevention training be mandated for all MHPs? In this scoping review with policy recommendations, we outline the ethical considerations forming the foundation for the argument that training should be a necessity. Current behaviors of undertrained MHPs may violate the ethical principle of nonmaleficence and ethical standards of practicing within boundaries of competence and recognizing and reducing bias due to stigma. We discuss how training addresses the ethical issues and suggest a training program as an example for consideration. Next, we offer practical recommendations for implementing training for MHPs and graduate students through organizational onboarding, continuing education for licensure, and accreditation.
... Interventions involving safety plan/crisis response plan (CRP) interventions for individuals presenting in crisis to an Emergency Department (ED) 174 or military personnel presenting in an emergency 24 were identified. Intervention components include: recognising warning signs, employing internal coping strategies, utilising social contacts as a distraction from suicidal thoughts, contacting family members or friends, contacting MH professionals or agencies and reducing access or use of lethal means. ...
... A case study was reported in the literature 174 . An RCT of CRPs versus safety contracts found that CRPs may reduce SAs and SI 24 and CRPs among this cohort were reported to be acceptable 25 . ...
... Zestien onderzoeken met 252.932 participanten werden geselecteerd: dertien gerandomiseerde trials [30][31][32][33][34][35][36][37][38][39][40][41], twee pre-post design onderzoeken [42,43] en een case-controlonderzoek [44]. Veertien onderzoeken evalueerden een unilevel-interventie, en twee een multi-level-interventie, waarvan één onderzoek twee levels had [41] en één drie [30][31][32][33][34][35][36][37][38][39][40][42][43][44][45]. ...
... Zestien onderzoeken met 252.932 participanten werden geselecteerd: dertien gerandomiseerde trials [30][31][32][33][34][35][36][37][38][39][40][41], twee pre-post design onderzoeken [42,43] en een case-controlonderzoek [44]. Veertien onderzoeken evalueerden een unilevel-interventie, en twee een multi-level-interventie, waarvan één onderzoek twee levels had [41] en één drie [30][31][32][33][34][35][36][37][38][39][40][42][43][44][45]. ...
Article
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Samenvatting Dit artikel geeft een overzicht van effectieve suïcidepreventie-interventies en hun betekenis voor het Nederlandse werkveld en de Landelijke Agenda Suïcidepreventie. We bespreken een in 2020 gepubliceerde systematische review die het effect van preventieve interventies op suïcides en suïcidepogingen evalueerde, en geven een update van de ontwikkelingen daarna. Zestien onderzoeken met 252.932 participanten lieten zien dat er effectieve suïcidepreventie-interventies bestaan, zowel voor het voorkómen van suïcides, als van suïcidepogingen. Multi-level-interventies hebben grotere effecten dan uni-level-interventies. Vooral keteninterventies die nadrukkelijk de verbinding tussen identificatie van mensen met suïciderisico op populatieniveau en toegang tot specialistische zorg leggen, verdienen landelijke prioriteit. Een digitaal beslissingsondersteunend instrument voor hulpverleners en ketenpartners van alle niveaus kan uitkomst bieden. Dit instrument werd ontwikkeld binnen SUPREMOCOL, een onderzoek naar de effectiviteit van een systeeminterventie voor suïcidepreventie, uitgevoerd in de provincie Noord-Brabant, dat significante resultaten had in het voorkómen van suïcide. Het is het enige wetenschappelijk onderzoek in Nederland dat expliciet suïcide en suïcidepogingen als uitkomsten van een suïcidepreventie-interventie evalueert. In Nederland is dat nodig in het kader van de Landelijke Agenda Suïcidepreventie.
... Previous qualitative studies of primary care providers [9,23] have echoed concerns about what to do once suicide risk is detected. Safety planning, a brief intervention for engaging patients with suicide risk that has substantial empirical support [12] should not be conflated with "contracting for safety", an outdated practice now seen as potentially harmful and counterproductive [40,41]. MacDonald et al.'s systematic review [42] that patients presenting with suicidality report experiencing care that "ranges from gentle to hostile". ...
Article
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Primary care clinics serve many patients experiencing latent or evident suicide risk and may benefit from implementing suicide care improvements such as the Zero Suicide model. However, little is known about the readiness of clinics to implement such initiatives. We interviewed a range of clinicians (e.g., medical providers, behavioral health providers, nurses; n = 24) from six integrated primary care clinics to better understand strengths and limitations of the milieu, how suicide risk is currently detected and managed, and which implementation strategies could be employed to improve suicide prevention. We found clinics were extremely busy and resource-constrained but had a strong and longitudinal commitment to patients and families. Suicide risk was detected in a variety of ways and clinicians had limited resources to offer these patients. Clinicians sought to preserve patients’ autonomy and trust while also ensuring their safety. Preferred strategies included dissemination of protocols and tools, training, electronic health record changes, and improved staffing. Our findings suggest that suicide prevention initiatives in primary care should attend to the constraints of the care setting, adapting their approach to ensure they fit with workflow while also centering patient autonomy and rapport.
... A CRP consists of written instructions for a person to use in a crisis. This includes identifying warning signs, coping strategies, seeking professional assistance, and seeking social support [14][15]. As with CRP, safety planning involves lethal means counselling to reduce the person's suicide options by making their environment safer [16]. ...
