An In-Depth Exploration of the Relationship Between Suicidal Ideation and Emotion Processes in Adolescents.

Previous research has shown a relationship between proximal (i.e., close-in-time) emotion experiences and suicidal ideation (SI). Yet, it remains unclear which emotion processes (i.e., the level of the emotion [intensity], how much emotions vary [variability], emotional consistency [inertia], how specific emotions are [differentiation]) and which emotions (i.e., sadness, hopelessness, anger, nervousness, happiness) are most potent predictors of SI. Seventy-seven adolescents (67.5% assigned female at birth) completed daily diaries for 4 weeks after psychiatric hospitalization. Levels of the above-mentioned emotions and frequency of SI were recorded. For each week and each emotion, mean (intensity), standard deviation (variability), autocorrelation (inertia), and intraclass correlation coefficients (ICCs; negative emotion differentiation) were calculated (i.e., four observations/person). Multilevel models examined whether (a) mean intensity, variability, and their interaction; and (b) mean intensity, inertia, and their interaction, were related to mean weekly SI frequency. A separate model examined whether negative emotion differentiation was related to mean weekly SI frequency after adjusting for mean intensity. A significant interaction between mean intensity of anger and variability of anger emerged (B = 0.54, SE = 0.24, p = .023); a positive relationship between mean anger and mean SI frequency was present at moderate or high levels of anger variability but not at its low levels. Mean intensity of most emotions was related to SI frequency in the expected directions. No other statistically significant findings emerged. Results revealed the importance of considering multiple emotion features, their dynamic nature, and their combined effect. Future research should explore mechanisms accounting for anger being related to heightened proximal SI, along with an examination of effective intervention strategies to reduce anger intensity and variability.

A latent profile analysis of at-risk first-year undergraduate students.

Objective: We examined whether meaningful subgroups of self-injurious behaviors (SIBs) would emerge within a pool of first-year college students already deemed at elevated risk. Participants: First-year undergraduates (N = 1,068) recruited in 2015-2018 Fall terms. Methods: Past-year nonsuicidal self-injury (NSSI) frequency, past-year number of NSSI methods used, lifetime suicide attempt (SA) history, and recency of SA were included in a latent profile analysis. Results: Four subgroups emerged: low SIB (n = 558, 52%), high NSSI only (n = 182, 17%), high SIB (n = 141, 13%), and high SA only (n = 187, 18%). Students in the high SIB group reported higher levels of suicidal ideation at baseline and follow-up in comparison to all groups. Those in the high NSSI only or high SIB groups had relatively higher levels of NSSI at baseline and follow-up. Conclusions: Findings highlight the amount of heterogeneity within a high-risk group, along with the importance of considering distal and proximal SIBs in university screening efforts.

Ecological Momentary Assessments and Passive Sensing in the Prediction of Short-Term Suicidal Ideation in Young Adults.

Importance: Advancements in technology, including mobile-based ecological momentary assessments (EMAs) and passive sensing, have immense potential to identify short-term suicide risk. However, the extent to which EMA and passive data, particularly in combination, have utility in detecting short-term risk in everyday life remains poorly understood. Objective: To examine whether and what combinations of self-reported EMA and sensor-based assessments identify next-day suicidal ideation. Design, Setting, and Participants: In this intensive longitudinal prognostic study, participants completed EMAs 4 times daily and wore a sensor wristband (Fitbit Charge 3) for 8 weeks. Multilevel machine learning methods, including penalized generalized estimating equations and classification and regression trees (CARTs) with repeated 5-fold cross-validation, were used to optimize prediction of next-day suicidal ideation based on time-varying features from EMAs (affective, cognitive, behavioral risk factors) and sensor data (sleep, activity, heart rate). Young adult patients who visited an emergency department with recent suicidal ideation and/or suicide attempt were recruited. Identified via electronic health record screening, eligible individuals were contacted remotely to complete enrollment procedures. Participants (aged 18 to 25 years) completed 14 708 EMA observations (64.4% adherence) and wore a sensor wristband approximately half the time (55.6% adherence). Data were collected between June 2020 and July 2021. Statistical analysis was performed from January to March 2023. Main Outcomes and Measures: The outcome was presence of next-day suicidal ideation. Results: Among 102 enrolled participants, 83 (81.4%) were female; 6 (5.9%) were Asian, 5 (4.9%) were Black or African American, 9 (8.8%) were more than 1 race, and 76 (74.5%) were White; mean (SD) age was 20.9 (2.1) years. The best-performing model incorporated features from EMAs and showed good predictive accuracy (mean [SE] cross-validated area under the receiver operating characteristic curve [AUC], 0.84 [0.02]), whereas the model that incorporated features from sensor data alone showed poor prediction (mean [SE] cross-validated AUC, 0.56 [0.02]). Sensor-based features did not improve prediction when combined with EMAs. Suicidal ideation-related features were the strongest predictors of next-day ideation. When suicidal ideation features were excluded, an alternative EMA model had acceptable predictive accuracy (mean [SE] cross-validated AUC, 0.76 [0.02]). Both EMA models included features at different timescales reflecting within-day, end-of-day, and time-varying cumulative effects. Conclusions and Relevance: In this prognostic study, self-reported risk factors showed utility in identifying near-term suicidal thoughts. Best-performing models required self-reported information, derived from EMAs, whereas sensor-based data had negligible predictive accuracy. These results may have implications for developing decision algorithms identifying near-term suicidal thoughts to guide risk monitoring and intervention delivery in everyday life.

