What is important to service users and staff when implementing suicide-focused psychological therapies for people with psychosis into mental health services?

Introduction: Suicide is a leading cause of death globally. People with psychosis are at increased risk of suicide death and up to half experience suicidal thoughts and/or engage in suicidal behaviors in their lifetime. Talking therapies can be effective in alleviating suicidal experiences. However, research is yet to be translated into practice, demonstrating a gap in service provision. The barriers and facilitators in therapy implementation require a thorough investigation including the perspectives of different stakeholders such as service users and mental health professionals. This study aimed to investigate stakeholders' (health professionals and service users) perspectives of implementing a suicide-focused psychological therapy for people experiencing psychosis in mental health services. Methods: Face-to-face, semi-structured interviews with 20 healthcare professionals and 18 service users were conducted. Interviews were audio recorded and transcribed verbatim. Data were analyzed and managed using reflexive thematic analysis and NVivo software. Results: For suicide-focused therapy to be successfully implemented in services for people with psychosis, there are four key aspects that need to be considered: (i) Creating safe spaces to be understood; (ii) Gaining a voice; (iii) Accessing therapy at the right time; and (iv) Ensuring a straightforward pathway to accessing therapy. Discussion: Whilst all stakeholders viewed a suicide-focused therapy as valuable for people experiencing psychosis, they also recognize that enabling successful implementation of such interventions will require additional training, flexibility, and resources to existing services.

Acceptability of a novel suicide prevention psychological therapy for people who experience non-affective psychosis.

OBJECTIVES: Suicide is a leading cause of death worldwide. People experiencing psychosis are at increased risk of death by suicide. Talking therapies can alleviate suicidal thoughts, plans, and attempts. Therapies need to also be acceptable to recipients. The aim of this study was to investigate the views on psychological therapy for people experiencing psychosis and suicidality using the Theoretical Framework of Acceptability. DESIGN: Qualitative interview study. METHODS: Participants were recruited from a randomised controlled trial comparing suicide prevention psychological therapy with treatment as usual. Individuals had a diagnosis of non-affective psychosis and experience of suicidal thoughts, plans and/or attempts. To assess the acceptability of the therapy, semi-structured interviews were conducted with 20 participants randomised to receive therapy. Data were deductively analysed using an adaptation of the Theoretical Framework of Acceptability. RESULTS: Interviews (Mean = 45 min) were conducted and audio recorded with 21 participants. Data were organised into six themes: 1. Affective attitude, 2. Burden, 3. Alliance, 4. Intervention coherence, 5. Perceived effectiveness, and 6. Self-efficacy. There was no evidence of issues relating to domains of ethicality and opportunity costs associated with receiving therapy. CONCLUSIONS: Talking about suicide was difficult and, at times, distressing, but it was perceived to be useful for understanding experiences. To be acceptable, it is important for therapists to ensure that clients' understanding of therapy aligns with expectations of effectiveness and to invest in building strong therapeutic alliances. Future research will benefit from examining therapists' experiences of delivering therapy through different modes (e.g. online, telephone).

Directly or Indirectly? The Role of Social Support in the Psychological Pathways Underlying Suicidal Ideation in People with Bipolar Disorder.

Contemporary theories of suicide, such as the Schematic Appraisals Model (SAMS), hypothesize that negative perceptions of social support are implicated in the pathways to suicidal experiences. The SAMS predicts that perceived social support influences suicidal ideation through appraisals of defeat and entrapment. However, such pathways have not been investigated in people who have bipolar disorder. This prospective four-month study tested the influence of perceived social support on later suicidal ideation via changes in defeat, entrapment, and hopelessness, in a sample of eighty euthymic participants with bipolar disorder (N = 62 at follow-up). Linear regression models tested the extent to which perceived social support at baseline predicted changes in suicidal ideation at four months directly and indirectly via changes in defeat, entrapment, and hopelessness. Perceived social support did not directly predict changes in suicidal ideation, but there was a significant indirect mediational pathway between perceived social support at baseline and changes in suicidal ideation over time, via changes in defeat, entrapment and hopelessness, supporting the SAMS. Psychological interventions which target negative perceptions of social support early, in tandem with addressing defeat, entrapment, and hopelessness over time, present a potentially effective approach to counter suicidal ideation in people who experience bipolar disorder.

Psychological Resilience to Suicidal Experiences in People with Non-Affective Psychosis: A Position Paper.

