A call to collaboration: the federal commitment to suicide prevention

The federal government, largely through the U.S. Department of Health and Human Services (HHS), sponsors an array of science-based suicide prevention initiatives. This article details the prevention-related agendas and collaborative efforts of five operating divisions within the Department of Health and Human Services: the Substance Abuse and Mental Health Services Administration, National Institutes of Health, Centers for Disease Control and Prevention, Indian Health Service, and Health Resources and Services Administration. The article highlights HHS's activities and their link to the National Strategy for Suicide Prevention, the plan which will guide the nation's suicide prevention efforts for the next decade.     

Suicide reduction and prevention: strategies and interventions

This paper focuses on suicide reduction and prevention. It considers what the United Kingdom government and associated bodies such as Department of Health, the National Health Service and Prison Service could do and are considering doing to prevent suicide in Britain. UK suicide statistics for the period 1971 and 1997 are compared and the Highland Health Board suicide prevention strategy for the 1990s is considered. The articles in this symposium are introduced and the recent UK legal cases involving Ms B and Diane Pretty are included.

Counsellors and psychotherapists have always been concerned, to varying degrees, about clients committing or attempting suicide [1]. It is a topic which can trigger much concern and interest with both neophyte and experienced therapists [2]. In the past decade there has been a growth in individual membership of counselling and psychotherapeutic professional bodies with more therapists becoming accredited and/or registered as qualified practitioners. Thus there has been additional pressure on therapists to adhere to professional codes of practice and ethics.To take the correct action and to be seen to take the correct action within client-therapist relationships is now paramount. It could be argued that this has always been the case. However, therapists not working within a professional framework may have had less incentive to act in a professional manner. A proactive approach may be recommended when seeing clients with suicidal ideation and/or intention (Palmer, 1995). In these cases, inaction can sometimes prove fatal so it is incumbent upon the therapist to support and help the client through the difficult period (Curwen, 1997).     

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.     

Residential Transience and Substance Use Disorder Are Independently Associated with Suicidal Thoughts,Plans, and Attempts in a Nationally Representative Sample of U.S. Adults

This study tests the association between past‐year residential transience (RT ), substance use disorder (SUD ), major depressive episode (MDE ), and suicidal outcomes in a nationally representative sample of noninstitutionalized, civilian, community‐dwelling adults who participated in the 2008–2013 National Surveys on Drug Use and Health. RT , SUD , and MDE were each significantly associated with suicidal thoughts, plans, and attempts in models adjusted for each other and sociodemographic covariates. Because RT is independently associated with each suicidal outcome, even when there is no co‐occurring SUD or MDE , assessment of RT should occur when screening for suicide.     

Preventing suicide through improved training in suicide risk assessment and care: an American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training

There are twice as many suicides as homicides in the United States, and the suicide rate is rising. Suicides increased 12% between 1999 and 2009. Mental health professionals often treat suicidal patients, and suicide occurs even among patients who are seeking treatment or are currently in treatment. Despite these facts, training of most mental health professionals in the assessment and management of suicidal patients is surprisingly limited. The extant literature regarding the frequency with which mental health professionals encounter suicidal patients is reviewed, as is the prevalence of training in suicide risk assessment and management. Most importantly, six recommendations are made to address the longstanding insufficient training within the mental health professions regarding the assessment and management of suicidal patients.     

Aspects of suicidal behavior, depression, and treatment in college students: results from the spring 2000 national college health assessment survey

The National College Health Assessment Survey (NCHA), sponsored by the American College Health Association, measured depression, suicidal ideation, and suicide attempts among 15,977 college students in the academic year 1999-2000. Similar to the National College Health Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention in 1995, 9.5% of students reported that they had seriously considered attempting suicide and 1.5% of students reported that they had attempted suicide within the last school year. The NCHA findings show a relationship between suicidal behavior and depressed mood. Depressed mood, difficulties of sexual identity, and problematic relationships all increase the likelihood of vulnerability to suicidal behavior. Less than 20% of students reporting suicidal ideation or attempts were receiving treatment.     