Predictors of suicide coping self-efficacy among youth presenting to a psychiatric emergency department.

INTRODUCTION: Low levels of youth-reported self-efficacy to cope with suicidal urges have been shown to prospectively predict repeat emergency department (ED) visits and suicide attempts, yet little is known about how self-efficacy may change following receipt of crisis services or about factors that may strengthen self-efficacy. Protective factors (e.g., parent-reported youth competence, parent-family connectedness, and receipt of mental health services) were examined in relation to self-efficacy at the time of a psychiatric ED visit and 2 weeks later. METHODS: Participants were 205 youth (ages 10-17), presenting to a psychiatric ED due to a suicide-related concern. Youth primarily identified as biological female (63%) and White (87%). Multivariate hierarchical linear regressions were used to examine candidate protective factors in relation to initial and follow-up suicide coping self-efficacy. RESULTS: Self-efficacy significantly improved in the 2 weeks following the ED visit. Parent-family connectedness was positively related to suicide coping self-efficacy at the time of the ED visit. Parent-family connectedness and receipt of inpatient psychiatric care following the ED visit were associated with higher follow-up suicide coping self-efficacy. CONCLUSIONS: During the adolescent developmental period when suicidal thoughts and behaviors notably increase, study findings highlight potential malleable intervention targets, including parent-family connectedness, that may strengthen suicide coping self-efficacy.

Using machine learning with intensive longitudinal data to predict depression and suicidal ideation among medical interns over time.

BACKGROUND: Use of intensive longitudinal methods (e.g. ecological momentary assessment, passive sensing) and machine learning (ML) models to predict risk for depression and suicide has increased in recent years. However, these studies often vary considerably in length, ML methods used, and sources of data. The present study examined predictive accuracy for depression and suicidal ideation (SI) as a function of time, comparing different combinations of ML methods and data sources. METHODS: Participants were 2459 first-year training physicians (55.1% female; 52.5% White) who were provided with Fitbit wearable devices and assessed daily for mood. Linear [elastic net regression (ENR)] and non-linear (random forest) ML algorithms were used to predict depression and SI at the first-quarter follow-up assessment, using two sets of variables (daily mood features only, daily mood features + passive-sensing features). To assess accuracy over time, models were estimated iteratively for each of the first 92 days of internship, using data available up to that point in time. RESULTS: ENRs using only the daily mood features generally had the best accuracy for predicting mental health outcomes, and predictive accuracy within 1 standard error of the full 92 day models was attained by weeks 7-8. Depression at 92 days could be predicted accurately (area under the curve >0.70) after only 14 days of data collection. CONCLUSIONS: Simpler ML methods may outperform more complex methods until passive-sensing features become better specified. For intensive longitudinal studies, there may be limited predictive value in collecting data for more than 2 months.

Temporal profiles of suicidal thoughts in daily life: Results from two mobile-based monitoring studies with high-risk adolescents.

