Safety Planning to Manage Suicide Risk with Older Adults: Case Examples and Recommendations.

Adults age 65 and older have high rates of suicide, despite recent efforts to reduce the suicide rate in this population. One suicide prevention strategy with burgeoning empirical support is safety planning; however, there is a lack of information and resources on safety planning for older adults to support uptake of this evidence-based practice in clinical settings where older adults are commonly seen. Safety plans can address risk factors for suicide in older adults, including social isolation, physical illness, functional limitations, and use of highly lethal means. Safety plans also promote relevant protective factors, including increasing use of coping strategies, social support, and help-seeking. Clinicians may encounter challenges and barriers to safety planning with older adults. This paper describes a collaborative, creative approach to safety planning that is relevant and useful for this vulnerable population. Using two case examples, we illustrate how to engage older adults in safety planning, including ways to minimize barriers associated with the aging process.

Consumer satisfaction with antipsychotic medication-monitoring appointments: the role of consumer-prescriber communication patterns.

OBJECTIVE: The study was designed to explore patterns of prescriber communication behaviors as they relate to consumer satisfaction among a serious mental illness sample. METHODS: Recordings from 175 antipsychotic medication-monitoring appointments between veterans with psychiatric disorders and their prescribers were coded using the Roter Interaction Analysis System (RIAS) for communication behavioral patterns. RESULTS: The frequency of prescriber communication behaviors (i.e., facilitation, rapport, procedural, psychosocial, biomedical, and total utterances) did not reliably predict consumer satisfaction. The ratio of prescriber to consumer utterances did predict consumer satisfaction. CONCLUSIONS: Consistent with client-centered care theory, antipsychotic medication consumers were more satisfied with their encounters when their prescriber did not dominate the conversation. PRACTICE IMPLICATIONS: Therefore, one potential recommendation from these findings could be for medication prescribers to spend more of their time listening to, rather than speaking with, their SMI consumers.

Health conditions, physical disabilities, perceived burdensomeness, and depressive symptoms influence suicidal ideation.

The roles of perceived burdensomeness and depressive symptoms in the relationship between physical disabilities or health conditions and suicidal ideation warrant examination. The authors examined indirect effects using cross-sectional data from adults who answered questions online. The serial indirect effect of the number of physical disabilities on suicidal ideation through perceived burdensomeness and depressive symptoms was not significant, but the serial indirect effects of the combined number of physical disabilities and health conditions and number of health conditions on suicidal ideation through perceived burdensomeness and depression were each significant. For those with disabilities or health conditions, perceived burdensomeness may precede depressive symptoms in the development of suicidal ideation.

The clinical application of suicide risk assessment: A theory-driven approach.

The interpersonal theory of suicide posits that thwarted belongingness (TB) and perceived burdensomeness (PB) increase suicide ideation; however, studies have found mixed results regarding this hypothesis among psychiatric inpatients. This study aimed to (a) demonstrate how assessing TB and PB using the Interpersonal Needs Questionnaire (INQ) can provide clinically useful information and (b) investigate how statistical methodology may impact the clinical application of the INQ. Participants were 139 (Sample 1) and 104 (Sample 2) psychiatric inpatients. In both samples, ordinal logistic regression results indicated TB and PB, separately, were significant predictors of suicide ideation-related outcomes; however, when examined as simultaneous predictors, TB was no longer a significant predictor. The interaction between TB and PB was not significant for either sample. Despite this, TB and PB scores provided clinically relevant information about suicide ideation-related outcomes. For example, the highest scores on TB and PB indicated a 93% and 95% chance of having some level of distress due to suicide ideation (Sample 1), a 91% and 92% chance of having some level of desire for death, and a 79% and 84% chance of having some level of desire for suicide, respectively (Sample 2). This study also proposes clinical cutoff scores for the INQ (for TB and PB, respectively, cutoff scores were 22 and 17 for distress due to suicide ideation, 33 and 17 for desire for death, and 31 and 22 for desire for suicide). Although these results indicate that multicollinearity between TB and PB may create interpretational ambiguity for clinicians, TB and PB may each be useful separate predictors of suicide ideation-related outcomes in psychiatric inpatient settings and should be incorporated into suicide risk assessment. KEY PRACTITIONER MESSAGE: The 15-item Interpersonal Needs Questionnaire (an assessment of thwarted belongingness and perceived burdensomeness) should be incorporated into suicide risk assessment. Among psychiatric inpatients, greater thwarted belongingness and perceived burdensomeness, as separate predictors, were associated with increased levels of distress due to suicide ideation, desire for death, and desire for suicide. The highest scores on thwarted belongingness and perceived burdensomeness indicated a 79% to 95% chance of experiencing an elevated level of distress due to suicide ideation, desire for death, or desire for suicide. Recommended clinical cutoff scores were provided. For example, thwarted belongingness cutoff score of 31 and perceived burdensomeness cutoff score of 22 maximized the sensitivity and specificity of the INQ to detect some level of desire for suicide.

