Implementing and evaluating a veterans crisis line quality improvement initiative: The safety planning pilot program.

The Veterans Crisis Line (VCL) is part of the U.S. Department of Veterans Affairs' suicide prevention mission. In 2021, VCL assessed the impact of a pilot implementation project of conducting six-part safety plans (SPs) instead of VCL's usual risk mitigation plan. VCL responders offered to complete six-part SPs with eligible callers. Parametric and nonparametric methods compared call characteristics and Veteran Health Administration (VHA) utilization of eligible callers, by SP completion. We forecasted the operational impact of VCL-wide implementation. 27.37% (N = 448/1,637) of calls to designated responders were eligible for SPs. Of those, 27.23% (N = 122/448) completed SPs. Common barriers were call interruptions and the veteran declining. Among veteran callers who use VHA, SP completers were more likely to accept clinical referrals and had more outpatient mental health appointments before and after their VCL call. Calls involving SPs had a call plus documentation time 175% longer than eligible calls without SPs (87.78 vs. 49.66 min). If SPs were implemented VCL-wide, this would require 3-5(4.12%) more responders per hour to maintain current VCL call answer speed. SPs are adaptable to VCL; however, implementation presents logistical barriers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Optimizing the Beck Scale for Suicide Ideation: An Item Response Theory Approach Among U.S. Military Personnel.

The Beck Scale for Suicide Ideation (BSS) is one of the most used and empirically supported suicide risk assessment measures for behavioral health clinicians and researchers. However, the 19-item BSS is a relatively long measure and can take 5 to 10 minutes to administer. This study used Item Response Theory (IRT) techniques across two samples of mostly U.S. military service members to first identify (n1 = 1,899) and then validate (n2 = 757) an optimized set of the most informative BSS items. Results indicated that Items 1, 2, 4, 6, and 15 provided a similar-shaped test information curve across the same range of the latent trait as the full-length BSS and showed reliable item functioning across participant characteristics. The sum score of these five items showed a linear score linkage with the full-scale score, ρ > 0.87, and was equally as sensitive as the full scale for prospectively predicting near-term suicidal behavior at 74% with a cut score ≥1 (equivalent to full-scale score ≥6). Results are consistent with those from civilian samples. In time- or length-limited assessments, using these five BSS items may improve administration efficiency over the full BSS, while maintaining classification sensitivity.This study suggests that summing Items 1, 2, 4, 6, and 15 of the Beck Scale for Suicide Ideation (BSS) is an acceptable approach for shortening the full-length measure.

Past Levels of Mental Health Intervention and Current Nondisclosure of Suicide Risk Among Men Older Than Age 50.

Suicide risk screening depends heavily on accurate patient self-report. However, past negative experiences with mental health care may contribute to intentional nondisclosure of suicide risk during screening. This study investigated among 282 men older than age 50 whether likelihood for current explicit risk nondisclosure was associated with previous highest level of mental health care received. This sample was selected post hoc out of a larger sample of participants from higher risk and lower help-seeking populations (i.e., military service members and veterans, men older than age 50, and lesbian gay bisexual, transgender, and queer young adults), however, the other groups were underpowered for analysis. Among these men, history of psychiatric hospitalization was significantly associated with likelihood for explicit nondisclosure of current suicide risk, while history of receiving only outpatient therapy for suicidal thoughts or behaviors was significantly associated with likelihood for full reporting of suicide risk. Severity of suicidal ideation and internalized stigma against mental illness were significant indirect contributors to the effect. Although causality could not be determined, results suggest that a potential cost to consider for psychiatric hospitalization may be future nondisclosure of suicide risk. Conversely, outpatient interventions that appropriately manage suicidal thoughts or behaviors may encourage future full reporting of suicide risk and improve screening detection.

Pilot study of the Collaborative Assessment and Management of Suicidality-Group.

