Modifying a cognitive behavioral suicide prevention treatment for adults with schizophrenia spectrum disorders in community mental health.

Suicide is among the leading causes of death for adults with schizophrenia spectrum disorders. Given a paucity of evidence-based interventions tailored for psychosis, we sought to modify a promising Cognitive-Behavioral Suicide Prevention for psychosis (CBSPp) treatment for adults in US community mental health (CMH) settings using community-based participatory research methods. This article presents our modification methodology, stakeholder data and scholarly expert input, and CBSPp adaptations prior to future intervention testing. Stakeholder data (n = 25) were collected from clients, providers, and peer advocates in a CMH setting in Michigan. Findings were subsequently presented to a panel of scholarly experts in the fields of suicide and psychosis research, intervention research, and implementation science for input. Emerging themes from stakeholders include logistic, perceptual, and clinical challenges in the process of introducing this treatment in a CMH setting. Consistent with literature, buy-in and support for the delivery of a new treatment emerged as important factors in modifying and implementing CBSPp. A final modification list is presented in this paper and collaborations among stakeholders, researchers, and scholarly experts are essential to navigate psychosocial treatment innovation barriers with an overall goal of improving access, feasibility, and quality of this suicide prevention treatment.

Longitudinal predictors of stigma in first-episode psychosis: Mediating effects of depression.

AIM: Stigma is commonly experienced among individuals with schizophrenia spectrum disorders and has been shown to be a barrier to help-seeking and behavioural service utilization. Given the established relationships between stigma, barriers to treatment, and poorer psychiatric outcomes including depression and psychotic symptoms, we examined the relationships between symptoms of depression, positive and negative symptoms, and the emergence of stigma longitudinally among a sample of first-episode of psychosis (FEP) participants in the United States. METHODS: Data were obtained from the Recovery After an Initial Schizophrenia Episode project of National Institute of Mental Health's Early Treatment Program. Participants (n = 404) included adults between ages 15 and 40 with schizophrenia or other psychotic disorders based on the DSM-IV. Data were analysed using structural equation modelling (SEM). RESULTS: Findings indicated that increased positive and negative symptoms independently related to greater symptoms of depression at baseline. Furthermore, increased positive symptoms and symptoms of depression at baseline independently related to the emergence of greater stigma being experienced over time. CONCLUSIONS: Considering the role that symptoms of depression played as a factor explaining the relationships between positive and negative symptoms and emergence of stigma over time among individuals in FEP, and symptoms of depression is important predictor of stigma and may furthermore present as a viable and less stigmatizing initial treatment target in the early course of a psychotic disorder.

Effectiveness of Suicide-Focused Psychosocial Interventions in Psychosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: Suicide ideation, plan, attempt, and death are significant and prevalent concerns among individuals with psychosis. Previous studies have focused on risk factors, but few have systematically evaluated the effect of psychosocial interventions on these experiences among individuals with psychosis. This study evaluated the effectiveness of psychosocial interventions in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. METHODS: Eight electronic databases were systematically searched from inception until June 30, 2019. Identified studies included both randomized controlled trials and controlled trials without randomization that examined psychosocial interventions for suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. A random-effects model was used to pool the effect sizes for synthesis. RESULTS: Eleven studies with 14 effect sizes (N=4,829 participants) were analyzed. The average age of participants ranged from 21 to 51, and most participants identified as male and non-Hispanic Caucasian or Chinese and were in an early or first-episode stage of illness. On average, participants who received psychosocial interventions were less likely than their counterparts in the control group to report suicide ideation, plan, and attempt and die by suicide (odds ratio [OR]=0.57, 95% confidence interval [CI]=0.41-0.78). Subgroup analyses further revealed significant reductions in suicide ideation (OR=0.73, 95% CI=0.55-0.97) and suicide death (OR=0.45, 95% CI=0.30-0.68) among intervention participants. CONCLUSIONS: Preliminary evidence indicated that psychosocial interventions are effective in reducing suicide ideation, plan, attempt, and death among individuals with psychotic symptoms. Intervention characteristics, however, varied across studies, which suggests a lack of consensus on best clinical practices.

Depression moderates the relationships between hallucinations, delusions, and suicidal ideation: The cumulative effect of experiencing both hallucinations and delusions.