It is important to understand the psychological factors which underpin pathways to suicidal experiences. It is equally as important to understand how people develop and maintain resilience to such psychological factors implicated in suicidal experiences. Exploring optimal routes to gaining this understanding of resilience to suicidal thoughts and acts in people with severe mental health problems, specifically non-affective psychosis, was the overarching aim of this position paper. There are five central suggestions: 1. investigating resilience to suicidal experiences has been somewhat over-looked, especially in those with severe mental health problems such as schizophrenia; 2. it appears maximally enlightening to use convergent qualitative, quantitative and mixed research methods to develop a comprehensive understanding of resilience to suicide; 3. relatedly, involving experts-by-experience (consumers) in suicide research in general is vital, and this includes research endeavours with a focus on resilience to suicide; 4. evidence-based models of resilience which hold the most promise appear to be buffering, recovery and maintenance approaches; and 5. there is vast potential for contemporary psychological therapies to develop and scaffold work with clients centred on building and maintaining resilience to suicidal thoughts and acts based on different methodological and analytical approaches which involve both talking and non-talking approaches.

A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol.

BACKGROUND: Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. METHODS: The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. DISCUSSION: This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.

Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators.

BACKGROUND: Suicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards. AIMS: To investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial. METHOD: Transcribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis. RESULTS: Facilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs' negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice. CONCLUSIONS: Staff beliefs that 'suicide-talk' could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units.

Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: randomised controlled trial.

BACKGROUND: Suicidal behaviour is common in acute psychiatric wards resulting in distress, and burden for patients, carers and society. Although psychological therapies for suicidal behaviour are effective in out-patient settings, there is little research on their effectiveness for in-patients who are suicidal.AimsOur primary objective was to determine whether cognitive-behavioural suicide prevention therapy (CBSP) was feasible and acceptable, compared with treatment as usual (TAU) for in-patients who are suicidal. Secondary aims were to assess the impact of CBSP on suicidal thinking, behaviours, functioning, quality of life, service use, cost-effectiveness and psychological factors associated with suicide. METHOD: A single-blind pilot randomised controlled trial comparing TAU to TAU plus CBSP in in-patients in acute psychiatric wards who are suicidal (the Inpatient Suicide Intervention and Therapy Evaluation (INSITE) trial, trial registration: ISRCTN17890126). The intervention consisted of TAU plus up to 20 CBSP sessions, over 6 months continuing in the community following discharge. Participants were assessed at baseline and at 6 weeks and 6 months post-baseline. RESULTS: A total of 51 individuals were randomised (27 to TAU, 24 to TAU plus CBSP) of whom 37 were followed up at 6 months (19 in TAU, 18 in TAU plus CBSP). Engagement, attendance, safety and user feedback indicated that the addition of CBSP to TAU for in-patients who are acutely suicidal was feasible and acceptable while on in-patient wards and following discharge. Economic analysis suggests the intervention could be cost-effective.DiscussionPsychological therapy can be delivered safely to patients who are suicidal although modifications are required for this setting. Findings indicate a larger, definitive trial should be conducted.Declaration of interestThe trial was hosted by Greater Manchester Mental health NHS Trust (formerly, Manchester Mental Health and Social Care NHS Trust). The authors are affiliated to the University of Manchester, Greater Manchester Mental Health Foundation Trust, Lancashire Care NHS Foundation trust and the Manchester Academic Health Sciences Centre. Y.A. is a trustee for a North-West England branch of the charity Mind.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths.

BACKGROUND: Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention. METHODS: Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment. RESULTS: Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians. CONCLUSIONS: We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting. TRIAL REGISTRATION NUMBER: ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

Improving the quality of prison research: A qualitative study of ex-offender service user involvement in prison suicide prevention research.

BACKGROUND: Suicide is the leading cause of avoidable death in prisons worldwide and suicide prevention is an international priority. Consequently, there is an urgent need to develop evidence-based treatments. We conducted a randomized controlled trial of a novel suicide prevention psychological therapy for male prisoners. To promote ecological validity by addressing the "real-world" situation of suicidal prisoners, we involved a consultant group of ex-offenders with past experience of being suicidal during imprisonment. Service user involvement in prison research is challenging and underdeveloped. OBJECTIVE: We aimed to investigate the ex-offender service user consultants' experiences of being involved in the research. DESIGN: Individual qualitative interviews were conducted and analysed using an Interpretative Phenomenology Analysis (IPA) framework. SETTING/PARTICIPANTS: The study was conducted at a university in North England, UK, comprising four ex-offenders with experience of being suicidal during past imprisonments. RESULTS: Two superordinate themes were identified: "Working Together" depicted participants' perceptions of the pivotal role of good relationships with researchers, and "Journey of Change" outlined how participants' involvement in the research impacted on their personal lives. DISCUSSION: Little is known about how to successfully involve ex-offender service users in research. Our results indicate the conditions necessary for successfully engaging ex-offender service users in research and have important implications for improving the quality of prison research. CONCLUSIONS: Involving forensic service users in research is feasible and should be encouraged, as despite certain challenges, it is highly rewarding both for the research and the ex-offender service users.

