A call to action: informing research and practice in suicide prevention among individuals with psychosis.

Although it is well established that individuals living with psychosis are at increased risk for suicidal ideation, attempts, and death by suicide, several gaps in the literature need to be addressed to advance research and improve clinical practice. This Call-to-Action highlights three major gaps in our understanding of the intersection of psychosis and suicide as determined by expert consensus. The three gaps include research methods, suicide risk screening and assessment tools used with persons with psychosis, and psychosocial interventions and therapies. Specific action steps to address these gaps are outlined to inform research and practice, and thus, improve care and prognoses among persons with psychosis at risk for suicide.

Preferences of U.S. Veterans Making and Receiving Caring Cards: A Peer Approach to Recovery-Oriented Suicide Prevention.

Caring Cards is a peer-adaptation of caring contacts for suicide prevention, in which people with lived experience of suicidal thoughts and behaviors create handmade cards for peers currently experiencing suicidal thoughts and/or behaviors. The present study used data from a feasibility/acceptability study of Caring Cards at a Veterans Affairs Medical Center to explore preferences for this type of recovery-oriented suicide prevention intervention. Participants were 55 Veterans with a past (card makers, n=21) or current (card recipients, n=34) high-risk indication for suicide. Card makers participated in a 3-month weekly 60-120-minute group therapy to create cards. Card recipients received these cards monthly for six months. Survey and interview data were collected post-intervention. Pragmatic analysis of interview responses revealed preferences related to participation length, card content and frequency, group formatting, and accessibility. Among both card makers (76.2%-85.7%) and card recipients (94.1%), a majority recommended offering this intervention for Veterans who have previously or are currently struggling with mental health concerns. Over 60% of card makers wanted receive cards and 52.9% of card recipients wanted to make cards. These data further support the importance of lived experience voices in intervention development. Caring Cards, an intervention specifically focusing on improving well-being, meaning-making, and fulfillment in one's life, regards Veteran preferences as salient in the future implementation of a recovery-oriented approach to suicide prevention.

Functional impairment, internalized stigma, and well-being: Considerations for recovery-oriented suicide prevention for U.S. Veterans with serious mental illness.

Veterans Health Administration's (VHA) Psychosocial Rehabilitation and Recovery Centers (PRRCs) provide recovery-oriented care to Veterans with serious mental illness (SMI). As part of program evaluation, PRRC providers regularly assess recovery-oriented outcomes. Given the high rates of suicidal thoughts and behaviors among Veterans with SMI, understanding such outcomes in relation to suicide risk is crucial. Among Veterans entering a PRRC (N=4,731), the present study aimed to a) report suicidal ideation frequency in the past two weeks across demographics and psychiatric diagnoses, b) explore rates of current functional impairment, internalized stigma, and well-being, and c) examine differences in suicidal ideation frequency and functional impairment, internalized stigma, and well-being. Measurements before treatment were utilized. Younger (ρ=-.08, p<.001), married (z=-5.23, p<.001) Veterans, those not identifying as Black or African American (z=-4.80, p<.001), not diagnosed with schizophrenia (z=-6.97, <.001), diagnosed with depressive disorders (z=-8.79, <.001), anxiety disorders (z=-5.01, <.001), posttraumatic stress disorder (z=-7.69, <.001), or personality disorders (z=-7.12, <.001) were significantly more likely to endorse suicidal ideation. Veterans in this cohort had higher than average functional impairment (M=18.05, SD=9.85), mild internalized stigma (M=2.36, SD=0.51), and lower than average well-being (M=18.96, SD=3.93). The more often a Veteran reported thinking about suicide in the past two weeks, the more likely the Veteran viewed themselves to be more functionally impaired (p<.001), reported higher levels of internalized stigma (p<.001), and reported lower levels of well-being (p<.001). Findings and limitations, particularly the suicidal ideation frequency measurement, are discussed to contextualize suggestions to integrate recovery-oriented practices and suicide prevention care.

