Evaluating the Experience of Teen-to-Teen Crisis Line Volunteers: A Pilot Study.

Teen-to-teen (t2t) crisis lines are a special type of crisis service where youth volunteers help their peers. Although prior research has examined the experience of adult crisis line responders, no research has examined the experience of adolescents who do this work. In collaboration with two of the largest t2t lines in the U.S., this pilot study is the first examination of t2t crisis line work. Volunteers (ages 14-20) reported: their primary motivation for joining the crisis lines was to help others and give back to the community; responding to a range of peers' problems on the t2t crisis line, including high-risk suicide contacts; and a range of ways the crisis line work impacted their lives. Findings provide preliminary information about the experience of adolescents engaging in t2t crisis line work. Additional research is needed in larger and more diverse samples to understand the impact of crisis line work for youth.

Future Directions in Suicide and Self-Injury Revisited: Integrating a Developmental Psychopathology Perspective.

The recent rise in suicide rates among children and adolescents has made suicide prevention in youth a major focus of government agencies and mental health organizations. In 2012, Nock presented future directions in the study of self-injurious thoughts and behavior (SITBs), highlighting the need to better examine which risk factors are associated with "each part of the pathway" to suicidal and non-suicidal self-injury in order to inform prevention and intervention efforts. Over the past decade, we have made important advances in understanding the development of SITBs and effective interventions. However, there are still major gaps of knowledge in our understanding of how to prevent suicide. Researchers have recently called for more studies focusing particularly on the pathway from suicidal ideation to suicidal behavior. However, we caution against prioritizing only a part of the suicide risk continuum (e.g., the transition from suicidal ideation to suicidal behavior) while minimizing research focusing on earlier developmental points of the pathway to suicide (e.g., the first development of suicidal ideation). We emphasize that childhood and adolescence represent a critical opportunity to intervene and prevent SITBs by altering developmental trajectories toward persistent and escalating SITBs over time. We advocate for integrating a developmental psychopathology perspective into future youth suicide research that focuses on how and when risk for SITBs first emerges and develops across childhood into emerging adulthood. This research is critical for informing interventions aimed at bending developmental pathways away from all SITBs. Here, we describe the need for future research that integrates key developmental psychopathology principles on 1) the identification of the continuum from developmentally typical to atypical as SITBs first emerge and develop, particularly among young children in early to middle childhood, 2) the way in which expressions of and risk for SITBs change across development, 3) how SITBs dynamically move along a continuum from typical to atypical over time, and 4) suicide prevention efforts. We also offer recommendations for future directions that focus on identifying disparities in SITBs occurring among minoritized youth within a developmental psychopathology perspective.

Thwarted Belongingness Mediates Interpersonal Stress and Suicidal Thoughts: An Intensive Longitudinal Study with High-risk Adolescents.

OBJECTIVE: Interpersonal negative life events (NLEs) have been linked to risk for suicidal thoughts and behaviors. However, little is known about how this risk is conferred over the short term and the mechanisms linking interpersonal NLEs to suicide risk, particularly in adolescents. This study used an intensive longitudinal design to examine thwarted belongingness with family and friends as potential mechanisms linking interpersonal NLEs to suicidal thoughts. METHOD: Forty-eight adolescents (Mage = 14.96 years; 64.6% female, 77.1% White), who recently received acute psychiatric care for suicide risk, were followed intensely for 28 days after discharge. Smartphone-based ecological momentary assessment was used to measure presence of interpersonal NLEs at the day level, fluctuations in thwarted belongingness with family and friends (separately) within day, and fluctuations in suicidal thoughts within day. A multi-level structural equation model was utilized to examine family thwarted belongingness and friend thwarted belongingness as parallel mediators in the relationship between interpersonal NLEs and next-day suicidal thoughts. RESULTS: Significant direct effects were observed between interpersonal NLEs and family thwarted belongingness, family thwarted belongingness and suicidal thoughts, and friend thwarted belongingness and suicidal thoughts. In addition, family, but not friend, thwarted belongingness significantly mediated the association between interpersonal NLEs and next-day suicidal thoughts. CONCLUSIONS: Interpersonal NLEs predicted greater suicidal thoughts over the short term (next day) in high-risk adolescents. Findings suggest how interpersonal NLEs may confer risk for suicidal thoughts - by reducing feelings of family belongingness. Future research is needed to examine how modifying belongingness may reduce suicide risk in adolescents.

