Clinical Assessment Of Suicide Risk Research Articles

Missed opportunities for suicide prevention in teens with ADHD

Epidemiological evidence links Attention Deficit Hyperactivity Disorder (ADHD) to increased risk of suicide. The research aimed to describe awareness among primary care pediatricians (PCPs) of ADHD as a risk factor for suicide and PCPs’ practices of suicide risk assessment (SRA) and firearms safety assessment (FSA) in teens with ADHD. An online survey was conducted among residents and attendings (N =68, response rate 72%) at an academic medical center. An open-ended question asking respondents to list up to 10 suicide risk factors was followed by Likert-scale items measuring knowledge, attitudes and self-reported practice. Analysis of variance and Pearson correlations were used to assess relationships between physicians’ personal and practice parameters and their SRA and FSA practices. Unprompted, only two doctors mentioned ADHD as a risk factor for suicide. Respondents rated ADHD significantly lower than depression as a factor that would motivate them to perform a clinical assessment of suicide risk and firearm safety; 4.07 (1.62) v 6.49 (0.97), p<0.001 and 4.01 (1.87) v 6.19 (1.22), p<0.001, respectively. Study data set is limited to a single institution and the sample size is small. PCPs are unlikely to recognize ADHD as a risk factor for suicide, and are therefore unlikely to thoroughly assess and intervene to prevent suicide in teens with ADHD.

Finding Effective and Efficient Ways to Integrate Research Advances Into the Clinical Suicide Risk Assessment Interview.

Research in clinical suicidology continues to rapidly expand, much of it with implications for day-to-day clinical practice. Clinicians routinely wrestle with how best to integrate recent advances into practice and how to do so in efficient and effective fashion. This article identifies five critical domains of recent research findings and offers examples of simple questions that can easily be integrated into a clinician's existing suicide risk assessment interview and related protocol helping inform the risk formulation process.

Columbia-Suicide Severity Rating Scale Screen Version: initial screening for suicide risk in a psychiatric emergency department.

Suicide screening is routine practice in psychiatric emergency (PE) departments, but evidence for screening instruments is sparse. Improved identification of nascent suicide risk is important for suicide prevention. The aim of the current study was to evaluate the association between the novel Colombia Suicide Severity Rating Scale Screen Version (C-SSRS Screen) and subsequent clinical management and suicide within 1 week, 1 month and 1 year from screening. Consecutive patients (N = 18 684) attending a PE department in Stockholm, Sweden between 1 May 2016 and 31 December 2017 were assessed with the C-SSRS Screen. All patients (52.1% women; mean age = 39.7, s.d. = 16.9) were followed-up in the National Cause of Death Register. Logistic regression and receiver operating characteristic curves analyses were conducted. Optimal cut-offs and accuracy statistics were calculated. Both suicidal ideation and behaviour were prevalent at screening. In total, 107 patients died by suicide during follow-up. Both C-SSRS Screen Ideation Severity and Behaviour Scales were associated with death by suicide within 1-week, 1-month and 1-year follow-up. The optimal cut-off for the ideation severity scale was associated with at least four times the odds of dying by suicide within 1 week (adjusted OR 4.7, 95% confidence interval 1.5-14.8). Both scales were also associated with short-term clinical management. The C-SSRS Screen may be feasible to use in the actual management setting as an initial step before the clinical assessment of suicide risk. Future research may investigate the utility of combining the C-SSRS Screen with a more thorough assessment.

Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: A 20-year total population study in Ontario, Canada