INTRODUCTION: Few evidence-based options exist for outpatient treatment of patients at risk of suicide, and to-date almost all research has focused on individually delivered psychotherapy. Group therapy for veterans at risk of suicide is a promising alternative. METHODS: Thirty veterans receiving care at an urban Veterans Affairs Medical Center in the southern United States were randomized to either care as usual (CAU) or to CAU plus the Collaborative Assessment and Management of Suicide-Group (CAMS-G). Veterans were assessed prior to randomization to condition and at 1, 3, and 6 months post-randomization on a range of suicide-specific measures, burdensomeness, belonging, treatment satisfaction, and group cohesion. RESULTS: Across measures and follow-up assessments, veterans in CAMS-G reported good satisfaction with the intervention, a sense of cohesion with other members of the group, and reduced symptom distress. Veterans in both conditions reported decreases in suicidal ideation and behavior, with CAMS-G participants potentially improving slightly faster. CONCLUSION: This description of CAMS-G for veterans adds to the growing literature on suicide-specific interventions and supports the need for additional research to determine if wide-spread rollout is justifiable.

Allowing nondisclosure in surveys with suicide content: Characteristics of nondisclosure in a national survey of emergency services personnel.

Suicide is a leading cause of morbidity, yet a significant challenge to receiving adequate support is an unwillingness to disclose mental health issues. The current study explores reasons for nondisclosure among emergency personnel, a population at risk of developing mental health problems. Twenty-nine police, ambulance, and fire and rescue agencies from around Australia participated in a mental health and wellbeing survey (N = 14,536, male = 60.5%, 52.0% over 45 years of age, heterosexual = 92.5%). Rates of mental health issues and perceptions of stigma were compared between participants who answered suicide-related questions and those who preferred not to say. Participants who preferred not to answer suicide-related questions (n = 1,098) reported higher rates of psychological distress (symptoms of depression and anxiety), and lower wellbeing and social support, than those who reported suicidal thoughts (n = 1,966) or no suicidal thoughts (n = 11,472). Perceptions of mental health stigma within the workplace, and regarding one's own mental health, also tended to be higher among nonresponders. Imputing their responses based on this survey information resulted in notably higher rates of estimated suicidal thoughts, plans, and attempts. Allowing for nondisclosure in self-report measures of suicide may provide more accurate prevalence estimates and facilitate identification of individuals most at risk of suicide. Addressing stigma in the workplace and also regarding one's own mental health issues may act to improve disclosure of suicidal thoughts and adaptive help-seeking behaviors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Improving Our Understanding of the Death/Life Implicit Association Test.

The "Death/Life" Implicit Association Test (d-IAT) is a reaction-time task which has been associated with past and future suicidal behavior; in some work, the association has been incremental to explicit self-report of suicide risk. Proposed mechanisms for this association relate to one's unwillingness or inability to completely disclose or be introspectively aware of implicit risk. This study investigated moderators of implicit-explicit concordance as well as predictors of d-IAT score unexplained by self-reported suicidal thoughts and behaviors among an online sample of 382 adults with higher demographic suicide risk (i.e., military service members and veterans, men over age 50, and LGBTQ young adults). Before and after controlling for current explicit report, results replicated the finding of a significant relationship between d-IAT score and severity of past suicidal behavior, and additionally indicated that suicide attempt history and wish to live moderated the association between d-IAT score and explicit report. Furthermore, results suggest that poor introspective awareness, rather than deception, may account for differences between implicit and explicit risk assessment. Continuing investigation of moderators and mechanisms of the d-IAT is needed to improve the utility and validity of using implicit suicide risk assessment as a clinical tool.

Allowing for Nondisclosure in High Suicide Risk Groups.

