Assessment of acquired capability for suicide in clinical practice

The Interpersonal Psychological Theory of suicide proposes that the interaction between Thwarted Belongingness, Perceived Burdensomeness, and Acquired Capability for Suicide (ACS) predicts proximal risk of death by suicide. Instruments to assess all three constructs are available. However, research on the validity of one of them, the acquired capability for suicide scale (ACSS), has been limited, especially in terms of its clinical relevance. This study aimed to explore the utility of the different versions of the ACSS in clinical assessment. Three versions of the scale were investigated, the full 20-item version, a 7-item version and a single item version representing self-perceived capability for suicide. In a sample of patients recruited from a clinic specialising in the treatment of suicidality and in a community sample, all versions of the ACSS were found to show reasonable levels of reliability and to correlate as expected with reports of suicidal ideation, self-harm, and attempted suicide. The item assessing self-perceived acquired capacity for suicide showed highest correlations with all levels of suicidal behaviour. However, no version of the ACSS on its own showed a capacity to indicate suicide attempts in the combined sample. It is concluded that the versions of the scale have construct validity, but their clinical utility is limited. An assessment using a single item on self-perceived ACS outperforms the full and shortened versions of ACSS in clinical settings and can be recommended with caution for clinicians interested in assessing this characteristic.     

Detecting Potential Underreporting of Suicide Ideation Among U.S. Military Personnel

Using a military sample comprised largely of National Guard personnel, zero‐inflation negative binomial regression was applied to estimate the effects of indirect, nonface valid indicators of suicide ideation [Thwarted Belongingness (TB), Perceived Burdensomeness (PB), and Hopelessness], in predicting suicide ideation. Data from a sample of 497 military personnel (82.1% male; m_age = 27.24; range = 18–59) were analyzed. TB and the interaction of TB with Hopelessness were significant predictors in the logistic regression, and in the negative binomial regression, the main effects of TB and hopelessness, and the interactions of TB with hopelessness and PB with hopelessness were significant. The findings further indicated that approximately 10% of those not reporting ideation would be predicted to be ideators. Clinically, these results indicate that, in samples reluctant to report ideation, the assessment of suicide risk may improve through the use of relevant measures that do not explicitly reference suicide thoughts.     

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.     

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide‐specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self‐reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence‐based components—entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre‐suicidal mental state, regardless of their self‐reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.     

Examining the Interpersonal–Psychological Theory of Suicide in an Inpatient Veteran Sample

Suicide among veterans is a pressing public health concern. The interpersonal–psychological theory of suicide proposes that perceived burdensomeness and thwarted belongingness lead to suicidal desire, whereas the acquired capability for suicide leads to suicide attempt in the presence of suicidal desire (Joiner, 2005). Two hypotheses derived from the interpersonal–psychological theory of suicide were tested in 185 veterans (96 women) entering inpatient psychiatric treatment. Burdensomeness and its interaction with belongingness significantly predicted current suicidal ideation. The three‐way interaction between burdensomeness, belongingness, and acquired capability did not significantly predict number of past suicide attempts. Clinical implications and directions for future research are discussed.     

A Preliminary Validation Study of Two Ultra‐Brief Measures of Suicide Risk: The Suicide and Perceived Burdensomeness Visual Analog Scales

The advent of rapid‐acting suicide‐focused interventions and longitudinal research designs employing high‐frequency, repeated measurement of suicide risk has resulted in a need to quantify suicide risk during very brief windows of time (e.g., minutes, hours, days). This has rapidly outpaced traditional methods for assessing suicide risk, which often focus on measuring indicators of suicide risk during much broader intervals of time (e.g., weeks to months). Valid and practical methods for rapidly assessing suicide risk during small time intervals are therefore needed. This study reports a preliminary examination of the Suicide Visual Analog Scale (S‐VAS) and the Perceived Burdensomeness Visual Analog Scale (PB‐VAS) in a clinical sample of suicidal adults. Results support the convergent validity, predictive validity, responsiveness, and clinical utility of both scales, suggesting the S‐VAS and PB‐VAS are valid methods for rapidly quantifying two dimensions of suicide risk.     