Article
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Background: Suicide is the act of injuring oneself with the intent to end one's life. The act of attempting suicide involves harming oneself with the intention of ending one's life without actually dying. The term suicide ideation (SI) refers to a variety of contemplations, wishes, and preoccupations with death and suicide. There is still a high suicide rate among late adolescents. It not only leads to the direct loss of many young lives, but also disrupts the psychosocial and socioeconomic environment. The objective of this study is to evaluate the socio-demographic profile, the frequency and intention of suicide, and the suicide rate among people with mental disorders. Methodology: This was an observational study performed in the forensic psychiatric department at the Mental Health Hospital, Taif, Saudi Arabia. During a one-year period, 654 patients of both genders visited the outpatient department (OPD). Suicidal patients admitted to the inpatient (IPD) ward (n = 16) between June 2020 and July 2021 were included in the study. A descriptive statistical analysis was conducted and presented as frequency and percentage categorical variables. We also evaluate suicide rates in psychiatric disorders. Results: The study has 625 males and 29 females from a total of 654 OPD patients. Among 16 suicidal admitted IPD patients, 13 were male (81.25%) and 3 were female (18.75%). The majority of patients (81.25%) were in the age group of 31 to 40 years. The maximum number of suicidal attempts was 68.75%, while suicidal ideation was 31.25%. 50% of patients were diagnosed with substance abuse with personality disorders, 31.25% were schizophrenic, and 18.75% suffered from depression. In our study, 11 patients attempted suicide (68.75%), and 5 patients had suicidal ideation (31.25%). Conclusions: Suicidal tendencies and thoughts are low among females and young adults between 21-30 years of age. Male gender, unmarried patients, and adolescents in the 31-40 age range were among the risk factors. These factors focus on improving treatment and support for these people, which may reduce their risk of repeating such behaviors.
... Because of this, suicidal ideation is not necessarily targeted directly in trauma-focused psychotherapies (Bryan and Rozek, 2018), based on the assumption that targeting PTSD symptoms will indirectly reduce suicidal ideation. Our results suggest suicidal desire and suicidal intent functioned as drivers rather than consequences of change in PTSD and depression symptoms, however, implicating the potential importance of directly targeting suicidal ideation early in the treatment process with evidence-based practices like crisis response planning, a safety planning-type intervention that has been shown to rapidly reduce suicidal ideation (Bryan et al., 2017(Bryan et al., , 2024. ...
... Furthermore, we sought to explore the utilization of a safety plan intervention, which has demonstrated effectiveness in reducing suicide risk and enhancing treatment adherence among neurotypical individuals. 16,17 By examining how clinicians currently employ existing practices and intervention tools for addressing suicidal behavior in individuals with ASD, we aimed to contribute to the development of future methods or adaptations in this field. ...
Article
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Background Several studies have demonstrated that individuals with autism spectrum disorder (ASD) are at a significantly higher risk of suicide, with over 7.5 times increased likelihood of dying by suicide and higher rates of suicidal ideation. The present study aimed to examine the perspectives and awareness of psychiatrists regarding suicidal behavior in individuals with ASD. Methods To achieve this, an online survey was developed to assess clinicians’ practices in evaluating suicidal thoughts and behaviors in individuals with ASD. Results A total of 143 psychiatrists, including 55 general adult psychiatrists and 88 child and adolescent psychiatrists, completed the cross-sectional survey. The results of the study revealed that clinicians reported lower rates of suicidal ideation and behavior in individuals with ASD compared to those without ASD (P < .05). Furthermore, it was found that the usage of screening tools for assessing suicidal behavior was significantly lower in the ASD group (P < .05). Conclusion The study aimed to investigate psychiatrists’ knowledge and screening practices regarding ASD and emphasize the importance of increasing knowledge and implementing effective screening and intervention practices to address the risk of suicidality in individuals with ASD.
... Drug delivery systems (DDS) refer to the technologies used to deliver therapeutic agents to their intended targets in the body. The development of DDS has revolutionized the field of medicine by enabling targeted and controlled drug release, improving therapeutic efficacy, and minimizing side effects [7,8]. One promising area of research in DDS is the use of nanomaterials for drug delivery, which offers advantages such as high drug loading capacity, prolonged circulation time, and enhanced bioavailability [9,10]. ...
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... The SPI is a single session intervention during which clinicians collaborate with patients to identify warning signs of future suicidal crises and create a written plan delineating a series of actionable coping steps to reduce suicide risk during future suicidal crises (Stanley & Brown, 2012). The SPI has been shown to reduce suicidal behaviors and increase treatment engagement in adult acute care settings (Bryan et al., 2017;Stanley et al., 2018). Although the SPI has yet to be formally studied within MCTs, it is an attractive candidate EBP for this context given that it can be completed in a single encounter. ...
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Mobile crisis teams (MCTs) deploy clinicians to assist individuals in acute crisis in the community. Little is known about the extent to which these teams provide evidence-based practices (EBPs) for suicide prevention nor the barriers they face. We surveyed 120 MCT clinicians across the United States about their: (1) use of suicide risk screening and assessment tools; (2) strategies used to address suicide risk (both EBPs and non-EBPs); and (3) perceived barriers to high-quality MCT services. Nearly all clinicians reported use of validated suicide screening tools and generic “safety planning.” However, a sizeable minority also reported use of non-EBPs. Open-ended responses suggested many client/family-, clinician-, and systems-level barriers to MCT use of EBPs for suicide prevention. We identified several targets for future implementation efforts, including the need for de-implementation strategies to reduce use of ineffective and potentially harmful practices, and unique aspects of MCTs that require tailored implementation supports.
... Although many suicide-focused interventions like the commitment to treatment agreement, crisis response plan or safety plan, means safety counseling, and safe storage are reasonably easy to understand, there are often unrecognized nuances to clinical implementation. Approximately one-third of clinicians who received training focused on suicide safety planning, for example, incorrectly identified contracting for safety as a component of the intervention (Wharff et al., 2012), even though contracting for safety has been discouraged for over a decade (Rudd et al., 2006) and found to be less effective than crisis response planning (Bryan et al., 2017). Mere access to manuals and workshop attendance is therefore insufficient. ...
