Identifying suicide ideation in mental health application posts: A random forest algorithm.

The growing use of digitized mental health applications requires new reliable early screening tools to identify user suicide risk. We used a lexicon-based random forest machine learning algorithm to predict suicide ideation scores from 714 online community text posts from December 2019 to April 2020. We validated predicted scores against expert-rated suicide ideation scores. The algorithm-predicted scores offered high validity and a low error rate and correctly identified 95% of expert-rated high-risk suicide ideation posts. Our findings highlight a potential new method to detect suicidal ideation of digital mental health application users.

Examining protective factors for substance use problems and self-harm behavior during adolescence: A longitudinal co-twin control study.

Sports participation, physical activity, and friendship quality are theorized to have protective effects on the developmental emergence of substance use and self-harm behavior in adolescence, but existing research has been mixed. This ambiguity could reflect, in part, the potential for confounding of observed associations by genetic and environmental factors, which previous research has been unable to rigorously rule out. We used data from the prospective, population-based Child and Adolescent Twin Study in Sweden (n = 18,234 born 1994-2001) and applied a co-twin control design to account for potential genetic and environmental confounding of sports participation, physical activity, and friendship quality (assessed at age 15) as presumed protective factors for adolescent substance use and self-harm behavior (assessed at age 18). While confidence intervals widened to include the null in numerous co-twin control analyses adjusting for childhood psychopathology, parent-reported sports participation and twin-reported positive friendship quality were associated with increased odds of alcohol problems and nicotine use. However, parent-reported sports participation, twin-reported physical activity, and twin-reported friendship quality were associated with decreased odds of self-harm behavior. The findings provide a more nuanced understanding of the risks and benefits of putative protective factors for risky behaviors that emerge during adolescence.

Sexual orientation and adolescent suicide attempt and self-harm: a co-twin control study.

BACKGROUND: Research has demonstrated that individuals who identify as a sexual minority (e.g., gay/lesbian, bisexual) are at increased risk for suicidality-related outcomes. However, previous research is primarily limited by the lack of adjustment for unmeasured (i.e., genetic and environmental) confounding factors and previous psychopathology. METHODS: Using the Child and Adolescent Twin Study in Sweden, we employed a co-twin control design to examine the extent to which the association between sexual orientation and adolescent suicide attempt and self-harm (SA/SH) was independent of genetic and environmental factors shared by twins, as well as measured symptoms of childhood psychopathology. RESULTS: Adolescents who identified as a sexual minority (i.e., gay/lesbian, bisexual, or other sexual orientation) were at two-fold increased odds for SA/SH (OR, 2.01 [95% confidence interval, 1.63-2.49) compared to heterosexual adolescents. When adjusting for all genetic and shared environmental factors that make twins similar and for measured childhood psychopathology, the association remained positive but attenuated to OR, 1.55 (1.11-2.16). CONCLUSIONS: Identifying as a sexual minority was associated with approximately 50% increased odds of SA/SH in adolescence after adjusting for unmeasured genetic and environmental factors shared by twins and for childhood psychopathology. The results support that environmental factors specifically associated with identifying as a sexual minority likely increase risk for SA/SH. Our findings highlight the need to monitor suicidality risk among this group.

The three-step theory of suicide: Description, evidence, and some useful points of clarification.

There has been considerable uptake of the Three-Step Theory (3ST) of suicide since its publication in 2015. The 3ST is a concise, evidence-based, and actionable theory that explains suicide in terms of four factors: pain, hopelessness, connection, and capability for suicide. The 3ST has not only been cited in hundreds of scientific papers, but incorporated into continuing education programs, gatekeeper training, and self-help resources. In this context, it is useful to clarify the theory's content and review its scientific support. Thus, the present article describes the 3ST, provides an updated evidence review for each of its premises, and offers several points of clarification so that the claims of the 3ST may be better understood, evaluated, and applied. To date, research (including research on correlates, risk factors, motivations, warning signs, and means-safety interventions) supports the 3ST. At the same time, there are aspects of the theory that are challenging to operationalize and that require further testing.

Clarifying the association of eating disorder features to suicide ideation and attempts.

