Passive Ideation Research Articles

Examining contemporaneous and temporal associations of real-time suicidal ideation using network analysis.

Suicidal ideation arises from a complex interplay of multiple interacting risk factors over time. Recently, ecological momentary assessment (EMA) has increased our understanding of factors associated with real-time suicidal ideation, as well as those predicting ideation at the level of hours and days. Here we used statistical network methods to investigate which cognitive-affective risk and protective factors are associated with the temporal dynamics of suicidal ideation. The SAFE study is a longitudinal cohort study of 82 participants with current suicidal ideation who completed 4×/day EMA over 21 days. We modeled contemporaneous (t) and temporal (t + 1) associations of three suicidal ideation components (passive ideation, active ideation, and acquired capability) and their predictors (positive and negative affect, anxiety, hopelessness, loneliness, burdensomeness, and optimism) using multilevel vector auto-regression models. Contemporaneously, passive suicidal ideation was positively associated with sadness, hopelessness, loneliness, and burdensomeness, and negatively with happiness, calmness, and optimism; active suicidal ideation was positively associated with passive suicidal ideation, sadness, and shame; and acquired capability only with passive and active suicidal ideation. Acquired capability and hopelessness positively predicted passive ideation at t + 1, which in turn predicted active ideation; acquired capability was positively predicted at t + 1 by shame, and negatively by burdensomeness. Our findings show that systematic real-time associations exist between suicidal ideation and its predictors, and that different factors may uniquely influence distinct components of ideation. These factors may represent important targets for safety planning and risk detection.

An empirical investigation of the distinction between passive and active ideation: Understanding the latent structure of suicidal thought content.

Although the distinction between passive and active suicidal ideation is well accepted by suicide researchers and clinicians, there has been very little empirical investigation into this distinction. The current study addressed this gap by examining the latent structure of suicidal ideation based on thought content. Participants from two distinct samples of U.S. adults (n1=6200; n2=10,625) completed a self-report assessment of eight commonly experienced suicidal thoughts using the Self-Injurious Thoughts and Behaviors Interview-Revised. Exploratory structural equation modeling was used to examine the latent structure of suicidal thoughts. The two-factor model demonstrated significantly better fit than the one-factor solution across both samples. Thoughts typically classified as passive ideation strongly loaded onto one factor, whereas thoughts typically classified as active ideation loaded onto the second factor. The two factors were highly correlated and some suicidal thoughts exhibited meaningful cross-loading. Our results suggest that passive and active ideation are two distinct constructs. Although they often co-occur, passive and active ideation are not nested constructs and should not be viewed as gradients of one underlying construct. Our findings suggest that at a minimum both passive and active ideation should be included in all suicide risk assessments and screenings.

Developing a New Suicide Risk Assessment for Virtual Encounters with Non-Clinicians