Chapter
This chapter reviews a cognitive behavioral therapy (CBT) model for supervision of clinical care involving suicidal individuals. It is almost a certainty that clinicians in training can expect to have contact with a client reporting suicidal thoughts and/or suicidal behavior. There is growing consensus regarding core competencies critical to effective clinical care for those experiencing suicidality, including assessment, clinical management, and ultimately treatment. This chapter provides a detailed review of identified core competencies, along with a competency-based framework for supervision, suggestions, strategies, and tasks geared toward helping prepare clinicians in training for the realities of clinical practice, coupled with a commitment to lifelong learning and continuous professional development.KeywordsSuicide riskCore competenciesClinical supervision strategiesClinical supervisionCBTSuicide assessmentSuicide treatmentClinician self-careLegal issuesFormulating riskSupervision agreementSelf-awarenessSuicideManaging careFluid vulnerability
... The SCS-R is used to differentiate people who have previously attempted suicide from people who have only had suicidal thoughts (Bryan et al., 2014). The SCS-R can also predict consecutive suicidal behavior after controlling for suicidal thoughts (Bryan et al., 2014Bryan, Mintz, et al., 2017). It can be said that the SCS-R is a reliable tool for measuring suicide risk beyond suicidal ideation. ...
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Suicidal thoughts and behaviors (STBs) are a significant public health problem. This study aims to examine the validity and reliability of the Turkish version of the Suicide Cognitions Scale-Revised (SCS-R). Participants (N = 442, age range: 18-29 years) completed the SCS-R, the Beck Depression Inventory, the Inventory of Statements About Self-injury, the Suicide Probability Scale, and the Suicide Rumination Scale. Principal component analysis showed that the SCS-R consisted of a single factor and that the SCS-R could differentiate between participants at high risk and low risk of suicide. High-to-moderate positive associations were found between the measures of depression, suicide probability, suicide rumination, and non-suicidal self-injury and suicide cognition. The Turkish version of the SCS-R has good psychometric properties. This scale can be used to screen for cognitive patterns that are most prone to suicide and to manage such cognitive characteristics, which are important steps for preventive interventions.
... The proposed SCS diagnosis would focus attention on current state-based risk factors, reducing dependence on self-reported suicidal ideation, which has been shown to lead to a high number of both false negatives and false positives (Berman, 2018). A state-like diagnosis would guide and support time-sensitive clinical judgment (Chu et al., 2015;Ribeiro et al., 2013), thereby improving and clarifying safety and discharge planning (Bryan et al., 2017). Importantly, the improved precision of risk assessment with a suicide-specific diagnosis would reduce unnecessary health-care expenses while simultaneously improving identification of patients truly in need of intensified care. ...
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The potential harms related to interventions for adults with suicide-related risk, particularly hospitalization, have been well documented. Much less work has focused on the potential harms related to interventions with youth struggling with suicidal thoughts and behaviors. Young people are most likely to receive mental health services in schools, which are recognized as meaningful sites for effective suicide prevention work. However, no overviews have conceptualized the potential harms to youth when schools engage in ineffective suicide prevention efforts. In this article, we discuss three prominent overlapping areas of potential harms: (1) privacy-related, (2) relationship-related, and (3) mental health-related. We then discuss key factors thought to influence the development and maintenance of these potential harms. We conclude by noting ways in which school-based mental health providers may attempt to reduce unintentional harms in this area, with an overarching goal of helping support school mental health providers and the youth they serve.
Article
Aim: Suicide safety planning is an intervention to help people stay safe during a suicidal crisis. This qualitative study aimed to explore professionals’ feedback regarding a cultural adaptation of an Iranian online suicide safety plan intervention (SPI). Furthermore, users' reactions to this adapted website were investigated. Method: Eleven professionals (72.7% male; Mage= 41.18; SDage= 7.11; range: 33 to 57 years), specialized in working with individuals at risk of suicide and fourteen patients/users (57.1% male; Mage= 24.57; SDage= 5.19; range: 20 to 36 years) took part in the study. Think-aloud, methods and semi-structured interviews were used to gather participants’ feedback. Data was analyzed using the thematic analysis method. Results: Three main themes emerged from the thematic analysis: (1.) Benefits of the safety plan intervention website, (2.) Challenges of the safety plan intervention website, and (3.) Suggestions for improving the safety plan intervention website. Conclusion: By incorporating cultural considerations and user preferences, the Iranian SPI website might serve the needs of its users and contribute to the overall well-being of the community.
Article
Objective: Safety planning for suicide prevention is an important quality metric for Zero Suicide implementation. We describe the development, validation, and application of electronic health record (EHR) programs to measure uptake of safety planning practices across six integrated healthcare systems as part of a Zero Suicide evaluation study. Methods: Safety planning was documented in narrative notes and structured EHR templates using the Stanley Brown Safety Planning Intervention (SBSPI) in response to a high-risk cutoff score on the Columbia Suicide Severity Rating Scale (CSSRS). Natural Language Processing (NLP) metrics were developed and validated using chart review to characterize practices documented in narrative notes. We applied NLP to measure frequency of documentation in the narrative text and standard programming methods to examine structured SBSPI templates from 2010-2022. Results: Chart reviews found three safety planning practices documented in narrative notes that were delivered to at least half of patients at risk: professional contacts, lethal means counseling for firearms, and lethal means counseling for medication access/storage. NLP methods were developed to identify these practices in clinical text with high levels of accuracy (Sensitivity, Specificity, & PPV ≥ 82%). Among visits with a high-risk CSSRS, 40% (Range 2-73% by health system) had an SBSPI template within 1 year of implementation. Conclusions: This is one of the first reports describing development of measures that leverage electronic health records to track use of suicide prevention safety plans. There are opportunities to use the methods developed here in future evaluations of safety planning.