Personal Recovery as a Protective Factor Against Suicide Ideation in Individuals With Schizophrenia.

Suicide rates are elevated in individuals with schizophrenia, yet evidence is mixed regarding the roles of positive and negative symptoms as risk factors for suicide in this population, suggesting that there may be other influential variables. One such variable may be personal recovery. Therefore, the purpose of this study was to test the hypothesis that personal recovery would moderate the relationship between symptoms of schizophrenia and suicide ideation. This hypothesis was tested in a sample of 169 individuals diagnosed with schizophrenia or schizoaffective disorder using a Poisson regression model. Results suggested that there was no significant interaction between recovery and symptoms of schizophrenia. However, recovery was a significant predictor of suicide ideation after controlling for psychiatric symptoms. These findings indicate that recovery is associated with lower suicide ideation and thus may protect against it. Thus, recovery should be assessed, and potentially intervened upon, to reduce suicide risk in individuals with schizophrenia.

Personality disorder traits, risk factors, and suicide ideation among older adults.

BACKGROUND: Personality disorder traits are relatively prevalent among older adults, and can be associated with complex and chronic difficulties, including suicide risk. However, there is a lack of research regarding personality disorders and suicide ideation in older adults. Depressive symptoms and hopelessness may be important to the relation between personality disorders and suicide risk. Additionally, variables from the interpersonal theory of suicide, perceived burdensomeness and thwarted belongingness, may be critical risk factors for suicide in this population. We hypothesized that perceived burdensomeness and thwarted belongingness, theory-based variables, would act as parallel mediators of the relation between personality disorder traits and suicide ideation, whereas depressive symptoms and hopelessness would not. METHODS: The hypothesis was tested in a sample of 143 older adults recruited from a primary care setting. Participants completed self-report questionnaires of personality traits, suicide ideation, depressive symptoms, hopelessness, perceived burdensomeness, and thwarted belongingness. RESULTS: Findings from a non-parametric bootstrapping procedure indicated that perceived burdensomeness, thwarted belongingness, and depressive symptoms mediated the relation between total personality disorder traits and suicide ideation. Hopelessness did not act as a mediator. CONCLUSIONS: These findings indicate that perceived burdensomeness, thwarted belongingness, and depressive symptoms are likely important risk factors for suicide ideation among older adults. Clinicians should be aware of these issues when assessing and treating suicide risk among older adults.

Social and psychological contributions to the co-occurrence of sub-threshold psychotic experiences and suicidal behavior.

PURPOSE: Psychotic experiences and suicidal behavior commonly co-occur in the general population, which can have implications for suicide prevention approaches. However, little is known about the nature of this relation in non-clinical samples. This cross-sectional study aimed to address a research gap by testing whether the relation between psychotic experiences and suicide-related outcomes (ideation, intent, and attempts) is explained by common social and psychological factors. METHODS: Young adult college students (N = 590) were assessed for psychotic experiences, suicidal behavior, and a comprehensive set of 24 potential shared risk factors selected through review of past epidemiological studies and meta-analyses. Nonparametric bootstrapped regression models were used to examine whether these factors attenuated or eliminated the associations between psychotic experiences and suicide-related outcomes. RESULTS: Psychotic experiences were associated with greater risk for suicidal ideation and behaviors. Adjustment for psychosocial factors, particularly those contributing to cumulative stress, accounted for the associations between psychotic experiences and suicide-related outcomes, except broadly defined suicidal ideation. CONCLUSIONS: These results suggest that the robust associations between psychotic experiences and suicidal behavior demonstrated in past studies may be primarily explained by shared risk factors, rather than by causal relations. In our sample, suicidal behavior and sub-threshold psychosis appear to be trans diagnostic clinical outcomes that share common causes, notably cumulative stress, but do not cause one another.