Suicidal Self‐Directed Violence Among Homeless US Veterans: A Systematic Review

A systematic review of the literature was conducted to investigate suicidal self‐directed violence and homelessness among US military veterans, and identify existing suicide prevention strategies. In November 2015, MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, Cochrane Library, Google, and Google Scholar were searched. Articles published since 1990 investigating self‐directed violence among homeless veterans were identified. Data were extracted and synthesized qualitatively. Nineteen observational studies were included. Suicide ideation rates were 1.3% (current), 7.0% (past week), 12.1%–18% (past 30 days), and 74% (lifetime). Suicide attempt rates were 0%–6% (past 30 days), 30.7%–31.5% (past 5 years), and 15%–46.6% (lifetime). Death by suicide rate was 81.0 per 100,000. No interventional studies to prevent self‐directed violence among homeless veterans were identified. Homeless veterans are at risk for self‐directed violence, suggesting the need for research to examine preventive strategies. A comprehensive public health approach to suicide prevention needs to focus on vulnerable populations, including homeless veterans.     

Dysfunctional Attitudes and Suicidal Ideation in Psychiatric Outpatients

To determine if specific sets of dysfunctional attitudes were related to suicidal ideation, the 100-item Dysfunctional Attitude Scale (DAS) was administered to 908 psychiatric outpatients along with the Beck Depression Inventory (BDI), Hopelessness Scale (BHS), Self-Concept Test (BST), and Scale for Suicide Ideation (SSI). The SSI was used to classify the outpatients into 97 (10.7%) suicide ideators and 811 (89.3%) nonideators, and the DAS was scored for nine subscales described by Beck, Brown, Steer, and Weissman (1991) . None of the DAS subscales discriminated the ideators and nonideators or was significantly related to SSI total scores of the suicide ideators after controlling for sex, age, diagnosis of a mood or panic disorder, comorbidity, presence of a personality disorder, a history of a past suicide attempt, the BDI, the BHS, and the BST. The contributions of sets of dysfunctional attitudes for identifying and explaining suicidal ideation were overshadowed by a history of a past suicide attempt and hopelessness.     

Social Problem-Solving and Suicidal Ideation Among Homeless Youth Receiving a Cognitive Therapy Intervention: A Moderated Mediation Analysis

Despite the high prevalence of suicidal ideation and attempts among homeless youth, little research has examined how suicide prevention interventions influence suicide-related risk and protective factors, and ultimately produce positive outcome in suicidality in this population. Drawing on the Diathesis-Stress Model and the Interpersonal Theory of Suicide, the current study examined whether participation in Cognitive Therapy for Suicide Prevention (CTSP) moderated the mediation link between social problem-solving, perceived burdensomeness and thwarted belongingness, and suicidal ideation among a sample of homeless youth experiencing suicidal ideation. Social problem-solving refers to a set of cognitive, emotional, and behavioral coping responses in the face of stressful situations, and it is identified as a potent protective factor in alleviating perceived burdensomeness and thwarted belongingness, and reducing suicidal ideation. Participants included 150 homeless youth (M age = 20.99, range = 18-24; 41% female) who were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) (n = 75) or Treatment as Usual alone (n = 75). Participants were assessed at baseline, 3, 6, and 9 months post-baseline. Findings showed that perceived burdensomeness mediated the association of social problem-solving with suicidal ideation only among youth participating in the CTSP condition. These findings provide evidence to support the promising effects of CTSP in enhancing the protective effects of social problem-solving on suicidal ideation through the mediating effects of perceived burdensomeness. Findings also have implications for improving intervention effectiveness with a community-based population at high risk of suicide.     

