"Psychotherapy in the Pressure Cooker": A Systematic Review of Single Session Psychosocial Interventions in Emergency Departments for Suicide-related Thoughts or Behaviors.

OBJECTIVES: Up to 20% of individuals who die by suicide have visited an emergency department (ED) within 4 weeks of their death. Limited guidance is available regarding the modification of clinical outcomes following a psychosocial intervention in the ED for pediatric and adult populations. METHODS: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted to identify studies focused on single-session psychosocial interventions for pediatric and adult patients experiencing suicide-related thoughts or behaviors (SRTB) in the ED. Two reviewers independently screened articles identified using the key terms suicide/self-harm, emergency department, and interview. Medline, PubMed, Embase, PsycINFO, CINAHL, and CENTRAL were searched from inception to August 2018. RESULTS: After screening 3234 abstracts, 29 articles were selected for full-text review and 14 articles, representing 8 distinct studies (N=782), were included. A high level of heterogeneity was present in the included articles, with 7 randomized-controlled trials, 2 nonrandomized-controlled trials, 2 cohort studies, 2 observational studies, and 1 feasibility study. Most of the included studies focused on adolescents (6 articles) or military veterans (7 articles). Strong statistical evidence of ED interventions improving outpatient service linkage was supported (χ2: 81.80, P<0.0001, 7 studies). CONCLUSIONS: The findings of this study suggested promising outcomes for patients presenting to the ED with SRTB who receive a single-session psychosocial intervention. All of the studies that measured such outcomes found significantly increased follow-up care in the intervention arm. Further research is needed to strengthen the evidence base, provide better patient representation, and improve our understanding of the mechanisms by which the psychosocial intervention for SRTB in the ED ameliorates patient outcomes (CRD42020156496).

Resting-state neural mechanisms of capability for suicide and their interaction with pain - A CAN-BIND-05 Study.

BACKGROUND: Suicidal ideation is highly prevalent in Major Depressive Disorder (MDD). However, the factors determining who will transition from ideation to attempt are not established. Emerging research points to suicide capability (SC), which reflects fearlessness of death and increased pain tolerance, as a construct mediating this transition. This Canadian Biomarker Integration Network in Depression study (CANBIND-5) aimed to identify the neural basis of SC and its interaction with pain as a marker of suicide attempt. METHODS: MDD patients (n = 20) with suicide risk and healthy controls (n = 21) completed a self-report SC scale and a cold pressor task measuring pain threshold, tolerance, endurance, and intensity at threshold and tolerance. All participants underwent a resting-state brain scan and functional connectivity was examined for 4 regions: anterior insula (aIC), posterior insula (pIC), anterior mid-cingulate cortex (aMCC) and subgenual anterior cingulate cortex (sgACC). RESULTS: In MDD, SC correlated positively with pain endurance and negatively with threshold intensity. Furthermore, SC correlated with the connectivity of aIC to the supramarginal gyrus, pIC to the paracingulate gyrus, aMCC to the paracingulate gyrus, and sgACC to the dorsolateral prefrontal cortex. These correlations were stronger in MDD compared to controls. Only threshold intensity mediated the correlation between SC and connectivity strength. LIMITATIONS: Resting-state scans provided an indirect assessment of SC and the pain network. CONCLUSIONS: These findings highlight point to a neural network underlying SC that is associated with pain processing. This supports the potential clinical utility of pain response measurement as a method to investigate markers of suicide risk.

Gatekeeper training for friends and family of individuals at risk of suicide: A systematic review.

AIMS: Gatekeeper training (GKT) is an important suicide prevention strategy. Studies have evaluated the effectiveness of GKT in different populations, often neglecting family and friends who play a vital role in caring for people with suicide risk. This review evaluated GKT programs targeting family and friends to determine their effectiveness in this specific population. METHODS: Academic databases were searched for studies on GKT programs. Programs involving family and friends caring for people with suicide risk were assessed for any impact on knowledge, self-efficacy, attitudes, and suicide prevention skills. RESULTS: Seventeen studies were reviewed. GKT showed significant gains on outcomes of interest. Three studies targeted family and friends, with one involving them in program creation and conduction and another adjusting the program after their input. CONCLUSIONS: GKT programs have potentially positive effects on family and friends caring for people with suicide risk. Few programs address the specific needs of this group, and programs adapted specifically for them are scarce. Future program development recommendations are discussed.