IntroductionThe COVID-19 pandemic has necessitated that many research encounters be conducted virtually. Non clinician staff (e.g. research assistants (RAs), study coordinators, or research trainees) with varying levels of clinical training and experience are typically the primary point of contact for research participants. Consequently, they are often the first to encounter suicidality. This highlights the need for robust virtual suicide risk assessment procedures that are at an appropriate level for research staff and optimized for remote clinical research visits. The current procedures for in-person visits conducted by the Geriatric Psychiatry Program at McLean Hospital require non-clinician staff to complete the full Columbia Suicide Severity Rating Scale (CSSRS) in situations of active suicidal ideation (SI) before requiring clinician notification and intervention. However, staff and clinicians both reported that the virtual visit format limited the quality of the assessment and the ability to respond rapidly in situations of passive suicidal ideation, especially when this ideation did not meet the threshold for clinician notification specified in the in-person protocol. Thus, we established the need for a specific virtual suicide risk assessment protocol. Here we present our process for needs assessment and its findings, which in turn have shaped our revised protocol.MethodsWe surveyed clinicians and social workers affiliated with the Geriatric Psychiatry Research Program at McLean Hospital. The first goal of this survey was to collect information on how clinicians respond to situations of suicidality during telehealth assessments, and how clinicians recommend that staff navigate these situations in a virtual research setting. The second goal was to gather qualitative data that would guide preparatory safety planning (PSP) that non-clinician staff could complete prior to research visits. Because there are no standardized instruments for the information we wanted to collect, we developed a survey based on consensus among research staff.ResultsOf the 19 clinicians surveyed, 11 completed the brief survey. Nine (81.8%) of the eleven clinicians that responded had needed to deal with a patient at imminent risk of suicide in any setting. Only three (27.27%) clinicians were fully comfortable using the in-person SI protocol for virtual encounters. All 11 (100%) of responding clinicians conveyed that PSP should include information on (a) the exact location of the patient's home, (b) contact information for friends and family, and (c) an assessment of firearm access. The PSP should be completed as early as feasible in the research process, prior to formal enrollment, even if there was no reason to suspect SI at the time. Additional qualitative feedback included recommendations for lowering the threshold for enacting the SOP from subjects expressing active SI to passive SI to facilitate earlier intervention. Clinicians also recommended training staff on formal assessment measures such as the combined SAFE-T (Suicide Assessment Five-step Evaluation and Triage) and CSSRS protocol in a structured interview so that they could conduct a more systematic assessment if passive SI was reported.ConclusionsAs more research encounters are conducted virtually, protocols designed for in-person assessment of suicide risk must be adapted. We found that the most useful addition to a virtual SI protocol may be to lower the threshold for action from active to passive SI and inclusion of PSP. Our findings also indicate that staff should be trained in standardized suicide assessment and that there should be a low threshold for conducting these assessments (i.e. passive ideation) and notifying clinicians. Our findings may be broadly generalizable to all mental health research settings that involve virtual assessment by non-clinician staff.This research was funded byThis work was supported in part by an unrestricted philanthropic gift from Eric Warren Goldman to the Technology and Aging Lab at McLean Hospital

Passive and active suicidal ideation among left-behind children in rural China: An evaluation of intrapersonal and interpersonal vulnerability and resilience.

Although theoretical conceptualizations of suicide hold that passive and active suicidal ideation are etiologically distinct, existing research observing this distinction is modest, with most prior studies focusing exclusively on active ideation. Understanding processes associated with passive ideation is clinically important insofar as passive ideation may precede active ideation, and thus serve as an earlier intervention target prior to potential onset of suicidal behavior. We aimed to evaluate intrapersonal and interpersonal vulnerability and resilience factors for passive ideation and differentiating passive from active ideation. Left-behind adolescents in rural China (n=371) were assessed for passive and active ideation, depressive symptoms, rumination, grit, peer support, and peer victimization. Overall, 15.9% of the sample endorsed passive ideation without active ideation, and 17.8% endorsed active ideation. In multivariate analyses, rumination and grit differentiated left-behind children with passive ideation from those with no ideation. Depressive symptom severity predicted active ideation among adolescents with passive ideation. The current findings suggest that rumination and grit may characterize passive ideation. Although passive and active ideation may differ modestly in vulnerability and resilience factors, depressive symptoms may be important to monitor among those with passive ideation and have not yet experience active ideation.

Passive and active suicidal ideation in Swedish 85-year-olds: Time trends 1986–2015

BackgroundOlder adults have high suicide rates. We investigated potential time trends in the prevalence of passive and active suicidal ideation in 85-year-olds. Further, we examined factors associated with such ideation in this age group. MethodsPopulation-based samples of 85-year-olds were interviewed in 1986 (N = 347), 2008 (N = 426) and 2015 (N = 320). Past-month passive/active suicidal ideation was evaluated with the Paykel questions. ResultsReporting any type of passive or active suicidal ideation was less common in 2008 (7.3%, p < 0.001) and 2015 (7.2%, p < 0.001) compared to 1986 (16.4%). The change was driven by decreases in passive ideation. Passive/active suicidal ideation was associated with higher MADRS score (OR: 1.2, 95% CI: 1.1–1.2, p < 0.001), institution residence (OR: 3.9, 95% CI: 1.7–8.9, p = 0.001) and feelings of loneliness (OR: 2.7, 95% CI: 1.4–5.2, p = 0.003). When stratified by sex, it was associated with institution residence (OR: 3.7, 95% CI: 1.4–9.9, p = 0.008) and feelings of loneliness (OR: 3.0, 95% CI: 1.4–6.3, p = 0.005) in women. In men, we observed a tenfold higher risk in those without partners (OR: 9.8, 95% CI: 2.9–33.5, p < 0.001). LimitationsWhile differential three-year mortality was not observed in 1986, mortality was higher among non-participants in 2008 and 2015. This might have inflated cohort differences in passive/active suicidal ideation. ConclusionAn initial decrease in the prevalence of passive/active suicidal ideation in 85-year-olds was observed but this positive trend did not persist. Results underline that preventive strategies targeting loneliness and focusing on institutional settings are needed, as are interventions for men without partners.

