Borderline Personality Traits Do Not Moderate the Relationship Between Depression, Beliefs, and Suicidal Thoughts and Behaviors.

Adults with clinically significant borderline personality disorder traits (BPTs) are at high risk of experiencing suicidal thoughts and behaviors (STBs). STBs among those with BPTs have been associated with suicidal beliefs (e.g., that one is unlovable or that distress is intolerable). However, the extent to which suicidal beliefs uniquely mediate the relationship between emotional distress and STBs among individuals with BPTs is not known. Individuals admitted to an inpatient unit (N = 198) with recent STBs completed assessments of BPTs, depression, suicidal beliefs, suicidal ideation, and suicide attempt history. Moderated mediation models were used to explore whether suicidal beliefs mediated the relationship between depression and STBs conditional on BPTs. Suicidal patients with versus without BPTs reported stronger suicidal beliefs and more severe STBs (i.e., suicidal ideation, lifetime attempts). Exploratory moderated mediation analysis demonstrated that suicidal beliefs mediated the relationship between depression and suicidal ideation as well as suicide attempts. The mediation effect of suicidal beliefs on the depression-ideation and depression-attempt relationship was not significantly moderated by BPTs. This study was cross-sectional and therefore the estimated mediation models must be considered exploratory. Longitudinal research will be needed to assess the potential causal mediation of suicidal beliefs on the relationship between depression and STBs. The results of this study suggest that suicidal beliefs may play a significant role in the relationship between depression and STBs for inpatients with a history of suicidality regardless of BPTs. This suggests suicidal beliefs may be an important treatment target for adults with a history of STBs.

Uncovering the role of substance use in suicide attempts using a mixed-methods approach.

INTRODUCTION: Substance use is an established risk factor for suicide attempt. Clarifying the role of substance use in suicide attempts may identify modifiable treatment targets. This study used mixed methods to associate substance use with suicide attempt history and identify pathways through which substance use contributes to attempts. METHODS: Study 1 included 213 adult inpatients (n = 127 with substance use disorder [SUD]), who completed assessments of suicide attempt history as well as demographic and clinical suicide risk factors. Study 2 was a narrative analysis of suicide attempt stories described by 20 inpatients diagnosed with SUD. RESULTS: In Study 1, patients with co-occurring alcohol and drug use disorders reported more actual lifetime suicide attempts than did those without SUD. In addition, alcohol and drug use disorders were independently associated with lifetime suicide attempts after controlling for demographic and clinical confounders. In Study 2, substance use played a role in all suicide attempts through at least one pathway before, during, or after a triggering stressor, or as suicide attempt method. CONCLUSIONS: Substances play a role in suicide attempt baseline risk, acute risk and as means. It is important to target chronic and acute substance use in suicide prevention treatment plans.

Finding Effective and Efficient Ways to Integrate Research Advances Into the Clinical Suicide Risk Assessment Interview.

Research in clinical suicidology continues to rapidly expand, much of it with implications for day-to-day clinical practice. Clinicians routinely wrestle with how best to integrate recent advances into practice and how to do so in efficient and effective fashion. This article identifies five critical domains of recent research findings and offers examples of simple questions that can easily be integrated into a clinician's existing suicide risk assessment interview and related protocol helping inform the risk formulation process.

Commentary on the Special Issue on Posttraumatic Stress and Suicide: Recognizing that simple things save lives.

This article offers commentary on the special issue of the Journal of Traumatic Stress dedicated to posttraumatic stress and suicide, with a specific focus on practical recommendations that can be integrated into day-to-day clinical practice. Given the complexity of the myriad associations among posttraumatic stress symptoms, the nature of trauma, and suicidality demonstrated in the articles in this issue, it is important for practitioners to utilize evidence-based approaches to clinical practice in order to be effective. The articles in this special issue offer findings that do just that, providing a foundation rich in practical applications to clinical work, including an understanding of potential mechanisms of action and related targeted interventions.

The Brief Suicide Cognitions Scale: Development and Clinical Application.