Alexithymia in People With Recurrent Suicide Attempts.

Background: Alexithymia, an inability to identify or describe emotions, is associated with suicidality yet the correlation with single or repeated suicide attempts is less clear. Aims: We aimed to assess the modifiability of alexithymia following a group psychosocial intervention focused on improving emotional literacy in those with a history of recurrent suicide attempts (RSA). Method: A total of 169 participants with self-reported RSA completed pre- and postgroup assessments of a 20-week group therapy intervention. Questionnaires assessed alexithymia, depression, impulsivity, and hopelessness; the Toronto Alexithymia Scale (TAS-20) was the primary outcome. Data were analyzed using multiple imputation. Results: Participants had on average 7.8 lifetime suicide attempts, 73% were female, and 16.6% had a >13-point reduction in TAS-20 scores after 20 weeks. Directed acyclic graph (DAG) analysis demonstrated significant relationships between alexithymia, depression, hopelessness, problem-solving, and satisfaction with life. Age of onset of suicidality was the only factor predictive of postintervention TAS-20 score in univariate linear regression. Limitations: The study limitations were its sample size, insufficient resources, and missing data. Conclusion: A change in TAS scores indicated that alexithymia can be a modifiable treatment target. Being able to identify and describe feelings may lead to improvement in depression, hopelessness, problem-solving, and satisfaction with life in this population.

Alexithymia and self-harm: A review of nonsuicidal self-injury, suicidal ideation, and suicide attempts.

INTRODUCTION: Suicide attempts are a significant global public health concern. Research into non-traditional factors, such as the presence of alexithymia, may shed light on the prediction of suicidal behaviours, which can aid intervention and prevention strategies. To ascertain whether alexithymia is a unique risk factor for suicide attempts, this article reviews the evidence on alexithymia related to suicidal ideation, attempts, and non-suicidal self-injury (NSSI). METHODS: A literature search was conducted for original articles examining the general and psychiatric populations. RESULTS: There is consistent evidence linking alexithymia with suicidal ideation and NSSI, but inconsistent evidence linking it to suicide attempts. CONCLUSION: The relationship between alexithymia and suicidality seems to differ based on whether the research focuses on suicidal ideation, suicide attempts, or NSSI. The relationship between alexithymia and suicidality can be understood within the context of multiple code theory and childhood trauma. Future research should explore the whether alexithymia can reliably distinguish between those with a single attempt and those with multiple suicide attempts as well as alexithymia levels pre- and post-intervention with suicide-related behavior as outcomes in treatment studies.

Client Evaluation of an Interprofessional Urgent Mental Health Care Program.

Urgent psychiatric care programs are hospital- or community-based outpatient services that expedite access to mental health care for high-risk individuals, yet these services are rarely evaluated from the perspectives of clients. A qualitative thematic analysis of 13 participant interviews of a psychiatric urgent care program allowed researchers to address this gap. Communication, responsiveness, and continuous availability were identified as critical in helping clients articulate their perceived self-stigma, needs, and preferences. A well-coordinated interprofessional team proactively reaching out to facilitate client engagement in care was noted as helpful. Successful transitions to ongoing care partially mitigated the frustration of a time-limited program. Researchers found that an interprofessional team enabled timely and ongoing contact, assistance with system navigation, and the ability to meet a broader range of urgent client needs, including addressing social determinants of health. Recommendations to improve the service included extended hours, improved access to psychotherapy, and integrated telephone crisis support. [Journal of Psychosocial Nursing and Mental Health Services, 57(3), 17-24.].

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts.

OBJECTIVE: This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process. DESIGN: Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants. METHODS: In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data. RESULTS: Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying. CONCLUSION: The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly. PRACTITIONER POINTS: Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

The effects of suicide ideation assessments on urges to self-harm and suicide.

