The Influence of Intersecting Identities on Self‐Harm,Suicidal Behaviors,and Depression among Lesbian,Gay, and Bisexual Individuals

Individuals with lesbian, gay, and bisexual (LGB) identities have higher prevalence of self‐directed violence, but very little is known about racial/ethnic differences between LGB populations. This study aimed to examine racial/ethnic differences in self‐harm, suicidal ideation, suicide attempt, and depression among LGB and heterosexual emerging adults. Data are compiled from the Fall 2008 and Spring 2009 National College Health Assessment and limited to respondents within emerging adulthood (ages 18–24) who indicated their sexual orientation and racial/ethnic identities (n = 89,199). Within each racial/ethnic group, LGB individuals were significantly more likely to report self‐harm, suicidal ideation, suicide attempt, and depression than non‐LGB individuals.     

The Association of Multiple Identities with Self‐Directed Violence and Depression among Transgender Individuals

Transgender individuals have a high prevalence of self‐directed violence; however, there is scant literature focusing on their unique experiences. The differences in self‐harm, suicidal ideation, suicide attempt, and depression based on racial/ethnic identity and sexual orientation were examined among transgender individuals. Data were gathered from the Fall 2008 and Spring 2009 National College Health Assessment. Across racial/ethnic identities, greater proportions of transgender students endorsed self‐directed violence than their cisgender peers. Among transgender individuals, sexual minorities were more likely to report suicidal ideation than their heterosexual peers, and racial/ethnic minorities had higher odds of attempting suicide than non‐Hispanic White individuals.     

Latino and Latina Adolescents' Help‐seeking Behaviors and Attitudes Regarding Suicide Compared to Peers with Recent Suicidal Ideation

Although Latinas have consistently reported higher rates of suicidal behavior for the past 20 years (CDC, 1996), there is a dearth of information regarding their help‐seeking attitudes and behaviors when dealing with distress and suicide. Associations between adolescents' ideation and help‐seeking from adults were different for non‐Hispanic Whites and Latinos from 14 high schools (N = 4,983). Among females, ideators and Latinas reported lower levels of help‐seeking attitudes than nonideators and non‐Hispanic Whites. Males showed interaction effects of ideation by race/ethnicity on help‐seeking. Within sex by race/ethnicity, differences showed that while non‐Hispanic White students reported consistent differences between suicidal ideation and no reported suicidal ideation, Latinos were more similar between these groups, particularly with having support from friends and family to seek help from adults. Research should clarify how culture contributes to decreased help‐seeking norms among those with suicidal ideation.     

Effect of Socioeconomic Status on the Linkage Between Suicidal Ideation and Suicide Attempts

Previous suicide attempts are a leading risk factor for completed suicide. To identify specific characteristics of those at high risk for attempts, we investigated associations with socioeconomic status (SES). Data from the 2013 Korean Community Health Survey (KCHS) included adults who reported suicidal ideation (N = 220,245). Attempts in the past 12 months were assessed. Associations of demographic, socioeconomic, and suicide‐related behavioral factors were analyzed using multiple logistic regression. Among those with suicidal ideation, 862 (3.9%) had attempted suicide. After stratification by age and gender, results showed that low education and unemployed young adult men and women had significantly higher rates of attempts. The lowest income level was associated with significantly higher rates of attempts in only young adult women. Among those with the lowest and highest income, the association between ideation and attempts was attenuated, whereas it was enhanced among other income groups.     

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.     

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.     

A Five‐Month Longitudinal Study of Psychache and Suicide Ideation: Replication in General and High‐Risk University Students

Shneidman's (1993) model of psychache as the cause of suicide was evaluated in a 5‐month longitudinal study of psychological pain and suicide ideation. Replicating across general (N = 683) and high‐risk undergraduates (N = 262), psychache was significantly associated with suicide ideation, and change in psychache was significantly associated with change in suicide ideation. For general suicide ideation and suicide preparation, these significant results were maintained even when depression and hopelessness were statistically controlled. This research is a unique contribution being the first large‐sample longitudinal study that evaluates and supports Shneidman's psychache causal model of suicidality in general and high‐risk groups.     

Screening for Suicidal Ideation and Attempts among Emergency Department Medical Patients: Instrument and Results from the Psychiatric Emergency Research Collaboration

Joint Commission National Patient Safety Goal 15 calls for organizations “to identify patients at risk for suicide.” Overt suicidal behavior accounts for 0.6% of emergency department (ED) visits, but incidental suicidal ideation is found in 3%–11.6%. This is the first multicenter study of suicide screening in EDs. Of 2,243 patients in six diverse emergency settings, 1,068 (47.7%) were screened with a brief instrument. Depression was endorsed by 369 (34.5%); passive suicidal ideation by 79 (7.3%); and active suicidal ideation by 24 (2.3%). One hundred thirty‐seven (12.8%) reported prior attempts, including 35 (3.3%) with current suicidal ideation. Almost half of those with current ideation had a prior attempt (43.8%) versus those without current ideation, 10.3%, χ² (1) = 75.59, p < .001. Twenty cases (25%) were admitted to medical services, but only 10 (12.5%) received mental health assessment; none were admitted directly to a psychiatry service. The prevalence of suicidal ideation here is similar to previous studies but the frequency of prior attempts has not been reported. The 35 cases with current ideation and prior attempt are at risk. As they did not present psychiatrically, they would likely have gone undetected. Despite reporting these cases to clinical staff, few received risk assessment.     

