Heightened Suicide Risk Research Articles

Sleep and circadian disruption in bipolar disorders: From psychopathology to digital phenotyping in clinical practice.

Sleep and biological rhythms are integral to mood regulation across the lifespan, particularly in bipolar disorder (BD), where alterations in sleep phase, structure, and duration occur in all mood states. These disruptions are linked to poorer quality of life, heightened suicide risk, impaired cognitive function, and increased relapse rates. This review highlights the pathophysiology of sleep disturbances in BD and aims to consolidate understanding and clinical applications of these phenomena. It also summarizes the evolution of sleep and biological rhythms assessment methods, including ecological momentary assessment (EMA) and digital phenotyping. It underscores the importance of recognizing circadian rhythm involvement in mood regulation, suggesting potential therapeutic targets. Future research directions include elucidating circadian clock gene mechanisms, understanding environmental impacts on circadian rhythms, and investigating the bidirectional relationship between sleep disturbances and mood regulation in BD. Standardizing assessment methods and addressing privacy concerns related to EMA technology and digital phenotyping are essential for advancing research. Collaborative efforts are crucial for enhancing clinical applicability and understanding the broader implications of biological rhythms in BD diagnosis and treatment. Overall, recognizing the significance of sleep and biological rhythms in BD offers promise for improved outcomes through targeted interventions and a deeper understanding of the disorder's underlying mechanisms.

Breaking the silence: leveraging social interaction data to identify high-risk suicide users online using network analysis and machine learning

Suicidal thought and behavior (STB) is highly stigmatized and taboo. Prone to censorship, yet pervasive online, STB risk detection may be improved through development of uniquely insightful digital markers. Focusing on Sanctioned Suicide, an online pro-choice suicide forum, this work derived 17 egocentric network features to capture dynamics of social interaction and engagement within this uniquely uncensored community. Using network data generated from over 3.2 million unique interactions of N = 192 individuals, n = 48 of which were determined to be highest risk users (HRUs), a machine learning classification model was trained, validated, and tested to predict HRU status. Model prediction dynamics were analyzed using introspection techniques to uncover patterns in feature influence and highlight social phenomena. The model achieved a test AUC = 0.73 ([0.61, 0.85], 95% CI), suggesting that network-based socio-behavioral patterns of online interaction can signal for heightened suicide risk. Transitivity, density, and in-degree centrality were among the most important features driving this performance. Moreover, predicted HRUs tended to be targets of social exchanges with lesser frequency and possessed egocentric networks with “small world” network properties. Through the implementation of an underutilized method on an unlikely data source, findings support future incorporation of network-based social interaction features in descriptive, predictive, and preventative STB research.

The Interplay between Binge Watching and Suicide Risk: Daytime Sleepiness and Maladaptive Daydreaming as Mediators

Binge watching, which entails consecutively viewing numerous episodes of a TV series or a selection of movies over an extended timeframe, often without pause, is notably widespread among young adults skilled in digital media usage. Nevertheless, this escalating habit can lead to problematic and addictive behavior, with potential associations including disruptions in sleep patterns, dreaming, and an elevated risk of suicide. The primary objective of this research was to assess whether daytime sleepiness and maladaptive daydreaming may impact the connection between binge watching and suicide risk and whether the hypothesized model is gender invariant. Self-report questionnaires were administered to a sample of 1012 emerging adults (50% girls) aged 18–25 (M = 21.73, SD = 2.28). Multivariate analysis of covariance (MANCOVA), structural equation modeling (SEM) with latent variables, and multiple-group path analysis (MGPA) were conducted. All direct and indirect paths were found to be statistically significant, and gender was found to be invariant. Specifically, the findings highlighted that higher binge watching, coupled with daytime sleepiness and maladaptive daydreaming, heightened suicide risk in both genders. Binge watching and sleep and dream issues are important factors to consider in the assessment of suicide risk, particularly among emerging adults who are already at a higher risk. It is thus important to prioritize the promotion of healthy media habits.