Advancements in mobile technology offer new possibilities to examine fine-grained processes underlying suicidal ideation in everyday, real-world conditions. Across two samples, this study examined temporal changes in near-term suicidal ideation in high-risk adolescents' daily life, and whether these dynamic experiences follow distinct longitudinal trajectories. Using latent process mixed modeling for multivariate outcomes, we investigated near-term changes in two parameters of suicidal thoughts (frequency and intensity) among adolescents who completed four-daily ecological momentary assessments (EMAs) during inpatient hospitalization (Sample 1: N = 61; 843 observations) or daily surveys for four weeks after discharge (Sample 2: N = 78; 1621 observations). Proximally assessed suicidal thoughts followed three trajectories characterized by low (Sample 1: 65.6%; Sample 2: 54%), declining (Sample 1: 4.9%; Sample 2: 15%), or persistently high (Sample 1: 29.5%; Sample 2: 31%) ideation in terms of frequency and urge severity. The persistent trajectory also showed consistently high within-person variability. The persistent group was differentiated by higher hopelessness and lower coping self-efficacy compared to the declining trajectory, and by an overall more severe clinical presentation relative to the low ideation trajectory. Suicidal thoughts in everyday life, across two contexts and regardless of data resolution (EMA and daily surveys), are not homogeneous and instead follow distinct longitudinal profiles. Findings point to the importance of closely monitoring suicidal ideation to identify patterns indicative of unrelenting suicidal thinking. Addressing high hopelessness and low self-efficacy may aid in reducing persistent ideation. Improving our understanding of how suicidal ideation unfolds in real-time may be critical to optimizing timely assessment and support.

Suicidal Desire in Adolescents: An Examination of the Interpersonal Psychological Theory Using Daily Diaries.

OBJECTIVE: Despite decades of research, relatively little is known about short-term predictors of suicidal thoughts and behavior. Intensive longitudinal methods are increasingly applied to investigate near-term risk factors of suicidal thoughts in daily life. The aim of this study was to examine short-term predictors of daily-level suicidal thoughts in a high-risk adolescent sample using the interpersonal-psychological theory of suicidal behavior (IPTS) as a guiding framework; the theory proposes that interpersonal experiences of thwarted belongingness in combination with perceived burdensomeness lead to suicidal desire. METHODS: Seventy-eight adolescents hospitalized due to suicide risk responded to one survey/day for 28 days after discharge (n = 1621 unique observations). Multilevel models examined IPTS-informed predictors of same- and next-day suicidal urge intensity. RESULTS: Partial and time-dependent support for the theory was found. The hypothesized two-way interaction between burdensomeness and thwarted belongingness (either family or peer) was significantly associated with increasing same-day, but not next-day, suicidal ideation; specifically, greater belongingness attenuated adverse impact of burdensomeness. The only significant predictor of next-day ideation was higher previous-day burdensomeness. Baseline burdensomeness also emerged as a predictor of day-to-day suicidal ideation. CONCLUSION: Using a theoretically informed model, this study offers an in-depth examination of short-term predictors of suicidal ideation among high-risk adolescents. Findings underscore the importance of fostering peer and family relationships in reducing suicidal thoughts in the post-discharge period. Results additionally suggest that both state- and trait-level burdensomeness have lasting influence on suicidal thoughts during this high-risk period. These findings could inform intervention efforts for high-risk youth.

Does coping reduce suicidal urges in everyday life? Evidence from a daily diary study of adolescent inpatients.

BACKGROUND: Youth suicide has been increasing at an alarming rate. Identifying how youth at risk for suicide cope with daily distress and suicidal thoughts could inform prevention and intervention efforts. We investigated the relationship between previous-day coping and next-day suicidal urge intensity in a high-risk adolescent sample for a 4-week period. We also investigated the influence of adolescents' average coping levels, over 4 weeks, on daily severity of suicidal urges. METHODS: A total of 78 adolescents completed daily diaries after psychiatric hospitalization (n = 1621 observations). Each day, adolescents reported their use of specific coping strategies, overall coping helpfulness, and intensity of suicidal urges. RESULTS: Greater professional support seeking from providers/crisis lines and perceptions of coping helpfulness on the previous day were associated with lower next-day suicidal urges. Adolescents who reported greater average use of cognitive strategies, personal support seeking from family/friends, and higher average perceptions of coping helpfulness, relative to others, had lower daily suicidal urges. Noncognitive strategy use was not related to daily suicidal urge intensity. CONCLUSION: Findings point to the benefit of intervention efforts focusing on strengthening personal and professional supportive relationships, assisting youth with developing a broader coping repertoire, and working with adolescents to identify strategies they perceive to be helpful.