Article
هدف الدراسة: تهدف هذه الدراسة إلى تعرف تأثير القيادة الرقمية بأبعادها في تطبيق إستراتيجيات إدارة الأزمات في ظل وجود الذكاء الاصطناعي متغيراً وسيطاً في وزارة الاتصالات وتكنولوجيا المعلومات الفلسطينية بالمحافظات الشمالية.تصميم/منهجية/طريقة الدراسة: اعتمدت الدراسة المنهج الوصفي التحليلي، واستخدمت الاستبانة أداة رئيسة لجمع البيانات المتعلقة بمتغيرات الدراسة، وحللت بيانات الدراسة واختبرت فروضها باستخدام أسلوب نمذجة المعادلة الهيكلية بالمربعات الصغرى الجزئية (PLS-SEM) بواسطة برنامج (SPSS V.25) و(Smart PLS V.30).عينة الدراسة وبياناتها: أجرت الدراسة الميدانية مسحاً شاملاً لجميع العاملين في الوظائف القيادية والإشرافية ضمن الفئات العليا الأولى والثانية، متمثلة في بــ (مدير عام، مدير، رئيس قسم)، ويبلغ عددهم (139) مبحوثاً مستجيباً.نتائج الدراسة: توصلت الدراسة إلى أن مستوى تطبيق متغيرات الدراسة المتمثلة في (القيادة الرقمية، وإستراتيجيات إدارة الأزمات، والذكاء الاصطناعي) قد جاءت بشكل عام بدرجة عالية، كما أظهرت نتائج الدراسة أن القيادة الرقمية بأبعادها مجتمعة تؤثر تأثيراً إيجابياً كبيراً في كل من تطبيق إستراتيجيات إدارة الأزمات والذكاء الاصطناعي، وبينت النتائج أيضاً أن تطبيق الذكاء الاصطناعي يؤثر تأثيراً معنوياً إيجابياً متوسطاً في تطبيق إستراتيجيات إدارة الأزمات، وأكدت نتائج الدراسة وجود وساطة جزئية للذكاء الاصطناعي في تعزيز تأثير القيادة الرقمية في تطبيق إستراتيجيات إدارة الأزمات. أصالة الدراسة: تعدَ هذه الدراسة- في حدود علم الباحث- الأولى من نوعها على مستوى البيئة الأجنبية والعربية، التي تناولت طبيعة التأثير غير المباشر للقيادة الرقمية في تطبيق إستراتيجيات إدارة الأزمات من خلال الدور الوسيط للذكاء الاصطناعي في أنموذج فرضي واحد.حدود الدراسة وتطبيقاتها: اقتصرت الدراسة على جميع العاملين في الوظائف القيادية والإشرافية في وزارة الاتصالات وتكنولوجيا المعلومات الفلسطينية بالمحافظات الشمالية.
Article
Background: The term "safety management planning" can be thought of as having evolved to constitute a number of different intervention types and components used across various clinical settings with various populations. This poses a challenge for effective communication between clinicians and likely variability in the clinical effectiveness of these interventions. Aim: This PRISMA Scoping Review aims to review the literature to ascertain which intervention components and characteristics currently fall under this umbrella term as well as in which contexts the plans are delivered and who is involved in the process. Method: Published research studies in PsycINFO, CINAHL Plus, MEDLINE, Science Direct and Web of Science were reviewed. Grey literature was searched using the databases Base and OpenGrey as well as through the search engine Google. Results: 2853 abstracts were initially identified for screening and 74 pieces of literature informed the final review, with 54 derived from the published academic literature and 20 from the grey literature. Results indicated that the safety plans are used with a wide variety of populations and often include components related to identifying warning signs, internal coping strategies, accessing social professional support amongst other components. Conclusion: Although most safety management plans described appeared to be based on specific interventions, there was a large amount of heterogeneity of components and characteristics observed. This was particularly the case with regards to safety management planning within the grey literature.
Article
To examine the differences in treatment seeking behaviors, previous suicidal thoughts, previous suicide attempts, and disclosure of suicidal thoughts among female service members (SM)/Veteran suicide decedents who used a firearm and those who used another method. Data was acquired from the National Violent Death Reporting System which is maintained and monitored by the Center for Disease Control and Prevention. Data included in the present study were from suicide deaths that occurred between 2003-2018. Female SM/Veterans who died by firearm suicide had lower proportions of current mental health or substance use treatment, lifetime mental health or substance use treatment, and previous suicide attempts compared to those who used another method. Female SM/Veterans who die by firearm suicide are less likely to encounter mental health services than those who use another method. Conversations on secure firearm storage need to occur outside of the health care setting.
Article
Romantic relationships can both attenuate and exacerbate suicide risk. Suicide prevention strategies in the United States have emphasized the importance of healthy connections with others; however, suicide prevention efforts overwhelmingly continue to focus on individual‐level interventions. This presents a missed opportunity to prevent suicide through a focus on romantic relationship factors that are strongly associated with suicidal thoughts and behaviors. To identify underutilized or new avenues for improving suicide prevention, the current article aims to (a) provide an overview of the literature on romantic relationship functioning and suicide risk in adults to elucidate potential prevention targets, and (b) use a public health framework to highlight evidence‐based and emerging avenues to prevent suicide by targeting relevant relationship factors.
