Risk Factors Associated with Suicidal Ideation and Suicidal Behavior in Wildland Firefighters.

INTRODUCTION: Wildland firefighters are posited to have a higher suicide rate than general firefighters and the general population. However, the rates and risk factors of suicide among wildland firefighters is not fully understood. METHODS: For this preregistered study, 564 participants were recruited from Facebook to obtain a final sample of 246 participants with valid data who were current or former wildland firefighters in the United States. Participants completed online measures of suicidal ideation, history of suicidal behaviors, posttraumatic stress disorder (PTSD) symptoms, problematic alcohol use, and occupational exposure to suicide. RESULTS: In this sample, 22% of wildland firefighters reported a history of at least one suicide attempt, and 36.7% reported current suicidal ideation. PTSD symptoms, but not problematic alcohol use or exposure to suicide, were positively associated with suicidal ideation and a history of suicide attempts. Additionally, PTSD symptoms explained significantly more variance in suicidal ideation than depression symptoms alone. CONCLUSIONS: Wildland firefighters demonstrate rates of suicide attempts that exceed those of non-wildland firefighters and of the general population at large. In addition, PTSD symptoms may contribute to suicidal thoughts and behaviors (STB) in this population. This is the largest study of STB in wildland firefighters to date.

The impact of relationship type and closeness on mental health following suicide loss.

BACKGROUND: Most research investigating the effect of suicide on loss survivors has been limited to first-degree family members. Few studies examine the impact of suicide on others outside the immediate family and the influence of relationship type and closeness on mental health. METHODS: This study used data from a sample obtained through random digit dialing (n = 805) to assess exposure to suicide loss, relationship types, perceived closeness, and mental health symptoms (prolonged grief, depression, anxiety, and posttraumatic stress disorder). RESULTS: Familial status, friend status, and higher perceived closeness were associated with prolonged grief, depression, and posttraumatic stress disorder, with the strongest adjusted associations observed for posttraumatic stress disorder and prolonged grief. In general, the magnitude of adjusted standardized associations for closeness and mental health symptoms was stronger than those observed for familial status and mental health symptoms and friend status and mental health symptoms. CONCLUSION: Closeness, familial status, and friend status are associated with mental health symptoms experienced after suicide loss, but the magnitude of associations was strongest for closeness. Future studies should examine perceived closeness in addition to other factors related to relationship type and dynamics to assess the complexities of suicide bereavement reactions.

Suicide risk profiles among service members and veterans exposed to suicide.

OBJECTIVES: Rates of suicide exposure are high among service members and Veterans and are especially concerning given the link between suicide exposure and subsequent suicide risk. However, to date, it is unclear which individuals who are exposed to suicide are subsequently at high risk for suicide. Latent profile analysis (LPA) can provide information on unique risk profiles and subgroups of service members and Veterans who have higher suicide risk after suicide exposure, which has not yet been empirically studied. The purpose of this study was to utilize LPA to identify subgroups of service members and Veterans who are at the highest risk for suicidal thoughts and behaviors following suicide exposure. METHODS: We analyzed data using LPA from 2570 service members and Veterans (82.1% male, 69.5% White, and 12.1% Latino/a/x) who completed the Military Suicide Research Consortium's Common Data Elements, a battery of self-report suicide-related measures. Psychopathology, substance use, mental health service utilization, interpersonal theory of suicide, and suicide exposure variables were used to validate classes. RESULTS: Three latent classes emerged from analyses, one low-risk class and two-high risk classes with differing profile compositions (one primarily differentiated by anxiety symptoms and one differentiated by substance use). CONCLUSION: Class-specific recommendations for suicide prevention efforts will be discussed.

Causes of death in individuals exposed to spousal, parental, and child suicide: a nationwide population-based cohort comparison study.

Exposure to suicide is associated with higher mortality, and the health impact varies depending on the types of kinship. However, the moderating role of kinship remains unclear. Therefore, this study aimed to compare causes of death between individuals exposed to spousal, parental, and child suicide to those exposed to natural or unnatural death. In this study, 1,929,872 individuals were enrolled, of whom 1,726,846 individuals were exposed to natural death, 141,206 individuals were exposed to unnatural death, and 61,820 individuals were exposed to suicide. To compare causes of death between kinship, stratified analysis and moderation analysis were conducted by using the Cox proportional hazard model and the cause-specific hazard model. Although higher mortality from specific causes, such as suicide, homicide, and vascular and unspecified dementia, was observed in individuals exposed to suicide compared to those exposed to natural and unnatural death (adjusted hazard ratio: 1.69 to 23.26), we did not observe higher all-cause mortality when compared to those exposed to unnatural death. Some causes of death were moderated by kinship. When compared to unnatural death, parental or spousal suicide was associated with higher mortality from suicide and homicide than child suicide (adjusted hazard ratio: 1.70 to 15.67), and parental suicide was associated with higher mortality from accidents than spousal suicide (adjusted hazard ratio: 1.81). These findings provide an integral understanding of the role of kinship in the impacts of suicide exposure on causes of death.