Thirty-day suicidal thoughts and behaviors among hospital workers during the first wave of the Spain COVID-19 outbreak.

BackgroundHealthcare workers are a key occupational group at risk for suicidal thoughts and behaviors (STB). We investigated the prevalence and correlates of STB among hospital workers during the first wave of the Spain COVID‐19 outbreak (March–July 2020).MethodsData come from the baseline assessment of a cohort of Spanish hospital workers (n = 5450), recruited from 10 hospitals just after the height of the coronavirus disease 2019 (COVID‐19) outbreak (May 5–July 23, 2020). Web‐based self‐report surveys assessed 30‐day STB, individual characteristics, and potentially modifiable contextual factors related to hospital workers' work and financial situation.ResultsThirty‐day STB prevalence was estimated at 8.4% (4.9% passive ideation only, 3.5% active ideation with or without a plan or attempt). A total of n = 6 professionals attempted suicide in the past 30 days. In adjusted models, 30‐day STB remained significantly associated with pre‐pandemic lifetime mood (odds ratio [OR] = 2.92) and anxiety disorder (OR = 1.90). Significant modifiable factors included a perceived lack of coordination, communication, personnel, or supervision at work (population‐attributable risk proportion [PARP] = 50.5%), and financial stress (PARP = 44.1%).Conclusions and RelevanceThirty‐day STB among hospital workers during the first wave of the Spain COVID‐19 outbreak was high. Hospital preparedness for virus outbreaks should be increased, and strong governmental policy response is needed to increase financial security among hospital workers.

Psychotic Experiences and Schizotypy in Early Adolescence Predict Subsequent Suicidal Ideation Trajectories and Suicide Attempt Outcomes From Age 18 to 38 Years.

Subclinical risk markers for schizophrenia predict suicidality, but little is known about the nature of the relationship. Suicidal ideation is often considered homogenous, but distinguishing passive from active ideation (ie, thoughts of death vs thoughts of killing oneself) and different temporal patterns may further the understanding of risk factors. We tested whether schizotypy and psychotic experiences (PEs) in early adolescence predict subsequent growth trajectories of suicidal ideation and suicide attempt outcomes. Participants were 1037 members of the population-representative Dunedin Study cohort. PE was measured at 11 years and schizotypy at 13 and 15 years. Outcomes were passive and active suicidal ideation, and suicide attempt, measured at 18, 21, 26, 32, and 38 years. Passive ideation was best represented by 2 trajectories, including persistent and transient ideation classes. Schizotypy predicted membership in the smaller persistent class (odds ratio [OR] = 1.21, P = .041), whereas PE was not associated with class membership. The probability of suicide attempts was 13.8% in the persistent ideation class, compared with 1.8% in the transient class. Active ideation was best represented by a 1-class model, the intercept of which was predicted by schizotypy (OR = 1.23, P = .015). Suicide attempts were predicted by schizotypy (OR = 1.53, P = .040) and PE (OR = 3.42, P = .046), and this was partially mediated by indirect effects via the active ideation trajectory. Findings indicate that adolescent schizotypy and PE are related to subsequent suicidal ideation and attempts. Suicidal ideation is heterogeneous, and schizotypy is specifically related to a persistent passive ideation subgroup.

Mental Health Problems and Risk of Suicidal Ideation and Attempts in Adolescents.