Identifying person-specific coping responses to suicidal urges: A case series analysis and illustration of the idiographic method.

INTRODUCTION: Suicide is a leading cause of death. One challenge to prevention efforts is the wide phenomenological heterogeneity in suicidal urges, thoughts, and behaviors across individuals at risk. Despite this heterogeneity, most suicide research estimates group-level effects by averaging across people as if they were the same, preventing detection of person-specific factors that may modulate risk and be key to effective prevention. The goal of the present study is to illustrate the idiographic (i.e., person-specific) approach and highlight its utility for suicide research. METHODS: We implemented a case series approach using three cases from a subset of psychiatrically hospitalized adolescents who provided intensive longitudinal data on daily urges and coping behavior after discharge following a suicide attempt. For illustration, person-specific, bidirectional links between suicidal urges and coping behavior were modeled across a series of cases using a vector autoregression approach. RESULTS: The relationship between suicidal urges and coping differed across the three individuals, who were presented to exhibit the range of this variability in the presence/absence and magnitude of effects. CONCLUSIONS: Individuals who report similar suicidal risk levels likely respond in individualized ways to suicidal urges (e.g., use different coping strategies), necessitating personalized assessment and treatment. We discuss implications for future suicide research.

Enhancing motivation and self-efficacy for safety plan use: Incorporating motivational interviewing strategies in a brief safety planning intervention for adolescents at risk for suicide.

Suicide is one of the leading causes of death among adolescents in the United States, and risk for recurring suicidal thoughts and behavior remains high after discharge from psychiatric hospitals. Safety planning, a brief intervention wherein the main focus is on identifying personal coping strategies and resources to mitigate suicidal crises, is a recommended best practice approach for intervening with individuals at risk for suicide. However, anecdotal as well as emerging empirical evidence indicate that adolescents at risk for suicide often do not use their safety plan during the high-risk postdischarge period. Thus, to be maximally effective, we argue that safety planning should be augmented with additional strategies for increasing safety plan use to prevent recurrent crises during high-risk transitions. The current article describes an adjunctive intervention for adolescents at elevated suicide risk that enhances safety planning with motivational interviewing (MI) strategies, with the goal of increasing adolescents' motivation and strengthening self-efficacy for safety plan use after discharge. We provide an overview of the intervention and its components, focusing the discussion on the in-person individual and family sessions delivered during hospitalization, and describe the theoretical basis for the MI-enhanced intervention. We then provide examples of applying MI during the process of safety planning, including example strategies that aim to elicit motivation and strengthen self-efficacy for safety plan use. We conclude with clinical case material and highlight how these strategies may be incorporated into the safety planning session. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adaptive intervention for prevention of adolescent suicidal behavior after hospitalization: a pilot sequential multiple assignment randomized trial.

BACKGROUND: The need for effective interventions for psychiatrically hospitalized adolescents who have varying levels of postdischarge suicide risk calls for personalized approaches, such as adaptive interventions (AIs). We conducted a nonrestricted pilot Sequential, Multiple Assignment, Randomized Trial (SMART) to guide the development of an AI targeting suicide risk after hospitalization. METHODS: Adolescent inpatients (N = 80; ages 13-17; 67.5% female) were randomized in Phase 1 to a Motivational Interview-Enhanced Safety Plan (MI-SP), delivered during hospitalization, alone or in combination with postdischarge text-based support (Texts). Two weeks after discharge, participants were re-randomized in Phase 2 to added telephone booster calls or to no calls. Mechanisms of change were assessed with daily diaries for four weeks and over a 1- and 3-month follow-up. This trial is registered with clinicaltrials.gov (identifier: NCT03838198). RESULTS: Procedures were feasible and acceptable. Mixed effects models indicate that adolescents randomized to MI-SP + Texts (Phase 1) and those randomized to booster calls (Phase 2) experienced significant improvement in daily-level mechanisms, including safety plan use, self-efficacy to refrain from suicidal action, and coping by support seeking. Those randomized to MI-SP + Texts also reported significantly higher coping self-efficacy at 1 and 3 months. Although exploratory, results were in the expected direction for MI-SP + Texts, versus MI-SP alone, in terms of lower risk of suicide attempts (Hazard ratio = 0.30; 95% CI = 0.06, 1.48) and suicidal behavior (Hazard ratio = 0.36; 95% CI = 0.10, 1.37) three months after discharge. Moreover, augmentation with booster calls did not have an overall meaningful impact on suicide attempts (Hazard ratio = 0.65; 95% CI = 0.17, 3.05) or suicidal behavior (Hazard ratio = 0.78; 95% CI = 0.23, 2.67); however, boosters benefited most those initially assigned to MI-SP + Texts. CONCLUSIONS: The current SMART was feasible and acceptable for the purpose of informing an AI for suicidal adolescents, warranting additional study. Findings also indicate that postdischarge text-based support offers a promising augmentation to safety planning delivered during hospitalization.