Unpacking the Meaning of Closeness, Reconsidering the Concept of Impact in Suicide Exposure, and Expanding Beyond Bereavement: "Just, I Hope You Don't Forget About Us".

Suicide exposure research has relied on samples of treatment-seeking kin, resulting in an attachment-based model centering bereavement as the most significant form of impact and obscuring other forms of significant and life-altering impact. From a community-based sample (N = 3010) exposed to suicide, we examine a subset (n = 104) with perceived high impact from the death yet low reported closeness to the person who died and analyze qualitative comments (n = 50). On average and out of 5.00, participants rated closeness as 1.56 but impact of death as 4.51. We illustrate dimensions of low closeness and identify themes on the meaning of impact: impact through society and systemic circumstances, impact through history and repeated exposure, impact through other people, impact as a motivator for reflection or change, and impact through shared resonance. Participants reported impact of death as significant or devastating, yet none of their comments reflected experiences typical of bereavement.

Suicide exposure experience screener for use in therapeutic settings: A validation report.

INTRODUCTION: A brief screener assessing experience of exposure to suicide for use in therapeutic settings is warranted. To examine the concurrent validity of such a screening tool, labeled as the Suicide Exposure Experience Screener (SEES), the associations of the two SEES items: (i) reported closeness with the person who died by suicide and (ii) perceived impact of suicide death with psychological distress are presented. METHODS: Five separate datasets comprising surveys from Australia, Canada, and the United States (Ncombined  = 7782) were used to provide evidence of concurrent validity of closeness and impact of suicide exposure. RESULTS: Overall, closeness and impact were significantly correlated with measures of global distress across five different datasets, showing small to medium effect sizes. Closeness and impact were also intercorrelated demonstrating a large effect size across all surveys. This report used cross-sectional data and comprised varied sample sizes across different datasets that influenced statistical significance of obtained effects and did not tease apart the roles of cumulative exposure of suicide and prolonged bereavement in experiencing global distress. CONCLUSION: The SEES has clinical utility in determining psychological distress in bereaved individuals and is recommended for use in therapeutic settings.

Occupational Suicide Exposure and Impact on Mental Health: Examining Differences Across Helping Professions.

The purpose of the current study was to examine the relationship of suicide exposure with depression, anxiety, and post-traumatic stress disorder across three occupational groups likely to be exposed to suicide (i.e., first responders, crisis workers, mental health professionals). An online survey was completed by 1,048 participants. Results indicated that first responders, mental health professionals, and crisis workers were all exposed to suicide in the routine course of their occupation. Exposure to suicide significantly impacted mental health, specifically on depression, anxiety, and PTSD symptoms. The level of exposure to suicide was associated with higher levels of depression, anxiety, and PTSD.

Suicide Exposure in Crisis Workers.

Background: Crisis workers provide services to individuals who are in acute distress. There is no research examining personal and occupational exposure to suicide in these workers. Aims: We aimed to examine the prevalence of personal, occupational, and colleague suicide exposure among crisis workers, the mental health outcomes associated with suicide exposures, and perceived professional preparedness for client suicide. Method: Crisis workers (n = 115) completed an online survey assessing suicide exposure, depression, anxiety, and posttraumatic stress disorder. Results: Over a third of participants (33.9%, n = 37) reported that they had lost at least one client to suicide, with an average of 2.30 clients (SD = 4.47) lost to suicide. Over three quarters (77.1%, n = 81) of study participants reported they had experienced at least one personal loss to suicide. Those who perceived their relationship to the personal suicide as close or very close had significantly greater PTSD symptoms (M = 3.29, SD = 2.23) than those who perceived their relationship as not at all close, not close, or somewhat close (M = 1.38, SD = 1.69), t(20) = -2.10, p = .049. Limitations: Snowball sampling is the study's main limitation. Conclusion: The current study demonstrates that a substantial percentage of crisis workers are exposed to suicide and additional research is needed to determine how exposures impact practice and personal symptoms in this population.

