Suicide Notes, Attempts, and Attempt Lethality During Episodes of Ideation Among Suicidal Soldiers and Marines.

OBJECTIVE: Suicide remains a significant public health problem among military personnel despite expanded suicide prevention efforts over the last two decades. It is important to understand the behavioral antecedents of suicide, including the writing of a suicide note, to inform efforts to identify imminent risk. However, the completion of a suicide note increasing the likelihood of making a suicide attempt (SA) and predicting a higher lethality SA during episodes of suicidality have not been evaluated. METHOD: To determine whether or not the completion of a suicide note increased the likelihood of making a SA during a given episode of suicidal ideation (current or worst) and predicted a higher lethality SA, we conducted secondary data analysis with a sample of 657 help-seeking, active-duty U.S. Soldiers and Marines. We hypothesized that service members who completed a suicide note would be more likely to make a SA during that given episode of suicidality and make a higher lethality SA. RESULTS: Completion of a suicide note increased the likelihood of making a SA in both current and worst episodes of suicidal ideation. Additionally, writing a suicide note predicted making a higher lethality SA during a service member's current episode of ideation but not their worst episode. CONCLUSIONS: This is the first study to examine note-writing behavior during episodes of suicidal ideation rather than following a suicide death or attempt, demonstrating a non-trivial number (17%) had written a suicide note and this increased the likelihood of making a SA and a higher lethality SA.HIGHLIGHTSThe first study of suicide notes during periods of ideation regardless of attempt.A suicide note written during an episode of ideation predicted making an attempt.A suicide note predicted making a more lethal suicide attempt.

On the Association Between Trauma-Related Shame and Symptoms of Psychopathology: A Meta-Analysis.

BACKGROUND: A number of studies have identified significant associations between trauma-related shame and psychopathology including posttraumatic stress disorder (PTSD), dissociation, and depression. The aim of this paper was to assess the extent to which trauma-related shame is associated with psychological distress across populations (e.g., veterans, college students, women, clinical samples) and offer via meta-analyses a preliminary conclusion about the importance of assessing trauma-related shame. METHODS: Records in Academic Search Complete, MedLine, MedLine Complete, PILOTS, PsycINFO, PsychTests, and PubMed were reviewed. Authors identified 25 studies that met the following inclusion criteria: (1) reported findings of an empirical study with quantitative results; (2) included any measurement of a trauma-related shame; and (3) included any measure of psychological distress or psychological symptoms. Data were extracted using a structured protocol, and random effects meta-analyses were calculated. FINDINGS: There were moderate weighted mean correlations between trauma-related shame and symptoms of psychopathology (r = 0.44), trauma-related distress (r = 0.49), and depression (r = 0.35). There was significant heterogeneity among studies. Neither study quality nor sample characteristics were significant moderators. CONCLUSION: This meta-analysis demonstrated robust associations between trauma-related shame and symptoms of psychopathology broadly as well as trauma-related distress and depression. The findings underscore the importance of explicitly assessing trauma-related shame as part of standard care for trauma survivors who present for treatment. Several treatments explicitly address the role of shame and have demonstrated efficacy for reducing symptoms of trauma-related distress.

Reducing short term suicide risk after hospitalization: A randomized controlled trial of the Collaborative Assessment and Management of Suicidality.

BACKGROUND: This study compared the "next day appointment" (NDA) use of the Collaborative Assessment and Management of Suicidality (CAMS) to treatment as usual (TAU) for individuals discharged from the hospital following a suicide-related crisis. We hypothesized that CAMS would significantly reduce suicidal thoughts and behaviors as well as improve psychological distress, quality of life/overall functioning, treatment retention and patient satisfaction. METHODS: Participants were 150 individuals who had at least one lifetime actual, aborted, or interrupted attempt and were admitted following a suicide-related crisis. There were 75 participants in the experimental condition who received adherent CAMS and 75 participants who received TAU. Suicidal thoughts and behaviors, psychological distress, and quality of life/overall functioning were assessed at baseline and at 1, 3, 6, and 12 months post-baseline. Treatment retention and patient satisfaction were assessed at post-treatment. RESULTS: Participants in both conditions improved from baseline to 12 months but CAMS was not superior to TAU for the primary outcomes. A small but significant improvement was found in probability of suicidal ideation at 3 months favoring TAU and amount of suicidal ideation at 12 months favoring CAMS. CAMS participants experienced less psychological distress at 12 months compared to baseline. LIMITATIONS: The study was limited by only one research clinic, lower than expected recruitment, and imbalance of suicidal ideation at baseline. CONCLUSIONS: All participants improved but CAMS was not more effective than TAU. The NDA clinic was feasible and acceptable to clients and staff in both conditions and future research should investigate its potential benefit.