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Background Suicide is the 12th leading cause of death in the United States. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill building are resource intensive and difficult to implement. Novel computer technologies harnessing artificial intelligence are now available, which hold promise for increasing the feasibility of providing trainees opportunities across a range of continuing education contexts to engage in skills practice with constructive feedback on performance. Objective This pilot study aims to evaluate the feasibility and acceptability of an eLearning training in suicide safety planning among nurses serving patients admitted to a US level 1 trauma center for acute or intensive care. The training included a didactic portion with demonstration, practice of microcounseling skills with a web-based virtual patient (Client Bot Emily), role-play with a patient actor, and automated coding and feedback on general counseling skills based on the role-play via a web-based platform (Lyssn Advisor). Secondarily, we examined learning outcomes of knowledge, confidence, and skills in suicide safety planning descriptively. Methods Acute and intensive care nurses were recruited between November 1, 2021, and May 31, 2022, to participate in a formative evaluation using pretraining, posttraining, and 6-month follow-up surveys, as well as observation of the nurses’ performance in delivering suicide safety planning via standardized patient role-plays over 6 months and rated using the Safety Plan Intervention Rating Scale. Nurses completed the System Usability Scale after interacting with Client Bot Emily and reviewing general counseling scores based on their role-play via Lyssn Advisor. Results A total of 18 nurses participated in the study; the majority identified as female (n=17, 94%) and White (n=13, 72%). Of the 17 nurses who started the training, 82% (n=14) completed it. On average, the System Usability Scale score for Client Bot Emily was 70.3 (SD 19.7) and for Lyssn Advisor was 65.4 (SD 16.3). On average, nurses endorsed a good bit of knowledge (mean 3.1, SD 0.5) and confidence (mean 2.9, SD 0.5) after the training. After completing the training, none of the nurses scored above the expert-derived cutoff for proficiency on the Safety Plan Intervention Rating Scale (≥14); however, on average, nurses were above the cutoffs for general counseling skills per Lyssn Advisor (empathy: mean 4.1, SD 0.6; collaboration: mean 3.6, SD 0.7). Conclusions Findings suggest the completion of the training activities and use of novel technologies within this context are feasible. Technologic modifications may enhance the training acceptability and utility, such as increasing the virtual patient conversational abilities and adding automated coding capability for specific suicide safety planning skills. International Registered Report Identifier (IRRID) RR2-10.2196/33695
Article
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While 10 million U.S. adults experience suicidal thoughts and 1.7 million attempt suicide annually, candid, truthful endorsement of assessment items related to suicidal ideation (SI) can be inhibited by stigma, shame, and embarrassment and a fear of involuntary hospitalization. Suicidal ideation in, and suicide attempts by, family members increase the suicide risk among other members by several times, and so accurate detection of SI is crucial for couple and family therapists. To address concerns about stigma and false negatives in screening for SI, a 19-item subtle screening of suicidal ideation (SSSI) was developed from a pool of 32 “proxy” items tapping psychological pain, emotional intelligence, and negative alterations in mood and cognitions. A demographics form, a measure of suicidal ideation, measures of anxiety, depression, and traumatic stress, and versions of the Beck Hopelessness Scale and the Interpersonal Needs Questionnaire were also used for data collection. Principal components analysis and reliability, correlation, and multiple regression procedures on data from a non-random, diverse sample of adults (N = 306) provided evidence of excellent reliability (α = .93) and convergent and discriminant validity for the SSSI. The three-dimensional SSSI accounted for 54.9% of the variance in a direct measure of suicidal thoughts, and a Receiver Operator Characteristic curve identified a cut-off score of 35 with a sensitivity of .937 and specificity of .81, indicating the instrument successfully identifies those with and without suicidal thoughts. Clinical implications and future research are discussed.
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Background: Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies. Aim: To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database. Methods: A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends. Results: Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment. Conclusion: This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societal attitudes toward suicide and homicides are essential components of a comprehensive strategy.
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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.
Article
Objective: The use of exclusion criteria in clinical trials can cause research participants to differ markedly from clinical populations, which negatively impacts generalizability of results. This study identifies and quantifies common and recurring exclusion criteria in clinical trials studying suicide risk reduction, and estimates their impact on eligibility among a clinical sample of adults in an emergency department with high suicide risk. Method: Recent trials were identified by searching PubMed (terms suicide, efficacy, effectiveness, limited to clinical trials in prior 5 years). Common exclusion criteria were identified using Qualitative Content Analysis. A retrospective chart review examined a one-month sample of all adults receiving psychiatric evaluation in a large urban academic emergency department. Results: The search yielded 27 unique clinical trials studying suicide risk reduction as a primary or secondary outcome. After research fundamentals (e.g. informed consent, language fluency), the most common exclusion criteria involved psychosis (77.8%), cognitive problems (66.7%), and substance use (63.0%). In the clinical sample of adults with high suicide risk (N = 232), psychosis exclusions would exclude 53.0% of patients and substance use exclusions would exclude 67.2% of patients. Overall, 5.6% of emergency psychiatry patients would be eligible for clinical trials that use common exclusion criteria. Conclusions: Recent clinical trials studying suicide risk reduction have low generalizability to emergency psychiatry patients with high suicide risk. Trials enrolling persons with psychosis and substance use in particular are needed to improve generalizability to this clinical population.
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Background Suicide safety planning is an evidence-based approach used to help individuals identify strategies to keep themselves safe during a mental health crisis. This study systematically reviewed the literature focused on mobile health (mHealth) suicide safety planning apps. Objective This study aims to evaluate the extent to which apps integrated components of the safety planning intervention (SPI), and if so, how these safety planning components were integrated into the design-based features of the apps. Methods Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we systematically analyzed 14 peer-reviewed studies specific to mHealth apps for suicide safety planning. We conducted an analysis of the literature to evaluate how the apps incorporated SPI components and examined similarities and differences among the apps by conducting a comparative analysis of app features. An independent review of SPI components and app features was conducted by downloading the available apps. Results Most of the mHealth apps (5/7, 71%) integrated SPI components and provided customizable features that expanded upon traditional paper-based safety planning processes. App design features were categorized into 5 themes, including interactive features, individualized user experiences, interface design, guidance and training, and privacy and sharing. All apps included access to community supports and revisable safety plans. Fewer mHealth apps (3/7, 43%) included interactive features, such as associating coping strategies with specific stressors. Most studies (10/14, 71%) examined the usability, feasibility, and acceptability of the safety planning mHealth apps. Usability findings were generally positive, as users often found these apps easy to use and visually appealing. In terms of feasibility, users preferred using mHealth apps during times of crisis, but the continuous use of the apps outside of crisis situations received less support. Few studies (4/14, 29%) examined the effectiveness of mHealth apps for suicide-related outcomes. Positive shifts in attitudes and desire to live, improved coping strategies, enhanced emotional stability, and a decrease in suicidal thoughts or self-harm behaviors were examined in these studies. Conclusions Our study highlights the need for researchers, clinicians, and app designers to continue to work together to align evidence-based research on mHealth suicide safety planning apps with lessons learned for how to best deliver these technologies to end users. Our review brings to light mHealth suicide safety planning strategies needing further development and testing, such as lethal means guidance, collaborative safety planning, and the opportunity to embed more interactive features that leverage the advanced capabilities of technology to improve client outcomes as well as foster sustained user engagement beyond a crisis. Although preliminary evidence shows that these apps may help to mitigate suicide risk, clinical trials with larger sample sizes and more robust research designs are needed to validate their efficacy before the widespread adoption and use.