Inaccurate disclosure of information is a significant limitation when relying on self-report for suicide risk screening. However, allowing for an explicit nondisclosure response option in screening items (e.g., "prefer not to disclose") may ultimately improve follow-up assessment validity. This study investigated explicit nondisclosure in suicide risk screening among military service members and veterans (n = 135), men older than 50 years, (n = 187), and LGBTQ (lesbian, gay, bisexual, transgender, or queer) young adults (n = 140); all higher risk and lower help-seeking populations. Results indicated that allowing for explicit nondisclosure minimally affected screening sensitivity and specificity. However, its selection was prevalent among higher risk participants, and was associated with experience of past unhelpful reactions and "avoidance of stigmatized consequences." Allowing for nondisclosure creates potential psychometric and classification advantages, and may be a safe and effective way to encourage discussion of barriers, build trust, maximize patient autonomy, and ultimately facilitate accurate risk disclosure to improve assessment validity.

Anxiety, depression, and the suicidal spectrum: a latent class analysis of overlapping and distinctive features.

Anxiety and depression diagnoses are associated with suicidal thoughts and behaviours. However, a categorical understanding of these associations limits insight into identifying dimensional mechanisms of suicide risk. This study investigated anxious and depressive features through a lens of suicide risk, independent of diagnosis. Latent class analysis of 97 depression, anxiety, and suicidality-related items among 616 psychiatric outpatients indicated a 3-class solution, specifically: (1) a higher suicide-risk class uniquely differentiated from both other classes by high reported levels of depression and anxious arousal; (2) a lower suicide-risk class that reported levels of anxiety sensitivity and generalised worry comparable to Class 1, but lower levels of depression and anxious arousal; and (3) a low to non-suicidal class that reported relatively low levels across all depression and anxiety measures. Discriminants of the higher suicide-risk class included borderline personality disorder; report of worthlessness, crying, and sadness; higher levels of anxious arousal and negative affect; and lower levels of positive affect. Depression and anxiety diagnoses were not discriminant between higher and lower suicide risk classes. This transdiagnostic and dimensional approach to understanding the suicidal spectrum contrasts with treating it as a depressive symptom, and illustrates the advantages of a tripartite model for conceptualising suicide risk.

Conceptual and Empirical Scrutiny of Covarying Depression Out of Suicidal Ideation.

Depression and suicidal ideation are highly intertwined constructs. A common practice in suicide research is to control for depression when predicting suicidal ideation, yet implications of this practice have not been subjected to sufficient empirical scrutiny. We explore what, precisely, is represented in a suicidal ideation variable with depression covaried out. In an adult psychiatric outpatient sample ( N = 354), we computed two variables-depression with suicidal ideation covaried out, and suicidal ideation with depression covaried out-and examined correlations between these residuals, three factors comprising a variegated collection of psychological correlates of suicidal ideation, psychiatric diagnoses, and past suicidal behavior. Findings indicated that suicidal ideation with depression covaried out appears to be characterized by fearlessness about death, self-sacrifice, and externalizing pathology. We propose that suicidal ideation may comprise two distinct components: desire for death (passive ideation and depressive cognitions) and will (self-sacrifice, fearlessness, externalizing behavior). Implications, limitations, and future directions are discussed.

Implicit Measures of Suicide Risk in a Military Sample.

Suicide has become an issue of great concern within the U.S. military in recent years, with recent reports indicating that suicide has surpassed combat related deaths as the leading cause of death. One concern regarding suicide risk in the military is that existing self-report measures allow service members to conceal or misrepresent current suicidal ideation or suicide plans and preparations. Implicit association tests (IATs) are computer-based, reaction time measures that have been shown to be resilient to such masking of symptoms. The death/suicide implicit association test (d/s-IAT) is an empirically supported IAT that is specific to death and suicide. The present study examined whether the performance of 1,548 U.S. military service members on the d/s-IAT significantly predicted lifetime suicidal ideation and depression. Zero-inflated negative binomial regression analyses were used to test these associations. Results indicated that the d/s-IAT was neither associated with history of suicidal ideation nor history of depression.

Initial validation of brief measures of suicide risk factors: Common data elements used by the Military Suicide Research Consortium.