A Comparison of Suicidal and Nonsuicidal Elders Referred to a Community Mental Health Center Program

Sociodemographics, clinical characteristics, and life stressors of community-dwelling suicidal risk and nonsuicidal risk elders referred to a community aging and mental health provider were compared in this study. Information was collected through case manager surveys and agency records on 683 older adults referred to the Elder Services Program of Spokane Mental Health in 1994 and the first 6 months of 1995. This sample included 109 individuals who were clinically judged to be at suicide risk by case managers at the time of initial assessment. Comparisons between suicidal risk and nonsuicidal risk elders indicated that suicidal elders were younger, more likely to be separated or divorced, and more likely to report a previous history of suicidal behavior. Results of a logistic regression analysis indicated that living alone, depression or anxiety disorder, and higher levels of emotional disturbance predicted suicide risk status. In addition, medical problems, family conflict, and relationship loss predicted suicide risk status in this particular sample. Individuals at suicide risk were also more likely to have a family physician than others. Implications of findings for identification and treatment of suicidal elders are discussed.     

Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

In response to high suicide rates among veterans, the Department of Veterans Affairs (VA) has mandated that veterans at risk for suicide be given Safety Plans (SP). Research on the efficacy of SPs, however, is unclear and no prior study has examined the degree to which more personally relevant (i.e., higher quality) SPs may be associated with better outcomes or evaluate which components of SPs may be most effective at reducing suicidal behavior. The goal of the present study was to examine whether more personally relevant (i.e., higher quality) SPs reduce future suicide-related outcomes (psychiatric hospitalization, self-harm, and suicide attempts), and to determine which components of a SP may be most effective at reducing these outcomes. Participants were 68 individuals enrolled in a longitudinal national registry of returning military veterans receiving care from the VA, and who had at least one suicide-related event in the VA Suicide Prevention Applications Network. Data were collected between December 2009 and September 2016 and were analyzed between March 2016 and February 2017. Scores of SP quality were used to predict suicide-related outcomes. SP quality was low. Higher SP quality scores predicted a decreased likelihood of future suicide behavior reports (note entered into veteran’s chart after a report of any self-harm behavior, including a suicide attempt). Higher scores on Step 3 (people and places that serve as distractions) predicted a decreased likelihood of future suicide behavior reports. More personally relevant SPs may reduce future suicide-related outcomes among veterans. Low SP quality scores highlight the need for training around SP implementation in the VA.     

Relation of Marital Separation and Divorce to Suicide: A Report*

ABSTRACT: This paper examines the relation of marital separation and divorce to suicide. The persons studied are applicants to the Benjamin Rush Center, the crisis clinic division of the Didi Hirsch Community Mental Health Center/Los Angeles Psychiatric Service. The sample consists of 238 subjects, of whom 39, or 16.4% were suicidal, and 23 had made one or more suicide attempts at some prior date. Those seriously discussing separation, but not actually separated, tended to be less frequently suicidal than the long-term separated/divorced (.05 < p >. 10). The study further examined the relationship of important events and interspouse transactions to suicide potential. Significant associations were found in the relationship of suicide potential to verbal attack by spouse (p =. 03), vacillation in the last two weeks (p =. 02), and vacillation since the first serious discussion of divorce (p =. 02). Several other associations approached statistical significance. The authors believe that the findings in regard to vacillation and interspouse aggression are especially interesting and merit further study.     

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.     

Understanding suicidal behaviour in young people referred to specialist CAMHS: a qualitative psychoanalytic clinical research project

A qualitative psychoanalytic clinical research project using a post-Kleinian contemporary approach was undertaken by a team of seven qualified and experienced child psychotherapists working in community Tier 3 Child and Adolescent Mental Health Services (CAMHS). A number of referred young people who deliberately harmed themselves or attempted suicide, who fulfilled the inclusion criteria and consented to participate, were offered an extended individual and family assessment. Grounded Theory analysis of the qualitative data led to the formulation of the Truth Danger Theory. Typical situations in which suicidal behaviour occurred were identified, including intergenerational confusion, neglect, physical and/or sexual abuse within the family, Oedipal conflict, maternal depression and families in which there was a chronically ill sibling. We found that there was a marked disparity between the young person's experience of relationships in the family and the family's own account of their situation, a fractured reality. This can be reflected in an incongruence in the young person's presentation, which may be misleading when assessing risk. The young person feels him/herself to be in a dead end from which there seems to be no escape. Self-harm, for some, contains this impossible dilemma (albeit pathologically) but when it does not, suicide may seem the only option. The Truth Danger Theory provides explanations and predictions for suicidal behaviour and has implications for clinical practice.     