Associations between sexual assault and suicidal thoughts and behavior: A meta-analysis.

OBJECTIVE: The goal of the present study was to conduct a quantitative review to determine the degree to which specific forms of suicidality (i.e., lifetime and past-year suicidal ideation and attempts) are associated with sexual assault (SA). It also examined whether the strength of the association between SA and suicidality was moderated by sample characteristics or the type of suicidality assessed. METHOD: A subset of studies (25 samples and 36 effects, reflecting N = 88,376 participants) from a prior meta-analysis assessing associations between SA and psychopathology was examined. Included studies provided the prevalence of suicidality in subsamples that had and had not been exposed to SA and/or an odds ratio comparing the prevalence in these groups. Random effects metaregression models aggregated prevalence estimates and odds ratios for lifetime and past-year suicidal ideation and suicide attempts in individuals in SA and no-SA groups. Analyses also examined whether sample characteristics (i.e., percent women, college sample) or type of suicidality moderated the magnitude of odds ratios. RESULTS: Subsamples exposed to SA reported a substantially higher prevalence of suicidality (27.25%) compared with unassaulted subsamples (9.37%). There were significantly higher rates of lifetime and past-year suicidal ideation, and lifetime suicide attempts in assaulted subsamples than in unassaulted subsamples. No tested moderators had significant associations with the strength of the relationship between SA and suicidality. CONCLUSION: Findings underscore the robust relationship between SA and both suicidal ideation and attempts and suggest that identifying moderators and mediators that explain it is a key directive for future research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Beliefs about causal factors for suicide in rural Alaska Native communities and recommendations for prevention.

Rural Indigenous communities in Alaska suffer staggeringly high rates of suicide. In close-knit Alaska Native villages, each suicide leaves a trail of affected family and community members in its wake. This research aimed to understand community perceptions of what causes suicide in rural Alaska Native villages and generate recommendations for prevention strategies. In-depth interviews were conducted with 25 Alaska Native university students who moved from rural villages to an urban area to attend college. All had been profoundly affected by others' suicides and shared their beliefs about causal factors and recommendations for prevention efforts. Perceived causes included resistance to seeking help or discussing personal problems, loss of culture, traumatic experiences, geographical and social isolation, lack of opportunity, substance abuse, and exposure to others' suicides. Participants believed that suicide is preventable and recommended multi-level approaches to address suicide disparities. They provided recommendations for potentially effective and culturally appropriate prevention strategies, including increasing cultural and social connections, educating community members about mental health, and increasing accessibility of counseling services/reducing barriers to mental health services utilization.

Life experiences preceding high lethality suicide attempts in adolescents at a level I regional trauma center.

OBJECTIVE: To describe life experiences associated with patterns of medically treated and documented self-directed violence among youth who attempted suicide using highly lethal means to understand precipitating factors among youth using such lethal means. METHOD: Using data from a regional, level 1 Trauma center, we identified all youth suicide attempt survivors who received treatment from 2010 to 2018 for a suicide attempt with a firearm, hanging, or jump from height injury (n = 42). We described differences in patient demographics and life experiences associated with patterns of self-directed violence by suicide attempt mechanism. We additionally assessed mechanisms used in any prior suicide attempts to identify potential increasing lethality of mechanism selection. RESULTS: There were 42 eligible patients included, of whom 40.5% attempted suicide with a firearm, 26.2% with hanging, 33.3% with jumping injury. A greater proportion of patients with firearm injuries endorsed social support and had fewer preparatory acts, history of self-harming behavior, prior suicide behaviors, and fewer prior attempts compared to patients who attempted suicide with other mechanisms. CONCLUSIONS: Given our findings, means safety should remain a key strategy to prevent highly lethal suicidal behavior among adolescents, especially with firearms, given that such attempts may occur prior to formal contact with mental health services.