The Military Suicide Research Consortium (MSRC) developed a 57-item questionnaire assessing suicide risk factors, referred to as the Common Data Elements (CDEs), in order to facilitate data sharing and improve collaboration across independent studies. All studies funded by MSRC are required to include the CDEs in their assessment protocol. The CDEs include shortened measures of the following: current and past suicide risk, lethality and intent of past suicide attempts, hopelessness, thwarted belongingness, anxiety sensitivity, posttraumatic stress disorder symptoms, traumatic brain injury, insomnia, and alcohol abuse. This study aimed to evaluate the psychometric properties of the CDE items drawn from empirically validated measures. Exploratory factor analysis was used to examine the overall structure of the CDE items, and confirmatory factor analyses were used to evaluate the distinct properties of each scale. Internal consistencies of the CDE scales and correlations with full measures were also examined. Merged data from 3,140 participants (81.0% military service members, 75.6% male) across 19 MSRC-funded studies were used in analyses. Results indicated that all measures exhibited adequate internal consistency, and all CDE shortened measures were significantly correlated with the corresponding full measures with moderate to strong effect sizes. Factor analyses indicated that the shortened CDE measures performed well in comparison with the full measures. Overall, our findings suggest that the CDEs are not only brief but also provide psychometrically valid scores when assessing suicide risk and related factors that may be used in future research. (PsycINFO Database Record

The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research.

Over the past decade, the interpersonal theory of suicide has contributed to substantial advances in the scientific and clinical understanding of suicide and related conditions. The interpersonal theory of suicide posits that suicidal desire emerges when individuals experience intractable feelings of perceived burdensomeness and thwarted belongingness and near-lethal or lethal suicidal behavior occurs in the presence of suicidal desire and capability for suicide. A growing number of studies have tested these posited pathways in various samples; however, these findings have yet to be evaluated meta-analytically. This paper aimed to (a) conduct a systematic review of the unpublished and published, peer-reviewed literature examining the relationship between interpersonal theory constructs and suicidal thoughts and behaviors, (b) conduct meta-analyses testing the interpersonal theory hypotheses, and (c) evaluate the influence of various moderators on these relationships. Four electronic bibliographic databases were searched through the end of March, 2016: PubMed, Medline, PsycINFO, and Web of Science. Hypothesis-driven meta-analyses using random effects models were conducted using 122 distinct unpublished and published samples. Findings supported the interpersonal theory: the interaction between thwarted belongingness and perceived burdensomeness was significantly associated with suicidal ideation; and the interaction between thwarted belongingness, perceived burdensomeness, and capability for suicide was significantly related to a greater number of prior suicide attempts. However, effect sizes for these interactions were modest. Alternative configurations of theory variables were similarly useful for predicting suicide risk as theory-consistent pathways. We conclude with limitations and recommendations for the interpersonal theory as a framework for understanding the suicidal spectrum. (PsycINFO Database Record

The Associations Between Army National Guard Versus Active Duty Soldier Status and Perceived Burdensomeness, Thwarted Belongingness, and Acquired Capability.

OBJECTIVE: This study aimed to examine if levels of thwarted belongingness, perceived burdensomeness, and acquired capability significantly differed between guardsmen and active duty soldiers. METHOD: Multivariate analysis of covariance was used to test for differences between active duty Army (n = 1,393) and Army National Guard (n = 623) groups, before and after controlling for the effects of age, gender, race, marital status, level of education, and deployment history. RESULTS: Guardsmen reported significantly higher mean levels of thwarted belongingness and perceived burdensomeness than did active duty soldiers, even after adjusting for demographic differences. Guardsmen also reported slightly lower levels of acquired capability, though this effect was accounted for by demographic differences. CONCLUSION: These findings support the notion that National Guard and active duty soldiers differ on perceived burdensomeness and thwarted belongingness. Additional research investigating sources of perceived burdensomeness and thwarted belongingness among guardsmen is needed.

"Are You Having Thoughts of Suicide?" Examining Experiences With Disclosing and Denying Suicidal Ideation.

