Evaluation of suicide risk among youths in community settings

Identifying youths in imminent danger of suicide and in need of emergency psychiatric services is a difficult task. Although clinicians have often described the psychiatric profile of youths at risk for suicide, there is little empirical evidence of successful strategies for identifying suicidal risk. Researchers are faced with a number of problems when attempting to validate risk evaluation procedures: Suicide risk profiles vary with age and developmental stage; there appear to be several patterns or subtypes of suicidal patterns; suicidality depends on one's current emotional state; evaluators are likely to be biased in the direction of over-estimating risk and are not likely to have extensive clinical training; imminent danger for suicide is time-limited; and a youth's risk will depend on surrounding environmental stressors and supports. These considerations force researchers to assume a strategic approach in defining levels of suicide risk and imminent danger of suicide. An example of a potential strategy for identifying risk among youths is outlined in this chapter. Although this strategic approach appears useful, researchers continue to be faced with major problems in validating such procedures. Determining the predictive validity of potential suicide screening procedures requires researchers to evaluate and to follow longitudinally a large sample of youths, while deliberately refraining from intervening to help those youths who appear to be in crisis.     

U.S. involuntary mental health commitment statutes: requirements for persons perceived to be a potential harm to self

The civil commitment statutes of all 50 states and the District of Columbia were reviewed to determine: (1) What is required for a person who is believed to be at serious and imminent risk of self-harm to be eligible for involuntary hospitalization; and (2) Whether an attempt to involuntarily hospitalize was required or was merely an option when the requirements found in number 1 were met. The analysis revealed that nearly 85% of the jurisdictions require dangerousness to self to be the result of a mental illness, and only two jurisdictions mandate attempts at involuntary commitment if a person is deemed to be an imminent harm to self. These results have implications for practice with individuals who are suicidal.     

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: The Importance of Active Engagement,Active Rescue,and Collaboration Between Crisis and Emergency Services

In 2012, the SAMHSA‐funded National Suicide Prevention Lifeline (Lifeline) completed implementation of the first national Policy for Helping Callers at Imminent Risk of Suicide across its network of crisis centers. The policy sought to: (1) provide a clear definition of imminent risk; (2) reflect the state of evidence, field experience, and promising practices related to reducing imminent risk through hotline interventions; and (3) provide a uniform policy and approach that could be applied across crisis center settings. The resulting policy established three essential principles: active engagement, active rescue, and collaboration between crisis and emergency services. A sample of the research and rationale that underpinned the development of this policy is provided here. In addition, policy implementation, challenges and successes, and implications for interventions to help Lifeline callers at imminent risk of suicide are detailed.     

The Suicidal Narrative and Its Relationship to the Suicide Crisis Syndrome and Recent Suicidal Behavior

In this study, we introduce the construct of the suicidal narrative, a hypothetical personal narrative linked to imminent suicide, and explore its relationship to near‐term suicidal risk and the suicide crisis syndrome (SCS). Psychiatric outpatients (N = 289) were administered the Columbia Suicide‐Severity Rating Scale (C‐SSRS), Suicide Crisis Inventory (SCI), and Suicide Narrative Inventory (SNI), a novel instrument combining the documented risk factors of Thwarted Belongingness, Perceived Burdensomeness, Humiliation, Social Defeat, Goal Disengagement, and Goal Reengagement. Dimensional measures of past month, lifetime, and past suicidal phenomena, incorporating ideation and behavior, were calculated from the C‐SSRS. Structural equation modeling was used to explore the interaction among variables. Factor analysis of the SNI yielded two orthogonal factors, termed Interpersonal and Goal Orientation. The former factor was comprised of Perceived Burdensomeness, Social Defeat, Humiliation, and Thwarted Belongingness, the latter of Goal Disengagement and Goal Reengagement. The Interpersonal factor correlated with both SCS severity and suicidal phenomena in each time frame and the Goal Orientation factor with no other variable. As hypothesized, the proposed model was significant for the past month only. Our findings support the construct of the suicidal narrative and its function as a near‐term suicidal risk factor.     