BackgroundSuicide is a major cause of mortality for individuals with schizophrenia spectrum disorders (SSD). Understanding the risk factors for suicide at time of diagnosis can aid clinicians in identifying people at risk. MethodsRecords from linked administrative health databases in Ontario, Canada were used to identify individuals aged 16 through 45 years who received a first lifetime diagnosis of SSD (schizophrenia, schizoaffective disorder, psychotic disorder not otherwise specified (NOS)) using a validated algorithm between 01/01/1993 and 12/31/2010. The main outcome was death by suicide following cohort entry until 12/31/2012. Outcomes75,989 individuals with a first SSD diagnosis (60.1% male, 39.9% female) were followed for an average of 9.56 years. During this period, 1.71% of the total sample (72.1% male, 27.9% female) died by suicide, after an average of 4.32 years. Predictors of suicide death included male sex (HR 2.00, 95% CI 1.76–2.27), age at diagnosis between 26 and 35 (HR 1.27, 95% CI 1.10–1.45) or 36–45 (HR 1.34, 95% CI 1.16–1.54), relative to 16–25, and suicide attempt (HR 2.23, 95% CI 1.86–2.66), drug use disorder (HR 1.21, 95% CI 1.04–1.41), mood disorder diagnosis (HR 1.32, 95% CI 1.17–1.50), or mental health hospitalization (HR 1.30 95% CI 1.13–1.49) in the 2 years prior to SSD diagnosis. InterpretationDeath by suicide occurs in 1 out of every 58 individuals and occurred early following first diagnosis of SSD. Psychiatric hospitalizations, mood disorder diagnoses, suicide attempts prior to SSD diagnosis, as well as a later age at first diagnosis, are all predictors of suicide and should be integrated into clinical assessment of suicide risk in this population.

Mental disorders and suicidal behavior in refugees and Swedish-born individuals: is the association affected by work disability?

BackgroundAmong potential pathways to suicidal behavior in individuals with mental disorders (MD), work disability (WD) may play an important role. We examined the role of WD in the relationship between MD and suicidal behavior in Swedish-born individuals and refugees.MethodsThe study cohort consisted of 4,195,058 individuals aged 16–64, residing in Sweden in 2004–2005, whereof 163,160 refugees were followed during 2006–2013 with respect to suicidal behavior. Risk estimates were calculated as hazard ratios (HR) with 95% confidence intervals (CI). The reference groups comprised individuals with neither MD nor WD. WD factors (sickness absence (SA) and disability pension (DP)) were explored as potential modifiers and mediators.ResultsIn both Swedish-born and refugees, SA and DP were associated with an elevated risk of suicide attempt regardless of MD. In refugees, HRs for suicide attempt in long-term SA ranged from 2.96 (95% CI: 2.14–4.09) (no MD) to 6.23 (95% CI: 3.21–12.08) (MD). Similar associations were observed in Swedish-born. Elevated suicide attempt risks were also observed in DP. In Swedish-born individuals, there was a synergy effect between MD, and SA and DP regarding suicidal behavior. Both SA and DP were found to mediate the studied associations in Swedish-born, but not in refugees.ConclusionThere is an effect modification and a mediating effect between mental disorders and WD for subsequent suicidal behavior in Swedish-born individuals. Also for refugees without MD, WD is a risk factor for subsequent suicidal behavior. Particularly for Swedish-born individuals with MD, information on WD is vital in a clinical suicide risk assessment.

The Role of Opiates in Social Pain and Suicidal Behavior.

With more than 800,000 deaths by suicide each year and 20 to 30 times more suicide attempts worldwide, suicide is a major public health problem. Current treatments of SB are mainly based on pharmacological treatments that are not specific of SB (e.g. antidepressants), and new therapeutic targets are urgently needed. Recent data strengthen the ancient conception pain (social, psychic, physical) that is at the core of the suicidal process and should be incorporated in the clinical assessment of suicide risk. Then, the mechanisms involved in the regulation of pain may open new avenues regarding therapeutic perspectives. Opiates appear to be a promising candidate in treatment of SB. Indeed, since the last two decades, growing evidences suggest an implication of the opioid system in the pathophysiology of SB, this conduct to the elaboration of randomized controlled trials (RCTs) using opiates in patients with SB. Results suggesting an anti-suicidal effect of buprenorphine and the potential opioidergic-related anti-suicidal effect of ketamine both contribute to the growing interest in opiates use in SB. In this review, we will summarize a large part of the evidence that leads researchers and clinicians to be interested in the use of opiates for SB treatment and discuss on new opioid pharmacological options for suicidal patients.