Late‐life Depression,Suicidal Ideation,and Attempted Suicide: The Role of Individual Differences in Maximizing,Regret, and Negative Decision Outcomes

Suicide rates are highest in adults of middle and older age. Research with psychiatric patients has shown that proneness to feel regret about past decisions can grow so intense that suicide becomes a tempting escape. Here, we examine the additional role of individual differences in maximizing, or the tendency to strive for the best decision, rather than one that is good enough. We provided individual‐difference measures of maximizing, regret proneness, and negative life decision outcomes (as reported on the Decision Outcome Inventory) to a nonpsychiatric control group, as well as three groups of psychiatric patients in treatment for suicide attempts, suicidal ideation, or non‐suicidal depression. We found that scores on the three individual‐difference measures were worse for psychiatric patients than for nonpsychiatric controls and were correlated to clinical assessments of depression, hopelessness, and suicidal ideation. More importantly, maximizing was associated with these clinical assessments, even after taking into account maximizers' worse life decision outcomes. Regret proneness significantly mediated those relationships, suggesting that maximizers could be at risk for clinical depression because of their proneness to regret. We discuss the theoretical relevance of our findings and their promise for clinical practice. Ultimately, late‐life depression and suicidal ideation may be treated with interventions that promote better decision making and regret regulation. Copyright © 2015 John Wiley & Sons, Ltd.     

Marital Discord and Suicidal Outcomes in a National Sample of Married Individuals

Suicide is the tenth leading cause of death in the United States, with an average of 105 suicides committed daily. The association between marital discord and 12‐month prevalence of suicidal ideation and suicide attempt was studied in a population‐based sample of married adults (N = 1,384). Marital discord was significantly and positively associated with suicidal ideation and suicide attempt, and these associations remained significant when controlling for demographics and 12‐month prevalence of mood, anxiety, and substance use disorders. Results suggest that marital discord is an important correlate of suicidal outcomes and may be important to target in preventing and treating suicide.     

Examining Proximal Risk Factors for Suicide in a Sample of Mexican Adults in Rehabilitation Centers

The cross‐cultural generalizability of the interpersonal theory of suicide was examined in this study. One hundred ninety‐nine adults in an inpatient setting in Mexico completed the Personal Resources Questionnaire, Beck Hopelessness Scale, Interpersonal Needs Questionnaire, Acquired Capability for Suicide Scale, and Suicide Behaviors Questionnaire‐Revised. Analyses revealed the interaction between perceived burdensomeness and thwarted belongingness did not predict suicide ideation. The interactions between perceived burdensomeness and thwarted belongingness and between perceived burdensomeness and acquired capacity significantly predicted suicidal behaviors, whereas the hypothesized three‐way interaction did not. These findings highlight the importance of perceived burdensomeness in the development of suicidal behaviors among Mexican‐origin adults.     

Clarifying the Role of Psychological Pain in the Risks of Suicidal Ideation and Suicidal Acts among Patients with Major Depressive Episodes

The role of psychological pain in the risk of suicide was explored using a three‐dimensional psychological pain model (pain arousal, painful feelings, pain avoidance). The sample consisted of 111 outpatients with major depressive episodes, including 28 individuals with suicidal histories. They completed the Chinese version of the Beck Scale for Suicide Ideation (BSI), the Beck Depression Inventory (BDI), the Psychache Scale, and the three‐dimensional Psychological Pain Scale (TDPPS). A structured clinical interview was conducted to assess the history of suicidal acts. Significant correlations were found among BDI, BSI, and TDPPS scores (p < .01). Stepwise regression analyses showed that only pain avoidance scores significantly predicted suicide ideation at one's worst point (β = .79, p < .001) and suicidal acts (β = .46, p < .001). Pain avoidance was also a better predictor of current suicidal ideation (β = .37, p = .001) than were BDI scores (β = .31, p < .01). Increased levels of pain avoidance during a major depressive episode may be a dominant component of the motivation for suicide. Future clinical assessments for populations at high risk of suicide should include measures of psychological pain to reduce the incidence of suicide.     

A Trait‐Interpersonal Analysis of Suicide Proneness Among Lesbian,Gay, and Bisexual Community Members

Suicide remains a concerning issue for lesbian, gay, and bisexual (LGB) persons. The integrated effects of five‐factor model personality traits and interpersonal‐psychological theory of suicide (IPTS) constructs on suicide proneness in a community sample of 336 LGB adults were examined. Results supported a model inclusive of all five‐factor model domains predicting IPTS constructs leading to suicide proneness. Effects of neuroticism and extraversion were both mediated by perceived burdensomeness and thwarted belongingness. Thwarted belongingness mediated the effect of agreeableness on suicide proneness. Identified mediation pathways build on existing trait‐interpersonal theory and may inform clinical services for sexual minority persons.     

