Uncontrollability of suicidal ideation adds incremental explanatory power in prediction of later suicidal ideation.

OBJECTIVE: Suicidal ideation and suicidal behaviors are major public health concerns in the United States and are difficult to treat and predict. Risk factors that are incrementally informative are needed to improve prediction and inform prevention of suicidal thoughts and behaviors. Uncontrollability of suicidal ideation, one parameter of suicidal ideation, is one such candidate. METHOD: In the current study, we assessed the predictive power of uncontrollability of suicidal ideation, over and above overall suicidal ideation, for future suicidal ideation in a large sample of active-duty service members. A total of 1044 suicidal military service members completed baseline assessments, of whom 664 (63.6%) completed 3-month follow-up assessments. RESULTS: While baseline overall suicidal ideation itself was the strongest predictor of future suicidal ideation, uncontrollability of suicidal ideation added some incremental explanatory power. CONCLUSION: Further study of uncontrollability of suicidal thought is needed to elucidate its impact on suicidal outcomes.

Improving Our Understanding of the Death/Life Implicit Association Test.

The "Death/Life" Implicit Association Test (d-IAT) is a reaction-time task which has been associated with past and future suicidal behavior; in some work, the association has been incremental to explicit self-report of suicide risk. Proposed mechanisms for this association relate to one's unwillingness or inability to completely disclose or be introspectively aware of implicit risk. This study investigated moderators of implicit-explicit concordance as well as predictors of d-IAT score unexplained by self-reported suicidal thoughts and behaviors among an online sample of 382 adults with higher demographic suicide risk (i.e., military service members and veterans, men over age 50, and LGBTQ young adults). Before and after controlling for current explicit report, results replicated the finding of a significant relationship between d-IAT score and severity of past suicidal behavior, and additionally indicated that suicide attempt history and wish to live moderated the association between d-IAT score and explicit report. Furthermore, results suggest that poor introspective awareness, rather than deception, may account for differences between implicit and explicit risk assessment. Continuing investigation of moderators and mechanisms of the d-IAT is needed to improve the utility and validity of using implicit suicide risk assessment as a clinical tool.

Examining the link between prior suicidality and subsequent suicidal ideation among high-risk US military service members.

BACKGROUND: Research is needed to identify the factors that explain the link between prior and future suicidality. This study evaluated possible mediators of the relationship between: (1) the severity of prior suicidality and (2) suicidal ideation severity at 3-month follow-up among a sample of high-risk military personnel. METHODS: US military service members referred to or seeking care for suicide risk (N = 624) completed self-report psychiatric domain measures and a clinician interview assessing prior suicidality severity at baseline. Three months later, participants completed a self-report measure of suicidal ideation severity. Three separate percentile bootstrap mediation models were used to examine psychiatric factors (i.e. alcohol abuse, anxiety sensitivity, hopelessness, insomnia, posttraumatic stress symptoms, suicidal ideation, and thwarted belongingness) as parallel mediators of the relationship between prior suicidality severity (specifically, suicidal ideation, suicide attempt, and overall suicidality - i.e. ideation/attempt severity combined) at baseline and suicidal ideation severity at follow-up. RESULTS: Hopelessness, specifically, and the total effect of all mediators, each significantly accounted for the relationship between prior suicidality severity and subsequent ideation severity across models. In the models with attempt severity and overall suicidality severity as predictors, thwarted belongingness was also a significant mediator. CONCLUSIONS: Hopelessness, thwarted belongingness, and overall severity of psychiatric indices may explain the relationship between prior suicidality severity and future suicidal ideation severity among service members at elevated suicide risk. Research is needed to replicate these findings and examine other possible mediators.

The psychometric properties of the Collaborative Assessment and Management of Suicidality rating scale.

OBJECTIVE: The CAMS Rating Scale (CRS) is an adherence measure for the Collaborative Assessment and Management of Suicidality (CAMS), a suicide-specific clinical intervention. This study examined the ability of the CRS to assess adherence to CAMS. METHODS: Video-recorded therapy sessions of clinicians delivering either CAMS or Enhanced Care-As-Usual (E-CAU) were rated with the CRS. These ratings (N = 98) were used to evaluate criterion validity, internal consistency, and factor structure. RESULTS: Criterion validity and factor analyses did not support the organization of the CRS into its current subscales. Furthermore, the identified factor model and item-level statistics revealed weak CRS items. Finally, internal consistency was higher among CAMS clinicians than among clinicians delivering E-CAU. CONCLUSION: These results establish the CRS as a measure that can effectively assess the adherence to CAMS in its current form. Potential revisions to future iterations of the CRS are discussed.