Suicidal tendencies among tattooed people

A number of studies suggest a higher prevalence of suicidal behaviour among body modified individuals compared to the general population. In order to study tattoo features correlated to suicidal behaviour, 184 tattooed individuals aged from 18 to 32 were split into three groups: “ideators” (n = 28), “attempters” (n = 55) and “no suicidal tendencies” (n = 101). The participants were allocated to groups based on their personal history of suicidal attempts and self-injurious behaviour and current suicidal ideation. The history of suicidal and self-injurious behaviour and tattoo features were assessed with a non-standardized self-report questionnaire. Actual suicidal ideation was assessed using Beck’s Hopelessness Scale and Holden’s Psychache Scale. Selfconcept as a possible mediator was assessed using the “Self-concept questionnaire” (V. V. Stolin, S. R. Pantileev). The data was processed with multinomial and logistic nominative regression. The results suppose that having a tattoo on body areas where tattooing is especially painful and having a tattoo depicting only words are associated to having committed a non-lethal suicidal attempt, with the latter fully mediated by its association to systematic self-injury. Results also suggest that there is no association between (a) suicidal behaviour or self-concept and (b) an aggressive tattoo plot, visibility, or number of tattoos. The results can be used as a component of a comprehensive suicidal risk assessment model or in clinical assessment of suicidal risk.

Predicting suicide: A comparison between clinical suicide risk assessment and the Suicide Intent Scale

BackgroundHow suicide risk should be assessed is under discussion with arguments for both actuarial and clinical approaches. The aim of the present study was to compare the predictive accuracy of a clinical suicide risk assessment to that of the Suicide Intent Scale (SIS) in predicting suicide within one year of an episode of self-harm with or without suicidal intent. MethodsProspective clinical study of 479 persons assessed in a psychiatric emergency department after an episode of self-harm. The clinical risk assessment and the SIS rating were made independently of each other. Suicides within one year were identified in the National Cause of Death Register. Receiver operating characteristic (ROC) curves were constructed, optimal cut-offs were identified and accuracy statistics were calculated. ResultsOf 479 participants, 329 (68.7%) were women. The age range was 18–95 years. During one-year follow up, 14 participants died by suicide. The area under the curve (AUC) for the clinical risk assessment and the SIS score were very similar, as were the accuracy statistic measures at the optimal cut-offs of the respective methods. The positive predictive value (PPV) of each assessment method was 6%. LimitationsThe clinical suicide risk assessment is not standardized. The number of suicides is small, not allowing for stratification by e.g. gender or diagnosis. ConclusionPredictive accuracy was similar for a clinical risk assessment and the SIS, and insufficient to guide treatment allocation.

Service utilization and suicide among people with schizophrenia spectrum disorders

ObjectiveTo compare individuals with and without schizophrenia spectrum disorders (SSD) (schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified) who die by suicide. MethodThis is a retrospective case control study which compared all individuals who died by suicide in Ontario, Canada with (cases) and without (controls) SSD between January 1, 2008 and December 31, 2012. Cases (individuals with SSD) were compared to controls on demographics, clinical characteristics, and health service utilization proximal to suicide. A secondary analysis compared the characteristics of those with SSD and those with severe mental illness (defined as those without SSD who have had a psychiatric hospitalization within the five-years before suicide (excluding the 30 days prior to death)). ResultsAmong 5650 suicides, 663 (11.7%) were by individuals with SSD. Compared to other suicides, SSD suicides were significantly more likely to be between the ages of 25–34. SSD suicide victims were significantly more likely to reside in the lowest income neighbourhoods and to reside in urban areas. SSD victims were also significantly more likely to have comorbid mood and personality disorders and all types of health service utilization, including outpatient mental health service contact in the 30 days prior to death, even when compared only with those who had a history of mental health hospitalization. ConclusionsIndividuals with schizophrenia spectrum disorder account for over 1 in 10 suicide deaths, tend to be younger, poorer, urban, more clinically complex, and have higher rates of mental health service contact prior to death. The demographic and service utilization differences persist even when the SSD group is compared with a population with severe mental illness that is not SSD. Suicide prevention strategies for people with schizophrenia spectrum disorder should emphasize the importance of clinical suicide risk assessment during clinical encounters, particularly early in the course of illness.

Prevalence and Risk Factors of Suicidal Ideation among Patients with Head and Neck Cancer: Longitudinal Study.