Feasibility and Acceptability of Ecological Momentary Assessment with High-Risk Suicidal Adolescents Following Acute Psychiatric Care.

Objective: The study purpose was to examine the feasibility and acceptability of intensive ecological momentary assessment (EMA) among high-risk adolescents with suicidal thoughts and behaviors following discharge from acute psychiatric care.Method: Fifty-three adolescents, 12-18 years old, and their parents, were recruited following discharge from acute psychiatric care for suicide risk. The study included a baseline assessment (adolescent and parent), 28 days of EMA surveys (5x per day) and wrist actigraphy (adolescent), and an interview at the end of the 28-day monitoring period (adolescent). Adolescents' outpatient clinicians were also surveyed about the study.Results: Study feasibility was indicated by a reasonable enrollment rate, high adherence to wearing the actigraphy device, and good adherence to EMA surveys (highest in the first week with significant drop-off in subsequent weeks). Adolescents reported their overall experience in the study was positive, the questions were understandable, their responses to questions were generally accurate, and the surveys were minimally burdensome. The study procedures did not appear to be iatrogenic; suicide attempts and rehospitalizations were not study related and occurred at a rate comparable to other adolescents at the recruitment site. Adolescents' clinicians reported that the study was somewhat positive and minimally burdensome for them, and somewhat positive for their patients and families.Conclusions: This study demonstrated that intensive EMA designs are feasible and acceptable among high-risk suicidal youth following acute psychiatric care. Specific procedures are provided for keeping adolescents safe during intensive EMA studies, including detailed information about the risk and safety monitoring plan.

Worry-related sleep problems and suicidal thoughts and behaviors among adolescents in 88 low-, middle-, and high-income countries: an examination of individual- and country-level factors.

A strong association between sleep problems and suicidal thoughts and behaviors (STBs) has been demonstrated in high-income countries. The sleep-STB relationship, however, is minimally understood among youth in low and middle-incomes countries. There also is a limited understanding of how individual- (i.e., age, sex) and country-level (i.e., economic inequality, economic quality) factors may moderate the magnitude of the sleep-STB association among youth. Data were analyzed from the cross-national Global School-based Health Survey 2003-2017, which assessed a range of health behaviors among school-enrolled adolescents aged 11-18 years from 88 low-, lower-middle, upper-middle, and high-income countries. Multilevel models were used to examine the influence of individual- and country-level factors on the association between past-year worry-related sleep problems and past-year suicide ideation, suicide plans, and suicide attempts. Worry-related sleep problems were significantly associated with suicide ideation, plans, and attempts. Adolescent sex, country economic quality (income group designation), and country economic inequality moderated the sleep-STB association, but age did not. The sleep-STB relationship was stronger for males and across macroeconomic indices, the relationship was generally strongest among upper-middle income countries (economic quality) and countries with a big income gap (economic inequality). When examining how individual-level factors differentially affected the sleep-STB relationship within economic quality (income group designation), the effects were driven by older adolescents in high-income countries for suicide ideation and suicide plans. Study findings suggest an important role for global macroeconomic factors, for males, and older adolescents in high-income countries in the sleep-STB relationship. Future directions include expanding worldwide coverage of countries, assessing a wider range of sleep problems, and longitudinal work to understand potential mechanisms in the sleep-STB relationship.

Annual Research Review: A meta-analytic review of worldwide suicide rates in adolescents.