Are all reasons for living made equally? Reasons for living and dysfunctional attitudes in psychotic disorders and bipolar I.

OBJECTIVES: Persons with schizophrenia, schizoaffective, or bipolar I disorder are more likely to die by suicide compared to the general population. Dysfunctional attitudes have been shown to be significant predictors of cognitive vulnerability to depression, hopelessness, and poor problem-solving skills, which predict suicidal ideation. Dysfunctional attitudes are common in persons with schizophrenia spectrum disorders (SSDs) and bipolar I. The Reasons for Living Inventory (RFLI) examines distinct reasons for not dying by suicide. This study's objectives were to examine the relationship between the RFLI subscales and dysfunctional attitudes among persons with SSDs and bipolar I. We hypothesized significant positive correlations between two RFLI subscales (Fear of Suicide and Fear of Social Disapproval) and total score on the Dysfunctional Attitude Scale (DAS). We did not expect significant correlations between other subscales. DESIGN AND METHODS: This correlational, cross-sectional study examined baseline scores on the RFLI and dysfunctional attitudes (DAS) among N = 102 outpatients with SSDs or bipolar I. RESULTS: Significant positive correlations were observed between RFLI subscales Fear of Suicide and Fear of Social Disapproval and DAS total scores. No other significant relationships were observed. CONCLUSIONS: Certain reasons for living (i.e. fear of suicide and social disapproval) may be associated with dysfunctional attitudes among persons with SSDs or bipolar I. These, in turn, may place these individuals at a greater risk for suicide by increasing their cognitive vulnerability. These findings may inform clinical treatment targets for persons with SSDs and bipolar I.

Testing the interpersonal theory of suicide in a sample of sexual minority young adults: Attention to within-group differences.

INTRODUCTION: This study investigated demographic differences in interpersonal theory of suicide factors and their associations with suicide attempts among sexual minority young adults. METHODS: 784 sexual minority young adults ages 18-29 (42.7% cisgender men, 42.2% cisgender women, 15.1% transgender/gender diverse; 62.2% non-Hispanic White; 50.5% gay/lesbian, 49.5% bisexual+) completed an online survey assessing lifetime suicide attempts and interpersonal theory of suicide factors. RESULTS: Demographic differences included (1) greater perceived burdensomeness among transgender/gender diverse participants compared to other gender groups; (2) greater acquired capability for suicide and suicide attempts among cisgender men compared to cisgender women; (3) greater acquired capability for suicide among bisexual+ compared to gay/lesbian participants; and (4) a lower number of suicide attempts among Asian/Asian American sexual minority participants compared to most other sexual minority participants. All interpersonal theory of suicide factors were significantly associated with a higher number of suicide attempts, though only perceived burdensomeness and acquired capability for suicide remained significant when examining all three simultaneously. No two- or three-way interactions between interpersonal theory of suicide factors were significant. CONCLUSION: The interpersonal theory of suicide may be useful for understanding suicide attempts in this population, with perceived burdensomeness and acquired capability being particularly relevant to consider.

Pilot feasibility trial of a brief mobile-augmented suicide prevention intervention for serious mental illness.

OBJECTIVE: People with serious mental illnesses (SMIs) are at high risk for suicidal ideation and behavior, and yet few suicide prevention interventions have been customized for this group. We describe the outcomes of a pilot trial of Mobile SafeTy And Recovery Therapy (mSTART), a four-session suicide-focused cognitive behavioral intervention for SMI, designed for the transition from acute to outpatient care and augmented with ecological momentary intervention to reinforce intervention content. METHODS: The primary objective of this pilot trial was to evaluate the feasibility, acceptability, and preliminary effectiveness of START. Seventy-eight people with SMI and elevated suicidal ideation were randomized to either: (a) mSTART or (b) START alone (i.e., without mobile augmentation). Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of mobile intervention), and 24 weeks. The primary outcome of the study was change in suicidal ideation severity. Secondary outcomes included psychiatric symptoms, coping self-efficacy, and hopelessness. RESULTS: A total of 27% of randomized persons were lost to follow-up after baseline, and engagement with mobile augmentation was variable. There was clinically significant improvement (d = 0.86) in suicidal ideation severity scores sustained over 24 weeks, with similar effects seen for secondary outcomes. Preliminary comparison indicated a medium effect size (d = 0.48) advantage at 24 weeks of mobile augmentation in suicidal ideation severity scores. Treatment credibility and satisfaction scores were high. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: START, regardless of mobile augmentation, was associated with sustained improvement in suicidal ideation severity and secondary outcomes in people with SMI at-risk for suicide in this pilot trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Suicide-Focused Group Therapy.