An Examination of Suicide Exposure and Fearlessness about Death on Suicide Risk among Active Duty Service Members, Veterans, and Civilians.

Suicide exposure is associated with an increased risk for suicide. There is limited research on the mechanisms that increase this risk. This study aims to: (1) compare suicide exposure and associated variables in veteran, active duty, and civilian participants, (2) examine the extent to which fearlessness about death and suicide risk factors differ as a function of group membership and suicide exposure, and (3) determine the degree to which relationship to the decedent, perceived closeness, and reported impact of the death are associated with fearlessness about death and suicide-related outcomes. 1,533 participants were included, of whom 48% of active duty service members, 65% of veterans, and 58% of civilians reported knowing someone who died by suicide. A series of regressions were conducted. There were group differences by military service on the suicide exposure variables. Furthermore, there were significant main effects for military service group and suicide exposure on the outcome variables. In general, civilians reported greater suicide risk and active duty service members reported greater fearlessness about death. Fearlessness about death mediated the associations between perceived closeness and a history of suicide attempts. The loss of a military colleague to suicide was found to be unique and distinguishable from other important relationships. Results suggest the need to consider suicide exposure and closeness as salient variables associated with fearlessness about death and suicide risk factors. Inquiring about suicide exposure, closeness to the decedent, fearlessness about death, and beyond familial losses to suicide may indicate important avenues of intervention.

Pulling Together - The Protective Role of Belongingness for Depression, Suicidal Ideation and Behavior Among Suicide-Bereaved Individuals.

Background: While belongingness has frequently been investigated in the general population as an antidote to experiencing depression, suicidal thoughts, and suicidal behavior, it has rarely been evaluated as a protective factor among individuals bereaved by suicide. Aims: We examined whether perceived belongingness could moderate the differences between suicide-bereaved, suicide-exposed, and nonexposed respondents regarding depression, suicide ideation, and suicide attempts. Method: We conducted an online survey of the adult Israeli population (N = 806), with 203 suicide-bereaved, 266 suicide-exposed, and 377 nonexposed respondents. Participants completed several questionnaires tapping depression and suicidality as well as perceived belongingness levels. Results: Individuals bereaved by suicide reported the highest levels of depression, suicide ideation, and suicide attempts in comparison with suicide-exposed and nonexposed individuals. However, belongingness was found to moderate these distinctions concerning suicide ideation and suicide attempts. Limitations: Belongingness was assessed by only a single question, and the online survey suffered from a relatively high nonresponse rate. Conclusion: Our results suggest that belongingness may act as a potent antidote to the adverse mental health consequences among individuals bereaved by suicide. Clinicians should accord adequate attention to fostering social connectedness among their clients bereaved by suicide.

Profiling Suicide Exposure Risk Factors for Psychological Distress: An Empirical Test of the Proposed Continuum of Survivorship Model.

The Continuum of Survivorship proposes a way in which individuals may experience the suicide death of someone known to them along a continuum from being exposed to the death through to long-term bereavement. The present study provides a first empirical testing of the proposed model in an Australian community sample exposed to suicide. Using a Latent Profile Analysis, we tested the suicide exposure risk factors (time since death, frequency of pre-death contact, reported closeness, and perceived impact) to map to the Continuum of Survivorship model. Results revealed identification of five profiles, with four ranging from suicide exposed to suicide bereaved long-term broadly aligning with the proposed model, with one further profile being identified that represented a discordant profile of low closeness and high impact of suicide exposure. Our findings demonstrate that while the proposed model is useful to better understand the psychological distress related to exposure to suicide, it cannot be used as "shorthand" for identifying those who will be most distressed, nor those who may most likely need additional support following a suicide death. Implications and future research directions are discussed.

Rates of exposure to natural, accidental, and suicide deaths.

OBJECTIVE: We expand upon previous research examining the prevalence of exposure to suicide deaths by comparing these to natural and accidental deaths. Furthermore, we examine whether participants are more apt to lie about the cause of death for a suicide than for an accidental or natural death. METHOD: The sample consisted of 1,430 respondents who were recruited via Amazon's Mechanical Turk to complete an online study. Participants completed measures to assess exposure to death, causes of death, and willingness to disclose the cause of death to others. RESULTS: Nearly all respondents (94.5%) had been exposed to a natural death, and most of our sample (63.2%) reported exposure to a suicide death. Among those affected by all three causes of death, RANOVA analysis also indicated that people lied about cause of suicide death to significantly more people than accidental or natural. CONCLUSIONS: Overall, the current study presents updated prevalence rates of exposure to various types of death and replicates previous findings of a decrease in willingness to disclose suicides when compared with other causes of death.