The study explored the development of the Brief Suicide Cognitions Scale (B-SCS), a simple and brief measure of suicide risk. The B-SCS provides a brief measure that captures critical aspects of suicide risk embedded in core beliefs about the self as unlovable, one's emotional experience as unbearable, and life problems as unsolvable (i.e., the suicidal belief system), resulting in chronic or enduring suicide risk and heightened vulnerability for acute episodes secondary to internal and external triggers. Data were analyzed from three diverse samples, including a student sample (N = 349), an inpatient psychiatric sample (N = 160), and a sample of emergency department (ED) patients presenting secondary to a suicidal crisis (N = 94). Those in the student and inpatient samples completed additional symptom measures (hopelessness, anxiety, depression) and the ED sample provided 6-month follow-up data for suicide attempts. Reliability (internal consistency, test-retest), concurrent validity, construct (divergent, convergent) validity, factorial, incremental, and predictive validity were evaluated, along with calculation of predictive value of negative and positive tests, sensitivity, and specificity estimates. The B-SCS demonstrated good reliability and validity, a unidimensional factor structure across samples, along with good predictive validity and value in real-world clinical settings. The B-SCS is a brief, reliable and valid measure of suicide risk, with good ability to identify those with enduring risk for subsequent suicide attempts. The B-SCS offers a unique contribution to understanding and assessing the nature of suicide risk over time targeting the suicidal belief system, with easy application across inpatient and outpatient clinical settings, and good predictive value.

Using Machine Learning to Predict Suicide Attempts in Military Personnel.

Identifying predictors of suicide attempts is critical in intervention and prevention efforts, yet finding predictors has proven difficult due to the low base rate and underpowered statistical approaches. The objective of the current study was to use machine learning to examine predictors of suicidal behaviors among high-risk suicidal Soldiers who received outpatient mental health services in a randomized controlled trial of Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT) compared to treatment as usual (TAU). Self-report measures of clinical and demographic variables, administered prior to the start of outpatient treatment to 152 participants with recent suicidal thoughts and/or behaviors were analyzed using machine learning software to identify the best combination of variables for predicting suicide attempts during or after treatment. Worst-point suicidal ideation, history of multiple suicide attempts, treatment group (i.e., BCBT or TAU), suicidogenic cognitions, and male sex were found, in combination, correctly classified 30.8% of patients who attempted suicide during the two-year follow-up period. This combination has higher sensitivity than many models that have previously been used to predict suicidal behavior. Overall, this study provides a combination of variables that can be assessed clinical to help identify high-risk suicidal individuals.

Longitudinal suicide ideation trajectories in a clinical trial of brief CBT for U.S. military personnel recently discharged from psychiatric hospitalization.

Research among adolescent samples has suggested patterns of change in suicidal ideation (SI) following psychiatric hospitalization discharge are heterogenous and predictive of subsequent suicide attempts. However, no studies have examined SI trajectories following discharge among adult samples or the effect of treatment on trajectories. We used growth mixture modeling to examine trajectories of SI among 152 active duty military personnel in a randomized controlled trial comparing brief cognitive-behavioral therapy (CBT) for suicide prevention to treatment as usual following discharge from inpatient psychiatric hospitalization for a suicide risk. Analyses of SI at baseline, 3-, 6-, and 12-months post-discharge among the full sample randomized to both conditions revealed two trajectories: rapid improvers (59.21%) and gradual improvers (40.79%). Gradual improvers were more than twice as likely to attempt suicide in the two years following discharge. Exploratory analyses suggested that, relative to those in the treatment as usual condition, those randomized to brief CBT in both trajectories may be less likely to make a suicide attempt during the follow-up period. Results replicate and extend prior research in identifying distinct ideation trajectories following psychiatric inpatient hospitalization for suicide risk to active-duty personnel in a treatment trial and linking these trajectories to suicide attempts during follow-up.

The role of depression and suicidal cognitions as contributors to suicide risk among active duty soldiers reporting symptoms of posttraumatic stress disorder.