Revealing suicide risk of young adults based on comprehensive measurements using decision tree classification

Predicting suicide risk based on risk and protective factors is a critical and complex endeavor. In this study, we combined insights from comprehensive aetiological theories on suicide with the methodological strengths of machine learning techniques. Our primary objectives were twofold: a) to identify hazardous feature combinations that characterize a high risk of suicide, and b) to enhance our understanding of the potential interactions between risk and protective factors related to suicide. We established an interpretable decision tree model to classify young adults at high risk of suicide, utilizing fifty-five variables covering distal, developmental, proximal, and social context factors from a large-scale cross-sectional survey (N = 88,214). The results highlighted the significance of variables such as self-compassion and non-suicidal self-injury (NSSI), and the accumulation of depressive symptoms, medium-to-low self-compassion, and a history of NSSI as substantial indicators of heightened suicide risk. This study serves as a valuable reference for the clinical identification of individuals at risk of suicide.

Risk factors for suicide in patients with pancreatic ductal adenocarcinoma: A population‐based study

AbstractBackgroundPatients diagnosed with pancreatic ductal adenocarcinoma (PDAC) face a notable risk of suicide. However, comprehensive population‐based studies on suicide risk in PDAC patients have been lacking. This study seeks to explore the suicide risk in PDAC patients and identify the specific risk factors associated with suicide‐related mortality.MethodsA cohort of 101,382 PDAC patients was extracted from the Surveillance, Epidemiology, and End Results database, spanning from January 1, 2000, to December 31, 2017. The study employed the standardized mortality ratio (SMR) to assess the relative risk of suicide in PDAC patients compared to the general US population. The Nelson–Aalen estimator and the Fine and Grey method were utilized to pinpoint the risk factors linked to suicide‐specific mortality.ResultsPDAC patients exhibited a 3.51‐fold higher risk of suicide compared to the general US population. This risk demonstrated an upward trend over the years. Notably, individuals aged 70–74 years faced a significantly elevated risk of suicide (SMR = 5.14, 95% CI: 3.10–8.03). Furthermore, there were distinct peaks in suicide risk at 1–4‐ and 25–28‐month post‐diagnoses (SMR = 15.04 and 2.72, respectively). Factors, such as gender, chemotherapy status, and marital status, emerged as significant independent predictors of suicide‐specific mortality in PDAC patients.ConclusionsThis study highlights a heightened suicide risk among PDAC patients in comparison to the general US population. It underscores the crucial need for continuous monitoring of the psychological well‐being of all PDAC patients. Additionally, considering the elevated risk, the application of antidepressant therapy could be beneficial for those identified as having a higher risk of suicide.

The interactive effects of AS and trauma exposure on suicide capability and suicide risk

BackgroundTrauma exposure has been linked with heightened suicide risk purportedly through habituation to threatening stimuli, thereby reducing fear of suicide. However, no research has examined variables that may influence this process. Anxiety sensitivity (AS) is one cognitive-affective factor that may strengthen the relationship between trauma exposure and reduced fear of suicide by amplifying traumatic reactivity. The present study evaluated this by examining the interaction of AS and trauma exposure type (e.g., direct vs. witnessed) predicting fear of suicide and self-reported suicide risk. MethodsParticipants (n = 124) were recruited for a long-term (∼3–4 years) follow-up after participation in a clinical trial targeting suicide risk factors and were asked to complete self-report measures of trauma history, AS, fear of suicide, and suicide risk. ResultsSignificant interactions emerged such that a greater number of direct traumasexperienced predicted lower fear of suicide and greater suicide risk among those with greater AS. The interactive effect of witnessed traumas and AS predicting suicidality was insignificant. Results remained even after including relevant covariates. DiscussionThe current findings suggest that AS augments the effects of repeated trauma exposure on fear of suicide and suicide risk. It is plausible these painful and provocative events are more potent among those with high AS due to the amplification of traumatic affective responses, though future research examining the longitudinal relations is needed to confirm this process.