The role of pride in women with anorexia nervosa: A grounded theory study.

OBJECTIVE: Theory and clinical literature suggest that pride may play an important role in the maintenance of restrictive eating disorders. A grounded theory study explored experiences of, and reflections on, pride among women with a current or past diagnosis of anorexia nervosa. DESIGN: This is a qualitative study using grounded theory. METHOD: Semistructured interviews were conducted with 21 women recruited from an eating disorder unit in England, and from a UK self-help organization. Grounded theory from a constructivist lens was used. Analysis involved coding, constant comparison, and memo-writing. RESULTS: Pride evolves over the course of anorexia nervosa. Two overarching conceptual categories were identified: 'pride becoming intertwined with anorexia' and 'pride during the journey towards recovery'. These categories encompassed different forms of pride: 'alluring pride', 'toxic pride', 'pathological pride', 'anorexia pride', 'shameful pride', 'recovery pride', and 'resilient pride'. Initially, pride contributed to self-enhancement and buffered negative emotions. As the condition progressed, pride became a challenge to health and interfered with motivation to change. During recovery, perceptions of pride altered as a healthy approach to living ensued. CONCLUSIONS: The evolving nature of pride plays a central role in development, maintenance, and treatment of anorexia nervosa. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery. Future work should investigate whether tackling pride in eating disorders increases treatment efficacy and reduces the risk of relapsing. PRACTITIONERS POINTS: Pride associated with anorexia appeared to evolve in nature. During early stages of the eating disorder, it stopped people from seeking help. Later on, it prevented them from seeing pride in healthy domains of life (outside anorexia). Over time, pride in anorexia became an overwhelming emotion that interfered with motivation to change. It is important for practitioners to assess and discuss pride in anorexia and its evolving nature during treatment. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery.

Development and Validation of the Pride in Eating Pathology Scale (PEP-S).

There is a growing body of theoretical and clinical literature highlighting the role of pride in maintaining eating disordered behaviours. Despite its clinical importance, there are no measures to assess feelings of pride associated with eating psychopathology. This study describes the development and validation of the Pride in Eating Pathology Scale (PEP-S), a self-report questionnaire that examines feelings of pride towards eating disordered symptoms (e.g., pride in food restriction, thinness and weight loss). Participants were 390 females, recruited from university and community populations, whose mean age was 26.99 years. Respondents rated pride in eating pathology on a 7-point Likert-scale. Principal Component Analysis indicated that the 60-item scale comprised a four component structure: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. These four components explained a total of 65.31% of the variance. The PEP-S demonstrated very good internal reliability (α ranging from 0.88 to 0.98) and very good test-retest reliability over a 3-week time-span (r ranging from 0.81 to 0.93). The PEP-S also showed excellent convergent and discriminant validity. Furthermore, the scale discriminated between women with high and low levels of eating psychopathology. The PEP-S is a psychometrically robust measure of pride in eating pathology. It has the potential to advance theoretical understanding and may also be clinically useful. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The PEP-S is a valid, reliable, quick and easy to administer self-report questionnaire that measures pride related to eating pathology. The PEP-S assesses four clinically relevant dimensions: (1) pride in weight loss, food control and thinness, (2) pride in healthy weight and healthy eating, (3) pride in outperforming others and social recognition and (4) pride in capturing other people's attention due to extreme thinness. The PEP-S has very good internal and test-retest reliability, and very good convergent and discriminant validity. The PEP-S distinguishes between women with higher and lower levels of eating psychopathology. The PEP-S makes an important contribution to understanding pride in eating psychopathology, which is essential from both clinical and theoretical perspectives.

Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis.

Although a considerable number of studies have indicated that the rates of suicidal thoughts and behaviors in Body Dysmorphic Disorder (BDD) are high, no systematic review has been undertaken to explore the strength and patterns of the relationship between suicidality and BDD. This is the first systematic review and meta-analysis which aimed to examine the association between BDD and suicidality and the mechanisms underlying suicidality in BDD. Searches of five bibliographic databases including Medline, PsychINFO, Embase, Web of Science and CINAHL, were conducted from inception to June 2015. Seventeen studies were included in the review. Meta-analyses were performed using random effect models to account for the high levels of heterogeneity in the data. A positive and statistically significant association was found between BDD and suicidality (OR=3.63, 95% CI=2.62 to 4.63). Subgroup analyses showed that BDD was associated with increased odds for both, suicide attempts (OR=3.30, 95% CI=2.18 to 4.43) and suicidal ideation (OR=2.57, 95% CI=1.44 to 3.69). The evidence concerning suicide deaths in BDD was scarce. BDD-specific factors and comorbid diagnoses of Axis I disorders were likely to worsen suicidality in BDD. However, the modest number, and the low methodological quality, of the studies included in this review suggest caution the interpretation of these findings.