BACKGROUND: Participants' safety is the primary concern when conducting research with suicidal or potentially suicidal participants. The presence of suicide risk is often an exclusion criterion for research participants. Subsequently, few studies have examined the effects of research assessments on study participants' suicidality. AIMS: The purpose of this research was to examine the patterns of postassessment changes in self-harm and suicide urges of study participants who were recently discharged from an inpatient psychiatric service. METHOD: Study participants (N = 120) were recruited from patients with a lifetime history of suicidal behavior admitted with current suicidal ideation or suicide attempt to an inpatient psychiatric service and/or a crisis stabilization unit. Participants were assessed for suicidal ideation with the Suicide Ideation Scale at 1, 3, and 6 months following their discharge from hospital. The risk assessment protocol was administered at the start and at the end of each of the study follow-up assessments. RESULTS: Changes in self-harm and suicide urges following study assessments were small, infrequent, and were most likely to reflect a decrease in suicidality. Similarly, participants rarely reported worsening self-control over suicidal urges, and when they did, the effect was minimal. By the end of the 6-month follow-up period, increases in self-harm and suicidal urges postassessment were not seen. CONCLUSION: The inclusion of suicidal participants in research interviews rarely increased suicide risk. Research involving suicidal individuals is possible when study protocols are well planned and executed by trained assessors and clinicians who are able to identify participants at risk and provide intervention if necessary. The few participants that required intervention had high levels of suicide ideation and behavior at baseline and almost all reported symptoms of posttraumatic stress disorder. Further study is needed to better characterize this subgroup of participants.

Help-seeking in transit workers exposed to acute psychological trauma: a qualitative analysis.

BACKGROUND: Traumatic events often occur in workplace settings and can lead to stress reactions such as Post-Traumatic Stress Disorder (PTSD). One such workplace is the transportation industry, where employees are often exposed to trauma. However, extant research shows that a considerable proportion of people with PTSD do not seek specialty mental health treatment. OBJECTIVE: In this qualitative study, we sought to better understand the experience of a traumatic event at work and the barriers and motivating factors for seeking mental health treatment. PARTICIPANTS: Twenty-nine Toronto Transit Commission (TTC) employees participated in a one-on-one interview, 18 soon after the traumatic event and 11 after entering a specialized treatment program. METHODS: Semi-structured, one-on-one interviews were conducting using qualitative description and analyzed using content analysis. RESULTS: Participants described emotional responses after the trauma such as guilt, anger, disbelief as particularly difficult, and explained that barriers to seeking help included the overwhelming amount and timing of paperwork related to the incident as well as negative interactions with management. Motivating factors included family and peer support, as well as financial and emotional issues which persuaded some to seek help. CONCLUSIONS: Seeking treatment is a multifactorial process. Implications and recommendations for the organization are discussed.

An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder.

This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.

Understanding the risks of recent discharge: the phenomenological experiences: trying to survive while living under the proverbial "Sword of Damocles".

BACKGROUND: Evidence indicates that people whose mental health problems lead them to require psychiatric hospitalization are at a significantly increased risk of suicide, and the period of time immediately following discharge after such hospitalizations appears to be a particularly high-risk time. AIMS: This paper reports on phenomenological findings from a federally funded, mixed-methods study that sought to better understand the observed increased risk for suicide following discharge from an inpatient psychiatric service. METHODS: A purposive sample of 20 recently discharged former suicidal inpatients was obtained. Data were collected from the participants in hermeneutic interviews lasting between 1 h and 2 h and analyzed according to van Manen's (1997) interpretation of hermeneutic phenomenology. RESULTS: Two key themes were induced: "Existential Angst at the Prospect of Discharge" and "Trying to Survive While Living Under the Proverbial 'Sword of Damocles'." Each of these was comprised of five themes with the second key theme - the focus of this paper - encompassing the following: "Needing Postdischarge Support," "Feeling Lost, Uncertain and Disorientated," "Feeling Alone and Isolated," "Suicide Remains an Option," and "Engaging in Soothing, Comforting Behaviors." CONCLUSIONS: The authors conclude that early exploration of and reconciling patients' expectations regarding inpatient care for their suicidality would appear to be an empirically based intervention that could diminish the postdischarge risk for further suicide attempts.

Prospective study of risk factors for increased suicide ideation and behavior following recent discharge.