Association of interleukin-6 with suicidal ideation in veterans: a longitudinal perspective.

Studies showing associations between inflammation in suicide are typically cross-sectional. Present study investigated how cytokine levels track with suicidal ideation and severity longitudinally. Veterans with a diagnosis of major depressive disorder (MDD) with or without suicide attempt history (MDD/SA n = 38, MDD/NS n = 41) and non-psychiatric non-attempter controls (HC n = 33) were recruited, MDD/SA and HC groups were followed longitudinally at 3 months and 6 months. Blood plasma was collected and processed using Luminex Immunology Multiplex technology. Significant differences in depression severity (BDI) and suicidal ideation severity (SSI) were observed across all groups at study entry, wherein MDD/SA group had the highest scores followed by MDD/NS and HC, respectively. Cytokines IL-1β, IL-4, TNF-α, IFN-γ, and IL-6 were examined at study entry and longitudinally, with IL6 levels differing significantly across the groups (p = 0.0123) at study entry. Significant differences in changes in cytokine levels between depressed attempters and the control group were detected for IL-6 (interaction F1,91.77 = 5.58, p = 0.0203) and TNF-α (F1,101.73 = 4.69, p = 0.0327). However, only depressed attempters showed a significant change, in IL-6 and TNF-α levels, decreasing over time [IL-6: b = -0.04, 95% CI = (-0.08, -0.01), p = 0.0245 and TNF-α: b = -0.02, 95% CI = (-0.04, -0.01), p = 0.0196]. Although IL-6 levels were not predictive of suicidal ideation presence [OR = 1.34, 95% CI = (0.77, 2.33), p = 0.3067], IL-6 levels were significantly associated with suicidal ideation severity (b = 0.19, p = 0.0422). IL-6 was not associated with presence of suicidal ideation. IL-6 however, was associated with severity of ideation, suggesting that IL-6 may be useful in clinical practice, as an objective marker of heightened suicide risk.

Differential spatial-social accessibility to mental health care and suicide

In recent years, the United States has been experiencing historically high suicide rates. In the face of mental health care provider shortages that leave millions needing to travel longer to find providers with schedule openings, if any are available at all, the inaccessibility of mental health care has become increasingly central in explaining suicidality. To examine the relationship between access to care and suicide, we leverage a dataset mapping all licensed US psychiatrists and psychotherapists (N= 711,214), as of early 2020, and employ real-world transportation data to model patients' mobility barriers. We find a strong association between reduced mental health care provider spatial-social accessibility and heightened suicide risk. Using a machine learning approach to condition on a host of 22 contextual factors known to be implicated in suicide (e.g., race, education, divorce, gun shop prevalence), we find that in locales where individuals seeking care can access fewer mental health care providers, already more likely to be saturated by demand, suicide risk is increased (3.2% for each reduced SD of psychiatrist accessibility; 2.3% for psychotherapists). Additionally, we observe that local spatial-social accessibility inequalities are associated with further heightened risk of suicide, underscoring the need for research to account for the highly localized barriers preventing many Americans from accessing needed mental health services.

Implicit identification with death detects and predicts short-term suicide risk among adolescents discharged from the emergency room.

Implicit identification with death, measured by the Death-Suicide-Implicit Association Test (D/S-IAT), has been found to predict long-term suicide risk among adolescents. However, previous studies did not examine the predictive utility of D/S-IAT on short-term suicide risk trajectories among adolescents, especially during the critical period following discharge from the emergency room (ER) due to suicide behaviors. This study examined the ability of the D/S-IAT to discriminate and predict suicide risk trajectories during the month following initial suicide risk assessment, among adolescents recently discharged from the ER. One hundred and fifteen adolescents aged 9-18 years (77.4% female) were assessed at clinic intake. All participants completed D/S-IAT and self-report measures for suicide risk, depression, and anxiety during intake and 1-month follow-up. The D/S-IAT distinguished and predicted participants with continued heightened suicide risk at follow-up, above and beyond depression, anxiety, and suicide risk level at intake. Along with conventional measures, D/S-IAT may be utilized to predict short-term suicide risk during post-ER discharge.