Physical Disability and the Interpersonal Theory of Suicide.

Interpersonal Theory of Suicide constructs were examined in individuals with physical disabilities, a population identified as having heightened suicidal ideation. Students (N = 184) answered online-based self-report questionnaires. Students with physical disabilities (n = 49) were expected to endorse higher levels of constructs relative to other students (n = 133). Analyses of covariance indicated that those with disabilities reported higher perceived burdensomeness, but not thwarted belongingness, fearlessness about death, or suicidal ideation. Suicide prevention efforts, particularly in university settings, may benefit from focusing on reducing perceived burdensomeness in this population, as these individuals may be at heightened risk.

The Mediating Role of Perceived Burdensomeness in Relations Between Domains of Cognitive Functioning and Indicators of Suicide Risk.

OBJECTIVES: Psychiatric inpatients are at elevated risk for suicide, but there are mixed findings regarding cognitive functioning (i.e., executive functioning and problem-solving abilities) and suicide risk in this population. We hypothesized that a mediating variable (i.e., perceived burdensomeness) may explain these mixed findings. METHOD: This hypothesis was tested in a sample of psychiatric inpatients admitted for suicide-related concerns (N = 110; 58.18% female, M(age) = 36.45) using a nonparametric bootstrapping procedure. RESULTS: Perceived burdensomeness did not act as a mediator between any domain of cognitive functioning and current suicide ideation nor presence of recent suicide attempts. However, perceived burdensomeness was the strongest predictor of suicide ideation and mediated the relation between objective problem-solving skill and suicide risk (a weighted variable comprising current ideation and previous attempts). CONCLUSIONS: Perceived burdensomeness may be associated with elevated suicide ideation, suggesting that perceived burdensomeness should be assessed to inform suicide risk decisions.

Self-rated health as a moderator of the relation between functional impairment and depressive symptoms in older adults.

OBJECTIVES: The purpose of this study was to examine the relation between functional impairment, self-rated health, and depressive symptoms. Independently, self-rated health and functional impairment each contribute to depressive symptoms; however, it remains unknown how these variables are related to depression in combination. It was hypothesized that self-rated health would moderate the relation between functional impairment and depressive symptoms in a sample of older adults. METHOD: A community sample of adults aged 60 and above was recruited from primary care clinics (n = 106); 98 of these participants had usable data. Participants completed self-report questionnaires that assessed depressive symptoms, functional impairment, and self-rated physical health. RESULTS: Self-rated health moderated the relation between functional impairment and depressive symptoms. For participants with poor self-rated health, greater functional impairment was associated with greater depressive symptoms. CONCLUSION: It appears that patient perceptions of health may be protective against depressive symptoms for those with functional impairment.

The mediating effect of perceived burdensomeness on the relation between depressive symptoms and suicide ideation in a community sample of older adults.

OBJECTIVES: Suicide is a prevalent problem in older adults. One of the best predictors of suicide in older adults is suicide ideation; suicide ideation has been frequently associated with depression. However, suicide ideation is not always present when an older adult is depressed and is sometimes present when an older adult is not depressed. Perceived burdensomeness, a recently proposed risk factor [Joiner Jr, T.E. (2005)], has been linked to suicide ideation in depressed samples and in older adults. Thus, perceived burdensomeness may be the necessary risk factor for suicide ideation. METHOD: The Geriatric Suicide Ideation Scale (GSIS; [Heisel et al. (2006)]), Center for Epidemiologic Studies Depression (CES-D; [Radloff, L.S. (1977)]) scale, and Suicide Cognitions Scale (SCS; [Rudd, M.D., Schmitz, B., McClenen, R., Joiner, T., Elkins, G., & Claassen, C.A. (n.d.)]) were completed by a community sample of older adults recruited from primary care clinics (n = 106). A regression analysis was conducted following Baron and Kenny's [1986] guidelines to test the hypothesis that perceived burdensomeness (measured by the SCS perceived burdensomeness subscale) mediates the relation between depression (assessed with the CES-D) and suicide ideation (measured by the GSIS suicide ideation subscale) in older adults. RESULTS: Perceived burdensomeness mediated the relation between depression and suicide ideation, accounting for 68.3% of the variance in suicide ideation. CONCLUSION: Perceived burdensomeness may explain the relation between depression and suicide ideation. Clinicians seeing older adults should assess for depression and perceived burdensomeness when determining suicide risk. Future research directions include treatment studies for perceived burdensomeness as a way to reduce suicide ideation.