(1) Determine 1-year period prevalence of suicidal ideation, suicide attempt, and completed suicide among patients newly diagnosed with a first occurrence of head and neck cancer (HNC). (2) Characterize stability and trajectory of suicidal ideation over the year following cancer diagnosis. (3) Identify patients at risk of suicidal ideation. Prospective longitudinal study with 1-year follow-up. Three university-affiliated outpatient departments of otolaryngology-head and neck surgery. The study comprised a representative sample of 223 consecutive patients who were newly diagnosed (<2 weeks) with a first occurrence of primary HNC, were ≥18 years old and able to consent, and had a Karnofsky Performance Scale score ≥60. Patients completed the Beck Scale for Suicidal Ideation and Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Sixteen percent (15.7%) of patients with HNC were suicidal <1 year from diagnosis, with point prevalences of 8.1% <2 weeks, 14.8% at 3 months, 9.4% at 6 months, and 10.4% at 12 months; 0.4% committed suicide within 3 months, and 0.9% attempted suicide. An a priori comprehensive conceptual model revealed 2 predictors of 1-year period prevalence of suicidal ideation in HNC: psychiatric history ( P = .017, β = 2.1, 95% CI = 0.4-3.8) and coping with the diagnosis by using substances (alcohol/drugs; P = .008, β = 0.61, 95% CI = 0.16-1.06). All other predictors, including medical predictors, were nonsignificant. A clinical suicide risk assessment revealed low risk among 71.4% and medium to high risk among 28.6%. Suicide prevention strategies are clearly needed as part of routine clinical care in head and neck oncology, as well as their integration into clinical practice guidelines for HNC.

Machine learning of neural representations of suicide and emotion concepts identifies suicidal youth.

The clinical assessment of suicidal risk would be significantly complemented by a biologically-based measure that assesses alterations in the neural representations of concepts related to death and life in people who engage in suicidal ideation. This study used machine-learning algorithms (Gaussian Naïve Bayes) to identify such individuals (17 suicidal ideators vs 17 controls) with high (91%) accuracy, based on their altered fMRI neural signatures of death and life-related concepts. The most discriminating concepts were death, cruelty, trouble, carefree, good, and praise. A similar classification accurately (94%) discriminated 9 suicidal ideators who had made a suicide attempt from 8 who had not. Moreover, a major facet of the concept alterations was the evoked emotion, whose neural signature served as an alternative basis for accurate (85%) group classification. The study establishes a biological, neurocognitive basis for altered concept representations in participants with suicidal ideation, which enables highly accurate group membership classification.

Age-specific suicide mortality following non-fatal self-harm: national cohort study in Sweden.

Possible age-related differences in risk of completed suicide following non-fatal self-harm remain unexplored. We examined associations between self-harm and completed suicide across age groups of self-harming patients, and whether these associations varied by violent index method, presence of mental disorder, and repeated self-harm. The design was a cohort study with linked national registers in Sweden. The study population comprised individuals aged ⩾10 years hospitalized during 1990-1999 due to non-fatal self-harm (n = 53 843; 58% females) who were followed for 9-19 years. We computed hazard ratios (HRs) across age groups (age at index self-harm episode), with time to completed suicide as outcome. The 1-year HR for suicide among younger males (10-19 years) was 14.6 [95% confidence interval (CI) 4.1-51.9] for violent method and 8.4 (95% CI 1.8-40.0) for mental disorder. By contrast, none of the three potential risk factors increased the 1-year risks in the youngest females. Among patients aged ⩾20 years, the 1-year HR for violent method was 4.6 (95% CI 3.8-5.4) for males and 10.4 (95% CI 8.3-13.0) for females. HRs for repeated self-harm during years 2-9 of follow-up were higher in 10- to 19-year-olds (males: HR 4.0, 95% CI 2.0-7.8; females: HR 3.7, 95% CI 2.1-6.5). The ⩾20 years age groups had higher HRs than the youngest, particularly for females and especially within 1 year. Violent method and mental disorder increase the 1-year suicide risk in young male self-harm patients. Further, violent method increases suicide risk within 1 year in all age and gender groups except the youngest females. Repeated self-harm may increase the long-term risk more in young patients. These aspects should be accounted for in clinical suicide risk assessment.