Background: Although there are several studies focusing on group models for therapy specific to suicidal thoughts and behaviors, scoping reviews providing an overview of these studies' findings are limited. Aims: The aim of this paper was to conduct a scoping review of group therapies that explicitly target suicidal thoughts and behaviors (i.e., suicide-focused) for adults and their suicide-related outcomes. Methods: Following the PRISMA-ScR guidelines, a literature search using PubMed, Cochrane Library, and PsycINFO to identify relevant records published between 2000 and 2021 as well as a review of reference lists from relevant records was conducted. Results: There were 14 records identified with 12 unique suicide-focused group therapies. Even with variable methodological designs, sample sizes (M = 136, SD = 98), and population targeted, all records showed reductions in suicide-related outcomes by the end of the therapy; although most were not powered to determine effectiveness. Limitations: This review only included records written in English and excluded support groups that were led by peers as the focus was on therapy groups and gray literature. Conclusions: There are few evaluated therapy groups that explicitly address suicidal thoughts and behaviors. Available data indicate suicide-focused group therapy are generally feasible, acceptable, and may reduce suicidal-related outcomes. This is encouraging for future research; recommendations to include randomized controlled trials of the efficacy of suicide-focused group therapy are discussed.

A peer approach to suicide prevention and recovery: Study protocol for a feasibility and acceptability trial of Caring Cards for veterans.

Introduction: There is a need to develop, evaluate, and implement interventions that reduce Veteran suicide. Caring Cards (CC) is a novel intervention that integrates aspects of caring contacts and peers (i.e., persons with lived mental health experience). In CC, Veterans meet in a weekly group to create hope-filled cards that are sent to Veterans with mental health concerns. This study will examine feasibility and acceptability of CC with Veterans with a history of and current elevated suicide risk via in-person and virtual modalities and preliminarily evaluate pre/post changes on suicide-specific outcomes. Methods: This 2-year open-trial study will employ a pre/post research design. Recruited Veterans with a history of suicide risk (n = 30) will make up CC groups (card makers) and Veterans currently at high-risk for suicide (n = 50) will be card recipients. Feasibility and acceptability (recruitment, retention, attendance, card receipt rates, and satisfaction questionnaire responses) and pre/post changes on suicide-specific outcomes (i.e., thwarted belonginess, perceived burdensomeness, social connectedness, suicidal ideation, and behavior) will be evaluated. Groups will meet weekly for 90-120 min for three to six months; card recipients will receive one card per month for six months. Discussion: This study builds on preliminary data which indicate Veterans are interested in and find participating in CC highly meaningful. This study is innovative as it will target two new Veteran populations and use both in-person and virtual modalities. If feasible and acceptable, a large-scale efficacy trial will be conducted to further examine CC as a suicide prevention intervention for Veterans.

Designed and created for a veteran by a veteran: A pilot study of caring cards for suicide prevention.