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.     

A Longitudinal Study of Racial Discrimination and Risk for Death Ideation in African American Youth

Although multiple studies have found that African Americans commonly experience racial discrimination, available studies have yet to examine how perceived racism might be related to suicide vulnerability in African American youth. The purpose of this study was to examine a framework for how perceived racial discrimination contributes to symptoms of depression and anxiety as well as subsequent suicide ideation and morbid ideation. Data were obtained from 722 African American youth at mean age 10.56 years (SD = 0.64); a second wave of data was obtained 2 years later. Results revealed both a direct effect and mediated effects of perceived racism on later suicide and morbid ideation. For boys and girls, the effect of perceived racism was mediated by symptoms of depression. However, the association was mediated by anxiety for girls, but not for boys in the current sample. Implications for future research and interventions are discussed.     

Independent Effects of Mental Disorders on Suicidal Behavior in the Community

This study assessed the independent contributions of nine common mental disorders on suicide ideation and suicide attempt. A community‐based survey of Australian adults (N  = 3,175) was conducted to identify common mental disorders associated with recent suicide attempt. Nine disorders were assessed using DSM ‐5 clinical criteria. Logistic regression models indicated that all disorders were significantly and independently associated with suicide ideation. However, only obsessive‐compulsive disorder and posttraumatic stress disorder were significantly associated with suicide attempt among participants with ideation, independently of other disorders (OR = 2.0 for both). Increasing comorbidity had a significant monotonic association with suicide ideation but not attempts.     

Feasibility of Assessing Suicide Ideation and History of Suicidal Behavior in Rural Communities

Suicide in rural areas has not received significant attention in the research literature to this point, although suicide rates are higher among adults and older adults in rural areas than in urban areas. The aims of the study were as follows: (1) establish the feasibility of assessing suicide ideation and history of suicidal behavior; (2) determine preliminary estimates of the prevalence of suicide ideation, and history of suicide attempts; and (3) examine the effectiveness and acceptability of safety and referral plans for individuals whose responses indicated elevated suicide risk, in rural communities with limited access to referral care. Participants were 96 adults aged 40 to 85 years old (M  =  57.34, SD  = 11.47) residing in West Texas. Our results indicate that 26% of participants endorsed a lifetime history of suicide ideation and/or suicide attempt(s) and 12.5% reported suicide ideation in the past year. In addition, 93.4% of participants reported that participation in our suicide‐focused study was an excellent or good experience. Results suggest that individuals in rural communities are willing to talk about suicide, found the experience helpful, and were satisfied with the referral process.     

Evaluating Supervision Models in Functional Family Therapy: Does Adding Observation Enhance Outcomes?

This study examined the effects of observation‐based supervision Building Outcomes with Observation‐Based Supervision of Therapy (BOOST therapists = 26, families = 105), versus supervision as usual (SAU therapists = 21, families = 59) on (a) youth externalizing behavior problems and (b) the moderating effects of changes in family functioning on youth externalizing behaviors for adolescents receiving Functional Family Therapy (FFT). Exploratory analyses examined the impact of supervision conditions on youth internalizing problems. In 8 community agencies, experienced FFT therapists (M = 1.4 years) received either BOOST or SAU supervision in a quasi‐experimental design. Male (59%) or female (41%) adolescents were referred for the treatment of behavior problems (e.g., delinquency, substance use). Clients were Hispanic (62%), African American (19%), Non‐Hispanic White (12%), or Other (7%) ethnic/racial origins. Therapists (female, 77%) were Hispanic 45%, African American (19%), White Non‐Hispanic (30%), or other (4%) ethnic/racial backgrounds. Analyses controlled for the presence or absence of clinically elevated symptoms on outcome variables. Clinical outcomes were measured at baseline, 5 months, and 12 months after treatment initiation. Clients with externalizing behavior above clinical thresholds had significantly greater reductions in problem behaviors in the BOOST versus the SAU conditions. Clients below thresholds did not respond differentially to conditions. Supervisors in BOOST had more experience with the FFT model; as such, the observed results may be a result of supervisor experience. The BOOST supervision was associated with improved outcomes on problem behaviors that were above clinical thresholds. The findings demonstrate the importance of addressing client case mix in implementation studies in natural environments.     