OBJECTIVE: We examine the relationships of eight eating disorder (ED) features to histories of suicide ideation and suicide attempts. METHOD: Participants were 387 adults (62% female, mean age = 36 years) recruited via an online platform, and oversampled for the presence of ED features, who completed standardized self-report measures of study variables. RESULTS: Different ED features predicted suicide ideation versus attempts. Specifically, Restrictive Eating (d = 0.44), Purging (d = 0.30), and Body Dissatisfaction (d = 0.27) were higher among ideators compared to nonsuicidal participants. In contrast, Muscle Building (d = 0.31), Excessive Exercise (d = 0.26), Cognitive Restraint (d = 0.23), and Restrictive Eating (d = 0.20) were higher among attempters compared to ideators-however, we note that the p-values for these effects range between 0.02 and 0.04 and it is unclear if they would replicate. Independent replication is important. CONCLUSION: Findings have implications for the conceptualization of suicide risk in individuals with EDs.

The role of theory for understanding and preventing suicide (but not predicting it): A commentary on Hjelmeland and Knizek.

Hjelmeland and Knizek suggest that parsimonious theory is inappropriate for explaining a highly complex and contextual phenomenon like suicide. Similar suggestions have been made by others. In this commentary, I counter that the pursuit of parsimonious theory is at the core of any scientific enterprise, including health sciences and suicide science. Using examples from physics and psychology, I illustrate that parsimonious theories have been essential for understanding highly complex and contextual phenomena like the motion of objects and the behavior of people. I further illustrate that these theories, despite their undeniable validity and enormous utility, have limited value for predicting future real-world events; thus, it is important not to conflate valid theory with highly accurate prediction of the future. To conclude, I offer suggestions for better evaluating and advancing suicide theory, and I affirm that the pursuit of parsimonious suicide theory is important and worthwhile, and must continue.

What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population-based birth cohort study.

BACKGROUND: Only one-third of young people who experience suicidal ideation attempt suicide. It is important to identify factors which differentiate those who attempt suicide from those who experience suicidal ideation but do not act on these thoughts. METHODS: Participants were 4,772 members of the Avon Longitudinal Study of Parents and Children (ALSPAC), a UK population-based birth cohort. Suicide ideation and attempts were assessed at age 16 years via self-report questionnaire. Multinomial regression was used to examine associations between factors that differentiated adolescents in three groups: no suicidal ideation or attempts, suicidal ideation only and suicide attempts. Analyses were conducted on an imputed data set based on those with complete outcome data (suicidal thoughts and attempts) at age 16 years (N = 4,772). RESULTS: The lifetime prevalence of suicidal ideation and attempts in the sample was 9.6% and 6.8% respectively. Compared to adolescents who had experienced suicidal ideation, those who attempted suicide were more likely to report exposure to self-harm in others (adjusted OR for family member self-harm: 1.95, for friend self-harm: 2.61 and for both family and friend self-harm: 5.26). They were also more likely to have a psychiatric disorder (adjusted OR for depression: 3.63; adjusted OR for anxiety disorder: 2.20; adjusted OR for behavioural disorder: 2.90). Other risk factors included female gender, lower IQ, higher impulsivity, higher intensity seeking, lower conscientiousness, a greater number of life events, body dissatisfaction, hopelessness, smoking and illicit drug use (excluding cannabis). CONCLUSIONS: The extent of exposure to self-harm in others and the presence of psychiatric disorder most clearly differentiate adolescents who attempt suicide from those who only experience suicidal ideation. Further longitudinal research is needed to explore whether these risk factors predict progression from suicidal ideation to attempts over time.

Symptoms of anorexia nervosa and bulimia nervosa have differential relationships to borderline personality disorder symptoms.

Eating disorders (EDs) and borderline personality disorder (BPD) are highly comorbid. BPD is characterized by the presence of at least five of nine symptoms. Given the number/variety of emotional and interpersonal symptoms that comprise BPD, some BPD traits may relate to EDs, whereas others may not be associated. This study examined relationships between BPD symptoms and symptoms of bulimia nervosa (BN) and anorexia nervosa (AN), including whether the nine BPD symptoms differentially relate to BN versus AN. Participants were 208 adolescent psychiatric inpatients. BPD symptoms, measured via structured interview, correlated more strongly with self-reported BN than AN symptoms. BN and AN symptoms were greater among individuals who endorsed unstable relationships, affective instability, emptiness, identity disturbance, inappropriate anger, dissociation/paranoia, and suicidal behavior. BN, but not AN symptoms, were higher when impulsivity was endorsed. Avoiding abandonment was neither related to BN nor AN. Affective instability, impulsivity, and anger had substantially larger associations with BN compared to AN, while identity disturbance was more strongly related to AN than BN. Findings provide useful information for targeting specific BPD symptoms to help prevent and reduce co-occurring EDs and BPD and the negative consequences associated with this comorbidity.

