Stability of Suicide Risk Prediction Models During Changes in Health Care Delivery.

OBJECTIVE: The authors aimed to use health records data to examine how the accuracy of statistical models predicting self-harm or suicide changed between 2015 and 2019, as health systems implemented suicide prevention programs. METHODS: Data from four large health systems were used to identify specialty mental health visits by patients ages ≥11 years, assess 311 potential predictors of self-harm (including demographic characteristics, historical risk factors, and index visit characteristics), and ascertain fatal or nonfatal self-harm events over 90 days after each visit. New prediction models were developed with logistic regression with LASSO (least absolute shrinkage and selection operator) in random samples of visits (65%) from each calendar year and were validated in the remaining portion of the sample (35%). RESULTS: A model developed for visits from 2009 to mid-2015 showed similar classification performance and calibration accuracy in a new sample of about 13.1 million visits from late 2015 to 2019. Area under the receiver operating characteristic curve (AUC) ranged from 0.840 to 0.849 in the new sample, compared with 0.851 in the original sample. New models developed for each year for 2015-2019 had classification performance (AUC range 0.790-0.853), sensitivity, and positive predictive value similar to those of the previously developed model. Models selected similar predictors from 2015 to 2019, except for more frequent selection of depression questionnaire data in later years, when questionnaires were more frequently recorded. CONCLUSIONS: A self-harm prediction model developed with 2009-2015 visit data performed similarly when applied to 2015-2019 visits. New models did not yield superior performance or identify different predictors.

Predicting risk of suicidal behavior from insurance claims data vs. linked data from insurance claims and electronic health records.

PURPOSE: Observational studies assessing effects of medical products on suicidal behavior often rely on health record data to account for pre-existing risk. We assess whether high-dimensional models predicting suicide risk using data derived from insurance claims and electronic health records (EHRs) are superior to models using data from insurance claims alone. METHODS: Data were from seven large health systems identified outpatient mental health visits by patients aged 11 or older between 1/1/2009 and 9/30/2017. Data for the 5 years prior to each visit identified potential predictors of suicidal behavior typically available from insurance claims (e.g., mental health diagnoses, procedure codes, medication dispensings) and additional potential predictors available from EHRs (self-reported race and ethnicity, responses to Patient Health Questionnaire or PHQ-9 depression questionnaires). Nonfatal self-harm events following each visit were identified from insurance claims data and fatal self-harm events were identified by linkage to state mortality records. Random forest models predicting nonfatal or fatal self-harm over 90 days following each visit were developed in a 70% random sample of visits and validated in a held-out sample of 30%. Performance of models using linked claims and EHR data was compared to models using claims data only. RESULTS: Among 15 845 047 encounters by 1 574 612 patients, 99 098 (0.6%) were followed by a self-harm event within 90 days. Overall classification performance did not differ between the best-fitting model using all data (area under the receiver operating curve or AUC = 0.846, 95% CI 0.839-0.854) and the best-fitting model limited to data available from insurance claims (AUC = 0.846, 95% CI 0.838-0.853). Competing models showed similar classification performance across a range of cut-points and similar calibration performance across a range of risk strata. Results were similar when the sample was limited to health systems and time periods where PHQ-9 depression questionnaires were recorded more frequently. CONCLUSION: Investigators using health record data to account for pre-existing risk in observational studies of suicidal behavior need not limit that research to databases including linked EHR data.

Complex modeling with detailed temporal predictors does not improve health records-based suicide risk prediction.

Suicide risk prediction models can identify individuals for targeted intervention. Discussions of transparency, explainability, and transportability in machine learning presume complex prediction models with many variables outperform simpler models. We compared random forest, artificial neural network, and ensemble models with 1500 temporally defined predictors to logistic regression models. Data from 25,800,888 mental health visits made by 3,081,420 individuals in 7 health systems were used to train and evaluate suicidal behavior prediction models. Model performance was compared across several measures. All models performed well (area under the receiver operating curve [AUC]: 0.794-0.858). Ensemble models performed best, but improvements over a regression model with 100 predictors were minimal (AUC improvements: 0.006-0.020). Results are consistent across performance metrics and subgroups defined by race, ethnicity, and sex. Our results suggest simpler parametric models, which are easier to implement as part of routine clinical practice, perform comparably to more complex machine learning methods.

Accuracy of ICD-10-CM encounter diagnoses from health records for identifying self-harm events.