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.     

Emotional Impact of a Video‐Based Suicide Prevention Program on Suicidal Viewers and Suicide Survivors

In light of continuing concerns about iatrogenic effects associated with suicide prevention efforts utilizing video‐based media, the impact of emotionally‐charged videos on two vulnerable subgroups—suicidal viewers and suicide survivors—was explored. Following participation in routine suicide education as a part of the U.S. Air Force Suicide Prevention Program's video‐based community briefing, a sample of young active duty airmen demonstrated small decreases in positive emotional states and larger decreases in negative emotional states, especially among suicidal females. No evidence of iatrogenic effects were observed among suicidal or survivor subgroups when compared to controls. Results support the use of video‐based media as a safe educational strategy that might actually serve to decrease emotional distress among vulnerable subgroups.     

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.     

Building Models for the Relationship Between Attitudes Toward Suicide and Suicidal Behavior: Based on Data from General Population Surveys in Sweden,Norway, and Russia

Our aim was to build a model delineating the relationship between attitudes toward suicide and suicidal behavior and to assess equivalence by applying the model on data from different countries. Representative samples from the general population were approached in Sweden, Norway, and Russia with the Attitudes Toward Suicide (ATTS) questionnaire. Data on experience of suicidal behavior among significant others and self‐reported suicidal expressions were also collected. Structural equation modeling resulted in gender and country specific models where experience of suicidal behavior among significant others and self‐reported suicidal expressions earlier in life predicted attitudes, and attitudes predicted current suicidal expressions. The models included the attitude factors acceptance of suicide, condemnation, and preventability; age and level of education were also incorporated. The different models reveal possible ways to better understand gender and culture‐specific paths between attitudes and suicidal behaviors, and their relevance in a suicide prevention context is considered.     

Miseries Suffered,Unvoiced, Unknown? Communication of Suicidal Intent by Men in “Rural” Queensland,Australia

It has long been argued that suicide prevention efforts in rural locations face not only structural barriers, such as a lack of accessible health care and specialized mental health services, but also a range of cultural barriers. A commonly discussed cultural factor that may contribute to higher rural suicide rates is low levels of help‐seeking behavior, which in turn act as a barrier to accessing and receiving care. However, the assumption that suicide by rural men is more likely to be accompanied by low help‐seeking behavior, relative to urban men, has not been well tested. Using data from the Queensland Suicide Register, this study evaluates one form of help‐seeking behavior—communication of suicidal intent—among men who died by suicide. Contrary to the expectation that suicide in rural areas would be associated with lower levels of help‐seeking behavior than suicide in urban areas, it was found that communication of suicidal intent was broadly comparable across rural and urban settings. The implications for suicide prevention policies and service delivery strategies are discussed.     

A Prospective Examination of the Interpersonal‐Psychological Theory of Suicidal Behavior Among Psychiatric Adolescent Inpatients

The challenge of identifying suicide risk in adolescents, and particularly among high‐risk subgroups such as adolescent inpatients, calls for further study of models of suicidal behavior that could meaningfully aid in the prediction of risk. This study examined how well the Interpersonal‐Psychological Theory of Suicidal Behavior (IPTS)—with its constructs of thwarted belongingness (TB), perceived burdensomeness (PB), and an acquired capability (AC) for lethal self‐injury—predicts suicide attempts among adolescents (N = 376) 3 and 12 months after hospitalization. The three‐way interaction between PB, TB, and AC, defined as a history of multiple suicide attempts, was not significant. However, there were significant 2‐way interaction effects, which varied by sex: girls with low AC and increasing TB, and boys with high AC and increasing PB, were more likely to attempt suicide at 3 months. Only high AC predicted 12‐month attempts. Results suggest gender‐specific associations between theory components and attempts. The time‐limited effects of these associations point to TB and PB being dynamic and modifiable in high‐risk populations, whereas the effects of AC are more lasting. The study also fills an important gap in existing research by examining IPTS prospectively.