Familias Unidas’ Crossover Effects on Suicidal Behaviors among Hispanic Adolescents: Results from an Effectiveness Trial

The long‐term impact of Familias Unidas on suicidal behaviors among Hispanic 8th graders (N = 746) was examined along with parent–adolescent communication as a moderator of intervention effectiveness. At baseline, 9.2% (95% CI = 7.3%–11.6%) of adolescents reported suicide ideation and 5.7% (95% CI = 4.1%–7.7%) reported a past year suicide attempt. There were no significant intervention effects on suicidal behaviors; however, parent–adolescent communication was a moderator of suicide attempts in the past year, across the intervention (b = ?.01, p = .01). Results suggest that Familias Unidas reduces suicidal behaviors among Hispanic adolescents with low levels of parent–adolescent communication despite no suicide‐specific intervention content. Implications of these findings are discussed.     

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.     

Body Mass Index Is an Important Predictor for Suicide: Results from a Systematic Review and Meta‐Analysis

Public health concerns for the independent management of obesity and suicidal behavior are rising. Emerging evidence suggests body weight plays an important role in quantifying the risk of suicide. In light of these findings, we aimed to clarify the association between body mass index (BMI) and suicidal behavior by systematically reviewing and evaluating the literature. Studies were identified by searching MEDLINE, EMBASE, PsycINFO, and CINAHL from inception to January 2015, supplemented by hand and grey literature searches. Study screening, data extraction, and risk of bias assessment were conducted in duplicate. We included 38 observational studies. Meta‐analyses supported an inverse association between BMI and completed suicide. Pooled summary estimates demonstrated that underweight was significantly associated with an increased risk of completed suicide (HR = 1.21, 95% CI 1.07 to 1.36, p = .002), and obesity (HR = 0.71, 95% CI 0.56 to 0.89, p = .003) and overweight (HR = 0.78, 95% CI 0.75 to 0.82, p < .0001) were significantly associated with a decreased risk of completed suicide relative to normal weight. A qualitative summary of the literature demonstrated conflicting evidence regarding the association between BMI and attempted suicide and revealed no association between BMI and suicidal ideation. BMI may be used to aid the assessment of suicide risk, especially that of completed suicide. However, unmeasured confounders and systematic biases of individual studies limit the quality of evidence.     

Body image and suicidal ideation in adolescents

Data from 231 adolescents (mean age = 15.7, SD = 1.39) were collected from a public school setting in the United States. Participants completed several measures, including those assessing depression, hopelessness, past suicidal behavior, body image, and current suicidal ideation. It was hypothesized that depression, hopelessness, past suicidal behavior, and body image (a risk factor seldom examined) would significantly predict current suicidal ideation and that there would be gender differences for body image. Regression analyses indicated that all risk factors including body image were significant predictors of current suicidal ideation for the whole sample. For both males and females, body image offered a unique contribution to the measurement of suicide ideation above and beyond the other risk factors, with body attitudes/feelings being the strongest predictor. Results encourage the inclusion of body image as a variable in risk models for adolescent suicidal ideation, as it likely accounts for additional variance above and beyond traditional risk factors.     

Loneliness and Suicidal Ideation in Drug‐Using College Students

The college years are marked by social changes and behavioral experimentation which may increase risk of suicidal ideation. We propose a novel pathway for the development of suicidal thoughts between two established suicide risk factors, loneliness and drug use, which have not been examined in a nonclinical sample. Data were collected from 207 undergraduate drug‐using students at a large southeastern university. As hypothesized, suicidal ideation was positively correlated with both loneliness (r = .40) and drug use (r = .29). After controlling for several demographic variables, social desirability, and anxiety sensitivity, drug use was tested as a potential mediator in the loneliness–suicidal ideation link using a single‐mediator model. Results indicated a significant indirect (mediated) effect of loneliness on suicidal ideation via drug use (ab = 0.09, 95% CI: 0.02–0.18), suggesting that loneliness may contribute to suicidal ideation through increased drug use among college students. Identification of and intervention with students reporting loneliness and drug use may be a promising suicide prevention strategy on college campuses.     

Factors Associated with Achieving Complete Mental Health among Individuals with Lifetime Suicidal Ideation

The objective of this study was to identify factors associated with complete mental health among Canadians who had ever seriously considered suicide. Data for this study were obtained from Statistics Canada's 2012 Canadian Community Health Survey–Mental Health (N = 2,844). The outcome variable examined in this study was complete mental health and was analyzed using binary logistic regression. Of the 2,844 respondents with lifetime suicidal ideation, 1,088 (38.2%) had complete mental health (i.e., had flourishing mental health, no mental illness, and no suicidal ideation in the past 12 months). Those who had a confidant were seven times more likely to have complete mental health. Other factors associated with achieving complete mental health among formerly suicidal respondents include being older, being a woman, having higher income, use of religious coping, and never previously having a mental illness. Considering the importance of these protective factors in formulating public health policies will allow for a more wide‐reaching approach to suicide prevention.     

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.