State earned income tax credits and suicidal behavior: A repeated cross-sectional study.

Suicide is an increasingly common cause of death in the United States and recent increases in suicide rates disproportionately impact low income individuals. We sought to assess the impact of income support in the form of state earned income tax credit policies on suicide-related behaviors. This state-level study used repeated cross-sectional data from vital records and the National Survey of Drug Use and Health data representative at the state-level. The population included adults who either died by suicide or were selected for in-person NSDUH interviews between 2008 and 2018. Exposure was measured as the generosity of a refundable state earned income tax credit policy measured as a percentage of the federal policy. Outcomes assessed were suicidal ideation, suicidal planning, non-fatal suicide attempt, suicide deaths, and combined fatal and non-fatal suicide attempts. Analyses were performed between April and June 2020. A 10 percentage-point increase in the generosity of state earned income tax credit was associated with lower frequency of non-fatal suicide attempts (prevalence ratio [PR] = 0.96; 95% CI: 0.93-0.99), combined fatal and non-fatal suicide attempts (PR = 0.96; 95% CI: 0.93-0.99), and suicide deaths (PR = 0.99; 95% CI: 0.99-1.00). This translates to 4 fewer suicide attempts per 10,000 population each year. Generous state earned income tax credit policies are associated with reductions in the frequency of most severe suicidal behavior. Income support policies may be one way to reduce suicide attempts and death, especially among low-income adults.

Borderline personality disorder and self-directed violence in a sample of suicidal army soldiers.

There has been a sharp increase in the military suicide rates in 2004. While, borderline personality disorder (BPD) has a stronger association with suicide attempts than any other mental health disorder, there is limited evidence concerning the prevalence and scope of BPD symptoms among military personnel. This secondary data analysis compared active duty suicidal soldiers to characterize the presence-absence of BPD diagnostic criteria and lifetime history of self-directed violence in a suicidal military sample. The current study examined data of 137 active Service Members with significant suicidal ideation. Approximately one-quarter of the soldiers in this sample met full diagnostic criteria for BPD. The presence of BPD criteria was generally consistent among participants with BPD who reported past self-directed violence relative to those who did not. The number of BPD criteria was a significant predictor of the odds of reporting any nonsuicidal self-injury (NSSI) as well as the amount of NSSI, but was not associated with suicide attempt. This study demonstrated that a nontrivial proportion of suicidal soldiers meet criteria for this condition, which is strongly associated with self-directed violence. It is important to rigorously assess for the presence-absence of BPD criteria among suicidal military personnel and cultivate prevention strategies and treatment options for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Alcohol Consumption, History of Sexual Assault in Adolescence, and Revictimization in a Sample of University Students in the Western United States.

This study evaluated alcohol consumption as a moderator of the association between adolescent sexual assault and risk of sexual assault in college. It was hypothesized that sexual assault in adolescence would be associated with higher risk of college victimization and that this association would be moderated by alcohol consumption. Predominantly female and European-American university students (N = 201) completed self-report measures of alcohol consumption and sexual assault victimization in adolescence and since enrolling in college at a medium-sized university in the Western United States. Controlling for effects of age and gender, there was a significant interaction between alcohol consumption variables (i.e., typical weekly alcohol consumption and binge drinking) and adolescent sexual assault, such that the greatest risk for sexual assault in college was incurred by the heaviest drinkers with the greatest frequencies of adolescent sexual assault. This study highlights the importance of considering past victimization history in concert with alcohol consumption in efforts to prevent sexual victimization in college.

Prehospital Patient Care Protocols for Suicidality in Washington State.