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Objective: This study examined whether posttraumatic stress disorder (PTSD) symptom change during a 3- and 2-week intensive treatment program (ITP)-based in cognitive processing therapy was predictive of reduced suicidal ideation (SI) following treatment. Method: Veterans completed either a 3-week (n = 274, Mage = 42.35, SD = 9.43, 64.23% male, 65.33% White) or 2-week (n = 177, Mage = 42.90, SD = 9.81, 57.63% male, 66.67% White) ITP and self-reported PTSD, depression, and SI symptoms prior to, during, and 3 months following treatment. Results: Mixed-effects-based two-stage location scale models assessed change in both overall PTSD severity over the course of the 3- and 2-week ITPs, as well as how this change predicted 3-month follow-up SI. Veterans in both programs reported moderate reductions in SI from baseline to posttreatment (3 weeks: d = 0.49; 2 weeks: d = 0.48). Of the 210 veterans across both programs who endorsed at least some SI at baseline, two-thirds (65.24%) reported reductions in SI posttreatment; three-quarters (74.45%) of these maintained posttreatment SI at 3-month follow-up that was lower than baseline levels. Conclusions: Both baseline SI and greater individual improvement in PTSD symptom severity during the ITPs were associated with lower SI at 3-month follow-up. Overall, study findings suggest that veterans with PTSD who also endorse SI can be successfully treated using the intensive delivery format and are likely to experience a reduction in SI both during and following treatment.
Article
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Suicide is a global public health concern. Training for mental health professionals (MHPs) is a common approach to ensuring sound clinical care for persons experiencing suicidality. This article proffers an updated set of suicide prevention core competencies for MHPs through a literature-driven process. First, we outline a stepwise model of suicide prevention training ranging from gatekeeper approaches to advanced suicide-specific assessment and intervention skills. We then review recent paradigm shifts in the suicide prevention literature: (a) emergence of ideation-to-action and fluidity theories; (b) shift to therapeutic prevention-focused risk assessment; (c) increased attention to cultural factors in suicide; and (d) advances in suicide-specific intervention. These trends in the suicide literature serve as a rationale to update the Core Competency Model (CCM) of Suicide Prevention, a training program intentionally designed to improve beginner-to-intermediate provider-focused (e.g., managing one’s own suicide attitudes) and clinical (e.g., clinical documentation) skills. We outline changes to competency wording and training, providing a sample CCM training curriculum. The Suicide Competency Assessment Form (SCAF), a self- and observer-rated measure of skill acquisition, is revised to reflect the updated competencies. Finally, we provide recommendations for (a) future psychometric assessment of the revised SCAF (SCAF-R); (b) suicide prevention training, implementation, and evaluation; and (c) ways to extend suicide prevention core competencies beyond MHPs.
Article
Introduction: Safety planning type interventions (SPTI's) are brief suicide-specific interventions. Little is known about safety plan use during high-risk periods, and whether safety plan use is influenced by baseline characteristics. This study examined how adolescents recently hospitalized for suicide risk use their safety plans post-discharge, tested moderators of safety plan utilization, and explored the relationship between changes in utilization and changes in suicidal ideation (SI) over time. Methods: Seventy-eight adolescents hospitalized for suicide risk who participated in a pilot trial of safety planning responded to one survey/day for 4 weeks post-discharge and completed a 1-month assessment. Results: Over 90% of adolescents reported having access to their safety plan during the month post-discharge. Safety plan use and SI declined over time. No baseline characteristics predicted safety plan use in the 4 weeks after discharge, or changes in safety plan use over time. However, the relationship between changes in safety plan use and changes in SI was moderated. For girls, SI and safety plan use rose and fell together; for boys, safety plan use declined regardless of changes in SI. Conclusions: High-risk adolescents retain and use their safety plans. Results underscore the importance of looking at sex effects on SPTI utilization.
Article
Objectives: Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. Results: After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). Conclusions: The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).
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To determine the risk factors for suicide, 6,891 psychiatric outpatients were evaluated in a prospective study. Subsequent deaths for the sample were identified through the National Death Index. Forty-nine (1%) suicides were determined from death certificates obtained from state vital statistics offices. Specific psychological variables that could be modified by clinical intervention were measured using standardized scales. Univariate survival analyses revealed that the severity of depression, hopelessness, and suicide ideation were significant risk factors for eventual suicide. A multivariate survival analysis indicated that several modifiable variables were significant and unique risk factors for suicide, including suicide ideation, major depressive disorder, bipolar disorder, and unemployment status.
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Background: Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance. Methods and findings: Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period. The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated. During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4-13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts. Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment. Conclusions: ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings. Trial registration: ClinicalTrials.gov NCT02505373.
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To determine the risk factors for suicide, 6,891 psychiatric outpatients were evaluated in a prospective study. Subsequent deaths for the sample were identified through the National Death Index. Forty-nine (1%) suicides were determined from death certificates obtained from state vital statistics offices. Specific psychological variables that could be modified by clinical intervention were measured using standardized scales. Univariate survival analyses revealed that the severity of depression, hopelessness, and suicide ideation were significant risk factors for eventual suicide. A multivariate survival analysis indicated that several modifiable variables were significant and unique risk factors for suicide, including suicide ideation, major depressive disorder, bipolar disorder, and unemployment status.