OBJECTIVE: The purpose of this study is to prospectively examine the association between predictors from the three thematic areas - suicidality, personal risk factors and patient care factors - and the occurrence of postdischarge suicide ideation and behavior in recently discharged patients. METHODS: The design is a prospective cohort study of all patients admitted to an inner city inpatient psychiatric service with a lifetime history of suicidal behavior and current suicidal ideation. Predictors of suicide ideation at 1, 3 and 6 months following discharge and suicide behavior over the 6 months of follow-up were examined. RESULTS: The incidence of death by suicide during the study period was 3.3% [95% confidence interval (CI)=0.9%-8.3%], and 39.4% (95% CI=30.0%-49.5%) of the surviving participants reported self-injury or suicide attempts within 6 months of hospital discharge. Risk factors such as recent suicide attempts, levels of depression, hopelessness and impulsivity were predictive of increased suicide ideation or behavior after discharge from the inpatient service. CONCLUSIONS: The high risk of suicide ideation, suicide attempts and suicide demonstrated in these recently discharged patients supports the need to develop selective prevention strategies.

Understanding the risks of recent discharge: the phenomenological lived experiences--"existential angst at the prospect of discharge".

BACKGROUND: Evidence indicates that people whose mental health problems lead them to require psychiatric hospitalization are at a significantly increased risk of suicide, and that the time immediately following discharge after such hospitalizations is a particularly high-risk time. AIMS: This paper reports on phenomenological findings from a federally funded, mixed-methods study that sought to better understand the observed increased risk for suicide following discharge from an inpatient psychiatric service. METHODS: A purposive sample of 20 recently discharged former suicidal inpatients was obtained. Data were collected in hermeneutic interviews lasting between 1 h and 2 h and analyzed according to van (1997) interpretation of hermeneutic phenomenology. RESULTS: Two key themes, "existential angst at the prospect of discharge" and "trying to survive while living under the proverbial 'sword of Damocles'" were induced. Each of these was comprised of five themes with the first key theme (which is the focus of this paper) encompassing the following: "Feeling scared, anxious, fearful and/or stressed," "Preparedness," "Leaving the place of safety," "Duality and ambivalence," and "Feel like a burden." CONCLUSIONS: Early exploration of and reconciling of patients' expectations regarding inpatient care for their suicidality would be empirically based interventions that could diminish the postdischarge risk for further suicide attempts.

A pilot study in suicide intervention training using a group intervention for patients with recurrent suicide attempts.

OBJECTIVE: This article describes psychiatric trainees' reflections regarding their participation in a psychosocial/psychoeducational group intervention for individuals with recurrent suicide attempts. METHODS: Fourteen psychiatric residents who completed at least one 20-week intervention cycle were given a 15-item questionnaire which consisted of 12 reflective statements rated on a 5-point Likert scale. The questionnaire assessed their perceptions of the training experience and subsequent comfort in managing recurrently suicidal patients. RESULTS: Thirteen residents (93%) completed the survey. Following the training experience, nearly all residents (85%) endorsed feeling more comfortable managing patients with recurrent suicide attempts. Training was perceived as having clinical and educational value and an impact on general practice. CONCLUSION: Although the intervention was associated with changes in psychiatric residents' perceived comfort in managing patients with recurrent suicide attempts, more rigorous research examining the effects of the intervention on suicidology training is needed.

Moving from full-time healing work to paid employment: challenges and celebrations.

BACKGROUND: The experiences and barriers associated with the return to paid employment following healing from recurrent suicide attempts related to mental illness have not been addressed in the literature to date. METHOD: This paper is a collaborative case study between graduates (experts by experience) and facilitators of a psychosocial/psychoeducational group for people with recurrent suicide attempts. The journeys taken by the experts by experience are explored through thematic narrative analysis. FINDINGS/RESULTS: Issues of stigma, disclosure, accommodations, maintaining wellness and coming to re-define a sense of self were consistent themes found throughout all narratives. CONCLUSIONS: The paper identified key areas of challenge and celebration, suggesting the need for enhanced support from health care providers, workplace managers, supervisors and colleagues for successful transitions into the workplace.

The perspectives of young adults on recovery from repeated suicide-related behavior.

