Evidence-based care for suicidality as an ethical and professional imperative: How to decrease suicidal suffering and save lives.

Suicide is a major public and mental health problem in the United States and around the world. According to recent survey research, there were 16,600,000 American adults and adolescents in 2022 who reported having serious thoughts of suicide (Substance Abuse and Mental Health Services Administration, 2023), which underscores a profound need for effective clinical care for people who are suicidal. Yet there is evidence that clinical providers may avoid patients who are suicidal (out of fear and perceived concerns about malpractice liability) and that too many rely on interventions (i.e., inpatient hospitalization and medications) that have little to no evidence for decreasing suicidal ideation and behavior (and may even increase risk). Fortunately, there is an emerging and robust evidence-based clinical literature on suicide-related assessment, acute clinical stabilization, and the actual treatment of suicide risk through psychological interventions supported by replicated randomized controlled trials. Considering the pervasiveness of suicidality, the life versus death implications, and the availability of proven approaches, it is argued that providers should embrace evidence-based practices for suicidal risk as their best possible risk management strategy. Such an embrace is entirely consistent with expert recommendations as well as professional and ethical standards. Finally, a call to action is made with a series of specific recommendations to help psychologists (and other disciplines) use evidence-based, suicide-specific, approaches to help decrease suicide-related suffering and deaths. It is argued that doing so has now become both an ethical and professional imperative. Given the challenge of this issue, it is also simply the right thing to do. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression.

Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage. Re-routing the innominate vein to the pulmonary venous atrium decompresses the thoracic duct, as atrial pressure is lower than systemic venous pressure in Fontan circulation. Transcatheter thoracic duct decompression is a new minimally invasive procedure that involves placing covered stents from the innominate vein to the atrium. Patients undergoing this procedure require multiple general anesthetics, presenting challenges in managing the sequelae of disordered lymphatic flow superimposed on Fontan physiology. We reviewed the first 20 patients at the Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for transcatheter thoracic duct decompression between March 2018 and February 2023. The patients ranged in age from 3 to 26 years. The majority had failed prior catheter-based lymphatic intervention, including selective embolization of abnormal lympho-intestinal and lympho-bronchial connections to treat lymphatic failure in a single compartment. Fourteen had failure in three lymphatic compartments. Patients were functionally impaired (ASA 3-5) with significant comorbidities. Concurrent with thoracic duct decompression, three patients required fenestration closure for the resultant decrease in oxygen saturation. Ten patients had improvement in symptoms, seven had no changes and three have limited follow up. Five (25%) of these patients were deceased as of January 2024 due to non-lymphatic complications from Fontan failure.

Facets of Suicidal Ideation.

According to SAMHSA (2023), approximately 16,600,000 American adults and teens reported having serious thoughts of suicide in 2022. While suicide prevention has primarily focused on suicide deaths and attempts, we contend that suicidal ideation (SI) deserves more in-depth investigation and should be an essential intervention target on its own. In support of this point, we provide three examples of ways to improve specificity in understanding of SI through the study of controllability of SI, the language used to assess SI, and measuring SI in real time. We also consider qualitative work on the content of SI, its treatment, and definitional considerations. We thus call for an increased general focus on SI within research, clinical care, and policy.

Factor Structure and Measurement Invariance of the Suicide Status Form-IV.

The Suicide Status Form-IV (SSF-IV) is the measure used in the Collaborative Assessment and Management of Suicidality (CAMS). The SSF-IV Core Assessment measures various domains of suicide risk. Previous studies established a two-factor solution in small, homogeneous samples; no investigations have assessed measurement invariance. The current investigation sought to replicate previous factor analyses and used measurement invariance to identify differences in the Core Assessment by race and gender. Adults (N = 731) were referred for a CAMS consultation after exhibiting risk for suicide. Confirmatory factor analyses indicated good fit for both one- and two-factor solutions while the two-factor solution is potentially redundant. Configural, metric, and scalar invariance held across race and gender. Ordinal logistic regression models indicated that neither race nor gender significantly moderated the relationship between the Core Assessment total score and clinical outcomes. Findings support a measurement invariant, one-factor solution for the SSF-IV Core Assessment.