Using Intensive Longitudinal Data to Identify Early Predictors of Suicide-Related Outcomes in High-Risk Adolescents: Practical and Conceptual Considerations.

Mobile technology offers new possibilities for assessing suicidal ideation and behavior in real- or near-real-time. It remains unclear how intensive longitudinal data can be used to identify proximal risk and inform clinical decision making. In this study of adolescent psychiatric inpatients (N = 32, aged 13-17 years, 75% female), we illustrate the application of a three-step process to identify early signs of suicide-related crises using daily diaries. Using receiver operating characteristic (ROC) curve analyses, we considered the utility of 12 features-constructed using means and variances of daily ratings for six risk factors over the first 2 weeks postdischarge (observations = 360)-in identifying a suicidal crisis 2 weeks later. Models derived from single risk factors had modest predictive accuracy (area under the ROC curve [AUC] 0.46-0.80) while nearly all models derived from combinations of risk factors produced higher accuracy (AUCs 0.80-0.91). Based on this illustration, we discuss implications for clinical decision making and future research.

Differentiating Adolescent Suicide Attempters and Ideators: A Classification Tree Analysis of Risk Behaviors.

PURPOSE: Although many youth consider suicide, only a subset act on suicidal thoughts and attempt suicide. The objective of this study was to identify patterns of risk factors that differentiate adolescents who experienced suicidal thoughts from those who attempted suicide. METHODS: This study analyzed data from the 2013, 2015, and 2017 National Youth Risk Behavior Surveys. Classification tree analysis was used to identify combinations of health risk behaviors and demographic factors that improved the identification of past-year suicide attempts among adolescents with past-year suicide ideation or planning (overall n = 7,493). RESULTS: Forty percent of the past-year ideators attempted suicide in the same period. The best-performing tree included three variables and defined four subgroups. Youth characterized by heroin use and past-year physical fights were at a strikingly high risk of being attempters (78%). Youth who had experienced rape were also likely to be attempters (58%), whereas those who had endorsed none of these three variables were relatively less likely to be attempters (29%). Overall, the tree's classification accuracy was modest (area under the curve = .65). CONCLUSIONS: This study advances previous research by identifying notable constellations of risk behaviors that accounted for adolescents' transition from suicidal ideation to behavior. However, even with many health risk behavior variables, a large sample, and a multidimensional analytic approach, the overall classification of suicide attempters among ideators was limited. Implications for future research are discussed.

Augmenting Safety Planning With Text Messaging Support for Adolescents at Elevated Suicide Risk: Development and Acceptability Study.

BACKGROUND: Suicide is the second leading cause of death among adolescents. A critical need exists for developing promising interventions for adolescents after psychiatric hospitalization who are at a high risk of experiencing repeated suicidal behaviors and related crises. The high-risk period following psychiatric hospitalization calls for cost-effective and scalable continuity of care approaches to support adolescents' transition from inpatient care. Text messages have been used to improve a wide range of behavioral and health outcomes and may hold promise as an accessible continuity of care strategy for youth at risk of suicide. OBJECTIVE: In this study of 40 adolescents at elevated suicide risk, we report on the iterative development and acceptability of a text-based intervention designed to encourage adaptive coping and safety plan adherence in the high-risk period following psychiatric hospitalization. METHODS: Adolescents (aged 13-17 years) who were hospitalized because of last-month suicide attempts or last-week suicidal ideation took part in either study phase 1 (n=25; 19/25, 76% female), wherein message content was developed and revised on the basis of feedback obtained during hospitalization, or study phase 2 (n=15; 11/15, 73% female), wherein text messages informed by phase 1 were further tested and refined based on feedback obtained daily over the course of a month after discharge (n=256 observations) and during an end-of-study phone interview. RESULTS: Quantitative and qualitative feedback across the 2 study phases pointed to the acceptability of text-based support. Messages were seen as having the potential to be helpful with the transition after hospitalization, with adolescents indicating that texts may serve as reminders to use coping strategies, contribute to improvement in mood, and provide them with a sense of encouragement and hope. At the same time, some adolescents expressed concerns that messages may be insufficient for all teens or circumstances. In phase 2, the passage of time did not influence adolescents' perception of messages in the month after discharge (P=.74); however, there were notable daily level associations between the perception of messages and adolescents' affect. Specifically, higher within-person (relative to adolescents' own average) anger was negatively related to liking text messages (P=.005), whereas within-person positive affect was associated with the perception of messages as more helpful (P=.04). CONCLUSIONS: Text-based support appears to be an acceptable continuity of care strategy to support adolescents' transition after hospitalization. The implications of study findings are discussed. Future work is needed to evaluate the impact of text-based interventions on suicide-related outcomes.