INTRODUCTION: This pilot study investigates feasibility and acceptability of Caring Cards, a suicide prevention intervention inspired by Caring Contacts and the Recovery Model, where Veteran peers create cards that are sent to Veterans recently discharged from a VA psychiatric hospitalization for suicide risk. METHODS: Caring Cards consists of: (1) a weekly outpatient group where Veterans (card makers) create cards, and (2) sending cards to recently discharged Veterans (card recipients). Feasibility for card makers was measured by attendance; acceptability (satisfaction) was examined. Card recipients were sent one caring card, one week post-discharge. Feasibility for recipients was measured by the percentage of Veterans that met eligibility and follow-up response rate; acceptability (satisfaction) was examined. RESULTS: Caring Cards is feasible and acceptable. The outpatient group had a higher attendance rate (81%) compared with other clinic groups. The percentage of eligible card recipients was 61%. Of these, 69% were reached for follow-up and 50% provided follow-up responses. Card makers and recipients both expressed positive experiences with Caring Cards. CONCLUSION: Caring Cards is a low-intensity, feasible, and acceptable intervention with potential benefits for both Veteran card makers and recipients. Additional research is needed to determine the efficacy of Caring Cards as a suicide prevention intervention.

A Brief Mobile-Augmented Suicide Prevention Intervention for People With Psychotic Disorders in Transition From Acute to Ongoing Care: Protocol for a Pilot Trial.

BACKGROUND: People with serious mental illnesses (SMIs) are at exceptionally high risk for lifetime suicidal ideation and behavior compared with the general population. The transition period between urgent evaluation and ongoing care could provide an important setting for brief suicide-specific interventions for SMIs. To address this concern, this trial, SafeTy and Recovery Therapy (START), involves a brief suicide-specific cognitive behavioral intervention for SMIs that is augmented with mobile phone interactions. OBJECTIVE: The primary aim of this pilot trial is to evaluate the feasibility, acceptability, and preliminary effectiveness of the intervention. METHODS: A 6-month pilot trial with 70 participants with a diagnosis of bipolar disorder, schizophrenia or schizoaffective disorder, and current active suicidal ideation were randomized to START or START with mobile augmentation. START consists of 4 weekly sessions addressing early warning signs and triggers, symptoms influencing suicidal thinking, and social relationships. Recovery planning is followed by biweekly telephone coaching. START with mobile augmentation includes personalized automated cognitive behavioral therapy scripts that build from in-person content. Participants were evaluated at baseline, 4 weeks (end of in-person sessions), 12 weeks (end of telephone coaching), and 24 weeks. In addition to providing point estimates of feasibility and acceptability, the primary outcome of the trial was the change in severity of suicidal ideation as measured with the Scale for Suicide Ideation (SSI) and secondary outcome included the rate of outpatient engagement. RESULTS: The trial is ongoing. Feasibility and acceptability across conditions will be assessed using t tests or Mann-Whitney tests or chi-square tests. The reduction of SSI over time will be assessed using hierarchical linear models. CONCLUSIONS: The design considerations and results of this trial may be informative for adapted suicide prevention in psychotic disorders in applied community settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03198364; http://clinicaltrials.gov/ct2/show/NCT03198364. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14378.

Systematic Review of the Inclusion of People With Psychosis in Suicide-Specific Clinical Trials.

Background: Psychosis is a significant, yet understudied, risk factor for suicide. There has yet to be a systematic investigation examining the rate and predictors of inclusion of psychotic disorders or symptoms in suicide-focused trials. Aim: Our aim was to conduct a systematic review of inclusion/exclusion of psychosis in studies with suicidal ideation or behavior as a primary endpoint, rate of inclusion across intervention type and other characteristics, and criteria used to exclude psychosis and accompanying rationale. Method: A literature search was conducted using PubMed, Cochrane Library, and PsycInfo to identify relevant articles published between 2000 and 2018. Statements regarding inclusion/exclusion were codified by authors. Results: Out of 122 studies selected, 75 (61.5%) excluded individuals with psychosis. This rate varied by intervention and sample size, but not by year of study or country of origin. Only 9% provided a rationale for psychosis exclusion. Limitations: Minimal reporting of participants' diagnosis in studies disallowed analysis of the rate of inclusion of psychosis in samples. Conclusion: Three out of five trials with suicide-related primary outcomes excluded psychosis; thus, people with psychosis are poorly represented in suicide-specific studies. This disparity could be remedied by either adapting protocols to include people with psychosis or developing new, tailored treatments.