Investigating the reliability of suicide attempt history reporting across five measures: A study of US military service members at risk of suicide.

OBJECTIVE: Utilizing a sample of military service members at risk of suicide, this study aimed to: (a) identify patterns of suicide attempt (SA) history reporting across five measures and (b) evaluate whether consistent SA reporters (i.e., individuals who consistently report an SA history across measures) differ from inconsistent SA reporters on other clinical severity indices. METHOD: Participants (N = 984) completed five validated SA history measures and self-report psychiatric symptom measures. RESULTS: Of the sample, 35.4% inconsistently responded to SA history measures. Inconsistent reporters disclosed more severe suicide threat histories than consistent reporters. On all other clinical severity indices, inconsistent reporters evinced either less severe or comparable symptom levels. CONCLUSIONS: A nontrivial portion of service members may respond inconsistently to different assessments of SA history. Research is needed to identify factors that account for inconsistent SA history reporting and to improve the accuracy of SA history assessments among military personnel.

Improving risk prediction accuracy for new soldiers in the U.S. Army by adding self-report survey data to administrative data.

BACKGROUND: High rates of mental disorders, suicidality, and interpersonal violence early in the military career have raised interest in implementing preventive interventions with high-risk new enlistees. The Army Study to Assess Risk and Resilience in Servicemembers (STARRS) developed risk-targeting systems for these outcomes based on machine learning methods using administrative data predictors. However, administrative data omit many risk factors, raising the question whether risk targeting could be improved by adding self-report survey data to prediction models. If so, the Army may gain from routinely administering surveys that assess additional risk factors. METHODS: The STARRS New Soldier Survey was administered to 21,790 Regular Army soldiers who agreed to have survey data linked to administrative records. As reported previously, machine learning models using administrative data as predictors found that small proportions of high-risk soldiers accounted for high proportions of negative outcomes. Other machine learning models using self-report survey data as predictors were developed previously for three of these outcomes: major physical violence and sexual violence perpetration among men and sexual violence victimization among women. Here we examined the extent to which this survey information increases prediction accuracy, over models based solely on administrative data, for those three outcomes. We used discrete-time survival analysis to estimate a series of models predicting first occurrence, assessing how model fit improved and concentration of risk increased when adding the predicted risk score based on survey data to the predicted risk score based on administrative data. RESULTS: The addition of survey data improved prediction significantly for all outcomes. In the most extreme case, the percentage of reported sexual violence victimization among the 5% of female soldiers with highest predicted risk increased from 17.5% using only administrative predictors to 29.4% adding survey predictors, a 67.9% proportional increase in prediction accuracy. Other proportional increases in concentration of risk ranged from 4.8% to 49.5% (median = 26.0%). CONCLUSIONS: Data from an ongoing New Soldier Survey could substantially improve accuracy of risk models compared to models based exclusively on administrative predictors. Depending upon the characteristics of interventions used, the increase in targeting accuracy from survey data might offset survey administration costs.

Relative Impact of Risk Factors, Thwarted Belongingness, and Perceived Burdensomeness on Suicidal Ideation in Veteran Service Members.

OBJECTIVE: We tested the associations between individualized risk factors, empirically validated constructs specific to suicide risk (i.e., thwarted belongingness and perceived burdensomeness, and two methods for conceptualizing suicidal ideation based on Suicide Index Score (SIS) and overall severity score of the Beck Scale for Suicide Ideation [BSS]). METHOD: The current study included a sample of 134 suicidal Veterans who were recruited from an inpatient psychiatry unit of a Veterans Affairs Medical Center. Participants completed the BSS, Interpersonal Needs Questionnaire, Outcome Questionnaire-45.2, Alcohol Use Disorder Identification Test, Drug Abuse Screening Test, and abbreviated versions of the Posttraumatic Stress Disorder Checklist-Military version (PCL-M) and Insomnia Severity Index. We used ordinary least squares regression with bootstrapping to conduct analyses due to the skewed distributions observed in the suicidal ideation outcomes. RESULTS: Thwarted belongingness was the only statistically significant correlate of the SIS, indicating a stronger desire to be dead than alive as Veterans perceived themselves as being increasingly disconnected and isolated from others (B = 0.36, standard error [SE] = 0.01, p = 0.005). In contrast, greater overall severity scores on the BSS were associated with higher ratings on the PCL-M (B = 0.21, SE = 0.07, p = 0.02) and for thwarted belongingness (B = 0.27, SE = 0.09, p = 0.04). Problematic alcohol use was significantly associated with lower overall severity scores (B = -.27, SE = 1.17, p < 0.001). CONCLUSION: Findings may inform clinical strategies for conceptualizing and targeting factors associated with suicidal risk.