Therapeutic Risk Management of the Suicidal Patient

This column is the third in a series describing a model for therapeutic risk management of the suicidal patient. In the preceding column, we described augmenting clinical suicide risk assessment with structured instruments. In this column, we describe how clinicians can use the totality of available clinical data to offer a two-dimensional risk stratification that qualifies risk in terms of both severity and temporality. By offering two separate designations that reflect severity for both acute and chronic risk, conceptualizing and communicating a patient's risk for suicide is accomplished in a more nuanced way, providing the level of detail necessary when working with high risk individuals, especially those struggling with chronic suicidal ideation. Formulations reflecting suicide risk need to be accurate and facilitate good clinical decision-making in order to optimally balance the principles of autonomy, non-maleficence, and beneficence. Stratifying risk in terms of both severity and temporality helps identify situations in which involuntary hospitalization is warranted, while also helping to minimize unnecessary admissions. Hence, two-dimensional risk stratification that addresses both acute and chronic risk for suicide is an essential component of therapeutic risk management of the suicidal patient.

Suicidal risk factors of recurrent major depression in Han Chinese women.

The relationship between suicidality and major depression is complex. Socio- demography, clinical features, comorbidity, clinical symptoms, and stressful life events are important factors influencing suicide in major depression, but these are not well defined. Thus, the aim of the present study was to assess the associations between the above-mentioned factors and suicide ideation, suicide plan, and suicide attempt in 6008 Han Chinese women with recurrent major depression (MD). Patients with any suicidality had significantly more MD symptoms, a significantly greater number of stressful life events, a positive family history of MD, a greater number of episodes, a significant experience of melancholia, and earlier age of onset. Comorbidity with dysthymia, generalized anxiety disorder (GAD), social phobia, and animal phobia was seen in suicidal patients. The present findings indicate that specific factors act to increase the likelihood of suicide in MD. Our results may help improve the clinical assessment of suicide risk in depressed patients, especially for women.

Asthma and suicide behaviors: Results from the Third National Health and Nutrition Examination Survey (NHANES III)

Asthma and suicide attempts are leading causes of morbidity and mortality among adults in the United States. The objective of this study was to investigate the relationship between asthma and suicidal ideation and suicide attempt among adults in the United States, and to examine whether timing of asthma, mood disorders, poverty, allergies, cigarette smoking and sex differences confound these relationships. Data were drawn from the Third National Health and Nutrition Examination Survey (NHANES III), a representative sample of adults (N = 6584) in the United States. Logistic regression analyses were used to examine the relationships between current and former asthma and suicidal ideation and suicide attempt, adjusting for demographics, poverty, smoking, allergies and mood disorders. Current asthma is significantly associated with an increased likelihood of suicidal ideation (OR: 1.77, CI: 1.11, 2.84) and suicide attempt (OR: 3.26, CI: 1.97, 5.39), after adjusting for mood disorders, smoking, poverty and demographics. There does not appear to be a significant relationship between former asthma and suicidal ideation or suicide attempt. These findings confirm and extend previous evidence by showing that the link between asthma and suicide-related outcomes is evident among adults in a representative sample and that this relationship persists after adjusting for a range of variables. This study may provide an empiric foundation for including asthma in the clinical assessment of suicide risk.

Predicting future suicide attempts among depressed suicide ideators: A 10-year longitudinal study

Suicidal ideation and attempts are a major public health problem. Research has identified many risk factors for suicidality; however, most fail to identify which suicide ideators are at greatest risk of progressing to a suicide attempt. Thus, the present study identified predictors of future suicide attempts in a sample of psychiatric patients reporting suicidal ideation. The sample comprised 49 individuals who met full DSM-IV criteria for major depressive disorder and/or dysthymic disorder and reported suicidal ideation at baseline. Participants were followed for 10 years. Demographic, psychological, personality, and psychosocial risk factors were assessed using validated questionnaires and structured interviews. Phi coefficients and point-biserial correlations were used to identify prospective predictors of attempts, and logistic regressions were used to identify which variables predicted future attempts over and above past suicide attempts. Six significant predictors of future suicide attempts were identified – cluster A personality disorder, cluster B personality disorder, lifetime substance abuse, baseline anxiety disorder, poor maternal relationship, and poor social adjustment. Finally, exploratory logistic regressions were used to examine the unique contribution of each significant predictor controlling for the others. Comorbid cluster B personality disorder emerged as the only robust, unique predictor of future suicide attempts among depressed suicide ideators. Future research should continue to identify variables that predict transition from suicidal thoughts to suicide attempts, as such work will enhance clinical assessment of suicide risk as well as theoretical models of suicide.