OBJECTIVE: Assess the accuracy of ICD-10-CM coding of self-harm injuries and poisonings to identify self-harm events. MATERIALS AND METHODS: In 7 integrated health systems, records data identified patients reporting frequent suicidal ideation. Records then identified subsequent ICD-10-CM injury and poisoning codes indicating self-harm as well as selected codes in 3 categories where uncoded self-harm events might be found: injuries and poisonings coded as undetermined intent, those coded accidental, and injuries with no coding of intent. For injury and poisoning encounters with diagnoses in those 4 groups, relevant clinical text was extracted from records and assessed by a blinded panel regarding documentation of self-harm intent. RESULTS: Diagnostic codes selected for review include all codes for self-harm, 43 codes for undetermined intent, 26 codes for accidental intent, and 46 codes for injuries without coding of intent. Clinical text was available for review for 285 events originally coded as self-harm, 85 coded as undetermined intent, 302 coded as accidents, and 438 injury events with no coding of intent. Blinded review of full-text clinical records found documentation of self-harm intent in 254 (89.1%) of those originally coded as self-harm, 24 (28.2%) of those coded as undetermined, 24 (7.9%) of those coded as accidental, and 48 (11.0%) of those without coding of intent. CONCLUSIONS: Among patients at high risk, nearly 90% of injuries and poisonings with ICD-10-CM coding of self-harm have documentation of self-harm intent. Reliance on ICD-10-CM coding of intent to identify self-harm would fail to include a small proportion of true self-harm events.

Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis.

OBJECTIVES: To characterize individual participant level response distributions to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration from 1979 to 2016. DESIGN: Individual participant data analysis. POPULATION: 232 randomized, double blind, placebo controlled trials of drug monotherapy for major depressive disorder submitted by drug developers to the FDA between 1979 and 2016, comprising 73 388 adult and child participants meeting the inclusion criteria for efficacy studies on antidepressants. MAIN OUTCOME MEASURES: Responses were converted to Hamilton Rating Scale for Depression (HAMD17) equivalent scores where other measures were used to assess efficacy. Multivariable analyses examined the effects of age, sex, baseline severity, and year of the study on improvements in depressive symptoms in the antidepressant and placebo groups. Response distributions were analyzed with finite mixture models. RESULTS: The random effects mean difference between drug and placebo favored drug (1.75 points, 95% confidence interval 1.63 to 1.86). Differences between drug and placebo increased significantly (P<0.001) with greater baseline severity. After controlling for participant characteristics at baseline, no trends in treatment effect or placebo response over time were found. The best fitting model of response distributions was three normal distributions, with mean improvements from baseline to end of treatment of 16.0, 8.9, and 1.7 points. These distributions were designated Large, Non-specific, and Minimal responses, respectively. Participants who were treated with a drug were more likely to have a Large response (24.5% v 9.6%) and less likely to have a Minimal response (12.2.% v 21.5%). CONCLUSIONS: The trimodal response distributions suggests that about 15% of participants have a substantial antidepressant effect beyond a placebo effect in clinical trials, highlighting the need for predictors of meaningful responses specific to drug treatment.

Associations between clinicians' emotion regulation, treatment recommendations, and patient suicidal ideation.

OBJECTIVE: This study examines how clinicians' emotional responses to suicidal patients and their emotion regulation abilities are related to their treatment recommendations for these patients and to patients' concurrent suicidal ideation and at one-month follow-up. METHODS: Adult psychiatric outpatients (N = 361) and the mental health professionals evaluating them for treatment (N = 43) completed self-report assessments following their first clinical meeting. Clinician emotion regulation traits, emotional responses to individual patients, and the recommended intensity of treatment were assessed. Patients were assessed for suicidal ideation immediately following the initial meeting and at a one-month follow-up. Moderation and mediation analyses were performed to examine the relationships between study variables. RESULTS: Patient suicidal ideation at the initial clinical encounter was associated with increased negative emotions in clinicians with lower emotion regulation. Further, recommended treatment intensity was associated with clinicians' negative emotional responses but not with patient suicidal ideation among clinicians with lower emotion regulation. CONCLUSIONS: Treatment intensification is related to clinicians' emotion regulation abilities. Clinicians' attention to their emotional responses may facilitate improved treatment process and ultimately may improve suicidal outcomes.

Correlates of Chronic Suicidal Ideation Among Community-Based Minor-Attracted Persons.

Elevated suicidal risk has been documented in adults who are sexually attracted to minors but the topic has not been adequately investigated, particularly outside the context of the criminal justice system. In this study, risk factors for chronic suicidal ideation were assessed in 333 community-based minor-attracted persons (95% male) via an online survey. Chronic suicidal ideation was endorsed by 38.1% of the participants but was associated neither to history of sexually engaging with a child nor to prior contact with the criminal justice system. In bivariate logistic regression analyses, significant unadjusted correlates included young age, less education, prior mental health treatment, weaker attraction to adult women, history of sexual abuse in the participants' own childhood, and the psychosocial effect of perceived stigma against pedophilia. In multivariable analysis, all these factors except education were uniquely associated with suicidal ideation. These results identify meaningful clinical risk factors and treatment targets in this population.