Suicide is a leading cause of death among youth worldwide. The purpose of the current review was to examine recent cross-national trends in suicide mortality rates among 10- to 19-year-olds. This study extracted suicide mortality data from the World Health Organization's (WHO) Mortality Database for the most recent year (since 2010) from any country with available high-quality data (as defined by the WHO's guidelines). Data on access to lethal means (firearms, railways) and measures of economic quality (World Bank Income Group) and inequality (Gini coefficients) were obtained from publicly available data sources. Cross-national suicide mortality rates in youth were heterogeneous. The pooled estimate across all ages, sexes, and countries was 3.77/100,000 people. The highest suicide rates were found in Estonia, New Zealand, and Uzbekistan. Suicide rates were higher among older compared with younger adolescents and higher among males than females. The most common suicide methods were hanging/suffocation and jumping/lying in front of a moving object or jumping from a height. Firearm and railway access were related to suicide deaths by firearms and jumping/lying, respectively. Economic quality and inequality were not related to overall suicide mortality rates. However, economic inequality was correlated with a higher ratio of male:female suicides. This study provides a recent update of cross-national suicide trends in adolescents. Findings replicate prior patterns related to age, sex, geographic region, and common suicide methods. New to this review are findings relating suicide method accessibility to suicide mortality rates and the significant association between income inequality and the ratio of male:female suicide. Future research directions include expanding the worldwide coverage to more low- and middle-income countries, examining demographic groupings beyond binary sex and to race/ethnicity within countries, and clarifying factors that account for cross-national differences in suicide trends.

Does higher-than-usual stress predict nonsuicidal self-injury? Evidence from two prospective studies in adolescent and emerging adult females.

BACKGROUND: Nonsuicidal self-injury (NSSI) is highly prevalent among adolescent and emerging adult females. Most studies examining the relationship between stress and NSSI largely have relied on aggregate self-report measures of stress and between-person models. Using data from two prospective samples, this manuscript tests the hypothesis that within-person models of NSSI provide better clinical markers of risk for NSSI than between-person models of NSSI. METHODS: Two samples (Sample 1: 220 high-risk girls, M age = 14.68, SD = 1.36, baseline assessment and 3-month follow-ups for 18 months; Sample 2: 40 emerging adult females with a history of NSSI, M age = 21.55, SD = 2.14, 14 days with daily retrospective reports) were followed prospectively and completed validated measures of stress and NSSI. Models were adjusted for age and depression. RESULTS: In Sample 1, a within-person model demonstrated that higher-than-usual (but not average) stress levels predicted NSSI within the same 3-month wave. In Sample 2, results from a within-person model with daily diary assessment data showed that higher-than-usual stress (but not average daily stress) predicted same-day NSSI. CONCLUSIONS: Together, our results suggest that higher-than-usual stress, relative to one's typical stress level, but not average stress levels, signals times of enhanced risk for NSSI. These results highlight the clinical utility of repeated assessments of stress.

Real-Time Monitoring of Suicide Risk among Adolescents: Potential Barriers, Possible Solutions, and Future Directions.

Recent advances in real-time monitoring technology make this an exciting time to study risk for suicidal thoughts and behaviors among youth. Although there is good reason to be excited about these methods, there is also reason for caution in adopting them without first understanding their limitations. In this article, we present several broad future directions for using real-time monitoring among youth at risk for suicide focused around three broad themes: novel research questions, novel analytic methods, and novel methodological approaches. We also highlight potential technical, logistical, and ethical challenges with these methodologies, as well as possible solutions to these challenges.

Implicit Identification with Death Predicts Suicidal Thoughts and Behaviors in Adolescents.

