Comparison of Suicide Attempters and Decedents in the U.S. Army: A Latent Class Analysis

A clearer understanding of risk factors for suicidal behavior among soldiers is of principal importance to military suicide prevention. It is unclear whether soldiers who attempt suicide and those who die by suicide have different patterns of risk factors. As such, preventive efforts aimed toward reducing suicide attempts and suicides, respectively, may require different strategies. We conducted a latent class analysis (LCA) to examine classes of risk factors among suicide attempters (n = 1,433) and decedents (n = 424). Both groups were represented by three classes: (1) External/Antisocial Risk Factors, (2) Mental Health Risk Factors, and (3) No Pattern. These findings support the conceptualization that military suicide attempters and decedents represent a single population.     

Insomnia Symptoms,Nightmares, and Suicide Risk: Duration of Sleep Disturbance Matters

Duration of insomnia symptoms or nightmares was investigated to see if it was related to suicide risk independent of current insomnia symptoms, nightmares, anxiety symptoms, depressive symptoms, and posttraumatic symptoms. The cross‐sectional study involved analyses of survey responses from undergraduate students who endorsed either insomnia symptoms (n = 660) or nightmares (n = 312). Both insomnia symptom and nightmare duration were significantly associated with suicide risk independent of current insomnia symptoms or nightmares, respectively. Relations were also significant after controlling for anxiety symptoms, depressive symptoms, and posttraumatic symptoms. Results suggest that duration of sleep disturbance is relevant when assessing suicide risk.     

Clarifying the Relationship of Parental Bonding to Suicide Ideation and Attempts

Suicide and suicidal behavior are major public health problems, especially among adolescents and young adults. Previous research has established links between parental bonding and suicidality; however, it remains unclear whether parental bonding is associated with suicide ideation, the progression from suicide ideation to suicide attempts, or both. This study examined the relation of parental bonding to suicide ideation and suicide attempts in adolescents from two settings: (1) acute psychiatric care (n = 172) and (2) high school (n = 426). All participants were administered validated measures of parental bonding, suicide ideation, and suicide attempts, as well as emotion dysregulation, loneliness, and self‐worth. In the psychiatric sample, lower parental care significantly differentiated adolescents with a history of suicide attempts from those with suicide ideation only or without histories of suicidality. This pattern remained even after controlling for other known correlates of suicidality (i.e., emotional dysregulation, loneliness, and low self‐worth). Similar effects were found in the community sample, although these findings failed to reach statistical significance. In both samples, parental overprotection was not associated with suicide ideation or suicide attempts. Results suggest that parental care may be an important risk factor for youth suicidal behavior and may help differentiate suicide attempters from suicide ideators.     

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow‐up (n = 168; 57%). Fifty‐three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.     

Trajectories of Suicide Ideation,Nonsuicidal Self‐Injury,and Suicide Attempts in a Nonclinical Sample of Military Personnel and Veterans

Nonsuicidal self‐injury (NSSI) is a risk factor for suicide attempts, but little is known about NSSI among military personnel and veterans, or about the temporal sequencing of NSSI relative to suicide ideation and attempts. This study evaluates trajectories of suicide ideation, NSSI, and suicide attempts in a sample of 422 military personnel and veterans. Of those with a history of NSSI, 77% also experienced suicide ideation. Suicide ideation emerged before NSSI (67%) more often than the reverse (17%). Of those with a history of suicide attempt, 41% also engaged in NSSI. NSSI emerged prior to the first suicide attempt (91%) more often than the reverse (9%). The length of time from suicide ideation to suicide attempt was longer for those who first engaged in NSSI (median = 3.5 years) compared with those who did not engage in NSSI (median = 0.0 years), Wald χ²(1) = 11.985, p = .002. Age of onset was earlier for participants reporting NSSI only compared with those reporting both NSSI and suicide attempts (16.71 vs. 22.08 years), F(1, 45) = 4.149, p = .048. NSSI may serve as a “stepping stone” from suicide ideation to attempts for 41% of those who attempt suicide.     

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.     