Suicide is a leading cause of preventable death in the United States and worldwide, with symptoms of depression and psychosis relating to increases in risk for ideation, attempt, and completion. This study examined moderating effects of depression in the relationships between three categories of psychotic symptoms (experiencing only hallucinations, only delusions, and both hallucinations and delusions) and suicidal ideation. Data (n = 12,195) were obtained from the cross-sectional Collaborative Psychiatric Epidemiology Surveys data which include large general population-based samples of households in the United States. Data were examined using Structural Equation Modeling (SEM) in Mplus 8. Approximately 19% of the sample met criteria for major depression and 13% reported having the experience of suicidal ideation. Only 16% of the sample reported having a diagnosis of schizophrenia and/or a psychotic disorder. Depression functioned as a moderator and among those who experienced depression, increases in all psychotic symptom categories significantly related to increased likelihood of experiencing suicidal ideation. Among those who were not depressed, increases in two psychotic symptom categories (only hallucinations and both hallucinations and delusions) were significantly related to greater likelihood of experiencing suicidal ideation. Findings emphasize the high-risk for ideation among individuals who experience hallucinations or delusions, with the cumulative effect of experiencing both hallucinations and delusions being most harmful in relation to the likelihood of experiencing suicidal ideation; particularly so among those who were depressed. Assessment of risk factors for suicidal ideation is imperative given its relationship to the potential of suicide attempt and/or completion.

Exploring the relationship between the anticipation and experience of pleasure in people with schizophrenia: An experience sampling study.

BACKGROUND: It has been hypothesised that a reduction in anticipatory pleasure contributes to reduced levels of functioning in people with schizophrenia. Previous research on anticipatory pleasure, however, reports mixed findings and has not yet examined the link between anticipatory pleasure and activity. The aim of this study is to examine how pleasure anticipation is related to difficulties engaging in activity in people with schizophrenia. METHOD: A healthy control group (n = 44) and a group of individuals with schizophrenia (n = 36) completed an experience sampling study using portable devices. Participants rated motivation, mood, functional, leisure and social activity levels; anticipatory and consummatory pleasure seven times a day for six consecutive days. Multi-level regression models were constructed to examine the role of anticipatory pleasure and/or motivation in predicting future activities. RESULTS: The findings showed no evidence for a motivation or pleasure deficit in people with schizophrenia. Yet, people with schizophrenia did fewer functional activities and spent more time "resting" or "doing nothing". In the control group, expectation was the only significant predictor of future activity. In contrast, none of the parameters assessed could predict experiences occurring in people with schizophrenia. CONCLUSIONS: In contrast with controls people with schizophrenia did not show a link between their predictions and the activities they engaged in. This appears to be an important process influencing functioning in people with psychosis. Future interventions targeting reduced functioning should focus on reinforcing the link between pleasure anticipation and goal-directed behaviour.

The COMMAND trial of cognitive therapy to prevent harmful compliance with command hallucinations: predictors of outcome and mediators of change.

BACKGROUND: Acting on harmful command hallucinations is a major clinical concern. Our COMMAND CBT trial approximately halved the rate of harmful compliance (OR = 0.45, 95% CI 0.23-0.88, p = 0.021). The focus of the therapy was a single mechanism, the power dimension of voice appraisal, was also significantly reduced. We hypothesised that voice power differential (between voice and voice hearer) was the mediator of the treatment effect. METHODS: The trial sample (n = 197) was used. A logistic regression model predicting 18-month compliance was used to identify predictors, and an exploratory principal component analysis (PCA) of baseline variables used as potential predictors (confounders) in their own right. Stata's paramed command used to obtain estimates of the direct, indirect and total effects of treatment. RESULTS: Voice omnipotence was the best predictor although the PCA identified a highly predictive cognitive-affective dimension comprising: voices' power, childhood trauma, depression and self-harm. In the mediation analysis, the indirect effect of treatment was fully explained by its effect on the hypothesised mediator: voice power differential. CONCLUSION: Voice power and treatment allocation were the best predictors of harmful compliance up to 18 months; post-treatment, voice power differential measured at nine months was the mediator of the effect of treatment on compliance at 18 months.

A Prospective Investigation of the Impact of Distinct Posttraumatic (PTSD) Symptom Clusters on Suicidal Ideation.