Prior research indicates that adults' implicit identification with death can be used to predict suicidal thoughts and behaviors (STBs) in the community. However, no studies have examined whether this effect is found among adolescents-a group for whom suicide is the 2nd leading cause of death. The current study tested the utility of implicit identification with death, using a Death Implicit Association Test (IAT), for detecting and predicting STBs in adolescents. Participants were 141 adolescents 12-19 years of age (81.6% female, 74.5% White) with a current psychiatric disorder and/or currently receiving outpatient psychiatric treatment. All participants completed the Death IAT and self-report measures of STBs at baseline, as well as self-report measures of STBs at 6-month and 1-year follow-ups. At baseline, stronger implicit identification with death (higher Death IAT score) was related to greater suicide ideation (SI) frequency, severity, and duration, but did not differ based on suicide attempt history. Prospectively, higher Death IAT scores predicted any occurrence (but not frequency) of SI over the subsequent year, but not when controlling for prior SI. Death IAT scores were higher among adolescents with prior attempts who reattempted suicide over the follow-up. Examination of stimuli-level results suggested that Death IAT differences may be driven by responses on trials with specific words, including suicide and die. Implicit identification with death may be a useful behavioral indicator of suicide risk in adolescents. Preliminary findings suggest that the Death IAT may aid in predicting STBs among youth receiving outpatient treatment.

Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth.

The current review provides an evidence base update of psychosocial treatments for self-injurious thoughts and behaviors (SITBs) in youth. A systematic search was conducted of 2 major scientific databases (PsycInfo and PubMed) and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) published prior to June 2018. The search identified 26 RCTs examining interventions for SITBs in youth: 17 were included in the 2015 review and 9 trials were new to this update. The biggest change since the prior review was the evaluation of Dialectical Behavior Therapy for adolescents (DBT-A) as the first Level 1: Well-established intervention for reducing deliberate self-harm (composite of nonsuicidal and suicidal self-injury) and suicide ideation in youth and Level 2: Probably efficacious for reducing nonsuicidal self-injury and suicide attempts. Five other interventions were rated as Level 2: Probably efficacious for reducing SITBs in youth, with the new addition of Integrated Family Therapy. This evidence base update indicates that there are a few promising treatments for reducing SITBs in youth. Efficacious interventions typically include a significant family or parent training component as well as skills training (e.g., emotion regulation skills). Aside from DBT-A, few treatments have been examined in more than one RCT. Given that replication by independent research groups is needed to evaluate an intervention as Well-established, future research should focus on replicating the five promising interventions currently evaluated as Probably efficacious. In addition, an important future direction is to develop brief efficacious interventions that may be scalable to reach large numbers of youth.

Annual Research Review: Suicide among youth - epidemiology, (potential) etiology, and treatment.

BACKGROUND: Suicide is a leading cause of death and a complex clinical outcome. Here, we summarize the current state of research pertaining to suicidal thoughts and behaviors in youth. We review their definitions/measurement and phenomenology, epidemiology, potential etiological mechanisms, and psychological treatment and prevention efforts. RESULTS: We identify key patterns and gaps in knowledge that should guide future work. Regarding epidemiology, the prevalence of suicidal thoughts and behaviors among youth varies across countries and sociodemographic populations. Despite this, studies are rarely conducted cross-nationally and do not uniformly account for high-risk populations. Regarding etiology, the majority of risk factors have been identified within the realm of environmental and psychological factors (notably negative affect-related processes), and most frequently using self-report measures. Little research has spanned across additional units of analyses including behavior, physiology, molecules, cells, and genes. Finally, there has been growing evidence in support of select psychotherapeutic treatment and prevention strategies, and preliminary evidence for technology-based interventions. CONCLUSIONS: There is much work to be done to better understand suicidal thoughts and behaviors among youth. We strongly encourage future research to: (1) continue improving the conceptualization and operationalization of suicidal thoughts and behaviors; (2) improve etiological understanding by focusing on individual (preferably malleable) mechanisms; (3) improve etiological understanding also by integrating findings across multiple units of analyses and developing short-term prediction models; (4) demonstrate greater developmental sensitivity overall; and (5) account for diverse high-risk populations via sampling and reporting of sample characteristics. These serve as initial steps to improve the scientific approach, knowledge base, and ultimately prevention of suicidal thoughts and behaviors among youth.

Understanding suicide risk within the Research Domain Criteria (RDoC) framework: A meta-analytic review.