BACKGROUND: This qualitative study sought to develop an understanding of how young adults between the ages of 18-25 years, who have a history of two or more suicide attempts, transition away from high-risk suicide-related behaviors. AIMS: To understand the transition to safer behaviors and to provide clinical suggestions for those who provide care to this population. METHODS: Sixteen young adults under the age of 25 years, who had completed at least one cycle of intervention for people with repeated suicide attempts, participated in this qualitative, grounded theory study. RESULTS: The young adults described a pathway that included three major elements: (a) "living to die", (b) ambivalence and tipping/turning points, and (c) a process of recovery that included small steps or phases (pockets of recovery) toward life. The journey was not always experienced as steady movement forward, and the potential for relapse either in the young people's behavior or their wish to engage in their relationship with death could ebb and flow. CONCLUSIONS: Clinicians need to be aware that the struggle to live is a process involving a fluid pathway moving between three key elements.

Repeat substance-using suicidal clients-how can we be helpful?

Care of clients with mental health and substance abuse problems accounts for a significant proportion of all emergency department (ED) visits. This qualitative research project sought to understand the ED experiences of men with a history of suicidal behavior and substance abuse and those of the emergency personnel who work with them. Understanding the unique positions of care providers and this client population in the ED setting can assist the social worker to advocate for this highly vulnerable group of clients and to assist an interprofessional team to develop better crisis interventions.

Reducing potential risk factors for suicide-related behavior with a group intervention for clients with recurrent suicide-related behavior.

BACKGROUND: This paper reports the results of a pilot study of a 20-week outpatient Psychosocial/Psychoeducational Intervention for Persons with Recurrent Suicide Attempts (PISA) targeting potential risk factors and areas of deficit, including cognitive, affective, and impulsivity known to characterize persons with recurrent suicide-related behavior. METHODS: One hundred sixty-three persons completed the 20-week intervention. Self-report questionnaires related to psychological deficits and risk factors associated with suicide-related behavior were given to participants before and after the intervention. Descriptive and paired t tests were performed using SPSS 15. RESULTS: This pilot study demonstrated that a 20-week group intervention led to significant pregroup and postgroup reductions in the risk factors associated with suicide-related behavior. Risk factors included cognitive factors: Beck Hopelessness Scale (P=.006), Satisfaction With Life Scale (P=.001), Problem Solving Inventory (P=.008); affective factors: Beck Depression Inventory (P=.018), Toronto Alexithymia Scale (P=.001); and impulsivity factors: Barratt Impulsivity Scale (P=.034). CONCLUSIONS: Findings in this pilot study suggest that participants in this short-term intervention report changes in identified risk factors and psychological deficits. These modest changes may be an important first step that facilitates persons at high-risk for suicide to access additional mental health services.

Experiences of substance-using suicidal males who present frequently to the emergency department.

OBJECTIVE: This qualitative study investigated the repeated use of the emergency department (ED) by men with a history of suicidal behaviour and substance abuse to understand the needs and barriers to care for this high-risk group. Identification of common themes from interviews with patients and health care workers can serve as a basis for improved ED-based interventions. METHODS: Using semistructured interviews, patients, ED staff and family physicians were asked about needs of the aformentioned group. Twenty-five patients were interviewed and completed questionnaires regarding their substance use, aggression, parasuicidal behaviour, alexithymia and childhood trauma. In addition, 27 staff members were interviewed. Interviews were tape-recorded, transcribed and qualitatively analyzed using an iterative coding process. RESULTS: Of the 25 patients, 23 (96%) had a mood or anxiety disorder and 18 (75%) had borderline personality disorder. One-half of the patients scored high and another quarter scored moderate on alexithymia testing. The ED was viewed as a last resort despite seeking help. Frustration was felt by both patients and staff regarding difficult communication, especially during an acute crisis. CONCLUSION: The ED plays an important role in the provision of care for men with recurrent suicidal behaviour and substance abuse. Some of the diagnoses and problems faced by these patients are beyond the purview of the ED; however, staff can identify mutual goals for crisis interventions, allow for frequent communication and seek to de-escalate situations through the validation of the stress patients are experiencing.