BACKGROUND: Military suicide rates have risen across all service branches, with the overall rate surpassing that of the general population for the first time in history in 2008. Service members with posttraumatic stress disorder (PTSD) are at a substantially higher risk for suicidal ideation, suicide attempts, and death by suicide than their peers without PTSD. While the link between PTSD and suicide is well established in the literature, less is known about the precise nature of that connection. Several constructs have been implicated as potential mediators of this relation, such as depression, alcohol use, suicidal cognitions, and sleep disturbance. Yet, to our knowledge, these constructs have never been examined simultaneously in a single model to determine mediational influence for suicide risk among soldiers with PTSD. METHODS: A sample of 172 active duty Army soldiers completed a series of measures targeting the aforementioned constructs. Data were analyzed using mediation model analyses. RESULTS: Suicidal cognitions fully mediated the relation between PTSD symptoms and current suicide risk severity. The indirect effect for suicidal cognitions was significantly larger than indirect effects for alcohol use, depression, and sleep disturbance. Exploratory analyses suggest serial mediation of the relation between PTSD and current suicide risk by depression and suicidal cognitions. LIMITATIONS: These results should be interpreted within the context of study limitations, to include use of self-report data and inability to firmly establish temporal sequencing assumed in mediation. CONCLUSIONS: Implications of this study include the improvement of suicide risk assessment and individualized treatment planning for suicidal military personnel with PTSD.

The Relationship between Post-Battle Experiences and Thwarted Belongingness and Perceived Burdensomeness in Three United States Military Samples.

Suicide rates within the military are elevated relative to the general population; however, research suggests that many of the suicide risk factors for military personnel are similar to the suicide risk factors for civilians. Given that many military specific experiences (e.g., number of deployments) are not considered robust predictors of either suicidal ideation or behavior, it has been posited that deployment specific experiences (e.g., post-battle experiences) may be better able to explain the increased rates of suicide among military personnel. Therefore, the current study aimed to examine the relationship between post-battle experiences and perceived burdensomeness (PB), thwarted belongingness (TB), and suicidal ideation within 3 different military samples: a non-clinical sample of Army National Guard personnel, a non-clinical sample of active duty U.S. Air Force Security Forces personnel, and a clinical sample of U.S. Army personnel receiving outpatient treatment. Post-battle experiences were found to be significantly associated with TB in both non-clinical samples; however, the association between post-battle experiences and TB was non-significant within the clinical sample. Furthermore, results indicated that post-battle experiences were not significantly associated with either PB or suicidal ideation in any of the samples. These findings suggest that in non-clinical samples, post-battle experiences impact a soldier's ability to feel connected to others. Within clinical samples, results indicate that post-battle experiences may not be a direct contributor to either PB or TB. These results indicate a need for universal intervention promoting interpersonal support of military personnel and their families prior to development of further need for psychological interventions. This upstream approach may decrease further development of TB and potentially prevent suicidal desire.

Economic Evaluation of Brief Cognitive Behavioral Therapy vs Treatment as Usual for Suicidal US Army Soldiers.

Importance: Brief cognitive behavioral therapy (BCBT) is a clinically effective intervention for reducing risk of suicide attempts among suicidal US Army soldiers. However, because specialized treatments can be resource intensive, more information is needed on costs and benefits of BCBT compared with existing treatments. Objective: To evaluate the cost-effectiveness of BCBT compared with treatment as usual for suicidal soldiers in the US Army. Design, Setting, and Participants: A decision analytic model compared effects and costs of BCBT vs treatment as usual from a US Department of Defense (DoD) perspective. Model input data were drawn from epidemiologic data sets and a clinical trial among suicidal soldiers conducted from January 31, 2011, to April 3, 2014. Data were analyzed from July 3, 2018, to March 25, 2019. Interventions: The strategies compared were treatment as usual alone vs treatment as usual plus 12 individual BCBT sessions. Treatment as usual could include a range of pharmacologic and psychological treatment options. Main Outcomes and Measures: Costs in 2017 US dollars, suicide attempts averted (self-directed behavior with intent to die, but with nonfatal outcome), suicide deaths averted, and incremental cost-effectiveness ratios, assuming a 2-year time horizon for treatment differences but including lifetime costs. Results: In the base-case analysis, BCBT was expected to avert approximately 23 to 25 more suicide attempts and 1 to 3 more suicide deaths per 100 patients treated than treatment as usual. Sensitivity analyses assuming a range of treatment effects showed BCBT to be cost saving in most scenarios. Using the federal discount rate, the DoD was estimated to save from $15 000 to $16 630 per patient with BCBT vs treatment as usual. In a worst-case scenario (ie, assuming the weakest plausible BCBT effect sizes), BCBT cost an additional $1910 to $2250 per patient compared with treatment as usual. Conclusions and Relevance: Results suggest BCBT may be a cost-saving intervention for suicidal active-duty soldiers. The costs of ensuring treatment fidelity would also need to be considered when assessing the implications of disseminating BCBT across the entire DoD.