BACKGROUND: The field is in need of novel and transdiagnostic risk factors for suicide. The National Institute of Mental Health's Research Domain Criteria (RDoC) provides a framework that may help advance research on suicidal behavior. METHOD: We conducted a meta-analytic review of existing prospective risk and protective factors for suicidal thoughts and behaviors (ideation, attempts, and deaths) that fall within one of the five RDoC domains or relate to a prominent suicide theory. Predictors were selected from a database of 4,082 prospective risk and protective factors for suicide outcomes. RESULTS: A total of 460 predictors met inclusion criteria for this meta-analytic review and most examined risk (vs. protective) factors for suicidal thoughts and behaviors. The overall effect of risk factors was statistically significant, but relatively small, in predicting suicide ideation (weighted mean odds ratio: wOR = 1.72; 95% CI: 1.59-1.87), suicide attempt (wOR = 1.66 [1.57-1.76), and suicide death (wOR = 1.41 [1.24-1.60]). Across all suicide outcomes, most risk factors related to the Negative Valence Systems domain, although effect sizes were of similar magnitude across RDoC domains. CONCLUSIONS: This study demonstrated that the RDoC framework provides a novel and promising approach to suicide research; however, relatively few studies of suicidal behavior fit within this framework. Future studies must go beyond the "usual suspects" of suicide risk factors (e.g., mental disorders, sociodemographics) to understand the processes that combine to lead to this deadly outcome.

Implicit identification with death predicts change in suicide ideation during psychiatric treatment in adolescents.

BACKGROUND: Suicidal thoughts and behaviors are major public health concerns in youth. Unfortunately, knowledge of reliable predictors of suicide risk in adolescents is limited. Promising research using a death stimuli version of the Implicit Association Test (Death IAT) indicates that stronger identification with death differs between adults with and without a history of suicidal thoughts and behaviors and uniquely predicts suicide ideation and behavior. However, research in adolescents is lacking and existing findings have been mixed. This study extends previous research by testing whether implicit identification with death predicts changes in suicide ideation during psychiatric treatment in adolescents. METHODS: Participants included 276 adolescents, ages 13-19, admitted to a short-term residential treatment program. At hospital admission and discharge, adolescents completed the Death IAT and measures of recent suicidal thoughts. RESULTS: At admission, implicit identification with death was associated with recent suicide ideation, but did not differ between those who engaged in prior suicidal behavior and those who did not. Prospectively, adolescents' implicit identification with death at admission significantly predicted their suicide ideation severity at discharge, above and beyond explicit suicide ideation. However, this effect only was significant for adolescents with longer treatment stays (i.e., more than 13 days). CONCLUSIONS: Implicit identification with death predicts suicidal thinking among adolescents in psychiatric treatment. Findings clarify over what period of time implicit cognition about death may predict suicide risk in adolescents.

Implicit cognition about self-injury predicts actual self-injurious behavior: results from a longitudinal study of adolescents.

BACKGROUND: The implicit association hypothesis of nonsuicidal self-injury (NSSI) proposes that individuals who engage in self-injury develop, over time, strong associations between themselves and NSSI, and their identification with this behavior guides their future selection of NSSI to cope. Prior research has established a relationship between implicit NSSI associations (using an Implicit Association Test for Self-Injury) and engagement in NSSI. However, previous studies have been small and cross-sectional, and thus underpowered to examine the nature of this association and the extent to which implicit associations predict the persistence of NSSI. METHODS: This study builds on previous research in a prospective, longitudinal examination of implicit self-identification with NSSI in a large sample of middle school students. NSSI behavior and implicit NSSI associations were assessed annually in school at three time points. RESULTS: Adolescents who engaged in NSSI exhibited stronger implicit self-identification with NSSI than adolescents who did not engage in NSSI. Moreover, implicit NSSI identification was stronger among adolescents who engaged in cutting, frequent NSSI, and recent NSSI. A reciprocal association was observed between NSSI frequency and implicit NSSI identification over 1 year. Notably, implicit NSSI identification uniquely and prospectively predicted engagement in NSSI over the subsequent year. CONCLUSIONS: Implicit self-identification with NSSI may track both trait- and state-related changes in the behavior and, importantly, may help predict continued engagement in NSSI.