OBJECTIVE: To characterize individuals' prior experiences with being asked whether they are having thoughts of suicide and to understand factors that affected their response accuracy. METHOD: Undergraduates (N = 306) reporting a lifetime history of suicidal ideation completed a web-based survey about their experiences being probed about suicidal thoughts. RESULTS: Nearly two-thirds of participants (63.1%) reported having been previously asked whether they were having thoughts of suicide, with health care providers comprising the plurality of probers. Individuals reported the greatest accuracy of ideation disclosure to mental health professionals. Stigma-related concerns were the most common barriers to accurate disclosure of ideation, whereas wanting emotional support and the prober to understand them were cited as facilitators for accurately responding. CONCLUSION: A number of factors influence the accurate and inaccurate disclosure of suicidal ideation. Further research is needed to understand how to facilitate accurate disclosure of suicidal ideation across settings and populations.

Ethical Issues and Practical Challenges in Suicide Research.

BACKGROUND: Research with human subjects represents a critical avenue for suicide prevention efforts; however, such research is not without its ethical and practical challenges. Specifically, given the nature of research with individuals at elevated risk for suicide (e.g., increased concerns regarding participant safety, adverse events, liability, difficulties often arise during the institutional review board (IRB) evaluation and approval process. AIMS: This paper aims to discuss IRB-related issues associated with suicide prevention research, including researcher and IRB panel member responsibilities, suicide risk assessment and management ethics and procedures, informed consent considerations, preparation of study protocols, and education and training. Points to consider and components to potentially include in an IRB application for suicide-related research are additionally provided. METHOD: Literature relevant to ethics in suicide research and suicide risk assessment and management was reviewed and synthesized. RESULTS: Suicide research can be conducted in accordance with ethical principles while also furthering the science of suicide prevention. CONCLUSION: Despite the challenging nature of suicide prevention research, empirically informed solutions exist to address difficulties that may emerge in interfacing with IRBs. There remain areas for improvement in the IRB approval process that warrant further investigation and work.

Insomnia and suicide-related behaviors: A multi-study investigation of thwarted belongingness as a distinct explanatory factor.

BACKGROUND: Insomnia is a robust correlate of suicidal ideation and behavior. Preliminary research has identified thwarted belongingness (c.f. social disconnection) as an explanatory link between insomnia and suicidal ideation. OBJECTIVES: This study replicates and extends previous findings using both cross-sectional and longitudinal designs in four demographically diverse samples. Additionally, the specificity of thwarted belongingness was evaluated by testing anxiety as a rival mediator. METHOD: Self-report measures of insomnia symptoms, thwarted belongingness, suicidal ideation and behavior, and anxiety were administered in four adult samples: 469 undergraduate students, 352 psychiatric outpatients, 858 firefighters, and 217 primary care patients. RESULTS: More severe insomnia was associated with more severe thwarted belongingness and suicidality. Thwarted belongingness significantly accounted for the association between insomnia and suicidality, cross-sectionally and longitudinally, beyond anxiety. Notably, findings supported the specificity of thwarted belongingness: anxiety did not significantly mediate the association between insomnia and suicidality, and insomnia did not mediate the relation between thwarted belongingness and suicidality. LIMITATIONS: This study relied solely on self-report measures. Future studies incorporating objective sleep measurements are needed. CONCLUSION: Findings underscore the utility of assessing and addressing sleep disturbances and social disconnection to reduce suicide risk.

Evidence for the Propositions of the Interpersonal Theory of Suicide Among a Military Sample.

OBJECTIVE: Although the interpersonal theory of suicide may explain the elevated suicide risk among military service members, past explorations have been equivocal. This study aimed to investigate the propositions of the interpersonal theory in a sample of U.S. Army recruiters. METHOD: Participants (N = 3,428) completed self-report measures assessing the interpersonal theory's constructs (i.e., thwarted belongingness (TB), perceived burdensomeness (PB), acquired capability for suicide), current suicidal ideation, agitation, and insomnia. History of depression was obtained from medical records. RESULTS: Hierarchical multiple regression analyses revealed that the interaction between TB and PB was associated with current suicidal ideation, controlling for depression, agitation, and insomnia. This effect was especially notable among those with high capability for suicide. CONCLUSION: Findings provide support for the interpersonal theory in a large, diverse military sample. It may be advantageous to assess and therapeutically address TB and PB among at-risk service members.