Nightmares and Suicide in Posttraumatic Stress Disorder: The Mediating Role of Defeat, Entrapment, and Hopelessness.

STUDY OBJECTIVES: Although nightmares appear to be related to suicidal behaviors, the mechanisms which underpin this relationship are unknown. We sought to address this gap by examining a multiple mediation hypothesis whereby nightmares were predicted to have an indirect effect on suicidal behaviors through perceptions of defeat, entrapment, and hopelessness. METHODS: Data were collected from 91 participants who had experienced trauma and symptoms of posttraumatic stress disorder (PTSD). Nightmares were measured by summing the frequency and intensity ratings of relevant items on the Clinician-Administered PTSD Scale. Participants also completed questionnaire measures of suicidal behavior, hopelessness, defeat, and entrapment. Given the interrelations between insomnia, PTSD, and suicide, a measure of insomnia was included as a covariate. Furthermore, analyses were conducted with and without those participants who had comorbid depression. RESULTS: Suicidal behaviors were higher in those participants who experienced nightmares (62%), in comparison to those who did not (20%). Bootstrapped analyses provided support for the hypothesized multistep mediational model. Specifically, nightmares were both directly and indirectly associated with suicidal behaviors, through perceptions of defeat, entrapment, and hopelessness, independent of comorbid insomnia and depression. CONCLUSIONS: For the first time we show that the relationship between nightmares and suicidal behaviors is partially mediated by a multistep pathway via defeat, entrapment, and hopelessness. Clinically, our work highlights the importance of monitoring and targeting nightmares and perceptions of defeat, entrapment, and hopelessness when working with clients who have experienced trauma. COMMENTARY: A commentary on this article appears in this issue on page 289.

An empirical investigation of suicide schemas in individuals with Posttraumatic Stress Disorder.

Posttraumatic Stress Disorder (PTSD) has been strongly associated with suicidality. Despite the growing evidence suggesting that suicidality is heightened by the presence of an elaborated suicide schema, investigations of suicide schemas are sparse. Using novel methodologies, this study aimed to compare the suicide schema of PTSD individuals with and without suicidal ideation in the past year. Fifty-six participants with a diagnosis of PTSD (confirmed via the Clinician Administered PTSD Scale) completed questionnaires to assess suicidality, depressive severity and hopelessness. A series of direct and indirect cognitive tasks were used to assess suicide schemas. The pathfinder technique was employed to construct graphical representations of the groups׳ suicide schemas. The suicidal group reported significantly more severe PTSD symptoms, depressive symptoms, hopelessness and suicidality. The suicide schema of the suicidal group was significantly more extensive compared to the non-suicidal group even after taking into account in the analyses group differences in clinical measures. Moreover, the suicide schemas of the two groups were qualitatively distinct from each other. These findings provide support for contemporary theories of suicide which view suicide schemas as an important indicator of suicide risk. The investigation of schema constructs opens a new avenue of research for understanding suicide.

Suicidality and posttraumatic stress disorder (PTSD) in adolescents: a systematic review and meta-analysis.

PURPOSE: There is growing evidence in the literature that a diagnosis of Posttraumatic Stress Disorder (PTSD) is an important contributory factor to suicidality in adolescents. However, there is no existing review of the literature examining the relationship between PTSD and suicidality in adolescents. This study aims to provide the first systematic review and meta-analysis of the association between PTSD and suicidality in adolescents. METHODS: Five bibliographic databases (Medline, EMBASE, PsycINFO, Web of Science and PILOT) were screened for suitable articles. Twenty-eight studies (which provided 28 independent samples) were included in the review. The overall meta-analyses of the association between PTSD and suicidality were followed by subgroup and meta-regression analyses. RESULTS: A highly significant positive association was found between PTSD and suicidality (d = 0.701, 95% CI 0.555-0.848). The subgroup and meta-regression analyses showed that the association between PTSD and suicidality persisted whilst adjusting for various sources of between-study heterogeneity, such as, different levels of severity of suicidality, target groups, and methodological quality of the studies. CONCLUSIONS: Suicidality in adolescents with PTSD is a major problem which requires further research effort. The implications of these results are discussed.