Evidence-based psychosocial treatments for self-injurious thoughts and behaviors in youth.

The purpose of this study was to review the current evidence base of psychosocial treatments for suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) in youth. We reviewed major scientific databases (HealthSTAR, MEDLine, PsycINFO, PubMed) for relevant studies published prior to June 2013. The search identified 29 studies examining interventions for suicidal or nonsuicidal SITBs in children or adolescents. No interventions currently meet the Journal of Clinical Child and Adolescent Psychology standards for Level 1: well-established treatments. Six treatment categories were classified as Level 2: probably efficacious or Level 3: possibly efficacious for reducing SITBs in youth. These treatments came from a variety of theoretical orientations, including cognitive-behavioral, family, interpersonal, and psychodynamic theories. Common elements across efficacious treatments included family skills training (e.g., family communication and problem solving), parent education and training (e.g., monitoring and contingency management), and individual skills training (e.g., emotion regulation and problem solving). Several treatments have shown potential promise for reducing SITBs in children and adolescents. However, the probably/possibly efficacious treatments identified each have evidence from only a single randomized controlled trial. Future research should focus on replicating studies of promising treatments, identifying active treatment ingredients, examining mediators and moderators of treatment effects, and developing brief interventions for high-risk periods (e.g., following hospital discharge).

How developmental psychopathology theory and research can inform the research domain criteria (RDoC) project.

The recently proposed Research Domain Criteria (RDoC) project has the potential to stimulate new research and overcome many of the limitations of the Diagnostic and Statistical Manual of Mental Disorders taxonomy. In the present article we focus, in three main sections, on how theory and research from developmental psychopathology can inform RDoC. First, we discuss the ontology of mental illness and the potential advantages of the RDoC approach to understanding the nature of mental illness. Second, we note potential issues to consider when implementing the RDoC framework, including (a) integrating developmental processes, (b) classifying mental illness within a dimensional approach, and (c) avoiding problems associated with biological reductionism. Third, we describe how a developmental psychopathology perspective may inform each of these potential issues within RDoC. Finally, we highlight the study of emotion and the centrality of affective processes within the RDoC framework. Specifically, we describe how constructionist models of emotion are consistent with developmental psychopathology and how this perspective on emotion can help to guide RDoC research.

An evaluation of emotion recognition, emotion reactivity, and emotion dysregulation as prospective predictors of 12-month trajectories of non-suicidal self-injury in an adolescent psychiatric inpatient sample.

BACKGROUND: Little is known about trajectories of NSSI. We aimed to identify NSSI trajectories in adolescent psychiatric inpatients and emotional processes that differentiate between trajectories. METHODS: Participants were 180 adolescents (71.7 % female; mean age of 14.89 years, SD = 1.35) from a psychiatric inpatient facility. NSSI was assessed at their index hospitalization, as well as 6, and 12 months after discharge. Emotion recognition, emotion reactivity, and emotion dysregulation were assessed at baseline. Latent class mixture modeling was used to identify different NSSI trajectories and ANOVAs were used to evaluate predictors of the trajectories. RESULTS: Analyses yielded three NSSI trajectories. These included a stable low-frequency class (90.53 % of sample), a stable moderate-frequency class, and a class characterized by high-frequency NSSI at baseline but that largely resolves by 6-month follow-up. After adjustments for multiple comparisons were made, only emotion regulation at baseline differentiated between the trajectories, with greater overall emotion dysregulation and greater emotional non-acceptance (a facet of emotion dysregulation) characterizing the initially high-frequency class and the stable moderate-frequency class more than the stable low-frequency class (ps < .05). Difficulties engaging in goal-directed behavior when distressed characterized the stable moderate-frequency NSSI class more than the stable low-frequency class (p < .05). Limitations The study sample consists predominantly of female and White adolescents and thus may not generalize to other demographic groups. CONCLUSIONS: The current findings suggest that interventions involving emotion regulation with adolescents who engage in NSSI would particularly benefit from a focus on increasing acceptance of emotional experiences.