Patterns of change in suicide ideation signal the recurrence of suicide attempts among high-risk psychiatric outpatients.

Suicide ideation is an inherently dynamic construct. Previous research implicates different temporal patterns in suicide ideation among individuals who have made multiple suicide attempts as compared to individuals who have not. Temporal patterns among first-time attempters might therefore distinguish those who eventually make a second suicide attempt. To test this possibility, the present study used a dynamical systems approach to model change patterns in suicide ideation over the course of brief cognitive behavioral therapy for suicide prevention (12 sessions total) among 33 treatment-seeking active duty Soldiers with one prior suicide attempt. Variable-centered models were constructed to determine if change patterns differed between those with and without a follow-up suicide whereas person-centered models were constructed to determine if within-person change patterns were associated with eventual suicide attempts. Severity of suicide ideation was not associated with the occurrence of suicide attempts during follow-up, but person-centered temporal patterns were. Among those who made an attempt during follow-up, suicide ideation demonstrated greater within-person variability across treatment. Results suggest certain change processes in suicide ideation may characterize vulnerability to recurrent suicide attempt among first-time attempters receiving outpatient behavioral treatment. Nonlinear dynamic models may provide advantages for suicide risk assessment and treatment monitoring in clinical settings.

Variables associated with reductions in insomnia severity among acutely suicidal patients receiving brief cognitive behavioral therapy for suicide prevention.

INTRODUCTION: This study compared changes in sleep disturbance over time across brief cognitive behavioral therapy for suicide prevention and treatment as usual and examined the mechanisms that link sleep disturbance with several suicide risk factors. METHOD: Active duty U.S. Army soldiers (N = 152) completed a randomized controlled trial to test the efficacy of brief cognitive behavioral therapy (n = 76) or treatment as usual (n = 76). Six assessments of insomnia symptoms, hopelessness, coping, and suicide beliefs were tracked over 24 months. RESULTS: Brief cognitive behavioral therapy patients reported a significant decrease in sleep disturbance symptoms over time while treatment as usual patients did not. These improvements were initially observed during treatment and carried over through 12-months. Changes in sleep disturbance predicted changes in suicide risk. Longitudinal growth modeling was used to assess potential mechanisms of this effect. Results suggested that changes in cognitive flexibility, as defined by measures of hopelessness and suicide beliefs, predicted change in sleep disturbance symptoms. These relationships did not differ across treatment groups. LIMITATIONS: The participants were active duty military personnel. Therefore, the results may not generalize to other patient populations. A greater number of assessment periods in closer proximity as well as additional measures of constructs of interest would have improved the internal validity of this study. CONCLUSIONS: Brief cognitive behavioral therapy significantly reduces sleep disturbance and suicide risk. Changes in cognitive flexibility, in part, explain change in sleep disturbance across both treatments.

Associations of patient-rated emotional bond and vocally encoded emotional arousal among clinicians and acutely suicidal military personnel.

OBJECTIVE: To determine if synchrony in emotional arousal and affective regulation between patients and clinicians reflect emotional bonding during emergency behavioral health appointments. METHOD: Audio recordings of suicide risk assessment interviews and crisis intervention planning with 54 suicidal active duty soldiers presenting to an emergency department or behavioral health clinic were analyzed. Emotional arousal was assessed using mean fundamental frequency. Patient-rated emotional bond was assessed with the Working Alliance Inventory, Short Form (Hatcher & Gillaspy, 2014). Actor-partner interdependence modeling was used to identify moment-to-moment patterns of covariance among clinician and patient emotional arousal. RESULTS: Greater synchrony in clinician and patient emotional arousal was positively associated with higher emotional bond ratings during the crisis intervention but not the risk assessment interview. During the risk assessment interview, higher emotional bond was associated with a dysregulating effect of the clinician on the patient's emotional arousal (i.e., larger fluctuations in the patient's emotional arousal). The reverse pattern was seen during the intervention: Higher emotional bond was associated with a regulating effect of the clinician on the patient's emotional arousal (i.e., smaller fluctuations in the patient's emotional arousal). Emotional bond during the intervention was also positively associated with a regulating effect of the patient on the clinician's emotional arousal. CONCLUSION: Emotional bonding during emergency clinical encounters is associated with patient-clinician synchrony in emotional states. During crisis interventions, emotional bonding is also associated with mutual down-regulation of emotional arousal among patients and clinicians. (PsycINFO Database Record