Suicide, Suicide Attempts, and Suicidal Ideation.

Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-to-action framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.

Characterizing Positive and Negative Emotional Experiences in Young Adults With Borderline Personality Disorder Symptoms.

OBJECTIVES: Some researchers suggest that borderline personality disorder (BPD) is characterized by elevated negative emotion; others argue that BPD involves both reduced positive and increased negative emotion. This study characterizes the emotional experiences of individuals with BPD symptoms in a combined university and community sample. METHOD: Participants (N = 150) completed a clinical interview assessing BPD symptoms and self-report measures of positive and negative emotion. A subset (n = 106) completed a measure of emotion daily for 2 weeks. Pearson's correlations and multilevel modeling were used to examine the cross-sectional and longitudinal relationships between BPD symptoms and emotions. RESULTS: BPD symptoms were robustly related to increased negative emotion; this relationship remained after accounting for positive emotion. BPD symptoms were weakly related to decreased positive emotion; this relationship was no longer significant after accounting for negative emotion. BPD symptoms predicted higher levels of negative and not positive emotion over 14 days. These patterns held for subscales assessing intensity, frequency, and duration of negative and positive emotions. CONCLUSION: Findings suggest that individuals with BPD features are chiefly distinguished by elevated negative emotional experience.

Dangerous Words? An Experimental Investigation of the Impact of Detailed Reporting About Suicide on Subsequent Risk.

OBJECTIVE: Media reporting guidelines exist for suicide-related content; however, no experimental studies have examined the impact of guideline violations. As such, we utilized an experimental design to determine whether reading an article about suicide that violated guidelines would impact mood and suicidality relative to the same article without violations and to an article detailing death by cancer, both immediately and during 1-month follow-up. METHOD: 273 students were randomly assigned to read one of three articles (1) an article that violated suicide reporting guidelines, (2) the same article with violations removed, or (3) an article that details death by cancer. RESULTS: Individuals assigned to read the original suicide article were no more upset immediately afterwards or during 1-month follow-up. Amongst participants with prior ideation, those who read the original article reported a lower likelihood of future attempt relative to either other condition. CONCLUSION: Results indicate some reporting guidelines may be unnecessary. Amongst individuals at risk for suicide, some guideline violations may be associated with a decreased likelihood of future attempt and result in a decrease in negative affect. Clinically, these results highlight the potential utility of exposing clients to in depth educational materials about suicide while mitigating concerns regarding certain aspects of the content.

Are Iranian obese women candidate for bariatric surgery different cognitively, emotionally and behaviorally from their normal weight counterparts?

OBJECTIVE: The purpose of the present study was to examine the cognitive, emotional and behavioral differences between obese and normal weight women. METHODS: The participants consisted of 60 obese women (BMI ≥ 35, Mean age 35.83) who were candidates for bariatric surgery and 60 normal weight women (BMI ≤ 24.90, Mean age 33.38) who were selected through convenient sampling method. The two groups were matched with respect to age and education. Measures included the Young Schema Questionnaire-Short Form, Difficulties in Emotion Regulation Scale (DERS) and the Binge Eating Scale. Independent sample t test and Mann-Whitney U tests were conducted to compare the two groups' scores on early maladaptive schemas, DER and binge eating. RESULTS: Results indicated that obese women candidate for bariatric surgery scored significantly higher on emotional deprivation, mistrust, failure, dependency, enmeshment, self-sacrifice, especially abandonment, social isolation, vulnerability, self-control and subjugation schemas, but not on shame, entitlement, emotional inhibition and unrelenting standards. Obese women also displayed higher scores on three subscales of DERS, i.e., goal, impulse and strategies. BE scores were significantly higher in obese women than normal weight ones. CONCLUSION: The findings showed that obese women candidates for bariatric surgery suffered from more cognitive, emotional and behavioral vulnerability compared to women with normal weight. Addressing these vulnerabilities among obese women could improve outcomes of weight loss surgeries and cognitive behavioral interventions so that weight regain is minimized and better outcomes are achieved.

Daily emotion in non-suicidal self-injury.