Obtaining recent estimates of the prevalence of suicide-related outcomes across adolescence and its associated mental health problems (MHPs) is important for clinical practice. We estimated the prevalence of suicide-related outcomes at ages 13, 15, 17, and 20 years (2011-2018) in a contemporary population-based cohort and documented associations with MHPs throughout adolescence. Data came from 1618 participants in the Québec Longitudinal Study of Child Development. Internalizing (depression and anxiety) and externalizing (oppositional/defiance, conduct issues, and attention deficit and/or hyperactivity) MHPs were assessed with validated questionnaires. Outcomes were self-reported past-year passive and serious suicidal ideation and suicide attempt. Lifetime prevalence of passive suicidal ideation (13-17 years old), serious suicidal ideation, and suicide attempt (13-20 years old) were 22.2%, 9.8%, and 6.7%, respectively. Prevalence was twice as high for females as for males. Overall, rates of passive (15-17 years old; 11.8%-18.4%) and serious ideation (13-20 years old; 3.3%-9.5%) increased over time but were stable for attempt (13-20 years old; 3.5%-3.8%). In univariable analyses, all MHPs were associated with suicide-related outcomes at all ages (risk rate ratio range: 2.57-3.10 [passive ideation] and 2.10-4.36 [suicide attempt]), and associations were similar for male and female participants (sex interaction P > .05). Magnitude of associations were generally stronger for more severe suicide-related outcomes (passive ideation < serious ideation < attempt). In multivariable analyses, internalizing problems were associated with suicidal ideation, whereas both depressive and conduct symptoms were associated with attempt. Suicidal ideation and attempt were common, especially for females and youth presenting with depressive and conduct problem symptoms. Clinicians should systematically assess suicidal risk in teenagers, especially in those presenting with MHPs.

Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation.

Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear. We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO. A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons. Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.

Suicidal ideation, suicidal behaviors, and attitudes towards suicide of adolescents enrolled in the Alternative Learning System in Manila, Philippines\u2014a mixed methods study

BackgroundGlobally, suicide is a significant cause of death among adolescents. Previous studies conducted in high-income countries suggest that students in alternative schools are more likely to engage in suicidal behaviors than those in formal schools. This study aimed to document suicidal ideation and behaviors among adolescent learners enrolled in the Alternative Learning System (ALS) in Manila, Philippines.MethodsA mixed methods study was conducted in 24 ALS centers in the city of Manila. ALS centers were stratified according to congressional district and selected using probability proportionate sampling. A cross-sectional survey to determine attitudes towards suicide and prevalence of suicidal ideation and behaviors was administered to 171 learners aged 13 to 17 years old. In-depth interviews with 18 teachers and 12 learners were conducted to explore the school psychosocial environment’s role on learners’ suicidal ideation and behaviors. Exploratory factor analysis was used to extract attitude factors. Fisher’s exact test and Student’s t-test were used to identify differences in sociodemographic characteristics and attitudes towards suicide between learners with or without suicidal ideation or behaviors. Qualitative data were analyzed using thematic analysis.ResultsNon-specific active thoughts were the most common type of lifetime suicidal ideation (40.9%) while passive ideation was the most common in the past month (13.5%). Aborted suicide attempt was the most frequent behavior in both lifetime (16.4%) and in the past month (4.7%). Non-fatal suicide attempt in the past month was 2.3%, reaching 12.9% for the entire lifetime. Age, sex, education, and attitudes towards suicide were significantly associated with suicidal ideation or behavior. Thematic analysis showed five themes: (1) fostering belongingness, (2) securing learners’ safety, (3) teaching philosophy, (4) teacher and learner beliefs towards suicidal behavior, and (5) availability of school-offered and community-based services.ConclusionSuicidal ideation and behaviors are prevalent among adolescent ALS learners. This study also showed a significant difference in attitudes towards suicide and sociodemographic characteristics between learners with and without suicidal ideation behaviors. It also suggests that the school psychosocial environment, through social norms and learner-teacher interactions, can potentially prevent progression of suicidal ideation to behavior, influence help-seeking, and promote mental health among learners.