A prospective study of suicidal ideation in posttraumatic stress disorder: the role of perceptions of defeat and entrapment.

OBJECTIVES: This study aimed to provide the first prospective test of the ability of defeat and entrapment to predict suicidal ideation in posttraumatic stress disorder (PTSD) after controlling for the effects of PTSD severity, comorbid depressive symptoms, and hopelessness on suicidal ideation. METHODS: Participants were 52 individuals diagnosed with PTSD. Baseline and follow-up assessments were 13 to 15 months apart. Defeat and entrapment were conceptualized and analyzed as a unique construct (defeat/entrapment) in this study. Multiple regression analysis was applied to examine the predictive effects of defeat/entrapment on suicidal ideation. RESULTS: Defeat/entrapment scores predicted changes in the levels of suicidal ideation at follow-up while controlling for baseline suicidal ideation, PTSD severity, comorbid depressive symptoms, and hopelessness. CONCLUSIONS: These outcomes provide support to contemporary models of suicidality that suggest that defeat/entrapment is a strong predictor of suicidality in PTSD.

Assessing the specificity of autobiographical memory in individuals at a trait-based vulnerability to bipolar disorder using a sentence completion task.

Overgeneral autobiographical memory recall has been associated with the diagnosis of bipolar disorder, but the role of overgenerality in the vulnerability to bipolar disorder remains under-researched. While a previous study suggested that high-risk individuals for bipolar disorder recall emotionally negative memories in specific detail, this is in contrast to memory recall patterns noted in bipolar samples. The Autobiographical Memory Test (AMT) used in previous non-clinical studies has also been criticised for not being sensitive to overgenerality due to its repetition of specificity instructions and practice trials. The traditional AMT format may allow some individuals to override their trait-based tendencies to be overgeneral. The current study used a sentence completion task to assess memory specificity in groups of students at a low and high trait-based vulnerability for bipolar disorder. In contrast to previous research, high-risk individuals recalled fewer specific positive memories and greater numbers of overgeneral negative memories than low-risk individuals. These results support the notion that the vulnerability for bipolar disorder might be associated with similar recall biases as demonstrated in bipolar samples, and that the AMT might not be sufficiently sensitive to detect overgenerality in non-clinical groups. The implications of these findings and directions for future research are discussed.

Hopelessness, defeat, and entrapment in posttraumatic stress disorder: their association with suicidal behavior and severity of depression.

Research has shown an increased frequency of suicidal behaviors in those with PTSD, but few studies have investigated the factors that underlie the emergence of suicidal behavior in PTSD. Two theories of suicide, the Cry of Pain and the Schematic Appraisal Model of Suicide, propose that feelings of hopelessness, defeat, and entrapment are core components of suicidality. This study aimed to examine the association between suicidal behavior and hopelessness, defeat, and entrapment in trauma victims with and without a PTSD diagnosis. The results demonstrated that hopelessness, defeat, and entrapment were significantly positively associated with suicidal behavior in those with PTSD. Hopelessness and defeat were also significantly positively associated with suicidal behavior in trauma victims without PTSD. In those with PTSD, the relationship between suicidal behavior and hopelessness and entrapment remained significant after controlling for comorbid depression. The findings provide support for the contemporary theories of suicidality and have important clinical implications.

A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression.

OBJECTIVE: A considerable number of studies have reported an increased frequency of suicidal behaviors among individuals diagnosed with posttraumatic stress disorder (PTSD). This study aims, first, to provide a comprehensive systematic review and meta-analysis of the association between a PTSD diagnosis and frequency of suicidality and, second, to examine the role of comorbid depression in the association between suicidality and PTSD. METHODS: Searches of Medline (June 2010), EMBASE (June 2010), PsycINFO (June 2010), PILOTS (June 2010), and Web of Science (June 2010) were conducted to identify studies that examined the association between PTSD and suicidality. The studies had to include an effect size of the association between PTSD and suicidality to be included in the meta-analysis. Sixty-three studies were eligible for inclusion in the meta-analysis. Overall and subgroup effect sizes were examined. RESULTS: A highly significant positive association between a PTSD diagnosis and suicidality was found. The PTSD-suicidality association persisted across studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different types of traumas. Comorbid major depression significantly compounded the risk for suicide in PTSD populations. CONCLUSION: The current meta-analysis provides strong evidence that a PTSD diagnosis is associated with increased suicidality. The crucial role of comorbid major depression in the etiology of suicidality in PTSD is also supported.