Suicide Ideation and Thwarted Interpersonal Needs among Psychiatric Inpatients: A Network Approach.

We aimed to demonstrate the utility of an item-level network analysis approach to suicide risk by testing the interpersonal psychological theory of suicide (IPTS) among 402 psychiatric inpatients. We hypothesized specific thwarted belongingness (TB) or perceived burdensomeness (PB; Interpersonal Needs Questionnaire items) facets would positively relate to passive or active suicide ideation, and these facets would positively relate to each other and form distinct clusters. We also tested TB and PB facets central to the networks as predictors of suicide ideation compared to the full TB and PB subscales. Face-valid items congruent with latent constructs proposed by the IPTS (i.e., feelings of burden on society, feeling that one does not belong) were the only two facets uniquely predictive of passive and active suicide ideation. Facets of TB and PB did not form distinct clusters. Item-level network analysis may have important conceptual, assessment, predictive, and clinical implications for understanding suicide risk.

Suicide-Related Training, Self-Efficacy, and Mental Health Care Providers' Reactions Toward Suicidal Individuals.

Background: Mental health care providers commonly encounter suicide ideation and suicidal behaviors among their patients despite a frequent lack of adequate knowledge and competence regarding suicide risk management. Aims: This study examined the associations among self-perceived sufficiency of training, self-efficacy, anxiety, and attitudes related to working with suicidal individuals. Method: Participants were 289 mental health care providers who completed a self-report survey. Results: Path analysis results indicated that perceived sufficiency of training was indirectly associated with negative attitudes (i.e., avoidance and discomfort) and cognitive and somatic anxiety about working with suicidal individuals through assessment self-efficacy. Limitations: The current study utilized cross-sectional data, and there were occupational heterogeneity and geographical homogeneity among the mental health care providers sampled. Conclusion: These findings suggest that sufficient suicide-related training focused on risk assessment may decrease mental health professionals' negative and anxious reactions toward suicidal individuals and enhance confidence in suicide risk management.

Cognitive impairment and depression symptoms are independently associated with suicidal ideation in US Veterans.

Depression is associated with cognitive impairment and suicidality. The independent association between cognitive impairment and suicidality is less clear. We examined the relationship between suicidal ideation and cognitive impairment in a sample of 50 veterans with depressive disorder diagnoses. Using zero-inflated Poisson regression, the severity of suicidal ideation was negatively associated with attention (incidence rate ratio [IRR] = 0.78, p < .001), memory (IRR = 0.87, p < .001), and total cognition (IRR = 0.90, p = .007) index scores as measured by the Dementia Rating Scale 2 (DRS-2). These three indices continued to significantly predict suicidal ideation severity once depression symptoms were controlled for.

The influence of experiences of stigma on recovery: Mediating roles of internalized stigma, self-esteem, and self-efficacy.

OBJECTIVE: Experiencing stigmatization regarding mental illness has harmful effects on recovery from serious mental illness (SMI). Stigma experiences can also lead to internalized stigma, the cognitive and emotional internalization of negative stereotypes, and application of those stereotypes to one's self. Internalized stigma may lead to additional harms, including decrements in self-esteem and self-efficacy. Therefore, this study examined the effects of stigmatization experiences on recovery-related outcomes through internalized stigma, self-esteem, and self-efficacy in a single comprehensive model. METHODS: Adults with SMI (n = 516) completed standardized measures assessing the variables of interest during baseline assessments for 2 randomized controlled trials. In a secondary analysis of the trial data, separate serial mediation models were tested for recovery orientation, perceived quality of life, and social withdrawal as outcomes, with experiences of stigma as the predictor variable and internalized stigma, self-esteem, and self-efficacy as serial mediators in that order. Alternate order and parallel mediation models were also tested to evaluate directionality. RESULTS: The serial mediation model was the best fit, although self-efficacy was not found to be a critical mediator. Experiences of stigma led to internalized stigma, which influenced self-esteem and recovery-related outcomes, consistent with the social-cognitive model of internalized stigma. CONCLUSION: This indicates that internalized stigma is an essential target for reducing the negative impact of stigmatization on recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Differences in suicide and death ideation among veterans and nonveterans with serious mental illness.