A Closer Look: Examination of Suicide Risk Screening Results and Outcomes for Minoritized Youth in Subspecialty Pediatrics.

To describe a sample of minoritized youth who screened positive for suicide risk within medical subspecialty pediatrics, compared to non-minoritized youth and describe the screening outcomes of these youth. This retrospective chart review from October 2018 to April 2021 used electronic medical record data from an academic pediatric medical subspecialty clinic that screens universally for suicide risk for all patients ages 9 and up. Chart reviews were conducted for 237 minoritized youth (operationalized as identifying as non-White or Hispanic/Latinx, identifying as a gender minority, and having a preferred language other than English) who screened positive for suicide risk. Descriptive statistics include need for escalation to an emergency room, connection to mental health care, receival of a mental health referral, and attendance at follow-up visits. Minoritized youth were more likely to screen positive and report a history of suicide attempt when compared to non-minoritized peers. Youth identifying as gender expansive had significant elevation in suicide risk. The majority of youth in this sample were already connected to mental health care, with youth preferring a language other than English being the least likely to be connected. Findings indicate heightened suicide risk for minoritized youth, with gender expansive youth having particularly elevated suicide risk. A need to support youth with a preferred language other than English in getting connected to mental health care was also revealed.

Examining facet-level distinctions within the trait-interpersonal model of suicide risk

Recent research has merged Five Factor Model (FFM) traits and Interpersonal Theory of Suicide (IPTS) risk factors within a trait-interpersonal theory of suicide to identify the effects of personality on social-cognitive suicide risk factors and subsequent engagement in suicide-related behaviors. Facet-level analyses may increase the identification of specific personality characteristics most associated with heightened suicide risk. The present study examined how FFM domains and facet-level traits differentially related to suicide risk within an IPTS framework. A sample of 281 community adults completed measures of thwarted belongingness, perceived burdensomeness, acquired capability, and FFM characteristics. Each IPTS risk factor demonstrated overlapping characteristics in relation to broad FFM domains that were differentiated by facet-level traits. Findings suggest that specific facet-level traits subsumed by broad FFM domains may explain inconsistent relations between FFM traits and suicide risk when examined at the domain level.

Perceived Impact of COVID-19 Among Callers to the National Suicide Prevention Lifeline.

Background: Research indicates that the COVID-19 pandemic caused increases in psychological distress and suicidal ideation. Aims: To describe the ways suicidal callers to the National Suicide Prevention Lifeline (Lifeline) perceived COVID-19 to have impacted them and assess whether these callers perceived COVID-19-related stress as contributing to their suicidal thoughts. Method: Telephone interviews were conducted with 412 suicidal callers to 12 Lifeline centers. Logistic regression analyses were used to examine the associations between demographic factors and individual COVID-19 stressors and to determine whether callers who endorsed COVID-19-related stress as contributing to their suicidal thoughts differed from those who did not regarding demographics, current suicide risk, history of suicidality, Lifeline use, or individual COVID-19 stressors. Results: Over half of callers reported that COVID-19-related stress contributed to their suicidal ideation (CRSSI). Callers who endorsed CRSSI had higher odds than those who did not of mentioning financial difficulties when asked how COVID-19 impacted them. The two groups of callers did not differ on the other factors examined. Limitations: Interviewed callers may not be representative of all Lifeline callers. Conclusion: Despite the subjective burden of COVID-19-related stress on suicidal Lifeline callers, this was not associated with new suicidality or heightened suicide risk.