Differential Effects of Brief CBT Versus Treatment as Usual on Posttreatment Suicide Attempts Among Groups of Suicidal Patients.

OBJECTIVE: The purpose of this study was to examine variability in outcomes (suicide attempt rates) across subgroups of patients who were randomly enrolled in brief cognitive-behavioral therapy (CBT) and treatment as usual. METHODS: A secondary analysis was conducted of data collected during a randomized clinical trial of brief CBT for suicide prevention in a sample of 176 U.S. military personnel who reported active suicide ideation in the past week or a suicide attempt in the past month. Latent-class analysis was used to identify empirically distinct and clinically meaningful patient subgroups. Rates of suicide attempts during a two-year follow-up period were compared across classes and treatment groups. RESULTS: Three latent classes corresponding to low (N=55), moderate (N=40), and high (N=57) suicide risk were identified. The classes significantly differed with respect to psychiatric symptom severity but not demographic or historical variables. Rates of suicide attempts during the two-year follow-up significantly varied across classes in treatment as usual but did not vary across classes in brief CBT (21% versus 10%, respectively, in the low-severity class, 8% versus 13% in the moderate-severity class, and 41% versus 10% in the high-severity class). Differences between treatment conditions in suicide attempt rates were statistically significant for the high-severity class. CONCLUSIONS: Treatment as usual was associated with variable rates of suicidal behavior, depending on suicide risk severity. Brief CBT contributed to consistently low rates of suicidal behavior regardless of patient severity.

Nonlinear Change Processes During Psychotherapy Characterize Patients Who Have Made Multiple Suicide Attempts.

Research suggests that multiple suicide attempters experience considerable variability in suicide ideation and longer-duration suicidal crises, which suggests the possibility of two states of stability (one low risk and one high risk). To date, however, few studies have examined nonlinear change processes in suicide ideation among patients. In a sample of 76 active duty U.S. Army soldiers receiving brief cognitive behavioral therapy for acute suicide risk, we examined differences in the ebb and flow of suicide ideation among multiple attempters, first-time attempters, and ideators. Results indicated that multiple attempters were characterized by two states of stability corresponding to low and high intensity suicide ideation; these states were separated by a region of instability corresponding to moderate intensity suicide ideation. In contrast, ideators and first-time attempters were characterized by only a single state of stability corresponding to low intensity suicide ideation. Among patients who have made multiple suicide attempts, suicide ideation may function as a bimodal rather than a continuous construct.

Mechanisms of Action Contributing to Reductions in Suicide Attempts Following Brief Cognitive Behavioral Therapy for Military Personnel: A Test of the Interpersonal-Psychological Theory of Suicide.

Brief cognitive behavioral therapy (BCBT) is associated with significant reductions in suicide attempts among military personnel. However, the underlying mechanisms of action contributing to reductions in suicide attempts in effective psychological treatments remain largely unknown. The present study conducted a secondary analysis of a randomized controlled trial of BCBT versus treatment as usual (TAU) to examine the mechanisms of action hypothesized by the interpersonal-psychological theory of suicide (IPT): perceived burdensomeness, thwarted belongingness, and fearlessness about death. In a sample of 152 active duty U.S. Army personnel with recent suicide ideation or attempts, there were significantly fewer suicide attempts in BCBT, but there were no differences between treatment groups from baseline to 6 months postbaseline on any of the 3 IPT constructs or their interactions. Tests of the moderated mediation failed to support an indirect effect for the IPT model, regardless of which IPT variables were specified as mediators or moderators. Results suggest that the IPT's hypothesized mechanisms of action do not account for reductions in suicide attempts in BCBT. Implications for clinical practice and research are discussed.