Workplace exposure to suicide among Australian mental health workers: A mixed-methods study.

Workplace exposure to suicide attempts and deaths has been widely recognized as an occupational hazard for mental health and social care workers, including mental health nurses. Research consistently demonstrates the adverse impact on professionals. This paper explores the results of an online survey examining suicide exposure and impact. Of the 3010 Australian adult participants who identified exposure to suicide attempts and/or deaths in a larger study, 130 indicated that the most impactful suicide attempt and/or death exposure was that of a client or service user. While distress levels were relatively low among participants with workplace exposure, the qualitative content from 53 participants provides illumination into this experience. Themes that emerged in the qualitative responses include impact on the professional, organization response, and lack of adequate resources and supports to prevent suicide. Previous research has examined the impact of suicide exposure among professionals specifically, but this is the first known study of participants in a community sample who identified the most impactful suicide attempt or death exposure they had experienced was that of a client in a mental health setting. Workplace exposure among mental health workers is common and can have both deleterious and positive effects. Bereavement focused outcomes, where the loss of an attachment relationship is the focus, does not capture the full range of experiences in workplace exposure. Systemic issues in mental health care contribute to further distress among exposed workers, and this requires additional investigation and response.

Sex Differences in Mental Health Outcomes of Suicide Exposure.

Past research has robustly supported differences in prevalence and severity of mental health disorders between males and females in general. Less is known in regards to how suicide exposure and related factors may be associated with these mental health outcomes in men and women. This study seeks to explore similarities and differences between suicide exposure experiences of males and females in regards to number of exposures to suicide, relationships to the deceased, perceptions of closeness to the deceased, and related mental health correlates. Clinical applications are then discussed. A dual-frame, random digit dial survey was utilized to identify sex-differentiated demographic and suicide-related factors associated with these correlates in a statewide sample of 1,736 adults. t-tests revealed statistically higher depression, anxiety, and prolonged grief mean scores for suicide-exposed females; statistically higher suicide ideation levels in suicide-exposed males, and no statistical differences between sexes in PTSD scores. Logistic regression analyses provided an in-depth look at similarities and differences in risk and protective factors between male and female outcomes with perceptions of closeness and kinship levels as most salient risk factors. Cross-sectional design limits assertions of causality and retrospective nature of study may introduce recall bias. Males and females may differ in mental health impacts after suicide exposure. Implications for future research, prevention program planning, and bereavement counseling approaches are discussed.

The Relationship Between Suicide-Related Exposure and Personal History of Suicidal Behavior in Transgender and Gender-Diverse Veterans.

Purpose: Transgender and gender-diverse (TGD) veterans experience a high prevalence of suicidal thoughts and behaviors (STBs). Within the general U.S. population, suicide-related exposure is an identified risk factor for STBs. This study explores the impact of suicide-related exposure in TGD veterans. Methods: Self-identified TGD veterans (n = 195) completed an online cross-sectional survey that included self-report measures of suicide-related exposures, experience of past-year suicidal ideation (SI), and history of suicide attempt (SA)(s). Results: A considerable number of respondents indicated that they were close to someone who attempted suicide (40.5%) or died by suicide (32.8%). When asked about the gender identity of decedents, 6.7% indicated that at least one individual was TGD and 18.5% indicated knowing at least one close TGD individual who attempted suicide. Exposure to SA and to suicide were both independently related to a history of at least one SA. Neither type of suicide exposure was related to past year SI. Participants exposed to the SA of a close TGD individual were more likely to report past-year SI than those not exposed. Conclusion: TGD veterans may be more vulnerable to suicidal behaviors if suicide-related exposures are experienced. Public health suicide prevention initiatives, both inside and outside of the TGD community, may help to reduce suicide in these veterans.

Providing support following exposure to suicide: A mixed method study.

Exposure to suicide and the associated impacts for those left behind can be long lasting and traumatic. Literature has predominantly examined the experience of suicide and impact from the perspective of those closest to the deceased-with studies primarily focused on kin relationships. Appropriate and timely support delivered by skilled professionals, through the provision of postvention support, has been suggested as a way to reduce morbidity and mortality associated with exposure to suicide. The evidence regarding what support, for whom, and the timing of support is scarce. As an extension of this scarcity, there is minimal research examining the ways in which provision of this postvention (that is, support following exposure to suicide) support impacts workers. This paper explores service use data gathered to evaluate a nation-wide Australian suicide postvention service, in conjunction with qualitative data from those providing postvention support to those exposed to suicide to understand who accesses support and the impact of providing such support on service providers. Postvention workers provide insight into the demands of responding to suicide, the pressure of being on call, and the ways in which they are able to maintain their well-being through external supervision.