Inconsistent findings have been reported by previous cross-sectional studies regarding the association between specific posttraumatic stress disorder (PTSD) symptom clusters and suicidality. To advance the understanding of the role of specific PTSD symptoms in the development of suicidality, the primary aim of this study was to investigate the predictive effects of the three specific PTSD symptom clusters on suicidal ideation prospectively. Fifty-six individuals diagnosed with PTSD completed a two-stage research design, at baseline and 13-15 months follow-up. The clinician administered PTSD scale (CAPS) was used to assess the severity of the PTSD symptom clusters and validated self-report measures were used to assess suicidal ideation, severity of depressive symptoms and perceptions of defeat entrapment. The results showed that only the hyperarousal symptom cluster significantly predicted suicidal ideation at follow-up after controlling for baseline suicidal ideation, severity of depressive symptoms and perceptions of defeat and entrapment. These findings suggest that both disorder-specific and transdiagnostic factors are implicated in the development of suicidal ideation in PTSD. Important clinical implications are discussed in terms of predicting and treating suicidality in those with PTSD.

Autonomic Regulation and Auditory Hallucinations in Individuals With Schizophrenia: An Experience Sampling Study.

Auditory Hallucinations (AH) cause substantial suffering and dysfunction, yet remain poorly understood and modeled. Previous reports have linked AH to increases in negative emotions, suggesting a role for the autonomic nervous system (ANS) in underlying this link. Employing an Experience Sampling Method (ESM) approach, 40 individuals with schizophrenia completed a 36-hour ambulatory assessment of AH and cardiac autonomic regulation. Participants carried mobile electronic devices that prompted them to report 10 times/d the severity of their momentary AH, along with a Holter monitor that continuously recorded their cardiac autonomic regulation. The clocks of the devices and monitors were synchronized, allowing for high time-resolution temporal linking of the AH and concurrent autonomic data. Power spectral analysis was used to determine the relative vagal (parasympathetic) contribution to autonomic regulation during 5 minutes prior to each experience sample. The participants also completed interview-based measures of AH (SAPS; PSYRATS). The ESM-measured severity of AH was significantly correlated with the overall SAPS-indexed AH severity, along with the PSYRATS-indexed AH frequency, duration, loudness, degree of negative content, and associated distress. A mixed-effect regression model indicated that momentary increases in autonomic arousal, characterized by decreases in vagal input, significantly predicted increases in ESM-measured AH severity. Vagal input averaged over the 36-hour assessment displayed a small but significant inverse correlation with the SAPS-indexed AH. The results provide preliminary support for a link between ANS regulation and AH. The findings also underscore the highly dynamic nature of AH and the need to utilize high time-resolution methodologies to investigate AH.

Culturally-adapted Family Intervention (CaFI) for African-Caribbeans diagnosed with schizophrenia and their families: a feasibility study protocol of implementation and acceptability.

BACKGROUND: African-Caribbeans in the UK have the highest schizophrenia incidence and greatest inequity in access to mental health services of all ethnic groups. The National Institute for Health and Care Excellence (NICE) highlights this crisis in care and urgent need to improve evidence-based mental healthcare, experiences of services and outcomes for this group. Family intervention (FI) is clinically and cost-effective for the management of schizophrenia but it is rarely offered. Evidence for FI with minority ethnic groups generally, and African-Caribbeans in particular, is lacking. This study aims to test the feasibility and acceptability of delivering Culturally-adapted Family Intervention (CaFI) to African-Caribbean service users diagnosed with schizophrenia. METHODS/DESIGN: This is a feasibility cohort design study. Over a 12-month intervention period, 30 service users and their families, recruited from hospital and community settings, will receive ten one-hourly sessions of CaFI. Where biological families are absent, access to the intervention will be optimised through 'family support members'; trusted individuals nominated by service users or study volunteers. We shall collect data on eligibility, uptake, retention and attrition and assess the utility and feasibility of collecting various outcome measures including readmission, service engagement, working alliance, clinical symptoms and functioning, perceived criticism, psychosis knowledge, familial stress and economic costs. Measures will be collected at baseline, post-intervention and at 3-month follow-up using validated questionnaires and standardised interviews. Admission rates and change in care management will be rated by independent case note examination. Variability in the measures will inform sample size estimates for a future trial. Independent raters will assess fidelity to the intervention in 10 % of sessions. Feedback at the end of each session along with thematically-analysed qualitative interviews will examine CaFI's acceptability to service users, families and healthcare professionals. DISCUSSION: This innovative response to inequalities in mental healthcare experienced by African-Caribbeans diagnosed with schizophrenia might improve engagement in services, access to evidence-based interventions and clinical outcomes. Successful implementation of CaFI in this group could pave the way for better engagement and provision across marginalised groups and therefore has potentially important implications for commissioning and service delivery in ethnically diverse populations. This study will demonstrate whether the approach is feasible and acceptable and can be implemented with fidelity in different settings.