Associations between clinicians' emotional responses, therapeutic alliance, and patient suicidal ideation.

BACKGROUND: Mental health clinicians frequently experience intense negative emotional responses to suicidal patients, which have been related to treatment outcome. This study examines the therapeutic alliance as a mediator of the relationship between clinicians' negative emotional responses at the initial encounter and patients' suicidal ideation (SI) concurrently and 1 month later. METHODS: We assessed 378 adult psychiatric outpatients (62.7% female; mean age = 39.1 ± 14.6 years) and their 61 treating clinicians. Following the initial encounter, self-report questionnaires assessed clinicians' emotional responses to their patients, patients' and clinicians' perception of the therapeutic alliance, and patients' SI. The SI was reassessed 1 month after the initial visit. Multilevel mediation analyses were performed. RESULTS: Patients' (but not clinicians') perception of the therapeutic alliance mediated the relationship between clinicians' negative emotional responses to patients and patients' SI 1 month following the initial visit (indirect effect estimate = 0.015; p < .001). CONCLUSIONS: The association between clinicians' negative emotional response and patients' prospective SI appears to be transmitted, at least partly, through the patients' perception of the poorer early quality of the therapeutic alliance. Thus, clinicians' awareness and management of their emotional states appear essential both for the identification of suicidal risk and to enhance therapeutic alliance and treatment outcomes.

Psychotic Symptoms Predict Suicidal Behavior Postdischarge in High Risk Psychiatric Inpatients.

BACKGROUND: Psychotic disorders, as well as psychotic symptoms, are associated with a greater lifetime risk of suicidal behavior (SB). It is not known, however, whether psychotic symptoms are independent predictors for short-term SB. METHODS: Data were collected from 201 psychiatric inpatients at Mount Sinai Beth Israel Hospital. Self-reported psychotic symptoms were assessed using the Brief Symptom Inventory (BSI). Postdischarge SB defined as an aborted, interrupted, or actual suicide attempt was assessed using the Columbia-Suicide Severity Rating Scale (C-SSRS), during the 4 to 8 weeks following discharge from an inpatient psychiatric unit (n=127, 63% retention). Logistic regressions were performed to assess the relationships between psychotic symptoms and SB, controlling for primary psychiatric disorders. RESULTS: Self-reported psychotic symptoms were associated with subsequent postdischarge SB. There was no significant difference between the SB versus no SB groups on the basis of primary psychiatric disorder. Self-reported psychotic symptoms remained an independent and significant predictor of postdischarge SB when the analysis controlled for primary psychiatric disorder. CONCLUSIONS: These results suggest that psychotic symptoms are a dimensional predictor of near-term postdischarge SB and are a necessary component of suicide risk assessment during inpatient hospitalization, independent of psychiatric diagnosis.

Emotional Pain Mediates the Link Between Preoccupied Attachment and Non-suicidal Self-Injury in High Suicide Risk Psychiatric Inpatients.

Background: Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts (SA). Both attachment disturbances and cognitive and emotional problems (e.g., emotional pain) have been associated with SA history. This study sought to determine differential contributions of attachment styles and cognitive and emotional states associated with SA to lifetime NSSI occurrence among adults hospitalized for suicide risk. Sampling and Methods: Adult psychiatric inpatients (n = 200) were assessed for attachment style, cognitive and emotional states, and lifetime NSSI within 72 h of hospitalization. Binary logistic regression and mediation analyses were performed. Results: Preoccupied attachment and emotional pain at admission were independently associated with lifetime NSSI. Emotional pain partially mediated the relationship between preoccupied attachment and lifetime NSSI. Limitations: The cross-sectional nature of the study and the use of a dichotomous (yes/no) measure of NSSI, not specifically designed for its assessment. Conclusions: Preoccupied attachment and emotional pain are associated with NSSI and may be useful targets for assessing risk of NSSI.

Determinants and Predictive Value of Clinician Assessment of Short-Term Suicide Risk.

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training.

Suicide Risk and Emotional Responses to Thoughts of Death: The Response to Morbid Ideations Questionnaire.