Fewer reasons for staying alive when you are thinking of killing yourself: The brief reasons for living inventory

The Linehan Reasons for Living Inventory is a 48-item scale on which respondents rate how important each item would be for living if suicide were contemplated. The inventory possesses good psychometric properties and can distinguish suicidal from nonsuicidal people among shoppers, psychiatric inpatients, college students, and adolescents. As its length limits its utility in many institutional and screening settings, the purpose of this study was (1) to develop a brief form of the Reasons for Living Inventory appropriate for clinical use and (2) to examine the predictive validity of this brief measure, named the Brief Reasons for Living Inventory (BRFL), to distinguish suicidal from nonsuicidal prison inmates. Results indicate that the brief form was as good as either the Beck Depression Inventory or the Beck Hopelessness Scale at predicting suicidality in this population. Further study is needed to validate the BRFL with different institutionalized and other populations as well as to assess its ability to discriminate suicide ideators from those engaging in overt suicidal behavior.Support for this project was provided in part by the New York State Office of Mental Health Bureau of Forensic Services and the New York State Department of Correctional Services.     

Adolescents with suicidal and nonsuicidal self-harm: clinical characteristics and response to therapeutic assessment

Self-harm is one of the best predictors of death by suicide, but few studies directly compare adolescents with suicidal versus nonsuicidal self-harm. Seventy adolescents presenting with self-harm (71% young women, ages 12-18 years) who participated in a randomized controlled trial were divided into suicidal and nonsuicidal self-harm categories using the Columbia Classification Algorithm of Suicide Assessment. Adolescents with suicidal self-harm were more likely than those with nonsuicidal self-harm to be young women, 22/23 (96%) versus 34/47 (72%), odds ratio (OR) = 8.33, 95% confidence interval (CI) [1.03, 50.0]; had a later age of onset of self-harm, 15.4 years vs. 13.8 years, mean difference = 1.6, 95% CI [.8, 2.43]; and used self-poisoning more often, 18/23 (78%) versus 11/47 (23%), OR = 3.43, 95% CI [2.00, 5.89]. Only those with nonsuicidal self-harm had an improvement on Children's Global Assessment Scale score following a brief therapeutic intervention, mean difference = 8.20, 95% CI [.97, 15.42]. However, there was no interaction between treatment and suicidality. There are important differences between adolescents presenting with suicidal and nonsuicidal self-harm. Suicidal self-harm in adolescence may be associated with a less favorable response to therapeutic assessment.     

Naturalistic evaluation of suicidal ideation: variability and relation to attempt status

Suicidal ideation has been thought to have a relatively stable course across weeks and months. However, daily changes in levels of ideation have not been adequately examined despite the importance of potential variability clinically and conceptually. For example, it has been suggested that variability in suicidal ideation may become less closely tied to variability in other mood symptoms (e.g., depression, hopelessness) among individuals with multiple suicide attempts. The present report had two related goals: (1) to prospectively evaluate suicidal ideation and related mood symptoms, and (2) to determine whether suicide attempt status predicted a decreased association between ideation and other mood symptoms. Non-clinical participants (N=108) with varying levels of suicidal ideation and number of previous suicide attempts completed the beck hopelessness scale (BHS), beck depression inventory (BDI), and suicide probability scale (SPS) every day for 4 weeks. Findings suggested considerable variability in suicidal ideation, especially for multiple attempters. Multiple attempt status predicted a decreased association between suicidal ideation and depression, although the results were only marginally significant. These findings have implications for conceptual models of suicide risk as well as assessment and treatment of suicidal individuals.     

Impact of a Suicide‐Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide‐specific interventions may offer benefits beyond conventional care. This naturalistic controlled‐comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide‐specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.     

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.     

Association of solitary binge drinking and suicidal behavior among emerging adult college students