Helping Callers to the National Suicide Prevention Lifeline Who Are at Imminent Risk of Suicide: Evaluation of Caller Risk Profiles and Interventions Implemented

Crisis lines are settings where identifying individuals at imminent risk of suicidal behavior and intervening to keep them safe are critical activities. We examined clinical characteristics of crisis callers assessed by telephone crisis helpers as being at imminent risk of suicide, and the interventions implemented with these callers. Data were derived from 491 call reports completed by 132 helpers at eight crisis centers in the National Suicide Prevention Lifeline network. Helpers actively engaged the callers in collaborating to keep themselves safe on 76.4% of calls and sent emergency services without the callers' collaboration on 24.6% of calls. Four different profiles of imminent risk calls emerged. Caller profiles and some helper characteristics were associated with intervention type. Our findings provide a first step toward an empirical formulation of imminent risk warning signs and recommended interventions.     

Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.     

Risk Factors Proximate to Suicide and Suicide Risk Assessment in the Context of Denied Suicide Ideation

Health care providers have significant opportunities to identify individuals at near‐term risk for suicide, but lack empirical data on near‐term risk factors. This study aimed to identify dynamic, state‐related risk factors observed by clinical practitioners within the last 30 days of life of 157 patients who died by suicide and to compare these near‐term risk factors among patients who denied versus responded positively to having suicide ideation (SI ) when last asked by a clinical practitioner prior to their death. Risk factors charted for the majority of all decedents were a history of prior suicide ideation and/or suicide attempt, current anxiety/agitation and sleep problems, current interpersonal problems or job/financial strain, current comorbid diagnoses, current social isolation/withdrawal, and a family history of mental disorder. Two‐thirds of patients denied having SI when last asked and one‐half of these patients were dead by suicide within 2 days. Decedents who denied having SI were quite similar in charted diagnoses, symptoms, behaviors, and environmental circumstances to decedents who responded affirmatively to having SI . Reliance on verbalized or reported SI as a gateway to a suicide risk assessment is questioned and the need for better understanding near‐term risk for suicide, particularly in the absence of stated SI , is highlighted.     

The Effects of the Family Bereavement Program to Reduce Suicide Ideation and/or Attempts of Parentally Bereaved Children Six and Fifteen Years Later

Findings concerning the long‐term effects of the Family Bereavement Program (FBP) to reduce suicide ideation and/or attempts of parentally bereaved children and adolescents are presented. Parental death is a significant risk factor for suicide among offspring (Guldin et al., 2015). This study is a long‐term follow‐up of 244 children and adolescents who had participated in a randomized trial of the FBP, examining the intervention effects on suicide ideation and/or attempts as assessed through multiple sources. Results indicate a significant effect of the FBP to reduce suicide ideation and/or attempts at the 6‐ and 15‐year follow‐up evaluation. The findings support the potential benefits of further research on “upstream” suicide prevention.     

Perceived Burdensomeness Predicts Outcomes of Short‐Term Psychological Treatment of Young People at Risk of Suicide

The interpersonal‐psychological theory of suicide (IPTS; Joiner, 2005 ) provides a model for understanding the mechanisms underlying suicide risk, but there is limited research measuring change in the constructs over the course of treatment. This study aimed to test whether changes in perceived burdensomeness (PB) and thwarted belongingness (TB) mediated the effects of changes in depression and hopelessness on suicide risk. The sample comprised 226 Australian young people (aged 12–24; 67.7% female; 5.7% Aboriginal and Torres Strait Islander) receiving short‐term psychological treatment for suicide‐related behaviors. Change scores over the course of therapy were generated using admission and discharge measures of PB, TB, depression, hopelessness, and suicide risk. Results revealed partial support for the theory. The relationship between changes in depression and hopelessness on suicide risk was fully mediated by changes in PB. However, changes in TB did not mediate these relationships. This study offers encouragement for the potential use of the IPTS in the context of psychological treatment of young people. Assessment of the IPTS constructs may be helpful in assessing change in suicide risk and further assist in treatment.     