Cognitive Behavioural Suicide Prevention for Male Prisoners: Case examples.

Suicide is a serious public health problem but a problem that is preventable. This complex and challenging problem is particularly prevalent amongst prisoners; associated with a five-fold increase in risk compared to the general community. Being in prison can lead people to experience fear, distrust, lack of control, isolation, and shame, which is often experienced as overwhelming and intolerable with some choosing suicide as a way to escape. Few effective psychological interventions exist to prevent suicide although cognitive behaviour therapies appear to offer some promise. Offering cognitive behaviour suicide prevention (CBSP) therapy to high risk prisoners may help to reduce the likelihood of preventable self-inflicted deaths. In this paper we present three cases drawn from a randomised controlled trial designed to investigate the feasibility of CBSP for male prisoners. Implications of the current findings for future research and clinical practice are considered.

The optimisation of experience sampling protocols in people with schizophrenia.

Experience sampling methodology (ESM) involves completing questionnaires during daily life and has been used extensively in people with schizophrenia to assess symptoms and behaviours. Despite considerable advantages over interview measures, there is limited information about its external validity. Our aim is to investigate whether ESM protocol implementation is affected differentially in people with schizophrenia and healthy individuals by factors such as mood, medication and symptoms which would have implications for validity. Fifty-three people with schizophrenia and fifty-eight controls from the general population completed seven ESM questionnaires per day for six consecutive days. Compliance and acceptability, including overall experience, training and disruption of normal routines, were recorded. Overall questionnaire completion rate in people with schizophrenia was comparable to controls (i.e. over 70%). People with schizophrenia completed significantly fewer questionnaires in the morning but did not show fatigue effects over the experience sampling period. Excluding questionnaires in the morning did not significantly alter the findings. In the schizophrenia group medication level and symptoms did not influence adherence. However, higher disruption was associated with reduced questionnaire completion in this group. These findings suggest that minimising disruption may enhance validity and completion rates. ESM is a valid methodology to use with people with schizophrenia.

Investigating the feasibility and acceptability of a cognitive behavioural suicide prevention therapy for people in acute psychiatric wards (the 'INSITE' trial): study protocol for a randomised controlled trial.

BACKGROUND: Suicide is a major cause of preventable death, and suicidal behaviour is prevalent in acute psychiatric wards. People admitted to acute psychiatric wards often experience repeated episodes of suicidal behaviour, causing great distress and heavy use of NHS services. There is little research investigating effective psychological treatments for suicidal patients in inpatient settings although previous research has found support for psychological therapies which specifically target suicidal behaviour. This paper describes the protocol of a single blind RCT to investigate the acceptability and feasibility of a cognitive behavioural intervention targeting suicidality (CBSP) for suicidal people in acute psychiatric wards. METHODS/DESIGN: A single blind RCT comparing treatment as usual (TAU) to TAU plus Cognitive Behavioural Suicide Prevention (CBSP) therapy (TAU + CBSP). Sixty participants (aged 18-65 years) who are suicidal, or have been within the past 3 months, will be recruited from NHS trusts in the North West of England. Our primary objective is to determine whether CBSP is feasible, acceptable and efficacious when compared to patients who receive TAU alone. Secondary aims are the impact of CBSP on suicidal thinking, behaviours, functioning, quality of life, service use and psychological factors associated with suicide. Assessments take place at baseline, 6 weeks and 6 months (end of treatment). The analysis will report on the feasibility and acceptability of CBSP. Qualitative data from staff and service users will inform feasibility and acceptability data. DISCUSSION: Psychiatric inpatients are a high-risk group and the use of psychological therapies in these settings is rare and requires evaluation. This study is essential to investigate the unique contextual challenges involved in delivering psychological therapy to suicidal inpatients and to identify any necessary modifications required within inpatient settings. The findings will inform a larger, definitive trial. TRIAL REGISTRATION: 15 March 2012, PB-PG-1111-26026, NIHR ISRCTN17890126 .

Effect of hopelessness on the links between psychiatric symptoms and suicidality in a vulnerable population at risk of suicide.