OBJECTIVE: While major theories of non-suicidal self-injury (NSSI) emphasize the behavior's role in emotion regulation, little is known about the daily emotional experiences of self-injurers. This study investigated the specific emotions that are characteristic of those who engage in NSSI. METHOD: University students (n = 84) with either no history or a recent history of NSSI completed daily diary and retrospective measures of emotional experience. To evaluate generalizability of findings, the retrospective measure was also administered to a diverse sample of U.S. adults (n = 92) with and without histories of NSSI. RESULTS: Results indicate that self-injurers experience greater negative emotionality, particularly self-dissatisfaction, compared to individuals with no NSSI history. Self-injurers also reported less positive emotion, but these effects were smaller. The pattern of results was similar when controlling for Axis I psychopathology and borderline personality disorder symptoms. CONCLUSIONS: Individuals who engage in NSSI experience more negative emotions, generally, and more self-dissatisfaction, specifically. Findings contribute to the growing literature on the role of emotion in the etiology and functions of NSSI.

Campbell's Law Explains the Replication Crisis: Pre-Registration Badges Are History Repeating.

Campbell's Law explains the replication crisis. In brief, useful tools such as hypotheses, p-values, and multi-study designs came to be viewed as indicators of strong science, and thus goals in and of themselves. Consequently, their use became distorted in unanticipated ways (e.g., hypothesizing after results were known [HARKing], p-Hacking, misuses of researcher degrees of freedom), and fragile findings proliferated. Pre-registration mandates are positioned as an antidote. However, I argue that such efforts, perhaps best exemplified by pre-registration badges (PRBs), are history repeating: Another useful tool has been converted into an indicator of strong science and a goal in and of itself. This, too, will distort its use and harm psychological science in unanticipated ways. For example, there is already evidence that papers seeking PRBs routinely violate the rules and spirit of pre-registration. I suggest that pre-registration mandates will (a) discourage optimal scientific practice, (b) exacerbate the file drawer problem, (c) encourage pre-registering after results are known (PRARKing), and (d) create false trust in fragile findings. I conclude that multiple design features can help support replicability (e.g., adequate sample size, valid measurement, robustness checks, pre-registration), none should be canonized, replication is the only arbiter of replicability, and the most important solution is sociocultural: to foster a field that reveres and reinforces robust science-just as we once revered and reinforced flashy but fragile science.

Trajectories of suicidal ideation during rTMS for treatment-resistant depression.

BACKGROUND: rTMS is a safe and effective intervention for treatment-resistant depression (TRD). However, there is limited data on its specific impact on suicidal ideation (SI), and the trajectory of SI over the treatment course. OBJECTIVE: This open-label clinical trial investigated SI outcomes and trajectories in patients with TRD receiving low-frequency rTMS (LFR) to the right dorsolateral prefrontal cortex (DLPFC; N = 55). METHODS: A latent class mixed-effect model was used to identify response trajectories for SI as well as core mood symptoms. Logistic regression analyses investigated risk factors associated with identified trajectories. RESULTS: For each symptom domain, we identified two distinct trajectories during LFR, one tracking improvement (SI: n = 35, 60 %; mood: n = 29, 53 %) and the other tracking no improvement (SI: n = 20, 40 %; mood: n = 26, 47 %). Male sex, higher baseline anxiety, and higher baseline SI were risk factors for no improvement of SI; while higher baseline anxiety and benzodiazepine use were risk factors for no improvement of mood. Mediation analyses showed that anxiety was a risk factor for no improvement of SI and mood independent of benzodiazepine treatment. CONCLUSIONS: This is the first study to investigate trajectories of response to LFR to the right DLPFC. SI and mood improved with LFR in most patients but the severity of anxiety symptoms was a factor of poor prognosis for both. Nuanced characterization of SI response to rTMS may lead to critical insights for individualized targeting strategies.

Psychache, Hopelessness, and Suicidal Ideation and Behaviors: A Cross-Sectional Study from China.

This study explored the relationship between variables emphasized in the theory's first step of the three-step theory (3ST)-psychache, hopelessness, and their interaction-to suicide-related variables (i.e., lifetime suicidal ideation and attempt, past-year suicidal ideation, communication of suicidal thoughts, and self-reported future suicide attempt likelihood). Chinese undergraduate students (N = 11,399; mean age = 20.69 ± 1.35) from seven provinces participated in this cross-sectional survey. They answered the Suicidal Behaviors Questionnaire-Revised, Psychache Scale, and Beck Hopelessness Scale. Bivariate and multivariate analyses were used to examine the association between psychache, hopelessness, and hopelessness × psychache interaction on the outcome variables. Bivariate analyses showed that psychache and hopelessness were correlated with suicidal ideation and behaviors. In multiple regression models, the interaction between psychache and hopelessness was significantly associated with past-year suicidal ideation and self-report chances of a future suicide attempt, p < 0.001, though effect sizes for the interaction term were small. The results are broadly consistent with the 3ST's proposition of how the combination of pain and hopelessness is related to various suicide-related variables. The low prevalence of suicide-related communication should inform future suicide prevention measures by encouraging help-seeking. Psychache as a correlate of the self-reported likelihood of a future attempt could be further investigated.