Insomnia brings soldiers into mental health treatment, predicts treatment engagement, and outperforms other suicide-related symptoms as a predictor of major depressive episodes.

Given the high rates of suicide among military personnel and the need to characterize suicide risk factors associated with mental health service use, this study aimed to identify suicide-relevant factors that predict: (1) treatment engagement and treatment adherence, and (2) suicide attempts, suicidal ideation, and major depressive episodes in a military sample. Army recruiters (N = 2596) completed a battery of self-report measures upon study enrollment. Eighteen months later, information regarding suicide attempts, suicidal ideation, major depressive episodes, and mental health visits were obtained from participants' military medical records. Suicide attempts and suicidal ideation were very rare in this sample; negative binomial regression analyses with robust estimation were used to assess correlates and predictors of mental health treatment visits and major depressive episodes. More severe insomnia and agitation were significantly associated with mental health visits at baseline and over the 18-month study period. In contrast, suicide-specific hopelessness was significantly associated with fewer mental health visits. Insomnia severity was the only significant predictor of major depressive episodes. Findings suggest that assessment of sleep problems might be useful in identifying at-risk military service members who may engage in mental health treatment. Additional research is warranted to examine the predictive validity of these suicide-related symptom measures in a more representative, higher suicide risk military sample.

Does Suicidal Ideation Influence Memory? A Study of the Role of Violent Daydreaming in the Relationship Between Suicidal Ideation and Everyday Memory.

Individuals at risk for suicide experience periods of emotional, enduring, and vivid thoughts about their death by suicide and frequently report violent daydreams about death. Daydreaming is associated with forgetfulness and memory impairments. However, no studies have examined whether suicidal ideation is associated with deficits in everyday memory capabilities and whether violent daydreaming may influence these relationships. This study tested these hypotheses in a sample of 512 young adults. Self-report measures of subjective everyday memory capabilities, violent daydreaming, and suicidal ideation were administered. Results indicated that suicidal ideation and violent daydreaming were each significantly associated with greater impairments in everyday memory retrieval and everyday memory encoding (i.e., attentional tracking). Furthermore, violent daydreaming accounted for the relationship between suicidal ideation and impairments in everyday memory retrieval and memory encoding. Notably, findings remained after controlling for gender and depressive symptoms, a robust predictor of memory impairments. Implications and limitations are discussed.

Who are we missing? Nondisclosure in online suicide risk screening questionnaires.

The use of self-report surveys for suicide risk screening is a key first step in identifying currently suicidal individuals and connecting them with appropriate follow-up assessment and care. Online methods for suicide risk screening are becoming more common, yet they present a number of complexities compared with traditional methods. This study aimed to assess whether forcing item responses may unintentionally hide or misrepresent otherwise useful missing suicide risk data. We investigated in secondary analyses of 3 independent samples of undergraduates (ns = 1,306; 694; 172) whether participants who chose not to respond specifically to current suicide risk screening items (i.e., Nondisclosers) scored significantly different from other risk response groups (i.e., Deniers, Lower-Risk Endorsers, and Higher-Risk Endorsers) on auxiliary measures related to suicidality. Multivariate Analysis of Variance (MANOVA) tests for each sample revealed that Nondisclosers were rare (ns = 7, 6, 7) and scored significantly higher than Deniers and similarly to Endorsers on suicide risk related measures. In 1 sample, Nondisclosers tended to score higher than all groups on suicide risk related measures. These findings suggest that nondisclosure for suicide risk screening questions is a preferred option for a distinct group of respondents who are likely at elevated suicide risk. Allowing for and flagging Nondisclosers for follow-up suicide risk assessment may be an ethical and feasible way to enhance the sensitivity of online suicide risk screenings for weary respondents, who if forced, may choose to underreport their suicide risk and misrepresent data. (PsycINFO Database Record