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The no-suicide contract is widely recommended as an important intervention in the care of suicidal patients; however, there are no data demonstrating its effectiveness or its acceptance in the professional community. This study examines the use of no-suicide contracts by psychiatrists in Minnesota. A postcard questionnaire was mailed to 514 psychiatrists in Minnesota inquiring about their practices and experiences with no-suicide contracts. There were 267 responses, yielding a response rate of 52%. No-suicide contracts were used by 152 (57%) of the respondents. Within this group, 62 (41%) of the psychiatrists had patients who committed suicide or made serious attempts after entering into a no-suicide contract. Among the respondents to the questionnaire, slightly more than half used no-suicide contracts, indicating that such contracts are not universally accepted as standard practice among these psychiatrists. More data are needed to determine the effectiveness of no-suicide contracts in preventing suicide.
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Suicide attempts constitute a major risk factor for completed suicide, yet few interventions specifically designed to prevent suicide attempts have been evaluated. To determine the effectiveness of a 10-session cognitive therapy intervention designed to prevent repeat suicide attempts in adults who recently attempted suicide. Randomized controlled trial of adults (N = 120) who attempted suicide and were evaluated at a hospital emergency department within 48 hours of the attempt. Potential participants (N = 350) were consecutively recruited from October 1999 to September 2002; 66 refused to participate and 164 were ineligible. Participants were followed up for 18 months. Cognitive therapy or enhanced usual care with tracking and referral services. Incidence of repeat suicide attempts and number of days until a repeat suicide attempt. Suicide ideation (dichotomized), hopelessness, and depression severity at 1, 3, 6, 12, and 18 months. From baseline to the 18-month assessment, 13 participants (24.1%) in the cognitive therapy group and 23 participants (41.6%) in the usual care group made at least 1 subsequent suicide attempt (asymptotic z score, 1.97; P = .049). Using the Kaplan-Meier method, the estimated 18-month reattempt-free probability in the cognitive therapy group was 0.76 (95% confidence interval [CI], 0.62-0.85) and in the usual care group was 0.58 (95% CI, 0.44-0.70). Participants in the cognitive therapy group had a significantly lower reattempt rate (Wald chi2(1) = 3.9; P = .049) and were 50% less likely to reattempt suicide than participants in the usual care group (hazard ratio, 0.51; 95% CI, 0.26-0.997). The severity of self-reported depression was significantly lower for the cognitive therapy group than for the usual care group at 6 months (P= .02), 12 months (P = .009), and 18 months (P = .046). The cognitive therapy group reported significantly less hopelessness than the usual care group at 6 months (P = .045). There were no significant differences between groups based on rates of suicide ideation at any assessment point. Cognitive therapy was effective in preventing suicide attempts for adults who recently attempted suicide.
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This article reviews the literature on the use of "no-suicide contracts" in clinical practice, including conceptual discussions, patient and clinician surveys, and a few empirical studies on clinical utility. Our primary conclusion is that no-suicide contracts suffer from a broad range of conceptual, practical, and empirical problems. Most significantly, they have no empirical support for their effectiveness in the clinical environment. The authors provide and illustrate the commitment to treatment statement as a practice alternative to the no-suicide contract.
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Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy. To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non-behavioral psychotherapy experts. One-year randomized controlled trial, plus 1 year of posttreatment follow-up. University outpatient clinic and community practice. One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors. Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005), required less hospitalization for suicide ideation (F(1,92) = 7.3; P = .004), and had lower medical risk (F(1,50) = 3.2; P = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P < .001) and had fewer psychiatric hospitalizations (F(1,92) = 6.0; P = .007) and psychiatric emergency department visits (F(1,92) = 2.9; P = .04). Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.
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The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.
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The Centers for Disease Control and Prevention recently reported that the nation’s mortality rate climbed in 2015 for the first time in a decade. This surprising result is linked to increases in the rate of several causes of death, including suicide. Indeed, the death rate for suicide has been rising steadily for over a decade. By now we are almost inured to news reports about high or rising rates among veterans, American Indian/Alaska Native young people, and other groups. At the same time, we hear frequently that research investments in suicide prevention are inadequate. Former National Institute on Mental Health Director Tom Insel has pointed out that research investments for suicide prevention lag far behind those for other causes of death in absolute terms and also considering the number of people affected.
Conference Paper
These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide and attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening/case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed.
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IMPORTANCE: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) is a multicomponent study designed to generate actionable recommendations to reduce Army suicides and increase knowledge of risk and resilience factors for suicidality. OBJECTIVES: To present data on prevalence, trends, and basic sociodemographic and Army experience correlates of suicides and accident deaths among active duty Regular Army soldiers between January 1, 2004, and December 31, 2009, and thereby establish a foundation for future Army STARRS investigations. DESIGN, SETTING, AND PARTICIPANTS: Analysis of trends and predictors of suicide and accident deaths using Army and Department of Defense administrative data systems. Participants were all members of the US Regular Army serving at any time between 2004 and 2009. MAIN OUTCOMES AND MEASURES: Death by suicide or accident during active Army service. RESULTS: The suicide rate rose between 2004 and 2009 among never deployed and currently and previously deployed Regular Army soldiers. The accident death rate fell sharply among currently deployed soldiers, remained constant among the previously deployed, and trended upward among the never deployed. Increased suicide risk was associated with being a man (or a woman during deployment), white race/ethnicity, junior enlisted rank, recent demotion, and current or previous deployment. Sociodemographic and Army experience predictors were generally similar for suicides and accident deaths. Time trends in these predictors and in the Army’s increased use of accession waivers (which relaxed some qualifications for new soldiers) do not explain the rise in Army suicides. CONCLUSIONS AND RELEVANCE: Predictors of Army suicides were largely similar to those reported elsewhere for civilians, although some predictors distinct to Army service emerged that deserve more in-depth analysis. The existence of a time trend in suicide risk among never-deployed soldiers argues indirectly against the view that exposure to combat-related trauma is the exclusive cause of the increase in Army suicides.
