A Community’s Response to Suicide Through Public Art: Stakeholder Perspectives from the Finding the Light Within Project

Suicide is a preventable public health problem and a leading cause of death in the United States. Despite recognized need for community-based strategies for suicide prevention, most suicide prevention programs focus on individual-level change. This article presents seven first person accounts of Finding the Light Within, a community mobilization initiative to reduce the stigma associated with suicide through public arts participation that took place in Philadelphia, Pennsylvania from 2011 through 2012. The stigma associated with suicide is a major challenge to suicide prevention, erecting social barriers to effective prevention and treatment and enhancing risk factors for people struggling with suicidal ideation and recovery after losing a loved one to suicide. This project engaged a large and diverse audience and built a new community around suicide prevention through participatory public art, including community design and production of a large public mural about suicide, storytelling and art workshops, and a storytelling website. We present this project as a model for how arts participation can address suicide on multiple fronts—from raising awareness and reducing stigma, to promoting community recovery, to providing healing for people and communities in need.     

The Predictors of Suicidality in Previous Suicide Attempters following Case Management Services

Suicide attempts constitute a serious clinical problem. People who have attempted suicide are at an elevated risk for additional suicide attempts, but there is limited evidence regarding the predictors of suicidality of suicide attempters following case management services. In the present study the indicators of suicidality after case management were examined. A total of 1,056 subjects who had recently attempted suicide were recruited from January 1, 2011, to June 30, 2011. The suicide prevention center of Kaohsiung City in Taiwan provided case management services and followed up on suicide attempt cases for 6 months. The salient factors for repeat suicide attempts were estimated using a logistic regression analysis. The results showed that multiple factors, including a “willingness to receive mental health services during a crisis,” “social support,” “a history of mental disorders,” and “a history of suicide,” could predict repeat suicide attempts with hazard ratios (0.58, 0.54, 3.84, 1.51) and 95% confidence interval (0.39–0.86, 0.36–0.83, 2.41–6.10, 1.03–2.21). The four factors mentioned above were the most accurate predictors of subsequent suicidality when case management services were utilized after 6 months of follow‐up. The findings of our study could help clarify future strategies for suicide prevention.     

Aktuelle Aspekte des Gefängnissuizids

Suicides present a major complication during imprisonment and contribute essentially to the high mortality rate of prisoners. All international studies found increased suicide rates among prisoners in comparison to the general population. This article reviews general and individual risk factors for suicide in prison and possible contributing specific stress factors during imprisonment. The main results of the analysis of the European Annual Prison Statistics from 1997 to 2007 are presented referring to macrostructural determining risk factors for suicide in prison. Measurements and prevention strategies are briefly discussed.     

Risk Factors,Warning Signs,and Drivers of Suicide: What Are They,How Do They Differ,and Why Does It Matter?

Research investigating suicide attempts and deaths by suicide has yielded many specific risk factors and warning signs for future suicidal behaviors. Yet, even though these variables are each valuable for suicide prevention efforts, they may be limited in their applicability to clinical practice. The differences among risk factors, warning signs, and “drivers,” which are person‐specific variables that lead individuals to desire death by suicide, are highlighted. The scarce evidence on drivers is described and specific recommendations for conducting future drivers‐focused research and targeting them in clinical practice are suggested.     

Suicide Causation: Pies,Paths, and Pointless Polemics

Most people readily agree that suicide is caused by a complex web of many different factors. However, for many people the concept of a single event resulting from the combined effect of a constellation of different factors (multiple causation) is imperfectly understood. Unfortunately, a naive understanding of multiple causation can lead to needless arguments about what “really” causes suicide, and pointless debate about the “right” point for preventive intervention. In this paper, I review several simple conceptual models of multiple causation as they relate to suicide prevention. I suggest that a more explicit understanding of the nature of multiple causation has the potential to obviate some of these misguided arguments and to facilitate cooperative prevention efforts among person who choose to apply their energies at different points in the causal chain of suicide.     

Treatment of Depression and Suicide in Older Adults

This article describes a cognitive behavior therapy (CBT) intervention for suicide prevention in older adults. Although many studies have found that CBT interventions are efficacious for reducing depressive symptoms in the elderly, researchers have yet to evaluate the efficacy of such interventions for preventing suicide or reducing suicide risk in older adults. In this article we describe a 12-session CBT protocol for reducing depression, suicide ideation, and other risk factors of late-life suicide. The following aspects of the treatment are described: assessing suicide risk, conceptualizing the problem through a cognitive behavioral framework, developing a safety plan, increasing hope and reasons for living, improving social resources, improving problem-solving skills and efficacy, improving adherence to medical regimen, and relapse prevention. In addition, we review other behavioral and cognitive strategies such as activity scheduling and cognitive restructuring that are commonly associated with CBT interventions for depression. We illustrate the application of these strategies through the use of case examples.     