Predicting suicidal behavior among lesbian, gay, bisexual, and transgender youth receiving psychiatric emergency services.

Lesbian, gay, bisexual, and transgender (LGBT) youth are at elevated risk for self-injurious thoughts and behaviors (SITBs). However, few studies have comprehensively examined SITBs and their longitudinal course in LGBT youth at high risk for suicide. The aims of the present study were to characterize histories of SITBs among high-risk LGBT youth and to examine prospective associations with suicidal behavior. Participants were 285 youth (41.8% LGBT) ages 13-25 years receiving psychiatric emergency department (ED) services. Post-discharge suicidal behavior was assessed via 4-month phone interviews and 12 month chart reviews. The sample was 42.1% male, 57.9% female, 2.5% gender minority, 41.8% sexual minority. LGBT participants were more likely to have prior psychiatric ED visits and hospitalizations, more frequent past week suicide ideation, and more severe nonsuicidal self-injury (NSSI). We conducted stratified survival analyses to identify predictors of time to suicidal behavior post discharge. The final model for LGBT youth included past week suicide ideation and past month NSSI episodes. Among non-LGBT youth, the final model included number of lifetime NSSI methods and use of a highly lethal suicide attempt method. Within this sample of youth receiving psychiatric emergency services, LGBT youth were overrepresented and had more severe histories of SITBs. Results suggest the importance of assessing both lifetime and recent factors (i.e., past week and month), particularly for LGBT youth. Future research should replicate these findings in larger samples to explore whether there are unique risk factors that can aid in predicting and preventing suicide among LGBT youth.

Short-term change and prediction of suicidal ideation among adolescents: a daily diary study following psychiatric hospitalization.

BACKGROUND: Our understanding of suicidal ideation (SI) and its risk precursors is largely informed by studies spanning over wide time intervals (weeks, months, years). Little is known about SI as it occurs in daily lives of individuals at risk for suicide, the extent to which suicidal thoughts are dynamic over short periods of time, and the degree to which theoretically informed risk factors predict near-term SI. METHODS: Thirty-four adolescents hospitalized due to last-month suicide attempt and/or last-week SI (76% female; ages 13-17) responded to daily surveys sent to their cell phones for four consecutive weeks after discharge (n = 652 observations). RESULTS: There was notable variability in day-to-day SI, with half of ideation ratings changing at least one within-person standard deviation from one day to the next. Results of mixed effects models revealed concurrent (same-day), but not short-term prospective (next-day), associations between SI (frequency, duration, urge) and well-established predictors (connectedness, burdensomeness, hopelessness). However, synergistic effects of low connectedness with either high burdensomeness or high hopelessness were reliably associated with more severe same- and next-day suicidal ideation. CONCLUSIONS: This study adds to emerging literature indicating that suicidal thoughts fluctuate considerably among individuals at risk for suicide, further extending it by focusing on adolescents in the critical posthospitalization period. Fostering high-risk adolescents' sense of connectedness to others may be an especially promising intervention target. Frequent assessment of SI and its predictors, independently and in combination, could help identify promising predictors of short-term risk and meaningful intervention targets in high-risk teens.

Rumination, Brooding, and Reflection: Prospective Associations with Suicide Ideation and Suicide Attempts.