[Correction Notice: An Erratum for this article was reported in Vol 26(3) of Psychology of Addictive Behaviors (see record 2012-13892-001). In the article, there is an error in the introductory paragraph. The number of students who had seriously considered attempting suicide in the Barrios, Everett, Simon, & Brener (2000) study should have been reported as 11.4%, not 1.4%. Additionally, in the Participants section, data for the study were collected from March 2009 to September 2010, not March 2009 to January 2010 as reported.] Emerging adult college students who binge drink in solitary contexts (i.e., while alone) experience greater depression and suicidal ideation than do students who only binge drink in social contexts, suggesting that they may be at greater risk for suicidal behavior. This study examined the association of a previous suicide attempt, one of the best predictors of future suicide attempts and suicide, and severity of recent suicidal ideation with drinking in solitary and social contexts. Participants were binge drinking, emerging adult (18- to 25-year-old) college students (N = 182) drawn from two studies of college drinkers. A logistic regression analysis revealed that both suicide attempt history and severity of suicidal ideation were significantly associated with a greater likelihood of being a solitary binge drinker as opposed to only a social binge drinker. Students with a previous suicide attempt were nearly four times more likely to be solitary binge drinkers. Multiple regression analyses revealed that suicide attempt history was significantly associated with greater frequency and quantity of drinking in solitary, but not social contexts. Suicidal ideation was significantly associated with drinks per solitary drinking day, but not frequency of solitary drinking once suicide attempt history was accounted for. Given the associations found between solitary binge drinking and a history of suicide attempts, as well as greater severity of recent suicidal ideation, it appears that these students are in need of suicide prevention efforts, including treatment efforts aimed at reducing binge drinking. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Sooner versus later: factors associated with temporal sequencing of suicide

There are few (if any) population-based prospective studies that provide information on factors associated with temporal sequencing of suicide. In this prospective population-based study, the National Health Interview Survey (NHIS), 1986-1994, was linked to the National Death Index (NDI), 1986-1997, to assess factors that predict recent (within 12 months of interview, termed sooner) suicide versus suicide further in the future (more than 12 months after interview, termed later). Of the 653 completed suicides in the NHIS cohort, 13.4 percent completed suicide within a year of interview, and 86.6 percent did so after a year. Sooner decedents were more likely to be White, less educated, unemployed, and to use firearms than any other method compared with later decedents. Surprisingly, sooner decedents had higher levels of self-rated health at baseline. These results have substantial implications for clinicians and other professionals who interact with people at highest risk of suicide. Unfortunately, it may be unrealistic to expect that health care providers can modify the behavior of individuals at highest risk of suicide.     

Habitual starvation and provocative behaviors: Two potential routes to extreme suicidal behavior in anorexia nervosa

Anorexia nervosa (AN) is perhaps the most lethal mental disorder, in part due to starvation-related health problems, but especially because of high suicide rates. One potential reason for high suicide rates in AN may be that those affected face pain and provocation on many fronts, which may in turn reduce their fear of pain and thereby increase risk for death by suicide. The purpose of the following studies was to explore whether repetitive exposure to painful and destructive behaviors such as vomiting, laxative use, and non-suicidal self-injury (NSSI) was a mechanism that linked AN-binge-purging (ANBP) subtype, as opposed to AN-restricting subtype (ANR), to extreme suicidal behavior. Study 1 utilized a sample of 787 individuals diagnosed with one or the other subtype of AN, and structural equation modeling results supported provocative behaviors as a mechanism linking ANBP to suicidal behavior. A second, unexpected mechanism emerged linking ANR to suicidal behavior via restricting. Study 2, which used a sample of 249 AN patients, replicated these findings, including the second mechanism linking ANR to suicide attempts. Two potential routes to suicidal behavior in AN appear to have been identified: one route through repetitive experience with provocative behaviors for ANBP, and a second for exposure to pain through the starvation of restricting in ANR.     

Targeting Perceived Burdensomeness to Reduce Suicide Risk

Perceived burdensomeness (PB), defined by an intractable perception of burdening others, often reflects a false mental calculation that one’s death is worth more than one’s life and has been supported as a significant risk factor for suicide. Because PB often reflects a distorted cognition, it may serve as a corrective and promising target for the intervention of suicide. More work on PB is needed in clinically severe and in military populations. Sixty-nine (Study 1) and 181 (Study 2) military participants at high baseline suicide risk engaged in interventions targeting constructs relating to PB. Baseline and follow-up measures (at 1, 6, 12, 18, and 24 months) of suicidal ideation were administered, and various statistical approaches—including repeated-measures ANOVA, mediation analyses, and correlating standardized residuals—explored whether suicidal ideation decreased specifically by way of PB. In addition to utilizing a larger sample size, Study 2 included an active PB-intervention arm (N = 181) and a control arm (N = 121), who received robust care as usual. In both studies, participants improved considerably regarding baseline to follow-up suicidal ideation. The results of Study 2 mirrored those of Study 1, corroborating a potential mediational role for PB in treatment-related improvements in suicidal ideation in military participants. Effect sizes ranged from .07–.25. Interventions tailored at decreasing levels of perceived burdensomeness may be uniquely and significantly effective in reducing suicidal thoughts.