An investigation of the interactive effects of the capability for suicide and acute agitation on suicidality in a military sample.

BACKGROUND: According to the interpersonal theory of suicide (1, 2), the difficulties inherently associated with death by suicide deter many individuals from engaging in suicidal behavior. Consistent with the notion that suicide is fearsome, acute states of heightened arousal are commonly observed in individuals immediately prior to lethal and near-lethal suicidal behavior. We suggest that among individuals who possess elevated levels of the capability for suicide, the heightened state of arousal experienced during periods of acute agitation may facilitate suicidal behavior in part because it would provide the necessary energy to approach a potentially lethal stimulus. Among individuals who are low on capability, the arousal experienced during agitation may result in further avoidance. METHODS: In the present project we examine how acute agitation may interact with the capability for suicide to predict suicidality in a large military sample (n = 1,208) using hierarchical multiple regression. RESULTS: Results were in line with a priori hypotheses: among individuals high on capability, as agitation increases, suicidality increases whereas as agitation increases among individuals low on capability, suicidality decreases. Results held beyond the effects of thwarted belongingness, perceived burdensomeness, and suicidal cognitions. CONCLUSIONS: Beyond further substantiating the link between agitation and suicide, findings of the present study provide evidence for the construct validity of the acquired capability as well as offer initial evidence for moderating role of capability on the effect of agitation on suicide. Limitations of the current study highlight a need for future research that improves upon the techniques used in the present study. Implications for science and practice are discussed.

Reconsidering the link between impulsivity and suicidal behavior.

It is widely accepted that suicidal behavior often occurs with little planning. We propose, however, that suicidal behavior is rarely if ever impulsive-that it is too frightening and physically distressing to engage in without forethought-and that suicidal behavior in impulsive individuals is accounted for by painful and fearsome behaviors capable of enhancing their capacity for suicide. We conducted a meta-analysis of the association between trait impulsivity and suicidal behavior and a critical review of research considering the impulsiveness of specific suicide attempts. Meta-analytic results suggest the relationship between trait impulsivity and suicidal behavior is small. Furthermore, studies examining a mediating role of painful and provocative behaviors have uniformly supported our model. Results from our review suggest that researchers have been unable to adequately measure impulsivity of attempts and that measures sensitive to episodic planning must be developed to further our understanding of this phenomenon.

The multidimensional scale of perceived social support: analyses of internal reliability, measurement invariance, and correlates across gender.

In this study, we examined estimates of internal consistency reliability, measurement invariance, and differential correlates of the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988) in samples of undergraduate men (n = 270) and women (n = 340). The MSPSS is designed to assess 3 sources of perceived social support: family, friends, and significant others. The participants ranged in age from 18 to 24 years (M(age) = 19.60, SD = 1.4 years). First, composite scale reliability and coefficient omega methods provided adequate estimates of internal consistency reliability for the original MSPSS total and subscale scores. Second, results of multiple-groups invariance confirmatory factor analysis provided support for configural and metric invariance. Partial measurement invariance was attained for scalar and strict measurement invariance across men and women. Additionally, given the high correlations among the first-order factors, we conducted multiple-groups bifactor item response theory (bifactor-IRT) analysis to evaluate further the performances of the individual MSPSS items across gender. Support for the bifactor model was strong. Third, we conducted a series of simultaneous regression analyses to identify potential correlates of the social support construct for women and men.

A qualitative description of female veterans' deployment-related experiences and potential suicide risk factors.

OBJECTIVE: A qualitative study among female Veterans from recent conflicts was conducted to explore the women's experiences and potential suicide risk factors according to the Interpersonal Psychological Theory of Suicide, including burdensomeness, failed belongingness, and acquired ability. METHODS: The presented paper is an extension of published work by Brenner et al. (2008) regarding mostly male combat Veterans. The methodology employed was qualitative descriptive with hermeneutic hues (Sandelowski, 2000). Interviews were conducted with 19 women, aged 24-52 years, all of whom had been deployed to combat zones in Iraq and/or Afghanistan. RESULTS: Transcripts were reviewed and themes emerged regarding women being a minority within their environment and deployment-related stressors. These experiences seemed to influence participants' views of the world and ways of coping. CONCLUSIONS: Among the interviewed female Veterans, preliminary support was provided for Joiner's concepts. Therapeutic strategies for applying themes to clinical practice (e.g., peer support, family therapy, interventions aimed at increasing distress tolerance) are provided.