Evaluation of a Suicide Prevention Center by Sampling the Population at Risk*

ABSTRACT: At present there are no clear guidelines for assessing the effectiveness of suicide prevention and crisis centers. This report focuses on one readily available source of data, specifically that segment of the population at risk made up of persons admitted to the inpatient service of a mental health center due to depressive and/or suicidal states, including suicide attempts. To determine the role of the suicide prevention center in providing services to this group, 575 persons meeting these criteria were interviewed. The findings included the following: (a) 11 percent had utilized suicide prevention center services, with 59 percent of these experiencing substantial benefit; (b) 20 percent stated they were unaware of the center; (c) 8 percent expressed the view that calling the center would be inappropriate because a suicide attempt was not imminent; and (d) 26 percent indicated an inclination to call the center in the event of subsequent difficulties. Experience suggests that response to a crisis (intervention) as well as response to low lethality callers with “everyday problems” (prevention) constitute valid functions of a suicide prevention and crisis center. Preoccupation with short-term goals, such as reducing the apparent suicide rate, should not dominate the conceptualizing of program evaluation methods.     

The Certification of Suicide in Eleven Western States: An Inquiry into the Validity of Reported Suicide Rates

ABSTRACT: From Durkheim's time to the present social researchers interested in the problem of suicide have relied upon officially reported rates of suicide to develop and test their theories. Despite the fact that the validity of any theory rests upon the accuracy of its underlying data, the relative accuracy of reported suicide rates have rarely been questioned or systematically evaluated. This paper investigates the process of death certification as practiced by a sample of 191 coroners in 11 western states. Findings indicate extensive variation in the backgrounds, professional resources, operating procedures, and governing statutes of coroners and coroners' offices and in policies concerning the use of the suicide mode. Since the coroner is generally charged with the official responsibility for certifying the mode of death when unnatural mode is suspect, the extent of variation found here calls into question the validity and comparability of reported suicide rates.     

Reactive aggression and suicide: Theory and evidence

Aggression confers risk for suicide. However, “aggression” is a heterogeneous construct, and it is likely that subgroups of individuals with particular types of aggression are at higher risk. We postulate that a subtype of aggression, reactive aggression, underlies the link with suicide with implications for suicide risk-recognition and prevention. The theoretical rationale and empirical evidence for the role of reactive aggression in suicide is presented from the perspectives of neurobiology, psychopathology, and overt violent behavior. It is hypothesized that partner–relationship disruptions amplify risk for suicide in the near term among reactive aggressive individuals, particularly those with psychiatric disorders, and preliminary evidence in support of this hypothesis is reviewed. We also discuss being jailed as a potential precipitant of suicide in reactive aggressive individuals. Recommendations are made to advance the study of reactive aggression and suicide, including methodological innovations and a greater focus on research of women and older adults.     

The Finno-Ugrian suicide hypothesis: variation in European suicide rates by latitude and longitude

The marked variation regarding the suicide rate in 34 European countries is well described by regressing the national suicide rate on the capital cities' latitudes and on an interaction term of squared latitude multiplied with longitude. The interaction term explains 40.8% and 29.1% of men's and women's suicide rate, respectively, and latitude explains a further significant increment of 10.9% and 10.6% variance of men's and women's suicide rate, respectively. This regression model quantifies the Finno-Ugrian suicide hypothesis of Kondrichin and of Marusic and Farmer. The European countries highest in suicide rate constitute a contiguous, J-shaped belt, spanning from Finland to Austria. This area maps onto the second principal component identified for European gene distribution, representing ancestral adaptation to cold climates and the Uralic language dispersion. Thus, population differences in genetic risk factors may account for the spatial pattern in European suicide rates.     

Is Veteran Status and Suicide Risk Assessed in Community Long‐Term Care? A Review of the States' Assessment Instruments

Given recent policy initiatives to address suicide risk among older persons and veterans, community‐based elder serving agencies may serve an important role in identifying and referring individuals at risk for suicide. A review of state‐level long‐term assessment instruments was conducted to determine whether veteran status and suicide are assessed. Data from forty‐three state's Units on Aging instruments were content analyzed. Results indicate that over two thirds of the states in this review included questions about suicide and veterans in their assessments, 69.8% and 67.4% respectively. Suicide risk among elders and veterans must be addressed at local, state, and federal levels so that concerted attention and oversight can be provided for matching elders to the services they need.     