BACKGROUND: There is need for deeper understanding of the processes by which suicidal thoughts lead to action. Examination of morbid ideation and the emotional sequelae of such ideation that may feed suicide ideation (SI) and attempts (SA) have been limited. METHOD: Adult psychiatric outpatients (N = 385) were administered the Response to Morbid Ideation Questionnaire (RMI-Q) and measures of SI, suicidal thoughts and behaviors (STB), and other psychiatric symptom severity. We examined (1) incidence and prevalence in mentation of morbid ideations and emotional responses to these ideations, (2) differences in emotional responses between individuals of varying levels of suicide history, and (3) the relationships of different types of morbid ideations and emotional responses with concurrent SI and symptom severity. RESULTS: Morbid ideation was reported by 87.5% of participants and associated with lifetime and concurrent levels of SI/STB. Calm/relieved emotional responses were associated with lifetime and concurrent levels of SI/STB, while negative-valence responses to morbid ideations were associated with concurrent severity of psychopathology. CONCLUSIONS: Our results suggest that the role of morbid ideation and its emotional sequelae in the development of suicidal motivation and action deserves further attention and may be a treatment target for suicide risk reduction.

Predictive Validity of Proposed Diagnostic Criteria for the Suicide Crisis Syndrome: An Acute Presuicidal State.

BACKGROUND: Determining imminent risk of suicide continues to challenge psychiatrists. To this end, we test the clinical utility of a proposed set of diagnostic criteria for the suicide crisis syndrome (SCS) for prediction of imminent suicidal thoughts and behaviors prospectively. METHOD: One hundred and seventy individuals hospitalized for suicidal thoughts and behaviors (STB) were evaluated within 72 hr of admission with measures assessing symptoms of the proposed SCS, history of STB, current ideation, and depression severity. Four-eight weeks following discharge, STB were reassessed. Associations between SCS and postdischarge attempts were examined using chi-square and logistic regression analyses. The receiver operator characteristic analysis was used to test the optimal number of symptoms required to meet proposed SCS criteria. RESULTS: The syndrome was maximally informative about short-term risk of postdischarge suicide behavior when all criteria were met. The syndrome conferred a sevenfold increase in risk of postdischarge suicide attempt, and significantly improved prediction by standard risk factors, which was null to limited. CONCLUSIONS: The SCS diagnostic criteria are supported and appear to describe a clinically meaningful syndrome in a high-risk population. Assessment of SCS may meaningfully improve clinical assessment of imminent suicide risk. Further study is needed to better understand the syndrome and its applicability in low-risk populations.

Attraction Versus Action in Pedophilic Desire: The Role of Personality Traits and Childhood Experience.

OBJECTIVE: Comparison of pedophilic individuals who do and do not refrain from sexually engaging with children may offer critically important information regarding the differential contributors to pedophilic attraction versus behavior. This study compared 5 traits that are potentially contributory to pedophilic attraction or behavior in both minor-attracted persons (MAPs) who refrain from sexually engaging with minors (nonacting MAPs) and those who have acted on pedophilic attractions and subsequently entered the criminal justice system (forensic MAPs). METHODS: Subjects included 195 nonacting MAPs, 50 forensic MAPs, and 60 healthy controls. Data on nonacting MAPs were drawn from an online survey, and data on the other 2 groups were based on prior in-person evaluations. Measures included the Millon Clinical Multiaxial Inventory-II (MCMI-II), Barratt Impulsiveness Scale (BIS-11), the MAP Questionnaire, and the Sexual History Questionnaire (SHQ). RESULTS: Both MAP groups scored higher than healthy controls on the domains of socially inhibited personality traits, propensity toward cognitive distortions, and subjects' own childhood sexual abuse (CSA). Forensic MAPs scored higher than nonacting MAPs on the CSA domain, but the 2 MAP groups differed little on the other 2 domains. Forensic MAPs also scored higher than the other 2 groups on the antisocial domain, whereas nonacting MAPs did not differ from controls on this measure. Nonacting MAPs scored higher than controls on impulsivity. CONCLUSIONS: Antisocial personality traits may be a primary driver of pedophilic behavior that is unrelated to pedophilic attraction. Socially inhibited personality traits and propensity toward cognitive distortions are associated with pedophilic attraction, although the direction of causation is not clear. CSA seems to increase the risk of both attraction and behavior.

Anhedonia and suicidal thoughts and behaviors in psychiatric outpatients: The role of acuity.