A psychometric assessment of the Military Suicide Attitudes Questionnaire (MSAQ)

Suicide rates remain high among military populations. Stigmatizing beliefs about suicide contribute to the problem of heightened suicide risk as a deterrent for help-seeking. Measurement of military suicide stigma is therefore an important gap in the literature as a necessity toward the development of military suicide prevention programming. This paper assessed the factor structure, reliability, and validity of the Military Suicide Attitudes Questionnaire (MSAQ). Study 1 featured secondary analysis of a suicide risk dataset from active duty treatment-seeking military personnel (N = 200). Study 2 was a secondary analysis of a statewide assessment of Army National Guard service members’ beliefs about mental health and suicide (N =1116). Factor analyses results collectively supported a four-factor Military Suicide Attitudes Questionnaire (MSAQ) structure: discomfort, unacceptability, support, and empathic views. Subscale reliabilities ranged from 0.77 to 0.83 across samples. Unacceptability and support displayed significant negative correlations with psychological distress. Men displayed more negative suicide-related beliefs compared to women counterparts. Discomfort and unacceptability beliefs displayed significant positive associations with perceived barriers to care. The final short version of the MSAQ is an efficient, multi-dimensional measure of military suicide-related beliefs. The instrument can be used for public health assessment and program evaluation in military settings.

Social and cultural dimensions of loss of a military colleague by suicide or traumatic death: A retrospective veteran study

Veterans who have been exposed to suicide or traumatic death of a colleague experience heightened suicide risk, particularly where they report a close relationship to the deceased. There is a dearth of qualitative studies investigating the experience of loss of a military colleague to inform responses that veterans perceive as helpful. This study addresses this gap, thematically analysing fifty-one semi-structured interviews conducted in 2013–2014 with veterans in the U.S. Commonwealth of Kentucky about their experiences of loss of a military colleague and what was helpful and unhelpful to them in the response. We found that veterans contextualised their experiences to military cultural norms and values. Coping without support was a cultural norm and expectation that could lead to deaths not being acknowledged and stigmatisation of expressing grief and help seeking. Veterans said clearly that this cultural norm does not supplant the responsibility to officially honour the deceased. Official acknowledgement of soldier deaths was important for honouring the deceased and supporting survivors. Opportunities to collectively honour a colleague and grieve were valued. These findings suggest that veteran suicide prevention and postvention practices should be framed in response to the cultural values held by veterans. Further, there is a need to dismantle the entrenched norms and expectations in the military context that act as barriers to being able to grieve the loss of a military colleague and seek support at times of distress.

The role of suicide stigma in self-disclosure among civilian and veteran populations

Widespread attempts to implement suicide prevention efforts may be hindered by stigma regarding suicidal thoughts and behaviors (STBs). Despite extensive literature linking general mental health stigma to numerous negative outcomes (i.e., reduced help-seeking), limited research has extended findings to STB-specific stigma. Thus, the present study aimed to examine the association between three types of STB stigma (public, self, and anticipated) and self-disclosure, a specific form of help-seeking for some individuals, among civilians and a population at heightened suicide risk, U.S. veterans. Participants (n = 500) reported a lifetime history of suicidal ideation (n = 253 identified as a U.S. veteran; n = 132 reported being enrolled in Veteran Health Administration [VHA] care) who completed self-report measures about their STB experiences, including stigma and self-disclosure. Results highlighted a significant association between greater self-stigma, as well as greater anticipated stigma, and a reduced likelihood of STB disclosure, among veterans but not civilians. No significant associations as a result of VHA care status were found. Together, findings suggest that individuals’ concerns related to STBs and STB disclosure may be grounded in past experiences in the military, and thus highlight the need for prevention efforts that protect against negative consequences related to STB disclosure.