Predictors of Emerging Suicide Death Among Military Personnel on Social Media Networks

Suicide is a leading cause of death in the United States and is the second leading cause of death in the U.S. military. Previous research suggests that data obtained from social media networks may provide important clues for identifying at‐risk individuals. To test this possibility, the social media profiles from 315 military personnel who died by suicide (n  = 157) or other causes (n  = 158) were coded for the presence of stressful life situations (i.e., triggers), somatic complaints or health issues (i.e., physical), maladaptive or avoidant coping strategies (i.e., behaviors), negative mood states (i.e., emotion), and/or negative cognitive appraisals (cognition). Content codes were subsequently analyzed using multilevel models from a dynamical systems perspective to identify temporal change processes characteristic of suicide death. Results identified temporal sequences unique to suicide, notably social media posts about triggers followed by more posts about cognitions, posts about cognitions followed by more posts about triggers, and posts about behaviors followed by fewer posts about cognitions. Results suggest that certain sequences in social media content may predict cause of death and provide an estimate of when a social media user is likely to die by suicide.     

Health Problems and Male Firearm Suicide

Drawing on constructs of masculinity as it relates to both gun ownership and men's health, we use a rich data set, the New Jersey Violent Death Reporting System as well as hospital discharge data, to analyze 3,413 completed male suicides between the years of 2003 and 2009. We test the hypotheses that the use of firearms is more common when physical health problems are cited as suicide circumstances, and that suicide decedents who use firearms have poorer physical health than those who used other methods. Results show that firearms are disproportionately used in male suicides when physical health is listed as a circumstance. Additionally, among suicide decedents with a hospitalization during the 3 years prior to death, those who used firearms were in poorer health than those who used other methods. These findings have implications for prevention efforts, because restricting access to lethal means is an important aspect of suicide prevention.     

Suicide planning among high school students who report attempting suicide

Using a nationally representative sample of 16,296 high school students, we examined those who reported attempting suicide but did not report a suicide plan in the past 12 months. Results from logistic regression analyses showed that the 15% of attempters who did not report planning were as likely to receive medical treatment after their attempt as the attempters who did report planning. They also were more likely than nonideators and less likely than attempters who reported planning to report substance use and weapon carrying. All attempters, regardless of planning, were at high risk for fighting. Additional effort is needed to understand and prevent unplanned suicide attempts.     

Nonsuicidal Self‐Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders

Nonsuicidal self‐injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood‐disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood‐disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16–3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.     

Treatment‐Resistant Depression and Risk of Suicide

We evaluated whether treatment‐resistant depression (TRD) as measured by the Massachusetts General Hospital (MGH) staging method was associated with suicide in a large U.S. health system. Data from the Veterans Health Administration and the National Death Index were used to conduct a case–control study of patients newly diagnosed with depression who received antidepressant treatment between 2003 and 2006. Suicide cases (N = 499) were matched with nonsuicide controls (N = 1994). Conditional logistic regression was used to assess whether MGH stage at time of suicide (or matched date) was associated with case status, adjusting for patient demographic characteristics, comorbidity, and service use. Results indicated 11.6% of suicide cases had MGH stage 3 or greater (indicating at least two antidepressant trials) compared to 6.4% of controls (p < .001). In adjusted analyses, suicide was not significantly more likely among patients with stage 3 or greater (OR 1.52; 95% CI: 0.98, 2.37) or stages 1.5–2.5 (OR 1.19; 95% CI: 0.91, 1.55) compared to patients with stage 1 or less (<10 weeks of antidepressant medication). Staging TRD using MGH criteria is unlikely to substantially improve suicide risk assessment of depressed patients beyond existing measures contained in health system records.     