Optimizing the Beck Scale for Suicide Ideation: An Item Response Theory Approach Among U.S. Military Personnel.

The Beck Scale for Suicide Ideation (BSS) is one of the most used and empirically supported suicide risk assessment measures for behavioral health clinicians and researchers. However, the 19-item BSS is a relatively long measure and can take 5 to 10 minutes to administer. This study used Item Response Theory (IRT) techniques across two samples of mostly U.S. military service members to first identify (n1 = 1,899) and then validate (n2 = 757) an optimized set of the most informative BSS items. Results indicated that Items 1, 2, 4, 6, and 15 provided a similar-shaped test information curve across the same range of the latent trait as the full-length BSS and showed reliable item functioning across participant characteristics. The sum score of these five items showed a linear score linkage with the full-scale score, ρ > 0.87, and was equally as sensitive as the full scale for prospectively predicting near-term suicidal behavior at 74% with a cut score ≥1 (equivalent to full-scale score ≥6). Results are consistent with those from civilian samples. In time- or length-limited assessments, using these five BSS items may improve administration efficiency over the full BSS, while maintaining classification sensitivity.This study suggests that summing Items 1, 2, 4, 6, and 15 of the Beck Scale for Suicide Ideation (BSS) is an acceptable approach for shortening the full-length measure.

Three-year follow-up of suicide prevention-focused group therapy for veterans.

The purpose of this study was to determine the long-term effects of a suicide prevention-focused group therapy for veterans recently discharged from an inpatient psychiatry setting following a suicidal crisis. There was interest in examining the impact of mechanisms of change identified in previous research on the group, including group cohesion, working alliance, and group sessions attended. Data were abstracted from the electronic medical record 3 years following completion of a previous study that involved the group therapy. A series of generalized linear and logistic mixed models were conducted to measure the associations between group cohesion, working alliance, session attendance, and health service utilization and suicide attempts. Thirty randomly selected veterans from the original sample completed a semistructured interview to discuss their experience in the group therapy. Study team members reviewed each transcription to identify themes related to veterans' experiences in the suicide prevention-focused group therapy. No suicides were observed in the 3-year follow-up period. When examining the full sample (N = 134), session attendance and inpatient hospitalization were not significantly associated but were positively associated after removing subjects who attended zero sessions (N = 93). Higher group cohesion was associated with a reduced likelihood of inpatient psychiatric hospitalization and greater engagement in outpatient mental health services. Four themes emerged regarding veterans' experience in the group through an analysis of the semistructured interviews. Suicide prevention-focused group therapy among veteran service members was not associated with an elevated risk of mortality. Future research is needed to further elucidate mechanisms of change and moderators of response. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Validation of the Suicide Resilience Inventory-25 (SRI-25) in adolescent psychiatric inpatient samples.

Resilience has been associated with a markedly decreased chance for risky behaviors following a trauma or other negative life event. This study examined the factor structure and psychometric properties of a self-report measure of resilience, the Suicide Resilience Inventory-25 (SRI-25; Osman et al., 2004 ), among psychiatric inpatient adolescents. In Study 1, we conducted confirmatory factor analysis to provide additional empirical support for the structure and invariance of the 3-factor model of the SRI-25 in youth samples, ages 14 to 17 years (N = 152 boys, 220 girls). Scale reliability analyses provided good evidence for internal consistency reliability of scores on the SRI-25 total and scales. In Study 2 (N = 30 boys, 40 girls), we presented data in support for the concurrent validity (i.e., known groups) of scores on the SRI-25. Additionally, we identified potential correlates for the SRI-25 total scale scores.

The Depression Anxiety Stress Scales-21 (DASS-21): further examination of dimensions, scale reliability, and correlates.

OBJECTIVES: We conducted two studies to examine the dimensions, internal consistency reliability estimates, and potential correlates of the Depression Anxiety Stress Scales-21 (DASS-21; Lovibond & Lovibond, 1995). METHOD: Participants in Study 1 included 887 undergraduate students (363 men and 524 women, aged 18 to 35 years; mean [M] age = 19.46, standard deviation [SD] = 2.17) recruited from two public universities to assess the specificity of the individual DASS-21 items and to evaluate estimates of internal consistency reliability. Participants in a follow-up study (Study 2) included 410 students (168 men and 242 women, aged 18 to 47 years; M age = 19.65, SD = 2.88) recruited from the same universities to further assess factorial validity and to evaluate potential correlates of the original DASS-21 total and scale scores. RESULTS: Item bifactor and confirmatory factor analyses revealed that a general factor accounted for the greatest proportion of common variance in the DASS-21 item scores (Study 1). In Study 2, the fit statistics showed good fit for the bifactor model. In addition, the DASS-21 total scale score correlated more highly with scores on a measure of mixed depression and anxiety than with scores on the proposed specific scales of depression or anxiety. Coefficient omega estimates for the DASS-21 scale scores were good. CONCLUSIONS: Further investigations of the bifactor structure and psychometric properties of the DASS-21, specifically its incremental and discriminant validity, using known clinical groups are needed.