BACKGROUND: Patients with suicidal thoughts and behavior represent a growing proportion of patients who present for Emergency Department care. Many of these patients arrive via ambulance. Several brief suicide- or self-harm-specific interventions have been developed for implementation in the Emergency Department setting. However, there is a dearth of training resources, patient care guidelines, and policy guidance to assist prehospital care providers in the treatment of EMS patients who are suicidal. We evaluated prehospital patient care protocols in Washington State to assess for the presence-absence of any suicide and/or self-harm specific protocols, as well as the inclusion of procedures above and beyond conventional approaches to scene safety and transport to the Emergency Department. METHODS: Prehospital patient care protocols were obtained for all counties in Washington State. Researchers rated protocols across seven domains, including the mention of any suicide- or self-harm-specific procedures. RESULTS: Approximately one-third of counties had any suicide- or self-harm-specific content in prehospital patient care protocols. There was no association between county-level rurality-urbanicity and the presence-absence of suicide- or self-harm-specific care. CONCLUSION: These findings demonstrated that little guidance exists for EMS providers in Washington State with regard to the screening or treatment of suicidal patients, above and beyond scene safety and transportation to hospital-based care. Development of guidelines for prehospital suicide care, as well as enhanced screening, assessment, and collaboration with on-call crisis resources has the potential to expand the scope of prehospital treatment for suicidal patients, and reduce burdens on patients, EMS providers, and Emergency Departments.

Usual Care for Emergency Department Patients Who Present with Suicide Risk: A Survey of Hospital Procedures in Washington State.

Hospital emergency departments (EDs) are important settings for the implementation of effective suicide-specific care. Usual care for suicidal patients who present to EDs remains understudied. This study surveyed EDs in Washington State to assess the adoption of written procedures for recommended standards of care for treating suicidality. Most (N = 79, 84.9%) of the 93 EDs in Washington State participated. Most (n = 58, 73.4%) hospitals had a written protocol for suicide risk assessment, but half (n = 42, 53.2%) did not include documentation of access to lethal means. There was evidence of an association between patient volume and the adoption of suicide-specific protocols and procedures. Our findings suggest the need to enhance the adoption and implementation of recommended standard care in this setting.

Murder-Suicides Perpetrated by Adolescents: Findings from the National Violent Death Reporting System.

OBJECTIVE: Murder-suicide is a rare and especially tragic form of violence. Nascent literature has characterized murder-suicide perpetrated by adults, but no study has focused on adolescents who perpetrated murder-suicide. METHOD: This study evaluated all cases of murder-suicide perpetrated by persons under age 21 who were included in the National Violent Death Reporting System, and categorized each incident using Joiner's perversion of virtue framework of murder-suicide. RESULTS: Forty-seven incidents of murder-suicide perpetrated by adolescents were identified, representing 56 victims. Most cases did not have sufficient information to be categorized within a particular perversion of virtue. Among the 20 cases who did have sufficient detail to be categorized, incidents were identified as perversions of self-control (n = 11), justice (n = 8), and mercy (n = 1). Most perpetrators were male, and the majority of victims were female. Additional victim, perpetrator, and incident characteristics are described. CONCLUSIONS: Our findings extend previous work by employing a coding system based on a theoretically derived framework for categorizing "genuine" murder-suicide and related behavior among adolescents. This study also characterized the nature of this complex and tragic sequence of behavior among adolescents, who are at elevated risk of suicide, and who may benefit from prevention efforts that effectively address means safety, suicidality, and intimate partner violence.

Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel.

OBJECTIVE: Suicide is a major public health concern among military servicemembers and previous research has demonstrated an association between bullying and suicide. This study evaluated the association between workplace bullying and suicidal ideation via perceived burdensomeness and thwarted belongingness which were hypothesized to mediate this association. METHOD: Four hundred and seventy-one suicidal Army Soldiers and U.S. Marines completed self-report measures of suicidal ideation, thwarted belongingness, perceived burdensomeness, and bullying. A series of regressions were used to test the hypothesized mediation model using the baseline data from a larger clinical trial. RESULTS: Perceived burdensomeness was a significant mediator of the association between bullying and the level of suicidal ideation, but thwarted belongingness was not a significant mediator. CONCLUSIONS: Perceived burdensomeness may represent a malleable target for intervention to prevent suicide among military service members, and should be evaluated further as an intervening variable with regard to suicidality in the setting of bullying victimization.