F93. SUBCLINICAL PSYCHOSIS COMPONENTS MAKE DIRECT AND INDIRECT CONTRIBUTIONS TO ACTIVE SUICIDE IDEATION IN ADOLESCENTS

BackgroundSubclinical psychosis predicts concurrent and future suicidal ideation and attempts. A key account of this relationship is that it is spurious—that suicidality and subclinical psychosis are both products of a common confounding factor such as environmental risk exposures (e.g., neglect or abuse) or the burden of general psychopathology. This account is unsatisfactory for several reasons, including that subclinical psychosis may be especially predictive of more lethal forms of suicidal behaviour. Moreover, few have considered the relationship in light of contemporary accounts of suicide. Therefore, we sought to better understand the link between subclinical psychosis and suicidality using a contemporary ideation–action framework in which perceived burden and thwarted belonging are distinguished as proximal pathways to suicidal ideation. We tested whether this framework fully mediates the relationship of subclinical psychosis with suicidal ideation, consistent with a common confounding factor account.MethodsRandomly sampled 15- to 18-year-olds from a socio-economically representative high school were invited to participate anonymously. Of those invited (n = 300), 59% provided informed consent and completed self-report measures of positive, negative, and disorganised components of subclinical psychosis (Schizotypal Personality Questionnaire [SPQ]), thwarted belonging and perceived burden (Interpersonal Needs Questionnaire), and passive and active suicidal ideation (Beck Scale for Suicide Ideation [BSS]). Participants were classified using BSS responses as non-ideators, passive ideators, or active ideators. In regression modelling (maximum likelihood estimation with bias-corrected bootstrapping), direct and indirect effects of SPQ components on ideator classifications were obtained. Mediators were perceived burden, thwarted belonging, and their interaction term. Sex and migrant status were entered as covariates.ResultsOf those with complete data (n = 156), 69.9% were non-ideators, 12.8% were passive ideators, and 17.3% were active ideators. In bivariate analyses, SPQ positive scores predicted passive ideation (r = .24, p < .001) but negative (r = .13, p > .05) and disorganised scores (r = .14, p > .05) did not. In contrast, active ideation was strongly predicted by negative (r = .39, p < .001) and disorganised scores (r = .34, p < .001) and less strongly predicted by positive scores (r = .19, p < .05). Mediation models predicted passive (R2 = .29, p < .05) and active ideation (R2 = .65, p < .001). Passive ideation was sensitive only to indirect effects of SPQ scores: negative (β = .14, p < .01) and disorganised SPQ scores (β = .11, p < .05) were mediated by perceived burden. For active ideation, negative (β = .17, p < .05) and disorganised scores (β = .14, p < .05) had similar indirect effects mediated by perceived burden but there were also direct effects of positive (β = -.44, p < .01) and negative SPQ scores (β = .37, p < .05). Thwarted belonging did not mediate the effects of SPQ scores on ideator status.DiscussionA contemporary ideation–action model of suicide did not fully account for the relationship between subclinical psychosis and suicidal ideation. Instead, some components of subclinical psychosis directly influenced suicidal ideation status: Positive subclinical psychosis components protected against active suicidal ideation whereas negative components increased the risk of active ideation. Negative and disorganised components of subclinical psychosis also increased the risk of ideation by increasing the perception of self-hate and liability on others. Subclinical psychosis makes a unique contribution to the prediction of suicidal ideation.

A longitudinal test of the predictions of the interpersonal-psychological theory of suicidal behaviour for passive and active suicidal ideation in a large community-based cohort

BackgroundThe Interpersonal-Psychological Theory of Suicide (IPTS) aims to elucidate the key antecedents of suicide deaths. Limited research has tested the IPTS in a community setting, and very little longitudinal research has been conducted. The current study longitudinally tested the predictions of the IPTS for suicidal ideation in a large population-based sample. MethodsThe PATH through Life study assesses three age cohorts (20's, 40's, 60's) every four years. Two interpersonal factors were estimated at the third wave of assessment: thwarted belongingness (TB) and perceived burdensomeness (PB). The roles of these factors in suicide ideation (active and passive) four years later were estimated using logistic regression models (n = 4545). ResultsA one SD increase in TB was associated with increased odds of 37% for passive ideation and 24% for active ideation. For PB, odds were increased 2.5-fold for passive ideation and 2.4-fold for active ideation. A significant negative PB × TB interaction was found for passive but not active ideation. Effects were not consistent by age group or gender. LimitationsProxy measures were used to assess the constructs. The extended timeframe and low prevalence of suicidal ideation limited power to find effects within subgroups. ConclusionsAlthough TB and PB were individually associated with suicidal thoughts, little evidence was found for the key predictions of the IPTS longitudinally. Further investigation of the dynamic interplay between interpersonal factors over time is needed.