A comparison of the clinical characteristics of women with recurrent major depression with and without suicidal symptomatology

The relationship between recurrent major depression (MD) in women and suicidality is complex. We investigated the extent to which patients who suffered with various forms of suicidal symptomatology can be distinguished from those subjects without such symptoms. We examined the clinical features of the worst episode in 1970 Han Chinese women with recurrent DSM-IV MD between the ages of 30 and 60 years from across China. Student's t tests, and logistic and multiple logistic regression models were used to determine the association between suicidality and other clinical features of MD. Suicidal symptomatology is significantly associated with a more severe form of MD, as indexed by both the number of episodes and number of MD symptoms. Patients reporting suicidal thoughts, plans or attempts experienced a significantly greater number of stressful life events. The depressive symptom most strongly associated with lifetime suicide attempt was feelings of worthlessness (odds ratio 4.25, 95% confidence interval 2.9-6.3). Excessive guilt, diminished concentration and impaired decision-making were also significantly associated with a suicide attempt. This study contributes to the existing literature on risk factors for suicidal symptomatology in depressed women. Identifying specific depressive symptoms and co-morbid psychiatric disorders may help improve the clinical assessment of suicide risk in depressed patients. These findings could be helpful in identifying those who need more intense treatment strategies in order to prevent suicide.

P03-479 - Suicide intent scale in the prediction of suicide

ObjectiveTo assess the predictive value of the Suicide Intent Scale in patients with a high suicide risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale would offer a better predictive value in case detection. Finally a short version of the scale was created after an item analysis.MethodEighty-one suicide attempters were assessed with the Beck‘s Suicide Intent Scale (SIS). All patients were followed up for cause of death. Receiver-operating characteristic (ROC) curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to predict suicide.ResultsSeven patients committed suicide during a mean follow up of 9.5 years. The major finding was that mean SIS distinguished between suicides and survivors. The positive predictive value was 16.7% and the AUC was 0.74. Only the planning subscale reached the statistical significance. Four items were used to test a short version of SIS in the suicide prediction. The positive predictive value was 19% and the AUC was 0.82.ConclusionsThe Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a short version of the scale may offer a better predictive value.

Suicide Intent Scale in the prediction of suicide

To assess the predictive value of the Suicide Intent Scale in patients with high suicide risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale may offer a better predictive value in suicide risk detection. Finally a shorter version of the scale was created after an item analysis. Eighty-one suicide attempters were assessed with the Beck's Suicide Intent Scale (SIS). All patients were followed up for cause of death. Receiver-operating characteristic (ROC) curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to predict suicide. Seven patients committed suicide during a mean follow up of 9.5 years. The major finding was that mean SIS scores distinguished between suicides and survivors. The positive predictive value was 16.7% and the Area Under Curve (AUC) was 0.74. Only the planning subscale reached statistical significance. Four items were used to test a shorter version of the SIS in the suicide prediction. The positive predictive value was 19% and the AUC was 0.82. The Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a shorter version of the scale may offer a better predictive value.

Suicide in Correctional Settings: Assessment, Prevention, and Professional Liability

This article reviews important details of the suicide risk assessment procedure as it pertains to incarcerated individuals. Research on correctional suicide risk factors is briefly outlined as a prelude to discussing current methods of clinical suicide risk assessment and prevention in correctional settings. A comprehensive and reliable procedure for eliciting suicidal ideation, behavior, planning, desire, and intent is described. Recommendations for formulating an individualized suicide risk reduction plan are presented, along with key principles of suicide risk assessment documentation. Finally, issues related to professional liability for suicide in corrections are discussed.