BACKGROUND: Anhedonia-impairment related to the experience of pleasure-has been identified as a potential risk factor for suicide, with some mixed findings. The current study sought to clarify the role of acuity of anhedonia in the relationship between anhedonia and suicidal thoughts and behaviors by comparing acutely and chronically anhedonic subjects on severity of suicidal ideation (SI) and suicide attempt (SA) history. METHODS: Psychiatric outpatients (N = 395) were administered the Columbia Suicide Severity Rating Scale, the Beck Scale for Suicidal Ideation and a modified version of the Snaith-Hamilton Pleasure Scale (SHPS); SI measures were readministered at a 1-month follow-up (N = 289, 73%). Participants were classified as acutely anhedonic, chronically anhedonic and nonanhedonic based on their responses to the SHPS at initial assessment. RESULTS: Controlling for symptoms of anxiety and depression, acute anhedonia was cross-sectionally and prospectively associated with greater severity of SI compared to the nonanhedonic group; no differences in severity of SI were found between the chronically anhedonic and nonanhedonic group at either time point. Anhedonia grouping was not associated with SA history. CONCLUSION: Changes in capacity to experience pleasure may be more informative of near-term SI than typically low pleasure levels. Future investigation should focus on the relationship between acute anhedonia and imminent suicidal behavior.

Qualitative Analysis of Attitudes Toward Adult-Child Sexual Activity Among Minor-Attracted Persons.

This study uses qualitative methodology to explore narrative responses to a question regarding the harmful versus beneficial effects of adult-child sex on children. Data were gathered from a survey of self-identified minor-attracted persons (MAPs). Two hundred and sixty-seven survey participants provided narrative responses. Results indicated a significant amount of variability in perceptions of harm and of mitigating or aggravating factors. Understanding the subjective perspectives of MAPs, the range of their attitudes, and the issues that they identify as pertinent is critically important for clinical efficacy in the treatment of pedophilia.

Emotional Responses to Suicidal Patients: Factor Structure, Construct, and Predictive Validity of the Therapist Response Questionnaire-Suicide Form.

BACKGROUND: Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of near-term suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting. METHODS: Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes. RESULTS: Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state- and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses. CONCLUSION: The TRQ-SF is a brief and reliable measure with a 3-factor structure. It demonstrates construct validity for assessing distinct suicide-related countertransference to psychiatric outpatients. Mental health professionals' emotional responses to their patients are concurrently indicative and prospectively predictive of suicidal thoughts and behaviors. Thus, the TRQ-SF is a useful tool for the study of countertransference in the treatment of suicidal patients and may help clinicians make diagnostic and therapeutic use of their own responses to improve assessment and intervention for individual suicidal patients.

Entrapment as a mediator of suicide crises.

BACKGROUND: Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients. METHODS: The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated. RESULTS: Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI. CONCLUSION: Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior.

Comparison of Self-Identified Minor-Attracted Persons Who Have and Have Not Successfully Refrained From Sexual Activity With Children.

The present study compares community-based minor-attracted persons (MAPs) with and without histories of sexual activity with children. MAP actors (N = 342) were significantly older than non-actors (N = 223), with longer duration of pedophilic attraction, more antisocial traits, greater attraction to boys, greater difficulty controlling their attraction, and more positive attitudes toward adult-child sexual activity. Additionally, more MAP actors reported prior mental health treatment, nonsexual offenses, and childhood sexual and nonsexual abuse. Over a third of the whole sample reported chronic suicidal ideation. These findings support the existence of MAPs who successfully refrain from sexually engaging with children, identifying multiple protective and risk factors.

Suicide Crisis Syndrome Mediates the Relationship Between Long-term Risk Factors and Lifetime Suicidal Phenomena.

In recent years, there has been growing attention to the distinction between acute and long-term suicidal risk factors. We have previously characterized an acute, negative affect state, termed the suicide crisis syndrome (SCS), as a marker of near-term suicidal risk. Here, we test whether documented long-term risk factors (i.e., trait vulnerabilities), including perfectionism, impulsivity, chronic substance abuse, insecure attachment, poor social support, and childhood trauma, associate to suicidal phenomena through a pathway of the SCS. A sample of 207 psychiatric inpatients were administered a battery of eight scales, including the Suicide Trigger Scale (STS-3) as a measure of the SCS. While both STS-3 and all trait vulnerabilities were associated with lifetime suicidal ideation and attempts, only STS-3 was related to pre-admission suicide attempts. The STS-3 significantly mediated the effect of each trait vulnerability on lifetime suicidal phenomena (combining ideation and behavior), with the proportion of mediating effect ranging from .29 to .56. Reverse mediation analyses were only significant for insecure attachment, supporting a largely unidirectional mediation effect. The SCS appears to serve as an acute risk factor for suicidal behavior in psychiatric inpatients and may act as a mechanism by which long-term risk factors increase suicidal risk.