Nonsuicidal self-injury disorder: an empirical investigation in adolescent psychiatric patients.

Nonsuicidal self-injury (NSSI) is a growing public health concern, especially among adolescents. In the current edition of the Diagnostic and Statistical Manual of Mental Disorders, NSSI is classified as a criterion of borderline personality disorder (BPD). However, a distinct NSSI disorder will now be included in DSM-5 as a "condition requiring further study." It is important to note that, at this time, there is little direct evidence supporting the DSM-5 proposal over the DSM-IV classification. To address this need, the current study examined the extent to which NSSI occurs independently of BPD and has clinical significance beyond a diagnosis of BPD in adolescent psychiatric patients. NSSI disorder was assessed based on the proposed DSM-5 criteria in 198 adolescents ages 12 to 18 (74% female; 64% Caucasian, 14% Hispanic, 10% African American, and 12% mixed/other ethnicity) from a psychiatric hospital. Major Axis I disorders, Axis II BPD, and suicide ideation and attempts were assessed with structured clinical interviews; emotion dysregulation and loneliness were measured with validated self-report questionnaires. First, results indicated that NSSI disorder occurred independently of BPD. Specifically, although there was overlap between the occurrence of BPD and NSSI disorder, this overlap was no greater than that between BPD and other Axis I disorders (e.g., anxiety and mood disorders). Second, NSSI disorder demonstrated unique associations with clinical impairment-indexed by suicide ideation and attempts, emotion dysregulation, and loneliness-over and above a BPD diagnosis. Taken together, findings support the classification of NSSI as a distinct and clinically significant diagnostic entity.

Warning signs for suicide attempts in psychiatric inpatients: Patient and informant perspectives.

OBJECTIVE: Warning signs can help prevent suicide attempts and death. It is important to develop an evidence base for warning signs that considers both self-perspectives (i.e., those at risk for suicide) and informant-perspectives (i.e., those who observe individuals at risk for suicide). METHODS: A questionnaire assessing a diverse set of 80 potential warning signs ("present in the minutes, hours, or days before the suicide attempts") was developed based on literature searches, lived experience consultations, and the American Association of Suicidology (AAS) expert consensus list. This questionnaire was administered to two samples: psychiatric inpatients who had attempted suicide (n = 476), and informants identified as friends, family, or caretakers of patients (n = 120). RESULTS: Hopelessness, anxiousness, and unbearable pain were each endorsed as warning signs by >80% of inpatients and informants. Warning signs were similar across patient and informant perspectives, and across sociodemographic and clinical characteristics. Some AAS warning signs were endorsed by few patients and informants (risky behaviors, alcohol or drug use, seeking revenge) and may warrant re-evaluation. CONCLUSIONS: Findings are consistent with models of suicide risk emphasizing pain, hopelessness, and anxiousness. Existing lists of warning signs may benefit from revision as the evidence base continues to develop.

Mental Disorders and Beyond in the Quest to Understand Suicide: A Reply to Joiner and Robison.

We reply to the thoughtful commentary by Joiner and Robison (this issue) about the documentary Robin's Wish. Joiner and Robison suggest that a major depressive episode may have been a proximal cause of Robin Williams' suicide, but that stigma surrounding mental illness led the documentary to eschew a role for depression. We find this perspective compelling and important. Mental illness can be an important cause of suicide, and stigma can harm our ability to understand and treat mental illness and suicide risk. As a complementary perspective, we discuss research and theory suggesting that mental illness does not explain all deaths by suicide. We present research and theory suggesting that suicide is motivated by pain and hopelessness, and that pain and hopelessness can be caused not only by mental illness but by other factors such as overwhelming interpersonal struggles or loss, seemingly insurmountable financial problems, chronic medical conditions, and systematic discrimination and persecution. Finally, we reaffirm Joiner and Robison's belief that understanding and preventing suicide requires the pursuit of accurate knowledge, unburdened by stigma that can harm progress and people.