Openness to firearm storage safety as a suicide prevention tool among those exposed to suicide: The role of perceived closeness to the suicide decedent.

BACKGROUND: Exposure to suicide and closeness to a suicide decedent may be relevant to means safety, especially in firearm owners. This study examines how such factors are associated with firearm owners' current firearm storage methods and openness to changing storage methods. METHOD: 300 firearm owners completed a survey on Amazon's Mechanical Turk program; 176 participants reported being exposed to suicide. Perceived closeness was rated as Not at all close, Close, or Extremely Close. RESULTS: Those exposed to suicide were more open to secure storage and temporarily storing the firearm with a trusted individual to prevent someone else's suicide. Those close to the suicide decedent were more likely to use secure storage practices, more open to using secure storage methods to prevent their own and someone else's suicide, and had a higher degree of storage methods in place compared to those not close to the decedent. LIMITATIONS: The sample may not be representative of all American firearm owners exposed to suicide. CONCLUSIONS: Being close to a suicide decedent may influence firearm owners' current storage practices and openness to changing storage methods. Such individuals may better relate to the suicide decedent and realize the significance of using secure storage methods to prevent suicide.

Evaluation of two web-based interventions in reducing the stigma of suicide.

Suicide is more highly stigmatized than most mental health conditions; however, no interventions have aimed to modify the stigma of suicide in the general population. This study tested the efficacy of two brief web-based interventions-psychoeducation and interpersonal exposure-in reducing suicide-related stigma in a student/community sample. A sample of 266 adults completed baseline measures of suicide-related stigma, were randomized into one of three conditions (psychoeducation, interpersonal exposure, control), in which they browsed an assigned website for twenty minutes, and completed post-intervention and one-month follow-up stigma measures. Results indicated that the two interventions were more efficacious than the control in reducing suicide-related stigma; this effect was accentuated for individuals without prior exposure to suicide. Although future research is needed to understand the mechanisms of change and the generalizability of these findings, it is possible that web-based interventions could be a cost- and time-effective avenue of targeting the widespread stigma of suicide.

Exposure to suicide and suicide bereavement among women firefighters: Associated suicidality and psychiatric symptoms.

OBJECTIVE: To examine experiences with suicide exposure and bereavement among women firefighters. METHODS: Women firefighters (N = 266, Mage  = 37.64y) completed self-report measures assessing their experiences with suicide exposure, history of suicidality, current psychiatric symptoms, and suicide risk. RESULTS: Three-fourths (74.4%) of participants reported knowing someone who had died by suicide; of these participants, 31.3% reported losing a fellow firefighter to suicide. Exposure to suicide during one's firefighting career was associated with more severe psychiatric symptoms and suicide risk. Greater impact of a suicide death was significantly associated with more severe current suicide risk, even after controlling for prior suicidality and other psychiatric symptoms. CONCLUSIONS: Women firefighters exposed to suicide during their careers may experience more severe psychiatric symptoms and increased suicide risk as compared to their counterparts without this exposure. In particular, women firefighters who are more severely impacted by a suicide loss may be at increased suicide risk.

Exposure to suicide in the family: Suicide risk and psychache in individuals who have lost a family member by suicide.

OBJECTIVE: The aim of the present study was to compare a sample of Portuguese individuals exposed to suicide in their families with a control group, for lifetime suicidality. This study also evaluated the incremental value of psychache (i.e., extreme psychological pain) in determining suicide risk beyond the contribution associated with having lost a family member by suicide. METHOD: A total of 225 community adults participated. Two groups were defined: a group exposed to suicide (n = 53), and a control group (n = 172). RESULTS: Results demonstrated that groups did significantly differ on the total score of the Suicide Behaviors Questionnaire-Revised (SBQ-R), on the four individual SBQ-R items, and on psychache. Results from a hierarchical multiple regression analysis demonstrated that having lost a family member by suicide and the construct of psychache each provided a significant unique contribution to explaining variance in suicide risk. The interaction between group membership and psychache also provided a further enhancement to the statistical prediction of suicide risk. CONCLUSION: Findings are discussed with regard to their implications for clinical intervention and postvention.