The aim of this study was to examine the impact of two risk factors working together on a measure of suicide probability in a highly vulnerable group who were male prisoners identified as being at risk of self harm. The first risk factor was psychiatric symptoms, including general psychiatric symptoms and symptoms of personality disorder. The second risk factor was psychological precursors of suicidal thoughts and behaviours which were defeat, entrapment, and hopelessness. Sixty-five male prisoners from a high secure prison in NW England, UK, were recruited, all of whom were considered at risk of suicide by prison staff. General psychiatric symptoms and symptoms of personality disorders predicted the probability of suicide. Hopelessness amplified the strength of the positive relationship between general psychiatric symptoms and suicide probability. These amplification effects acted most strongly on suicidal ideation as opposed to negative self evaluations or hostility. In contrast, defeat, entrapment and hopelessness did not affect the relationship between personality disorders and suicide probability. Clinical assessments of highly vulnerable individuals, as exemplified by prisoners, should include measures of a range of general psychiatric symptoms, together with measures of psychological components, in particular perceptions of hopelessness.

Investigating the empirical support for therapeutic targets proposed by the temporal experience of pleasure model in schizophrenia: A systematic review.

BACKGROUND: Anhedonia and amotivation are substantial predictors of poor functional outcomes in people with schizophrenia and often present a formidable barrier to returning to work or building relationships. The Temporal Experience of Pleasure Model proposes constructs which should be considered therapeutic targets for these symptoms in schizophrenia e.g. anticipatory pleasure, memory, executive functions, motivation and behaviours related to the activity. Recent reviews have highlighted the need for a clear evidence base to drive the development of targeted interventions. OBJECTIVE: To review systematically the empirical evidence for each TEP model component and propose evidence-based therapeutic targets for anhedonia and amotivation in schizophrenia. METHOD: Following PRISMA guidelines, PubMed and PsycInfo were searched using the terms "schizophrenia" and "anhedonia". Studies were included if they measured anhedonia and participants had a diagnosis of schizophrenia. The methodology, measures and main findings from each study were extracted and critically summarised for each TEP model construct. RESULTS: 80 independent studies were reviewed and executive functions, emotional memory and the translation of motivation into actions are highlighted as key deficits with a strong evidence base in people with schizophrenia. However, there are many relationships that are unclear because the empirical work is limited by over-general tasks and measures. CONCLUSIONS: Promising methods for research which have more ecological validity include experience sampling and behavioural tasks assessing motivation. Specific adaptations to Cognitive Remediation Therapy, Cognitive Behavioural Therapy and the utilisation of mobile technology to enhance representations and emotional memory are recommended for future development.

Predicting the future in schizophrenia: The discrepancy between anticipatory and consummatory pleasure.

When predicting future emotions we use inaccurate biases which rely on our most salient and recent experiences. In schizophrenia, there appears to be a specific deficit in this anticipatory process which is associated with reduced motivation and engagement. The nature of this deficit and how it differs to the general population is unclear. This study introduces a new task examining the discrepancy between anticipated and experienced pleasure and investigates its potential usefulness to characterise the pleasure deficit in people with schizophrenia. Forty-eight healthy controls and 50 individuals with schizophrenia completed the Components of Pleasure Task (COP) which uses a range of images to generate anticipatory and experiential ratings. Participants also completed measures of mood and symptoms. Individuals with schizophrenia had a larger anticipatory-consummatory discrepancy score. This was due to under-anticipating highly pleasant stimuli and over-anticipating low pleasantness stimuli. People with schizophrenia are blunted compared to controls when anticipating stimuli, considering highly and lowly rated stimuli alike. A greater discrepancy between anticipated and experienced pleasure may contribute to negative symptoms such as poor motivation and social withdrawal. Reducing the discrepancy between experienced and anticipated pleasure may be a target for interventions aiming to reduce negative symptoms.

Mobile early detection and connected intervention to coproduce better care in severe mental illness.

Current approaches to the management of severe mental illness have four major limitations: 1) symptom reporting is intermittent and subject to problems with reliability; 2) service users report feelings of disengagement from their care planning; 3) late detection of symptoms delay interventions and increase the risk of relapse; and 4) care systems are held back by the costs of unscheduled hospital admissions that could have been avoided with earlier detection and intervention. The ClinTouch system was developed to close the loop between service users and health professionals. ClinTouch is an end-to-end secure platform, providing a validated mobile assessment technology, a web interface to view symptom data and a clinical algorithm to detect risk of relapse. ClinTouch integrates high-resolution, continuous longitudinal symptom data into mental health care services and presents it in a form that is easy to use for targeting care where it is needed. The architecture and methodology can be easily extended to other clinical domains, where the paradigm of targeted clinical interventions, triggered by the early detection of decline, can improve health outcomes.

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

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

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

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

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

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