Effect of Augmenting Standard Care for Military Personnel With Brief Caring Text Messages for Suicide Prevention: A Randomized Clinical Trial.

Importance: Accessible and cost-effective interventions for suicidality are needed to address high rates of suicidal behavior among military service members. Caring Contacts are brief periodic messages that express unconditional care and concern and have been previously shown to prevent suicide deaths, attempts, ideation, and hospitalizations. Objective: To test the effectiveness of augmenting standard military health care with Caring Contacts delivered via text message to reduce suicidal thoughts and behaviors over 12 months. Design, Setting, and Participants: This randomized clinical trial was conducted at 3 military installations in the southern and western United States. Soldiers and Marines identified as being at risk of suicide were recruited between April 2013 and September 2016. The final follow-up was in September 2017. Interventions: Both groups received standard care, and the Caring Contacts group also received consisted of 11 text messages delivered on day 1, at week 1, at months 1, 2, 3, 4, 6, 8, 10, and 12, and on participants' birthdays. Main Outcomes and Measures: Primary outcomes were current suicidal ideation and suicide risk incidents (hospitalization or medical evacuation). Secondary outcomes were worst-point suicidal ideation, emergency department visits, and suicide attempts. Suicidal ideation was measured by the Scale for Suicide Ideation, suicide risk incidents, and emergency department visits by the Treatment History Interview; attempted suicide was measured by the Suicide Attempt Self-Injury Count. Results: Among 658 randomized participants (329 randomizely assigned to each group), data were analyzed for 657 individuals (mean [SD] age, 25.2 [6.1] years; 539 men [82.0%]). All participants reported suicidal ideation at baseline, and 291 (44.3%) had previously attempted suicide. Of the 657 participants, 461 (70.2%) were assessed at 12 months. Primary outcomes were nonsignificant. There was no significant effect on likelihood or severity of current suicidal ideation or likelihood of a suicide risk incident; there was also no effect on emergency department visits. However, participants who received Caring Contacts (172 of 216 participants [79.6%]) had lower odds than those receiving standard care alone (179 of 204 participants [87.7%]) of experiencing any suicidal ideation between baseline and follow-up (odds ratio, 0.56 [95% CI, 0.33-0.95]; P = .03) and fewer had attempted suicide since baseline (21 of 233 [9.0%] in the group receiving Caring Contacts vs 34 of 228 [14.9%] in the standard-care group; odds ratio, 0.52 [95% CI, 0.29-0.92]; P = .03). Conclusions and Relevance: This trial provides inconsistent results on the effectiveness of caring text messages between primary and secondary outcomes, but this inexpensive and scalable intervention offers promise for preventing suicide attempts and ideation in military personnel. Additional research is needed. Trial Registration: ClinicalTrials.gov identifier: NCT01829620.

Emotional reactivity, trauma-related distress, and suicidal ideation among adolescent inpatient survivors of sexual abuse.

Adolescent psychiatric inpatients suffer high rates of childhood sexual abuse, trauma-related distress, and suicidality. This study evaluated the hypothesis that three domains of resiliency (i.e., Sense of Mastery, Sense of Relatedness, and Emotional Reactivity) would mediate the effect of trauma-related distress upon suicidal ideation, while accounting for symptoms of depression, and that the indirect effect of trauma-related distress upon suicidal ideation would be greater among survivors of childhood sexual abuse. Chart review patients included 550 adolescents admitted to a public psychiatric hospital in a Northwestern US State from 2010 to 2015. Adolescents completed self-report measures of trauma-related distress, depression, resiliency, and suicidal ideation. Half of the adolescents in this study reported past history of childhood sexual abuse, and more than half disclosed history of attempted suicide. There was a group noninvariant indirect effect of trauma-related distress upon suicidal ideation via emotional reactivity among survivors of childhood sexual abuse (ß = 0.10, 95% ACI: 0.04 to .17), as well as a group invariant direct effect of depression symptoms (ß = 0.88, p < .001). The other two domains of resiliency, sense of mastery and sense of relatedness did not mediate the association between trauma-related distress and suicidal ideation. These findings demonstrate the importance of emotional reactivity with regard to suicidal ideation, as well as the association between depression symptoms and suicidal ideation in this clinical population, and suggest the potential utility of skills-based interventions, and the need for trauma-informed policy and procedures in adolescent psychiatric inpatient settings.