The Struggle to Prevent and Evaluate: Application of Population Attributable Risk and Preventive Fraction to Suicide Prevention Researach

Population attributable risk (PAR) estimates have been used in suicide research to evaluate the impact of psychosocial and socioeconomic risk factors, including affective disorders, traumatic life events, and unemployment. A parallel concept of preventive fraction (PF), allowing for estimation of the impact of protective factors and effectiveness of preventive interventions, is practically unknown in suicidology. The study authors discuss the application of both concepts to suicide research and prevention, and review literature on the subject. Despite several methodological and conceptual limitations, both PAR and PF are valuable instruments to inform development and evaluation of suicide prevention programs.     

Risk and protective factors for suicide among Guyanese youth: Youth and stakeholder perspectives

Guyana, a low-to-middle-income country (LMIC) in South America, leads the world in youth suicide. As an understanding of risk and protective factors is critical to the development of culturally informed suicide prevention efforts, research exploring these factors among youth in Guyana is needed. The current study expands on current research on adolescent suicide in Guyana and LMICs broadly by using qualitative focus groups and interviews to explore adult stakeholders' and youth's perspectives. Participants included 17 adult stakeholders and 40 adolescents in Guyana. Data were analysed using a grounded theory approach. Themes related to participants' perceptions of risk factors for suicide included demographic characteristics, pressure and expectations, adults' responses to youth, limited coping with stressful life events and exposure to suicide. Themes related to protective factors for suicide included positive social support and involvement in community activities. Findings have implications for the development and tailoring of suicide prevention efforts for Guyanese youth.     

The cultural theory and model of suicide

A growing body of research has demonstrated important variations in the prevalence, nature, and correlates of suicide across ethnic and sexual minority groups. Despite these developments, existing clinical and research approaches to suicide assessment and prevention have not incorporated cultural variations in any systematic way. In addition, theoretical models of suicide have been largely devoid of cultural influence. The current report presents a comprehensive analysis of literature describing the relationship between cultural factors and suicide in three major ethnic groups (African Americans, Asian Americans, and Latinos) and LGBTQ¹ sexual minority groups. We utilized an inductive approach to synthesize this variegated body of research into four factors that account for 95% of existing culturally specific risk data: cultural sanctions, idioms of distress, minority stress, and social discord. These four cultural factors are then integrated into a theoretical framework: the Cultural Model of Suicide. Three theoretical principles emerge: (1) culture affects the types of stressors that lead to suicide; (2) cultural meanings associated with stressors and suicide affect the development of suicidal tendencies, one's threshold of tolerance for psychological pain, and subsequent suicidal acts; and (3) culture affects how suicidal thoughts, intent, plans, and attempts are expressed. The Cultural Model of Suicide provides an empirically guided cohesive approach that can inform culturally competent suicide assessment and prevention efforts in future research and clinical practice. Including both ethnic and sexual minorities in our investigations ensures advancement along a multiple identities perspective.     

Social and individual risk factors for suicide ideation among Chinese children and adolescents: A multilevel analysis

The objective of this study was to investigate the prevalence and predictors of suicide ideation among primary, middle and high school students. We used multilevel modelling to investigate suicide ideation among 12,733 Chinese children and adolescents aged 9–18 years from wide range of areas across China. Approximately, 32.09% of children and adolescents reported suicide ideation, with females were more likely to report suicide ideation than males (38.09% vs. 29.95%). Our results showed that the risk factors in primary school students were different from middle and high school student groups, whereas significant risk factors for middle and high school students were similar. The city's standard of living as indicated by the Engel coefficient and the city's divorce rate were positively associated with the prevalence of suicide ideation; in contrast, the school's pupil‐to‐teacher ratio was negatively correlated with elevated suicide ideation. Significant risk factors for suicide ideation included study anxiety, self‐accusation tendency, impulsive tendency, terror tendency and physical symptoms. These results have important implications for the prevention of suicide, suggesting that both contextual (city‐level) and compositional (individual‐level) factors could be important targets for prevention and intervention for children and adolescents at risk of suicide ideation.     

The Great Black Hope: Hope and Its Relation to Suicide Risk among African Americans

Positive psychology has garnered considerable scholarly interest recently and has been suggested to hold promise in the application to suicide research and prevention; however, empirical research has lagged behind these suggestions. This is the first study to examine the relationship between hope and a specific theory of suicide in African Americans. It was hypothesized that (1) hope would negatively predict the interpersonal suicide risk factors of burdensomeness and thwarted belongingness; and positively predict acquired capability to enact suicide; (2) hope would negatively predict suicidal ideation; and (3) the interpersonal suicide risk factors would predict suicidal ideation. Results were primarily as predicted. Implications for hope theory and Joiner's theory of suicidal behavior are discussed, as well as implications for clinical practice.     

How do personality disorders modify suicide risk?

There is a lack of psychological autopsy studies assessing the influence of axis II disorders on other risk factors for suicide. Therefore, we investigated if the estimated suicide risk for axis I disorders and socio-demographic factors was modified by personality disorders. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) by psychological autopsy method in 163 completed suicides and by personal interview in 396 population-based control persons. Personality disorders modify suicide risk, differently for affective disorders, substance use disorders, smoking, life events during the last three months, and socio-demographic factors such as being single. Estimated suicide risk for socio-demographic factors and life events is not substantially altered following adjustment for affective disorders or substance use disorders. These findings suggest that treatment of personality disorders is essential for suicide prevention.     