Individuals with serious mental illness and veterans are two populations at elevated risk for suicide; however, research has not examined whether veterans with serious mental illness may be at higher suicide risk than nonveterans with serious mental illness. Additionally, overlapping risk factors for suicide in these populations may account for differences in suicide-related outcomes between these groups. Therefore, the aim of this study was to identify differences in death ideation and suicide ideation among veterans and nonveterans with serious mental illness. We also aimed to explore these effects after adjusting for potentially shared risk factors. We found that veterans with serious mental illness reported death ideation and suicide ideation more than twice as often as nonveterans with serious mental illness. After adjusting for demographic, psychiatric, and theory-driven risk factors, the effect of veteran status on death ideation remained significant, though the effect on suicide ideation was no longer significant. Depressive and psychotic symptoms were significant predictors of death ideation; depressive symptoms and hostility were significant predictors of suicide ideation. Clinicians should particularly monitor death ideation and suicide ideation in veterans with serious mental illness, as well as associated clinical risk factors such as depression, psychotic symptoms, and hostility. (PsycINFO Database Record

Mental Health Professionals' Suicide Risk Assessment and Management Practices.

BACKGROUND: Approximately 20% of suicide decedents have had contact with a mental health professional within 1 month prior to their death, and the majority of mental health professionals have treated suicidal individuals. Despite limited evidence-based training, mental health professionals make important clinical decisions related to suicide risk assessment and management. AIMS: The current study aimed to determine the frequency of suicide risk assessment and management practices and the association between fear of suicide-related outcomes or comfort working with suicidal individuals and adequacy of suicide risk management decisions among mental health professionals. METHOD: Mental health professionals completed self-report assessments of fear, comfort, and suicide risk assessment and management practices. RESULTS: Approximately one third of mental health professionals did not ask every patient about current or previous suicidal thoughts or behaviors. Further, comfort, but not fear, was positively associated with greater odds of conducting evidence-based suicide risk assessments at first appointments and adequacy of suicide risk management practices with patients reporting suicide ideation and a recent suicide attempt. LIMITATIONS: The study utilized a cross-sectional design and self-report questionnaires. CONCLUSION: Although the majority of mental health professionals report using evidenced-based practices, there appears to be variability in utilization of evidence-based practices.

Association of Electroconvulsive Therapy With Psychiatric Readmissions in US Hospitals.