Article
These guidelines review what is known about the epidemiology, causes, management, and prevention of suicide an attempted suicide in young people. Detailed guidelines are provided concerning the assessment and emergency management of the children and adolescents who present with suicidal behavior. The guidelines also present suggestions on how the clinician may interface with the community. Crisis hotlines, method restriction, educational programs, and screening case-finding suicide prevention strategies are examined, and the clinician is advised on media counseling. Intervention in the community after a suicide, minimization of suicide contagion or imitation, and the training of primary care physicians and other gatekeepers to recognize and refer the potentially suicidal child and adolescent are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
The usual care for suicidal patients who are seen in the emergency department (ED) and other emergency settings is to assess level of risk and refer to the appropriate level of care. Brief psychosocial interventions such as those administered to promote lower alcohol intake or to reduce domestic violence in the ED are not typically employed for suicidal individuals to reduce their risk. Given that suicidal patients who are seen in the ED do not consistently follow up with recommended outpatient mental health treatment, brief ED interventions to reduce suicide risk may be especially useful. We describe an innovative and brief intervention, the Safety Planning Intervention (SPI), identified as a best practice by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention (www.sprc.org), which can be administered as a stand-alone intervention. The SPI consists of a written, prioritized list of coping strategies and sources of support that patients can use to alleviate a suicidal crisis. The basic components of the SPI include (a) recognizing warning signs of an impending suicidal crisis; (b) employing internal coping strategies; (c) utilizing social contacts and social settings as a means of distraction from suicidal thoughts; (d) utilizing family members or friends to help resolve the crisis; (e) contacting mental health professionals or agencies; and (f) restricting access to lethal means. A detailed description of SPI is described and a case example is provided to illustrate how the SPI may be implemented.
Article
Suicide is a leading cause of deaths of U.S. service members. Medical care providers may play a role in suicide prevention. We summarized the outpatient experiences of service members prior to suicide or self-inflicted injury and compared them with service members without suicidal behavior. During 2001-2010, 45 percent of individuals who completed suicide and 75 percent of those who injured themselves had outpatient encounters within 30 days prior to suicide/self-harm. Primary care was the most frequently visited clinical service prior to suicide/self-harm. As compared to their counterparts, service members with suicidal behavior had especially excessive outpatient visit rates within, but not prior to, 60 days of their deaths/injuries. The finding suggests that there may be one or more "triggering" events that lead to care-seeking. These results may help identify individuals that should be screened for suicide risk.
Article
The No Harm Contract has been widely accepted in clinical practice, yet there is no broad consensus as to its value. This paper examines the contract and offers recommendations for its use as well as cautions about its misuse. After a literature review, the No Harm Contract is examined from diagnostic, therapeutic, and medicolegal perspectives. Diagnostically, the No Harm Contract can be used to assess the nature and severity of a patient's suicidality, uncover specific troubling issues precipitating suicidal thoughts, and evaluate the patient's competency to contract. Therapeutically, the contract affords an opportunity to initiate a therapeutic alliance, establish the limits of the psychotherapeutic framework, and reduce both patient and clinician anxiety. Medicolegally, the contract is not legally binding and grants no suicide malpractice suit protection. Although the No Harm Contract is a frequently used clinical tool that can provide diagnostic information and therapeutic advantage, it can also short-circuit comprehensive suicidal assessment and disposition decisions.
Article
The rapid growth of managed care has accelerated the evolution of the clinical record. Previously used for process notations, global assessment, and treatment planning, the record is increasingly used to demonstrate accountability to third-party payers and to the legal system. This article discusses the documentation of accountability in the case of potential client suicide or violence toward others.
Article
In the managed care era, mental health professionals increasingly rely upon suicide prevention contracts in the management of patients at suicide risk. Although asking a patient if he or she is suicidal and obtaining a written or oral contract against suicide can be useful, these measures by themselves are insufficient. "No harm" contracts cannot take the place of formal suicide risk assessments. Obtaining a suicide prevention contract from the patient tends to be an event whereas suicide risk assessment is a process. The suicide prevention contract is not a legal document that will exculpate the clinician from malpractice liability if the patient commits suicide. The contract against self-harm is only as good as the underlying soundness of the therapeutic alliance. The risks and benefits of suicide prevention contracts must be clearly understood.
Article
No-suicide contracts, in their various forms, can deepen commitment to a positive action, strengthen the therapeutic alliance, facilitate communication, lower anxiety, aid assessment, and document precautions. Conversely, they can anger or inhibit the client, introduce coercion into therapy, be used disingenuously, and induce false security in the clinician. Research on no-suicide contracts (frequency surveys, assessments of behavior after contracting, and opinions of users) has limitations common to naturalistic studies, and is now ready for more rigorous methods. Mental health professions should be trained to deal with suicidal individuals, including how to use no-suicide contracts. Good contracts are specific, individualized, collaborative, positive, context-sensitive, and copied. However, they are not a thorough assessment, a guarantee against legal liability, nor a substitute for a caring, sensitive therapeutic interaction. No-suicide contracts are no substitute for sound clinical judgment.
Article
This article describes the development, administration, and reliability of the Cornell Services Index (CSI), a new instrument that measures health service use. The CSI was developed to create a standardized measure of the quantity and characteristics (for example, site and provider) of services used by adults. Descriptive data are provided to illustrate the application of the CSI in a community sample of adults who were newly admitted to outpatient mental health clinics. These data provide information about the pathways to care. The interrater and test-retest reliability of the CSI were evaluated by using a sample of 40 adults who were seeking mental health treatment. Descriptive data on service use in a sample of 1,279 adults seeking care in outpatient mental health clinics was provided to demonstrate the application of the CSI. The CSI is a portable, easy to use, and brief assessment of service use. It has good interrater and test-retest reliability among adults without cognitive impairment. In the three months before seeking care, 31 percent of the adults interviewed had made a mental health visit, 36 percent had been hospitalized, and more than half (59 percent) had made a medical visit. Twenty-three percent of adults had sought care from a hospital's emergency department. The CSI is a reliable method to assess health service use for adults. The measure can extend assessment of use beyond the traditional mental health service use questions and provide a snapshot of service use patterns across types, providers, and sites of service among adults who seek mental health care.
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