Chronic Pain, Hopelessness, and Suicide Risk Among Adult Medical Inpatients.

BACKGROUND: Medically ill adults are at elevated risk for suicide. Chronic pain and hopelessness are associated with suicide; however, few studies have examined the interaction between chronic pain and hopelessness in predicting suicide risk among hospitalized adults. OBJECTIVE: This study aimed to describe the association between chronic pain, hopelessness, and suicide risk, defined as recent suicidal ideation or lifetime suicidal behavior. In addition, we examined the interaction between chronic pain and hopelessness. METHODS: This was a secondary analysis of a multisite study to validate the Ask Suicide-Screening Questions (ASQ) among adult medical inpatients. Participants reported if they experienced chronic pain that impacted daily life and if they felt hopeless about their medical condition and provided their current pain rating on a 1 to 10 scale, with 10 being the most severe pain. A t-test compared pain severity scores by ASQ outcome. A binary logistic regression model described the association between chronic pain, hopelessness, and suicide risk; parameter estimates are expressed as odds ratios (OR) for interpretation. The interaction between chronic pain and hopelessness was examined in both the transformed (logit) and natural (probability) scales of the generalized linear model. RESULTS: The sample included 720 participants (53.2% male, 62.4% White, mean age: 50.1 [16.3] years, range = 18-93). On the ASQ, 15.7% (113/720) of patients screened positive. Half (360/720) of the sample self-reported chronic pain. Individuals who screened positive had higher pain rating scores than those who screened negative (t = -4.2, df = 147.6, P < 0.001). Among all patients, 27.2% (196/720) felt hopeless about their medical condition. In the logistic regression model, patients with chronic pain (adjusted OR: 2.29, 95% confidence interval [CI]: 1.21-4.43, P = 0.01) or hopelessness (adjusted OR: 5.69, 95% CI: 2.52-12.64, P < 0.001) had greater odds of screening positive on the ASQ. The interaction effect between pain and hopelessness was not significant in the transformed (B = -0.15, 95% CI: -1.11 to 0.82, P = 0.76) or natural (B = 0.08, 95% CI: -0.07 to 0.23, P = 0.28) scale. CONCLUSIONS: There were significant independent associations between (1) chronic pain and suicide risk and between (2) hopelessness and suicide risk. Future research should examine the temporality and mechanisms underlying these relationships to inform prevention efforts for medically ill adults.

A New Drug Discovery Platform: Application to DNA Polymerase Eta and Apurinic/Apyrimidinic Endonuclease 1.

The ability to quickly discover reliable hits from screening and rapidly convert them into lead compounds, which can be verified in functional assays, is central to drug discovery. The expedited validation of novel targets and the identification of modulators to advance to preclinical studies can significantly increase drug development success. Our SaXPyTM ("SAR by X-ray Poses Quickly") platform, which is applicable to any X-ray crystallography-enabled drug target, couples the established methods of protein X-ray crystallography and fragment-based drug discovery (FBDD) with advanced computational and medicinal chemistry to deliver small molecule modulators or targeted protein degradation ligands in a short timeframe. Our approach, especially for elusive or "undruggable" targets, allows for (i) hit generation; (ii) the mapping of protein-ligand interactions; (iii) the assessment of target ligandability; (iv) the discovery of novel and potential allosteric binding sites; and (v) hit-to-lead execution. These advances inform chemical tractability and downstream biology and generate novel intellectual property. We describe here the application of SaXPy in the discovery and development of DNA damage response inhibitors against DNA polymerase eta (Pol η or POLH) and apurinic/apyrimidinic endonuclease 1 (APE1 or APEX1). Notably, our SaXPy platform allowed us to solve the first crystal structures of these proteins bound to small molecules and to discover novel binding sites for each target.

Advancing Suicide Intervention Strategies for Teens (ASSIST): study protocol for a multisite randomised controlled trial.