Suicide mortality of suicide attempt patients discharged from emergency room, nonsuicidal psychiatric patients discharged from emergency room, admitted suicide attempt patients, and admitted nonsuicidal psychiatric patients

The suicide mortality rate and risk factors for suicide completion of patients who presented to an emergency room (ER) for suicide attempt and were discharged without psychiatric admission, patients who presented to an ER for psychiatric problems other than suicide attempt and were discharged without psychiatric admission, psychiatric inpatients admitted for suicide attempt, and psychiatric inpatients admitted for other reasons were examined. The records of 3,897 patients who were treated at a general hospital in Seoul, Korea, from July 2003 to December 2006 were reviewed. Forty-three of the 3,897 subjects died by suicide during the 2.5-year observation period. Compared to the general Korean population, the suicide mortality rate was 82-fold higher for suicide attempt patients, admitted; 54-fold higher for suicide attempt patients, discharged; 21-fold higher for nonsuicidal patients, admitted; and 11-fold higher for nonsuicidal patients, discharged. In all four groups, diagnosis of a depressive disorder and suicide attempt at presentation were each significant independent risk factors for suicide completion. These results highlight the need for suicide prevention strategies for depressed patients who present to the ER or are admitted to a psychiatric ward after a suicide attempt.     

2005 Shneidman Award Address. Integratively assessing risk and protective factors for adolescent suicide

This article briefly reviews key issues in adolescent suicide risk assessment and proposes that assessing risk and protective factors in combination has the best probability of informing the field's understanding of this complex problem. Several newer measures are described along with summaries of their psychometric properties. A recommended protocol utilizing 4 developmentally appropriate, valid, and reliable self-report measures is suggested as a parsimonious way of gathering information on the range of risk and protective factors. Finally, a novel approach of employing short-term longitudinal studies to test models of adolescent suicide attempts is described along with a rationale for not focusing research efforts on completed suicide. Implications of this approach for prevention efforts conclude the article.     

Future Well-Being Among People Who Attempt Suicide and Survive: Research Recommendations

Over 48,000 people died by suicide in 2018 in the United States, and more than 25 times that number attempted suicide. Research on suicide has focused much more on risk factors and adverse outcomes than on protective factors and more healthy functioning. Consequently, little is known regarding relatively positive long-term psychological adaptation among people who attempt suicide and survive. We recommend inquiry into the phenomenon of long-term well-being after nonfatal suicide attempts, and we explain how this inquiry complements traditional risk research by (a) providing a more comprehensive understanding of the sequelae of suicide attempts, (b) identifying protective factors for potential use in interventions and prevention, and (c) contributing to knowledge and public education that reduce the stigma associated with suicide-related behaviors.     

A Systematic Review of Suicide Prevention Programs for Military or Veterans

Military personnel and veterans have important suicide risk factors. After a systematic review of the literature on suicide prevention, seven (five in the U.S.) studies of military personnel were identified containing interventions that may reduce the risk of suicide. The effectiveness of the individual components was not assessed, and problems in methodology or reporting of data were common. Overall, multifaceted interventions for active duty military personnel are supported by consistent evidence, although of very mixed quality, and in some cases during intervals of declines in suicide rates in the general population. There were insufficient studies of U.S. Veterans to reach conclusions.     

Risk Factors of a Suicide Reattempt by Seasonality and the Method of a Previous Suicide Attempt: A Cohort Study in a Japanese Primary Care Hospital

Suicide has a great impact on the individual whose life is lost and the bereaved family members. The risk of a suicide reattempt is particularly high during the first 12 months after a suicide attempt. In this cohort study, risk factors for a suicide reattempt were explored among 291 patients at suicide risk. Clinical and demographic data were collected from a Japanese primary care hospital. Past psychiatric history and multiple diagnoses were associated with suicide reattempts in both genders. Drug overdose, past psychiatric history, and the summer season were linked to suicide reattempts among males. Past psychiatric history and multiple diagnoses were linked to suicide reattempts among females. Appropriate assessment of past psychiatric history, season and method of suicide attempt, gender, and diagnosis may play a role in preventing suicide.     

Perceptions concerning college student suicide: data from four universities

The issue of suicide, including prevention, intervention, and postvention, continues to be a problem on college campuses. For this study, data concerning a variety of issues related to college student suicide were collected from 1,865 students at four different universities. Incidence, risk factors, and potential solutions are described, as well as implications for mental health professionals in university settings.     

The Suicidal Inmate: A Comparison of Inmates Who Attempt Versus Complete Suicide

The aim of this study was to identify risk factors distinguishing inmates who attempt suicide from inmates who complete suicide. Compared with attempters, completers tended to be older, male, more educated, and married or separated/divorced; pretrial, committed for a violent crime, incarcerated in jail, housed in an inpatient mental health unit or protective custody setting, living in a single cell, not on suicide precautions, not previously under close observation; and more likely to act during overnight hours and die by hanging/self‐strangulation. Targeted assessment of a broad range of risk factors is necessary to inform suicide prevention efforts in correctional facilities.