Differentiating Suicide Ideators from Attempters: Violence—A Research Note

Which factors distinguish suicide attempters from suicide ideators is a relatively neglected question in suicidology. Data from the 2001 Youth Risk Behavior Survey, encompassing 1,439 youth suicide ideators and 1,097 attempters, was used to explore which factors best differentiate suicide attempters from ideators, with a focus on violence involvement. Measures of violence include the contexts of fights, dating, and weapons carrying. Controls were incorporated for psychiatric disorders, risky sexual behavior, school integration, and demographics. Controlling for the other variables, violence differentiated attempts from ideation: fighting (OR = 2.18) and weapon carrying (OR = 1.13). Psychiatric factors that predicted attempts over ideation included major depression (OR = 1.86), use of cocaine (OR = 2.34), and having a suicide plan (OR = 2.69), while demographic factors included gender, age, residence in the Midwest, and Hispanic, African American, or Asian ethnicity. A supplementary analysis (N = 11,546) determined that violence also helped to differentiate suicide ideators from nonsuicidal youth. Four factors (including violence involvement, eating disorders, and gender consistently) differentiated both between suicide attempts and ideation, and also between suicide ideators and nonsuicidal youth. The link between violence involvement and suicidality is interpreted in terms of the capability for suicide from the interpersonal theory of suicide.     

Metaanalysis of Mood and Substance Use Disorders in Proximal Risk for Suicide Deaths

Evidence for proximal risk factors for suicide is based on case–control psychological autopsy studies, with these reports showing that mood and substance use disorders are the most prevalent mental disorders among suicide decedents worldwide and are associated with marked risk. However, moderators of risk and the degree of risk associated with (nonalcohol) drug use disorder are unknown. A comprehensive search was used to identify 35 case–control psychological autopsy studies published worldwide over a 30‐year period that were metaanalyzed using random effects models. Major depression, odds ratio (95% confidence interval) = 9.14 (5.53, 15.09), and drug use disorder, OR (95% CI) = 7.18 (3.22, 16.01), had large effect sizes, among other results. Risk estimates associated with major depression were greater in studies with a larger proportion of women and those conducted in Asia compared with other regions. There was no evidence of publication bias or that any one study had a disproportionate impact on findings. Risk for suicide associated with major depression appears to be moderated by sex and/or world region. Drug use disorder is a potent risk factor, illustrating the importance of assessing drug use in clinical risk assessment.     

Suicide Disclosure in Suicide Attempt Survivors: Does Family Reaction Moderate or Mediate Disclosure's Effect on Depression?

Existing literature has found a link between disclosure of a stigmatized identity and improved mental health; however, research on the impact of suicide disclosure to family members is scarce. Suicide attempt survivors (n = 74) in the United States were examined to assess whether family reaction moderates or mediates the relationship between suicide disclosure and subsequent depression symptoms. Family reaction did not moderate but did mediate the relationship between disclosure and depression symptoms while controlling for time since most recent attempt. Higher rates of disclosure predicted more positive family reactions, which in turn predicted less severe depression symptoms. Findings indicate that family members can play an essential role in the recovery process after an attempt occurs, which has important implications for both researchers and clinicians who seek to decrease stigma for attempt survivors while simultaneously decreasing the likelihood of future attempts.     

Understanding the Pathways from Depression to Suicidal Risk from the Perspective of the Interpersonal–Psychological Theory of Suicide

Suicide is a major public health concern, especially in adolescence. Identifying risk factors for suicide is important to effectively prevent such behavior. Depression is one of the most widely examined risk factors for suicidal risk. How depression and suicidal risk are related, however, is still not clear. This study tested a model with three key constructs of the interpersonal–psychological theory of suicidal behavior (IPTS)—perceived burdensomeness, thwarted belongingness, and nonsuicidal self‐injury (NSSI)—as mediators in the relationship between depression and suicidal risk among Chinese adolescents. Chinese high school students (N = 1,074; 54.2% male; M_age = 13.87 years, SD = 1.48) completed questionnaires assessing all study variables. Results suggested that perceived burdensomeness and NSSI partially mediated the relationship between depression and suicidal risk. Findings of this study emphasize the importance of the IPTS framework in understanding the possible mechanisms underlying the relationship between depression and suicidal risk, and suggest a possible avenue for suicide interventions.     