INTRODUCTION: Brief interventions that reduce suicide risk following youth's experience with acute care due to suicidality are needed. METHODS AND ANALYSIS: The study will use a three-arm randomised controlled trial designed to test the effectiveness of the Safety Planning Intervention with structured follow-up (SPI+) and the Collaborative Assessment and Management of Suicidality (CAMS) compared with enhanced usual care. The primary outcomes measure will be suicidal events, defined as death by suicide, attempted suicide, preparatory acts toward imminent suicidal behaviour or suicidal ideation resulting in a change in emergency evaluation or inpatient admission. Secondary measures will be the number of suicide attempts and severity of suicidal ideation. The experimental interventions, SPI+ and CAMS, consist of up to eight sessions over approximately 8 weeks that are designed to manage (SPI+) or treat (CAMS) patient-identified 'drivers' of suicidal thoughts and behaviours. Mechanisms and moderators of change will be evaluated to understand treatment impacts. ETHICS AND DISSEMINATION: This study has been approved by the Seattle Children's Institutional Review Board and is monitored by external agencies including the University of Washington Institute for Translational Health Sciences, and a National Institute of Mental Health (NIMH)-appointed Data Safety and Monitoring Board. Trial results will help establish evidence towards safe and effective treatment strategies for youth transitioning from acute to outpatient care due to a suicidal crisis. The data will be shared with the NIMH Data Archives and disseminated through publications and conferences. TRIAL REGISTRATION NUMBER: NCT05078970.

Uncontrollability of suicidal ideation adds incremental explanatory power in prediction of later suicidal ideation.

OBJECTIVE: Suicidal ideation and suicidal behaviors are major public health concerns in the United States and are difficult to treat and predict. Risk factors that are incrementally informative are needed to improve prediction and inform prevention of suicidal thoughts and behaviors. Uncontrollability of suicidal ideation, one parameter of suicidal ideation, is one such candidate. METHOD: In the current study, we assessed the predictive power of uncontrollability of suicidal ideation, over and above overall suicidal ideation, for future suicidal ideation in a large sample of active-duty service members. A total of 1044 suicidal military service members completed baseline assessments, of whom 664 (63.6%) completed 3-month follow-up assessments. RESULTS: While baseline overall suicidal ideation itself was the strongest predictor of future suicidal ideation, uncontrollability of suicidal ideation added some incremental explanatory power. CONCLUSION: Further study of uncontrollability of suicidal thought is needed to elucidate its impact on suicidal outcomes.

Emotional distress and dysregulation as treatment targets to reduce suicide in psychosis: a scoping review.

There is a pressing need for effective treatments that address the high rate of suicide observed among people with psychosis. In this scoping review we highlight two suicidogenic treatment targets that have been relatively neglected in people with psychotic disorders: emotional distress and emotion dysregulation. We review the research on these constructs in psychosis and their relationship to suicide in this population, and then make clinical recommendations based on research findings. Emotional distress and emotional dysregulation may be promising treatment targets for suicide among people with psychosis.

Targeting Perceived Burdensomeness to Reduce Suicide Risk.

Perceived burdensomeness (PB), defined by an intractable perception of burdening others, often reflects a false mental calculation that one's death is worth more than one's life and has been supported as a significant risk factor for suicide. Because PB often reflects a distorted cognition, it may serve as a corrective and promising target for the intervention of suicide. More work on PB is needed in clinically severe and in military populations. Sixty-nine (Study 1) and 181 (Study 2) military participants at high baseline suicide risk engaged in interventions targeting constructs relating to PB. Baseline and follow-up measures (at 1, 6, 12, 18, and 24 months) of suicidal ideation were administered, and various statistical approaches-including repeated-measures ANOVA, mediation analyses, and correlating standardized residuals-explored whether suicidal ideation decreased specifically by way of PB. In addition to utilizing a larger sample size, Study 2 included an active PB-intervention arm (N = 181) and a control arm (N = 121), who received robust care as usual. In both studies, participants improved considerably regarding baseline to follow-up suicidal ideation. The results of Study 2 mirrored those of Study 1, corroborating a potential mediational role for PB in treatment-related improvements in suicidal ideation in military participants. Effect sizes ranged from .07-.25. Interventions tailored at decreasing levels of perceived burdensomeness may be uniquely and significantly effective in reducing suicidal thoughts.