Perceived changes in social interactions following military psychiatric hospitalization for a suicidal crisis

ABSTRACT Introduction Changes in social interactions following psychiatric hospitalization, a period characterized by heightened suicide risk, are important to understand. Objective: We qualitatively explored perceived changes in social interactions one month after inpatient psychiatric discharge following a suicidal crisis. Methods: A total of 113 United States Service members, recruited in the context of a psychotherapy randomized controlled trial, described the extent to which social interactions with family members, peers, and military commanders had changed. Results: Most participants (82.3%) reported at least some change in social interactions, conveying six common themes. Showing more care and checking in more were frequently reported for family (24.8%, 20.4%), commanders (23.0%, 16.8%), and by peers (12.4%, 10.6%). Showing more concern was most frequently reported for family (13.3%) followed by peers (6.2%) and commanders (6.2%). Participants reported showing more caution from peers (14.2%), commanders (13.3%) and family (6.2%). Acting more distant was reported from commanders (7.1%), peers (7.1%), and family (5.3%). Showing negative reaction(s) was reported from commanders (8.0%), family (3.5%) and rarely for peers (0.9%). Conclusion: Inpatient providers are encouraged to prepare patients for potential changes in social interactions following psychiatric discharge and how to best respond to these changes.

Evaluating Suicide Risk Using the Reasons for Dying-Reasons for Living (RFD-RFL) Index in a Military Psychiatric Inpatient Setting

The present study aimed to explore reasons for dying (RFD) and reasons for living (RFL) among suicidal inpatients, conceptualize the RFD-RFL index, and examine whether suicide risk indicators were associated with the RFD-RFL index scores. Participants were military personnel (N = 167) psychiatrically hospitalized following a suicide-related crisis who provided baseline data as part of a randomized controlled trial. Family was the most commonly reported RFL (39.7%) and was the top ranked RFL for 65.9% of participants. The most frequently endorsed RFD categories included general descriptors of self (26.9%), general statements about escape (19.7%), and others/relationships (19.1%). Greater RFD-RFL index scores were associated with a greater wish to die relative to wish to live, greater hopelessness, and with a history of lifetime multiple suicide attempts. Endorsing more RFD relative to RFL may indicate heightened suicide risk. Results of this study identify the characteristics of RFD and RFL among a high-risk, military sample, and provide preliminary support for the clinical utility of evaluating the quantities of RFD and RFL. Clinicians are encouraged to explore RFD and RFL when working with suicidal patients. Future research may explore military-specific RFD and evaluate the validity of the proposed RFD-RFL index.

A pandemic of Body, Mind, and Spirit: The Burden of "Social Distancing" in Rural Communities During an Era of Heightened Suicide Risk.

A pandemic of Body, Mind, and Spirit: The Burden of "Social Distancing" in Rural Communities During an Era of Heightened Suicide Risk.

Factors Affecting Suicide Risk in People with Alcohol Use Disorder

Although heightened risk for suicide has long been associated with alcohol use disorder (AUD), questions remain about the potentially confounding

ADDRESSING AN UNMET NEED FOR MENTAL HEALTH SUPPORT DURING CARE TRANSITIONS FROM NURSING FACILITIES

Mental health (MH) disorders are common among skilled nursing facility (SNF) residents and may inhibit rehabilitation goals. Moreover, discharges to the community from SNFs are periods of heightened suicide risk within the Veterans Health Administration (VHA), suggesting an urgent need for improved continuity of MH care. This paper presents results of medical records reviews indicating a potential gap in MH services at discharge from VHA SNFs. A quality improvement project (”Suicide Awareness for Veterans Exiting Community Living Centers” – SAVE-CLC), designed to address this gap, will also be discussed. Piloted in 3 sites (N = 66) in 2018, SAVE-CLC clinicians administered depression screens by phone to 47 Veterans (71%) after SNF discharge and helped connect Veterans to MH services. 24 Veterans (26%) received a second such call. Patients and caregivers expressed high satisfaction with SAVE-CLC (n = 35, 97%). Implications for quality improvements in SNF care transitions will be discussed.