OBJECTIVE: Rumination is often cited as a risk factor for suicide, yet few studies of rumination have utilized clinical samples, and no studies have examined its prospective association with suicide attempts. The purpose of this study was to examine concurrent and prospective associations of brooding and reflection (the two components of rumination) with suicide ideation and suicide attempts among a high-risk clinical sample. METHOD: Participants were 286 adolescents and young adults (77% Caucasian, 59% female) aged 13-25 seeking psychiatric emergency services. A majority (71%) were presenting with a primary complaint of suicide ideation or recent suicide attempt. Participants completed a baseline assessment at the index visit; 226 participants (79%) completed a 4-month follow-up assessment of suicidal thoughts and behaviors. RESULTS: Brooding was associated with lifetime history of one or more suicide attempts, but not concurrent suicide ideation. Reflection was not associated with lifetime suicide attempts or concurrent suicide ideation. Furthermore, prospective associations of brooding and reflection with suicide ideation and suicide attempts were weak-to-small in magnitude and statistically nonsignificant. CONCLUSIONS: Rumination appears to have a limited association with suicide-related outcomes within a high-risk clinical sample. Additional longitudinal studies utilizing clinical samples are critically needed to better understand these associations.

Prospective Associations of Coping Styles With Depression and Suicide Risk Among Psychiatric Emergency Patients.

Suicide is the second leading cause of death for those ages 13-25 in the United States. Coping is a mediator between stressful life events and adverse outcomes, and coping skills have been incorporated into interventions (e.g., cognitive-behavioral therapy, dialectical behavior therapy, safety-planning interventions) for suicidal populations. However, longitudinal research has not directly examined the prospective associations between multiple coping styles and suicide-related outcomes in high-risk samples. This study identified cross-sectional and 4-month longitudinal associations of coping styles with suicide risk factors (i.e., depression, suicidal ideation, suicidal behavior) in a sample of 286 adolescent and young adult psychiatric emergency patients. Positive reframing was the coping style most consistently associated with positive outcomes, whereas self-blame and disengagement were consistently associated with negative outcomes. Active coping protected against suicidal behavior for males, but not for females. This was the first study to examine longitudinal relationships between coping and suicide-related outcomes in a high-risk clinical sample. Findings suggest that clinical interventions with suicidal adolescents and young adults may benefit from a specific focus on increasing positive reframing and reducing self-blame.

Parental Self-Efficacy to Support Teens During a Suicidal Crisis and Future Adolescent Emergency Department Visits and Suicide Attempts.

This study of adolescents seeking emergency department (ED) services and their parents examined parents' self-efficacy beliefs to engage in suicide prevention activities, whether these beliefs varied based on teens' characteristics, and the extent to which they were associated with adolescents' suicide-related outcomes. Participants included 162 adolescents (57% female, 81.5% Caucasian), ages 13-17, and their parents. At index visit, parents rated their self-efficacy to engage in suicide prevention activities and their expectations regarding their teen's future suicide risk. Adolescents' ED visits for suicide-related concerns and suicide attempts were assessed 4 months later. Parents endorsed high self-efficacy to engage in most suicide prevention activities. At the same time, they endorsed considerable doubt in being able to keep their child safe if the teen has thoughts of suicide and in their child not attempting suicide in the future. Parents whose teens experienced follow-up suicide-related outcomes endorsed, at clinically meaningful effect sizes, lower self-efficacy for recognizing suicide warning signs, for obtaining the teen's commitment to refrain from suicide, and for encouraging their teen to cope, as well as lower confidence that their teen will not attempt suicide; self-efficacy to recognize warning signs was at trend level. Despite endorsing high self-efficacy for the majority of suicide prevention activities, parents of high-risk teens expressed less confidence in their capacity to influence their teen's suicidal behavior, which could undermine parents' effort to implement these strategies. The relationship between parental self-efficacy and youth suicide-related outcomes points to its potential value in guiding clinical decision making and interventions.

Positive and Negative Expectations of Hopelessness as Longitudinal Predictors of Depression, Suicidal Ideation, and Suicidal Behavior in High-Risk Adolescents.

The relationship between hopelessness and depression in predicting suicide-related outcomes varies based on the anticipation of positive versus negative events. In this prospective study of adolescents at elevated risk for suicide, we used two Beck Hopelessness Scale subscales to assess the impact of positive and negative expectations in predicting depression, suicidal ideation, and suicidal behavior over a 2- to 4-year period. In multivariate regressions controlling for depression, suicidal ideation, and negative-expectation hopelessness, positive-expectation hopelessness was the only significant predictor of depressive symptoms and suicidal behavior. Clinical interventions may benefit from bolstering positive expectations and building optimism.