Past Levels of Mental Health Intervention and Current Nondisclosure of Suicide Risk Among Men Older Than Age 50.

Suicide risk screening depends heavily on accurate patient self-report. However, past negative experiences with mental health care may contribute to intentional nondisclosure of suicide risk during screening. This study investigated among 282 men older than age 50 whether likelihood for current explicit risk nondisclosure was associated with previous highest level of mental health care received. This sample was selected post hoc out of a larger sample of participants from higher risk and lower help-seeking populations (i.e., military service members and veterans, men older than age 50, and lesbian gay bisexual, transgender, and queer young adults), however, the other groups were underpowered for analysis. Among these men, history of psychiatric hospitalization was significantly associated with likelihood for explicit nondisclosure of current suicide risk, while history of receiving only outpatient therapy for suicidal thoughts or behaviors was significantly associated with likelihood for full reporting of suicide risk. Severity of suicidal ideation and internalized stigma against mental illness were significant indirect contributors to the effect. Although causality could not be determined, results suggest that a potential cost to consider for psychiatric hospitalization may be future nondisclosure of suicide risk. Conversely, outpatient interventions that appropriately manage suicidal thoughts or behaviors may encourage future full reporting of suicide risk and improve screening detection.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group.

INTRODUCTION: Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative. METHODS: Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6 months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion. RESULTS: Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster. CONCLUSION: This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

Development and evaluation of the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory.

We describe the development of a new self-report instrument, the Social Anxiety and Depression Life Interference-24 (SADLI-24) inventory. We initially retained 30 content specific items for the instrument (Study 1). In Study 2 (N = 438), we established a 2-factor solution, Social Anxiety Life Interference-12 (SALI-12) and Depression Life Interference-12 (DLI-12). We also examined estimates of known-groups and concurrent validity. Confirmatory factor analysis in Study 3 (N = 430) provided support for the oblique two-factor structure. In Study 4 (N = 179), we provided additional support for estimates of known-groups validity. In Study 5 (N = 63), we evaluated estimates of test-retest reliability. Both SADLI-24 scale scores showed good estimates of internal consistency.

Evaluation of the psychometric properties of the Interpersonal Needs Questionnaire-12 in samples of men and women.

This study analyzed the psychometric properties of the Interpersonal Needs Questionnaire-12 (INQ-12; Van Orden, Witte, Gordon, Bender, & Joiner, 2008a), designed to test Joiner's interpersonal-psychological theory of suicide. Study participants included 785 U.S. undergraduates (58.6% female; 77.2% White; ages 18-25). Confirmatory bifactor analyses discerned a general factor for overall distress, while also supporting separate subfactors for perceived burdensomeness and thwarted belongingness. The scale's factor structure did not vary by gender, and internal consistency reliability was strong among the male and female samples. Correlational analyses supported the scale's content validity. Overall, the analyses preliminarily support continued use of the INQ-12.

The Anxiety Depression Distress Inventory-27 (ADDI-27): a short version of the Mood and Anxiety Symptom Questionnaire-90.

The authors conducted three studies to construct and examine the psychometric properties of a 27-item version of the Mood and Anxiety Symptom Questionnaire-90 (MASQ-90; Watson & Clark, 1991a). The Anxiety Depression Distress Inventory-27 (ADDI-27) contains three empirically derived scales: Positive Affect, Somatic Anxiety, and General Distress, which are relevant dimensions of the tripartite model of affect. Each scale is composed of nine items, and the estimate of scale reliability for each scale score was ≥ .80 across the three studies. Results of exploratory and confirmatory factor analyses provided adequate support for a 3-factor model. Additional estimates of concurrent validity documented the ADDI-27 scales' convergent and discriminant validity. We also identified three construct relevant correlates for each scale score. Overall, the ADDI-27 appears to be a content valid, reliable, and multidimensional measure of the tripartite model of affect.