The Collaborative Assessment and Management of Suicidality compared to enhanced treatment as usual for inpatients who are suicidal: A randomized controlled trial.

Background: Although use of inpatient crisis hospital intervention for suicide risk is common, the evidence for inpatient treatments that reduce suicidal thoughts and behaviors is remarkably limited. To address this need, this novel feasibility pilot randomized controlled trial compared the use of the Collaborative Assessment and Management of Suicidality (CAMS) to enhanced treatment as usual (E-TAU) within a standard acute inpatient mental health care setting. Objectives: We hypothesized that CAMS would be more effective than E-TAU in reducing suicidal thoughts and behaviors. As secondary outcomes we also investigated depressive symptoms, general symptom burden, reasons for living, and quality of the therapeutic relationship. Methods: All patients were admitted due to acute suicidal thoughts or behaviors. They were randomly assigned to CAMS (n = 43) or E-TAU (n = 45) and assessed at four time points (admission, discharge, 1 month and 5 months after discharge). We used mixed-effects models, effect sizes, and reliable change analyses to compare improvements across and between treatment groups over time. Results: Intent-to-treat analyses of 88 participants [mean age 32.1, SD = 13.5; n = 47 (53%) females] showed that both groups improved over time across all outcome measures with no significant between-group differences in terms of change in suicidal ideation, depression, reasons for living, and distress. However, CAMS showed larger effect sizes across all measures; for treatment completers CAMS patients showed significant improvement in suicidal ideation (p = 0.01) in comparison to control patients. CAMS patients rated the therapeutic relationship significantly better (p = 0.02) than E-TAU patients and were less likely to attempt suicide within 4 weeks after discharge (p = 0.05). Conclusions: CAMS and E-TAU were both effective in reducing suicidal thoughts and symptom distress. Within this feasibility RCT the pattern of results was generally supportive of CAMS suggesting that inpatient use of CAMS is both feasible and promising. However, our preliminary results need further replication within well-powered multi-site randomized controlled trials. Trial registration: DRKS-ID/ICTRP-ID: DRKS00013727. The trial was retrospectively registered in the German Clinical Trials Register, registration code/ DRKS-ID: DRKS00013727 on 12.01.2018 and also in the International Clinical Trials Registry Platform of the World Health Organization (identical registration code).

A test of invariance of the construct of suicidal ideation across three diverse samples.

BACKGROUND: Suicide treatment research has placed major emphasis on preventing behavior, an observable phenomenon. Suicidal ideation (SI), however, is a distressing experience that annually impacts >15 million Americans; yet the construct validity of SI has not been well established, limiting empirical attention. METHOD: We compared the coherence of three SI items (diminished wish to live, urge to die/controllability, suicide intent/expectations) and four related items across three adult samples (N = 314) that differed based on current SI severity and assessment time-scales (retrospective versus momentary). RESULTS: A measurement model with scalar invariance had acceptable fit (CFI = 0.969, RMSEA = 0.076), indicating that the SI items consistently loaded onto one construct across samples. The structural model with metric invariance also had acceptable fit (CFI = 0.956, RMSEA = 0.063) and three of four related items (burdensome, hopelessness, and fatigue, but not agitation) were associated with SI across samples. LIMITATIONS: Use of existing data limited the items considered. CONCLUSIONS: Suicidal ideation is a coherent construct independent of the items used to assess it, the assessment's time-scale (retrospective versus momentary), or the severity of thoughts, and is worthy of greater empirical, clinical, and policy attention.

Using the Delphi Method for Determining Key Performance Elements for Delivery of Optimal Suicide-Specific Interventions in Emergency Departments.