Suicide Among Health Care Practitioners and Technicians in Colorado: An Epidemiological Study

Suicide is a public health concern with risks that vary between occupation groups. Many suicide victims with a health care occupation die by poisoning, but few studies have epidemiologically studied this association. The objective of this study was to quantify the increased risk of suicide death by poisoning among health care professionals in Colorado. Eleven years (2004–2014, N = 8,753) of suicide deaths in Colorado were compiled from the Colorado Violent Death Reporting System. A retrospective cohort study using multivariate logistic regression was conducted to examine the risk associated with having a health care occupation and eventual suicide death by poisoning, compared independently to firearm and hanging methods. Suicide victims with a health care occupation were more likely to die by poisoning rather than by hanging (RR 1.54, 95% CI: 1.41–1.68) or firearm (RR 1.79, 95% CI: 1.60–2.01), when compared to suicide victims without a health care occupation. The association between health care occupation and suicide method was significantly (p = .032) modified by gender. The results show that health care workers who die by suicide have an increased risk of eventual suicide death by poisoning rather than by firearm or hanging. These results can be used to inform tailored suicide prevention efforts in health care professionals.     

Young Adult Follow‐up of Adolescent Girls in Juvenile Justice Using the Columbia Suicide Severity Rating Scale

This study focused on the reliability and validity of the Columbia Suicide Severity Scale (C‐SSRS). Severely delinquent adolescent girls (n = 166) participated in a treatment trial and repeated assessments over time. Lifetime suicide attempt history was measured using the C‐SSRS in early adulthood (n = 144; 7–12 years postbaseline). Nonclinician raters showed strong interrater reliability using the C‐SSRS. Self‐reports, caseworker reports, and caregiver reports of girls' suicide attempt histories collected at baseline correlated with adult participants' recollections of their baseline attempt histories. Suicidal ideation measured prospectively across a 7‐ to –12‐year period was associated with retrospectively reported suicide attempt across the same period.     

The Association Between Gender,Ethnicity, and Suicidality Among Vocational Students in Israel

Gender and ethnicity are significant factors when evaluating suicidal risk, especially among ethnically diverse populations. In the current study we explored the association between gender, ethnicity, and suicide ideation and attempts among Arab and Jewish vocational education and training high school students in Israel. Students (N = 3,554) completed a self‐report survey evaluating suicide ideation and attempts, depression, anxiety, somatization, and sense of belonging. Hierarchical generalized linear modeling indicated that female Arab adolescents had elevated levels of suicide ideation, higher rates of suicide attempts, and greater psychological distress than Arab males and Jewish students. Furthermore, female Arab adolescents were found to be more susceptible to suicide ideation when depression levels were high. These results are discussed in the context of the double‐jeopardy Arab young women face, as members of a minority ethnic group in Israel and their status as women within the patriarchal Arab culture.     

Coping Card Usage can Further Reduce Suicide Reattempt in Suicide Attempter Case Management Within 3‐Month Intervention

This randomized controlled trial was designed to evaluate the effectiveness of using crisis coping cards (n = 32) in the case management of suicide prevention compared with case management without the use of coping cards (n = 32) over a 3‐month intervention period. The generalized estimating equation was used to examine the interaction effect between treatments and time on suicide risk, depression, anxiety, and hopelessness. Results indicated that subsequent suicidal behaviors, severity of suicide risk, depression, anxiety, and hopelessness were reduced more in the coping card intervention group compared to the case management only group. Moreover, for the survival curves of time to suicide reattempt, the coping card group showed a significantly longer time to reattempt than the case management only group at 2‐month and 3‐month intervention periods.     

Sexual Assault,Overweight, and Suicide Attempts in U.S. Adolescents

Associations between overweight, sexual assault history, and suicide attempts were examined among 31,540 adolescents from the combined 2009 and 2011 nationally representative Youth Risk Behavior Surveys samples. These variables have not previously been studied concurrently. It was hypothesized that overweight and sexual assault, together, would interact and result in increased suicide attempts. Findings across analyses included (a) no significant associations between sexual assault and overweight in females or males (p = .65 and p = .90, respectively), (b) statistically significant associations between female (but not male) overweight status and suicide attempts (p = .001), (c) a strong association between sexual assault and suicide risk in males (p < .001) and females (p < .001), and (d) an elevated risk for suicide in overweight males with co‐occurring sexual assault, with over 33% of males with such histories attempting suicide. Preliminary findings have powerful implications for research and secondary prevention.