Suicide Ideation Among Transgender and Gender Diverse Adolescents: The Role of Parental Invalidation of Adolescents' Gender Identity.

Transgender and gender diverse (TGD) youth experience chronic and acute stress associated with their gender identity contributing to their increased risk of suicide and suicide ideation (SI) compared to non-TGD peers. This study examined how invalidating and accepting gender-related experiences with a parent impact SI severity among TGD adolescents cross-sectionally and longitudinally, within-person. Participants were 15 TGD adolescents with past month SI recruited across community and clinical settings. Adolescents completed a baseline assessment of validated interviews and self-report measures on parental invalidation and SI severity. Over a 14-day follow-up period, adolescents reported instances of parental gender invalidation and acceptance, relative stress of those experiences, and SI severity multiple times/day via ecological momentary assessment (EMA). Bivariate associations of parental invalidation and acceptance with SI were examined at baseline, while multilevel models examined the relationship within-person over follow-up. Cross-sectionally, greater perceived invalidation and non-affirmation by their parents was associated with more severe SI. Over the follow up, instances of perceived parental invalidation were associated with passive SI within-person. Findings partially support the minority stress theory and social safety perspective by showing that perceived gender-invalidation from parents affects SI in TGD adolescents, both cross-sectionally and longitudinally. Further research is needed to identify specific emotional and cognitive factors, such as perceived stress, that contribute to the risk of SI among TGD youth and inform the development of targeted interventions for this vulnerable population.

Nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients.

Nonsuicidal self-injury (NSSI) is a growing public health concern, especially among adolescents. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, NSSI is classified as a criterion of borderline personality disorder (BPD). However, a distinct NSSI disorder will now be included in DSM-5 as a "condition requiring further study." It is important to note that, at this time, there is little direct evidence supporting the DSM-5 proposal over the DSM-IV classification. To address this need, the current study examined the extent to which NSSI occurs independently of BPD and has clinical significance beyond a diagnosis of BPD in adolescent psychiatric patients. NSSI disorder was assessed based on the proposed DSM-5 criteria in 198 adolescents ages 12 to 18 (74% female; 64% Caucasian, 14% Hispanic, 10% African American, and 12% mixed/other ethnicity) from a psychiatric hospital. Major Axis I disorders, Axis II BPD, and suicide ideation and attempts were assessed with structured clinical interviews; emotion dysregulation and loneliness were measured with validated self-report questionnaires. First, results indicated that NSSI disorder occurred independently of BPD. Specifically, although there was overlap between the occurrence of BPD and NSSI disorder, this overlap was no greater than that between BPD and other Axis I disorders (e.g., anxiety and mood disorders). Second, NSSI disorder demonstrated unique associations with clinical impairment-indexed by suicide ideation and attempts, emotion dysregulation, and loneliness-over and above a BPD diagnosis. Taken together, findings support the classification of NSSI as a distinct and clinically significant diagnostic entity.

The use of advanced technology and statistical methods to predict and prevent suicide.

In the past decade, two themes have emerged across suicide research. First, according to meta-analyses, the ability to predict and prevent suicidal thoughts and behaviours is weaker than would be expected for the size of the field. Second, review and commentary papers propose that technological and statistical methods (such as smartphones, wearables, digital phenotyping and machine learning) might become solutions to this problem. In this Review, we aim to strike a balance between the pessimistic picture presented by these meta-analyses and the optimistic picture presented by review and commentary papers about the promise of advanced technological and statistical methods to improve the ability to understand, predict and prevent suicide. We divide our discussion into two broad categories. First, we discuss the research aimed at assessment, with the goal of better understanding or more accurately predicting suicidal thoughts and behaviours. Second, we discuss the literature that focuses on prevention of suicidal thoughts and behaviours. Ecological momentary assessment, wearables and other technological and statistical advances hold great promise for predicting and preventing suicide, but there is much yet to do.