Determinants and Predictive Value of Clinician Assessment of Short‐Term Suicide Risk

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short‐term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10‐point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire‐Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one‐month follow‐up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow‐up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.     

Loneliness and Suicidal Risk in Young Adults: Does Believing in a Changeable Future Help Minimize Suicidal Risk Among the Lonely?

This study examined loneliness and future orientation as predictors of suicidal risk, namely, depressive symptoms and suicide ideation, in a sample of 228 college students (54 males and 174 females). Results of regression analyses indicated that loneliness was a significant predictor of both indices of suicidal risk. The inclusion of future orientation was found to significantly augment the prediction model of both depressive symptoms and suicide ideation, even after accounting for loneliness. Noteworthy, beyond loneliness and future orientation, the Loneliness × Future Orientation interaction term was found to further augment both prediction models of suicidal risk. Consistent with the notion that future orientation is an important buffer of suicidal risk, among lonely students, those with high future orientation, compared to low future orientation, were found to report significantly lower levels of depressive symptoms and suicide ideation. Some implications of the present findings for studying both risk and protective factors associated with suicidal risk in young adults are discussed.     

Suicide Crisis Syndrome Mediates the Relationship Between Long‐term Risk Factors and Lifetime Suicidal Phenomena

In recent years, there has been growing attention to the distinction between acute and long‐term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS ), as a marker of near‐term suicidal risk. Here, we test whether documented long‐term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS . A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS ‐3) as a measure of the SCS . While both STS ‐3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS ‐3 was related to pre‐admission suicide attempts. The STS ‐3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long‐term risk factors increase suicidal risk.     

Changing Rates of Suicide Ideation and Attempts Among Inuit Youth: A Gender‐Based Analysis of Risk and Protective Factors

Inuit in Canada currently suffer from one of the highest rates of suicide in the world. The objective of this study was to explore the prevalence of suicide ideations and attempts among 15–24 year olds living in Nunavik, Québec, and to explore risk and protective factors of suicide attempts as a function of gender. A cross‐sectional survey was conducted in 2004 across Nunavik. Univariate and multivariate logistic regressions were conducted. A total of 22% of young males and 39% of females adults reported past suicidal attempts. Gender differences were observed in relation to associated risk and protective factors as well as degree of exposure to risk factors. Suicide prevention must include alcohol and drug prevention programs and rehabilitation services, interventions to reduce physical and sexual violence and their long‐term impacts on Inuit youth, as well as exposure to culturally meaningful activities.     

The effects of emotion on tip-of-the-tongue states

Tip-of-the-tongue states (TOTs) are judgments of the likelihood of imminent retrieval for items currently not recalled. In the present study, the relation of emotion to the experience of TOTs is explored. Emotion-inducing questions (e.g.), “What is the term for ritual suicide in Japan?”) were embedded among neutral questions (e.g., “What is the capital of Denmark?”). Participants attempted to recall the answers and, if unsuccessful, were asked if they were in a TOT and given a recognition test. For unrecalled items, there were significantly more TOTs for the emotional items than for the neutral items, even though the recognition performance was identical. There were more TOTs for questions that followed emotional questions than TOTs for questions that followed neutral questions, suggesting the emotional arousal lasts beyond the specific question. These findings suggest that emotional cues increase the likelihood of TOTs. These data are consistent with a metacognitive view of TOTs.     

Permitting suicide of competent clients in counseling: legal and moral considerations

State statutes, case law, and professional codes of ethics in the mental health professions typically stress either a duty or the permissibility of disclosing confidential information in order to prevent clients from seriously harming themselves. These sources are intended to address cases where clients are deemed to be suffering from cognitive dysfunction for which paternalistic intervention, including involuntary hospitalization, is considered necessary to prevent self-destructive behavior. The counselor's moral and legal responsibility is less apparent when mentally competent clients desire suicide as release from irremediable suffering due to severe physical illness, and this desire is defensible within these clients' value systems. This paper will explore moral and legal dimensions of a counselor's decision not to intervene in such cases. The concept of permitted suicide will be introduced and defined, and guidelines for its application developed.