Importance: Although electroconvulsive therapy (ECT) is considered the most efficacious treatment available for individuals with severe affective disorders, ECT's availability is limited and declining, suggesting that information about the population-level effects of ECT is needed. Objective: To examine whether inpatient treatment with ECT is associated with a reduction in 30-day psychiatric readmission risk in a large, multistate sample of inpatients with severe affective disorders. Design, Setting, and Participants: A quasi-experimental instrumental variables probit model of the association correlation of ECT administration with patient risk of 30-day readmission was estimated using observational, longitudinal data on hospital inpatient discharges from US general hospitals in 9 states. From a population-based sample of 490 252 psychiatric inpatients, a sample was drawn that consisted of 162 691 individuals with a principal diagnosis of major depressive disorder (MDD), bipolar disorder, or schizoaffective disorder. The key instrumental variable used in the analysis was ECT prevalence in the prior calendar year at the treating hospital. To examine whether ECT's association with readmissions was heterogeneous across population subgroups, analyses included interactions of ECT with age group, sex, race/ethnicity, and diagnosis group. The study was conducted from August 27, 2015, to March 7, 2017. Main Outcome and Measures: Readmission within 30 days of being discharged. Results: Overall, 2486 of the 162 691 inpatients (1.5%) underwent ECT during their index admission. Compared with other inpatients, those who received ECT were older (mean [SD], 56.8 [16.5] vs 45.9 [16.5] years; P < .001) and more likely to be female (65.0% vs 54.2%; P < .001) and white non-Hispanic (85.3% vs 62.1%; P < .001), have MDD diagnoses (63.8% vs 32.0%; P < .001) rather than bipolar disorder (29.0% vs 40.0%; P < .001) or schizoaffective disorder (7.1% vs 28.0%; P < .001), have a comorbid medical condition (31.3% vs 26.6%; P < .001), have private (39.4% vs 21.7%; P < .001) or Medicare (49.2% vs 39.4%; P < .001) insurance coverage, and be located in urban small hospitals (31.2% vs 22.3%; P < .001) or nonurban hospitals (9.0% vs 7.6%; P = .02). Administration of ECT was associated with a reduced 30-day readmission risk among psychiatric inpatients with severe affective disorders from an estimated 12.3% among individuals not administered ECT to 6.6% among individuals administered ECT (risk ratio [RR], 0.54; 95% CI, 0.28-0.81). Significantly larger associations with ECT on readmission risk were found for men compared with women (RR, 0.44; 95% CI, 0.20-0.69 vs 0.58; 95% CI, 0.30-0.88) and for individuals with bipolar disorder (RR, 0.42; 95% CI, 0.17-0.69) and schizoaffective disorder (RR, 0.44; 95% CI, 0.11-0.79) compared with those who had MDD (RR, 0.53; 95% CI, 0.26-0.81). Conclusions and Relevance: Electroconvulsive therapy may be associated with reduced short-term psychiatric inpatient readmissions among psychiatric inpatients with severe affective disorders. This potential population health effect may be overlooked in US hospitals' current decision making regarding the availability of ECT.

Explanatory risk factors in the relations between schizotypy and indicators of suicide risk.

Schizotypy has been linked to suicide risk, but it is not known whether established suicide-related risk factors mediate this relation. The aim of this study was to assess the mediating effects of depressive symptoms, social anxiety, self-esteem, and intimate disclosure in peer relationships in the relation between interpersonal schizotypy and suicide ideation or lifetime suicide attempts. This aim was tested in 590 young adults using a nonparametric bootstrapping procedure. After inclusion of the mediators, interpersonal schizotypy was no longer directly associated with either suicide ideation or lifetime suicide attempts. Depression and self-esteem mediated the relation between interpersonal schizotypy and suicide ideation. No variables mediated the relation between interpersonal schizotypy and lifetime suicide attempts, and there were no significant direct relations when mediators were included. Schizotypy appears to be a distal risk factor for suicidal behavior; assessing depressive symptoms and self-esteem may provide more proximal information about suicide risk, and may be targets for mitigating suicide risk in individuals with schizotypy.

The interactive effects of negative symptoms and social role functioning on suicide ideation in individuals with schizophrenia.

Findings regarding the protective effect of social role functioning on suicide ideation in individuals with schizophrenia have been mixed. One reason for such inconsistencies in the literature may be that individuals with prominent negative symptoms of schizophrenia may not experience a desire for social closeness, and therefore social role functioning may not influence suicide risk in these individuals. The aim of this study was to examine the moderating effects of self-reported desire for social closeness and interviewer-rated negative symptoms on the relationship between social role functioning and suicide ideation. Our sample consisted of 162 individuals who had been diagnosed with schizophrenia-spectrum disorders; all participants completed self-report questionnaires and clinician-administered interviews, and moderation hypotheses were tested with a non-parametric procedure. The results indicated that motivation and pleasure-related negative symptoms moderated the relationship between social role functioning and suicide ideation; self-reported desire for social closeness and negative symptoms related to expression did not have such a moderating effect. Specifically, better social role functioning was associated with less suicide ideation only in those individuals who had low motivation and pleasure-related negative symptoms; no significant relationship was observed between social role functioning and suicide ideation among those with elevated motivation and pleasure-related negative symptoms. These findings suggest that assessing for negative symptoms and social role functioning may inform suicide risk assessments in individuals with schizophrenia, and improving social role functioning may reduce suicide ideation among those with few motivation and pleasure-related negative symptoms.