OBJECTIVE: Evidence-based suicide prevention interventions directed to those seeking psychiatric crisis services for suicidality in the emergency department (ED) can reduce death by suicide and related suffering. Best practice guidelines for the care of suicidal patients in the ED exist but are not accompanied by fidelity tools for use in determining whether the interventions were applied, particularly when more than one intervention is delivered concurrently. We sought to develop a universal, treatment-agnostic Suicide Care Fidelity Checklist comprised of Key Performance Elements (KPE) across the recommended suicide-specific ED interventions. METHOD: A comprehensive review of published care standards was first conducted to determine suicide-specific ED best practice treatment domains and KPEs. Subject matter experts (SMEs) were identified for each domain. Using the Delphi Consensus method, SMEs iteratively revised and refined the KPEs within their domain until achieving KPE item consensus. RESULTS: A total of three iterations was required to obtain consensus in five of six domains: comprehensive suicide assessment, lethal means counseling, suicide crisis planning, behavioral skills training, and psychoeducation about suicidality. Consensus was not fully attained for the domain involving engagement with people with lived experience. CONCLUSIONS: We successfully identified six intervention domains and 74 KPEs across domains (60 deemed essential, and 14 deemed optional), with full consensus reached for 70 KPEs. While replication of the initial findings is required, the Suicide Care Fidelity Checklist can be used as a fidelity checklist to verify delivery of suicide-specific ED interventions.HIGHLIGHTSApplied Delphi Consensus method with suicide-specific subject matter experts.Generated a treatment-agnostic, universal set of suicide prevention KPEs for EDs.Expert-derived KPEs help real-world settings to assess suicide care fidelity.

The Influence of Cyberbullying on Nonsuicidal Self-Injury and Suicidal Thoughts and Behavior in a Psychiatric Adolescent Sample.

Cyberbullying is a well-established risk factor for suicidal thoughts and behavior in adolescents. However, research examining the differential influence of different forms of cyberbullying on suicidality is limited. This exploratory study investigated the association between cyberbullying and self-injurious thoughts and behaviors separately. Specifically, the study sought to examine how being the subject of online rumors, illicit photographs, and threatening messages related to nonsuicidal self-injury (NSSI), suicidal ideation (SI), and suicide attempt (SA) history in an adolescent psychiatric sample (n = 64). The findings demonstrated that endorsement of any form of cyberbullying was significantly associated with NSSI. Further, victims of online rumors were over fifteen times more likely to engage in NSSI, and all participants who reported involvement in illicit photographs endorsed NSSI. Additionally, participants who endorsed involvement in an online rumor were nearly seventeen times more likely to report SA history. The forms of cyberbullying assessed were not significantly associated with SI.

Three-year follow-up of suicide prevention-focused group therapy for veterans.

The purpose of this study was to determine the long-term effects of a suicide prevention-focused group therapy for veterans recently discharged from an inpatient psychiatry setting following a suicidal crisis. There was interest in examining the impact of mechanisms of change identified in previous research on the group, including group cohesion, working alliance, and group sessions attended. Data were abstracted from the electronic medical record 3 years following completion of a previous study that involved the group therapy. A series of generalized linear and logistic mixed models were conducted to measure the associations between group cohesion, working alliance, session attendance, and health service utilization and suicide attempts. Thirty randomly selected veterans from the original sample completed a semistructured interview to discuss their experience in the group therapy. Study team members reviewed each transcription to identify themes related to veterans' experiences in the suicide prevention-focused group therapy. No suicides were observed in the 3-year follow-up period. When examining the full sample (N = 134), session attendance and inpatient hospitalization were not significantly associated but were positively associated after removing subjects who attended zero sessions (N = 93). Higher group cohesion was associated with a reduced likelihood of inpatient psychiatric hospitalization and greater engagement in outpatient mental health services. Four themes emerged regarding veterans' experience in the group through an analysis of the semistructured interviews. Suicide prevention-focused group therapy among veteran service members was not associated with an elevated risk of mortality. Future research is needed to further elucidate mechanisms of change and moderators of response. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Reducing short term suicide risk after hospitalization: A randomized controlled trial of the Collaborative Assessment and Management of Suicidality.