Dialectical Behavior Therapy Is Effective for the Treatment of Suicidal Behavior: A Meta-Analysis.

Dialectical Behavior Therapy (DBT) prioritizes suicidal behavior and other self-directed violence as the primary treatment targets, and has been demonstrated to reduce self-directed violence in clinical trials. This paper synthesizes findings from controlled trials that assessed self-directed violence and suicidality, including suicide attempts, non-suicidal self-injury (NSSI), suicidal ideation, and accessing psychiatric crisis services. Eighteen controlled trials of DBT were identified. Random effects meta-analyses demonstrated that DBT reduced self-directed violence (d = -.324, 95% CI = -.471 to -.176), and reduced frequency of psychiatric crisis services (d = -.379, 95% CI = -.581 to -.176). There was not a significant pooled effect of DBT with regard to suicidal ideation (d = -.229, 95% CI = -.473 to .016). Our findings may reflect the prioritization of behavior over thoughts within DBT, and offer implications for clinical practice and future research concerning the implementation of DBT for acute suicidality.

Coping self-efficacy and trauma-related shame mediate the association between negative social reactions to sexual assault and PTSD symptoms.

Previous research has identified trauma-related shame as a mediator of the association between negative social reactions to sexual assault disclosure and psychological distress, including posttraumatic stress disorder (PTSD) symptoms. However, few studies have considered protective factors that may mitigate the effects of trauma-related shame. This study evaluated trauma-coping self-efficacy and trauma-related shame as mediators of the association between negative reactions to sexual assault disclosure and PTSD symptoms. It was hypothesized that both trauma-coping self-efficacy and trauma-related shame would mediate this association. One hundred thirty-two psychology undergraduates, who reported experiencing sexual assault and had disclosed the sexual assault to at least 1 other person, completed self-report measures of history of sexual assault, negative social reactions, trauma-related shame, trauma-coping-self-efficacy, and PTSD symptoms online. The hypothesized mediation model was evaluated via a series of regressions and included gender and history of sexual assault as covariates. Participants reported significant histories of sexual assault and elevated symptoms of PTSD. Both trauma-related shame and trauma-coping self-efficacy significantly mediated the association between negative social reactions and PTSD symptoms. Trauma-coping self-efficacy and trauma-related shame are significant intervening variables with regard to the association between negative social reactions and PTSD symptoms. These malleable points of therapeutic intervention warrant additional research and highlight the need for clinical practice that explicitly addresses shame and enhances coping self-efficacy among undergraduates who disclose sexual assault. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Intentional Injury and the Risk of Subsequent Hospitalization for Attempted Suicide.

OBJECTIVE: Trauma patients are at increased risk of suicidal behavior. The association between assault injury and subsequent suicidal behavior relative to unintentional injury remains under-studied. This study hypothesized that trauma patients with assault injuries would demonstrate greater risk of subsequent suicide attempt hospitalization compared to patients with unintentional injury. METHOD: Trauma patients hospitalized in Washington State were identified via administrative records. Proportional hazard analysis was conducted to test differences in risk of suicide attempt hospitalization up to 5 years after the initial trauma hospitalization, and time to onset of first suicide attempt hospitalization by subgroup. RESULTS: Approximately 2% (n = 1264) of trauma inpatients were subsequently hospitalized for attempted suicide, and 0.3% died by suicide (n = 177) during the follow-up period. Relative to patients with unintentional injuries, those with assault-related injuries (aHR = 1.38, 95% CI: 1.02 to 1.86), and self-inflicted injuries (aHR = 8.22, 95% CI: 7.24 to 9.33) demonstrated greater risk of suicide attempt hospitalization after discharge. CONCLUSION: These findings demonstrate a greater risk of suicidal behavior among trauma patients with assault injuries relative to patients with unintentional injuries. This suggests the importance of intentional cause of injury as a risk factor for suicidal behavior to be considered in assessment of suicidality and discharge planning for trauma patients.