BACKGROUND: This study compared the "next day appointment" (NDA) use of the Collaborative Assessment and Management of Suicidality (CAMS) to treatment as usual (TAU) for individuals discharged from the hospital following a suicide-related crisis. We hypothesized that CAMS would significantly reduce suicidal thoughts and behaviors as well as improve psychological distress, quality of life/overall functioning, treatment retention and patient satisfaction. METHODS: Participants were 150 individuals who had at least one lifetime actual, aborted, or interrupted attempt and were admitted following a suicide-related crisis. There were 75 participants in the experimental condition who received adherent CAMS and 75 participants who received TAU. Suicidal thoughts and behaviors, psychological distress, and quality of life/overall functioning were assessed at baseline and at 1, 3, 6, and 12 months post-baseline. Treatment retention and patient satisfaction were assessed at post-treatment. RESULTS: Participants in both conditions improved from baseline to 12 months but CAMS was not superior to TAU for the primary outcomes. A small but significant improvement was found in probability of suicidal ideation at 3 months favoring TAU and amount of suicidal ideation at 12 months favoring CAMS. CAMS participants experienced less psychological distress at 12 months compared to baseline. LIMITATIONS: The study was limited by only one research clinic, lower than expected recruitment, and imbalance of suicidal ideation at baseline. CONCLUSIONS: All participants improved but CAMS was not more effective than TAU. The NDA clinic was feasible and acceptable to clients and staff in both conditions and future research should investigate its potential benefit.

The Content of Patient-Identified Suicidal Drivers within CAMS Treatment Planning.

The Collaborative Assessment and Management of Suicidality (CAMS) is an evidence-based, suicide-focused, clinical framework that effectively treats people who are suicidal across clinical settings. A central tool within CAMS is the Suicide Status Form (SSF) which is a multipurpose assessment, treatment planning, tracking, to clinical outcome tool that guides suicide-focused care from the start of CAMS treatment to completion. Previous SSF assessment research investigated the content of patient-written qualitative responses to SSF assessment prompts which were reliably coded into twelve content categories. Four coding categories captured 70% of written responses revealing the content of patients' suicidal ideation which centered on: relationships, vocation, the self, and unpleasant internal states. While qualitative SSF assessment research has thus revealed key information about suicidal ideation content, patient-identified "drivers" of suicide within CAMS treatment planning have not yet been examined qualitatively. "Drivers" of suicide are the issues that compel one to consider suicide, and ultimately become the focus of CAMS treatment; thus, it is important to examine their qualitative content. The present exploratory study investigated suicide driver content collected in the context of two randomized controlled trials of CAMS. Reliably coded qualitative content of patient-articulated drivers were comparable to previously noted SSF content assessment results, emphasizing the following driver issues: (1) Relationships, (2) Unpleasant Internal States (e.g., suffering and anxiety), (3) Role Responsibility (vocational concerns), and (4) the Self (e.g., self-hatred or esteem issues). These four coding themes captured 70% of 332 total treatment planning drivers obtained from 166 patients who were suicidal and seeking treatment. Implications of these findings are discussed.

Emotion-related impulsivity and suicidal ideation: Towards a more specific model.

OBJECTIVES: Suicidal ideation is a pervasive and painful experience that varies considerably in its phenomenology. Here, we consider how one key risk variable might inform our understanding of variation in suicidal ideation: emotion-related impulsivity, the trait-like tendency towards unconstrained speech, behaviour, and cognition in the face of intense emotions. We hypothesized that emotion-related impulsivity would be tied to specific features, including severity, perceived lack of controllability, more rapidly fluctuating course, higher scores on a measure of acute suicidal affective disturbance, and more emotional and cognitive disturbance as antecedents. METHODS: We recruited two samples of adults (Ns = 421, 221) through Amazon Mechanical Turk (MTurk), with oversampling of those with suicidal ideation. Both samples completed psychometrically sound self-report measures online to assess emotion- and non-emotion-related dimensions of impulsivity and characteristics of suicidal ideation. RESULTS: One form of emotion-related impulsivity related to the severity, uncontrollability, dynamic course, and affective and cognitive precursors of ideation. CONCLUSIONS: Despite limitations of the cross-sectional design and self-report measures, the current findings highlight the importance of specificity in considering key dimensions of impulsivity and suicidal ideation.