Associations of suicidality with cognitive ability and cognitive insight in outpatients with Schizophrenia

BackgroundPrevious literature suggests that better cognitive ability and insight are associated with greater lifetime risk of suicide attempts in schizophrenia, counter to the direction of association in the general population. However, the conjoint association between distinct cognitive domains, insight, and suicidality has not been assessed. MethodIn a cross-sectional study, 162 adults with schizophrenia or schizoaffective disorder completed cognitive testing via the MATRICS battery, symptom and cognitive insight assessments, along with the Columbia Suicide Severity Rating Scale. We then contrasted participants based on history of suicidality by cognitive domains and insight measures and conducted multivariate analyses. ResultsAlthough a history of any passive ideation was not associated with cognitive ability or insight, verbal learning was positively associated with a greater history of suicidal attempt and prior ideation with a plan and intent. Higher cognitive insight, and the self-reflectiveness subscale insight, was also associated with history of passive or active suicidal ideation. Cognitive insight and cognitive ability were independent from each other, and there were no moderating influences of insight on the effect of cognitive ability on suicide related history. Exploratory analyses revealed that history of planned attempts were associated with greater verbal learning, whereas histories of aborted attempts were associated with poorer reasoning and problem-solving. ImplicationsAlthough cross-sectional and retrospective, this study provides support that greater cognitive ability, specifically verbal learning, along with self-reflectiveness, may confer elevated risk for more severe suicidal ideation and behavior in an independent fashion. Interestingly, poorer problem-solving was associated with aborted suicide attempts.

Preliminary evidence that schizophrenia liability at age 15 predicts suicidal ideation two years later

We tested artifactual and theory-based accounts of the relationship between schizophrenia liability and suicidality. At baseline, 387 adolescents (12 to 17years) completed measures of schizotypy, hopelessness, and depressed affect. After two years, schizotypal and non-schizotypal subsamples (n=16 and 31, respectively) self-reported passive suicidal ideation, active ideation, and serious ideation and action. Taxonic schizotypy predicted passive ideation (OR=8.15, 95% CI 1.34, 49.60) even when controlling for depressed affect. Hopelessness did not predict suicidality or moderate schizotypy–suicidality relationships. Findings were consistent with the interpersonal theory of suicide and contrary to the artifactual account of the association.

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

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

Death and suicidal ideation among nursing home residents in a Chinese city – a pilot study

This paper examines death and suicidal ideation among nursing home residents in a Chinese City using a questionnaire survey data. Findings from the survey show that 17.4% of the participants have death and suicidal ideation, and the prevalence of passive and active ideation are 15.4% and 6.2% respectively. The presence of death and suicidal ideation among nursing home residents correlates with depressive symptoms, life satisfaction, and satisfaction with nursing home services. As death and suicidal feelings are risk factors for suicide, the findings imply that implementing depression prevention programmes and improving service quality of nursing homes are vital in preventing suicides among nursing home residents.

Suicide ideation, plans, and attempts among general practice patients with chronic health conditions in Puerto Rico

Background:Little is known about suicidal ideation among general practice patients in Puerto Rico. In this study we examined the rates, severity, and correlates of suicidal ideation, plans, and attempts among general practice patients with chronic illnesses. This is important in targeting appropriate interventions and management approaches to minimize and prevent suicide.Methods:We screened patients with chronic physical conditions at general practices. Suicidal ideation was assessed with the suicidality module of the Mini International Neuropsychiatric Interview. Major depression was assessed with the Patient Health Questionnaire depression module. The relationship between sociodemographic factors, depression and suicidal ideation was examined with multiple logistic regression analysis. Among the subgroup that acknowledged suicidal ideation, we used multinomial logistic regression analysis to estimate simultaneously the multivariate associations of depression and sociodemographic factors with suicidality risk levels.Results:Of the 2068 patients screened, 15.4% acknowledged recent suicidal ideation. Among this group, 8.6% reported passive ideation, 3.7% active ideation without a plan, and 3.1% active ideation with a plan or attempt. According to multivariate logistic regression, suicidal ideation was higher among patients with moderately severe depression and severe depression than for those with milder symptoms. Patients aged 64 years or younger were over one and a half times more likely to acknowledge suicidal ideation than those aged 65 years and older. Compared with patients having a college degree, those with lower education had a twofold higher risk of suicidal ideation. Multinomial logistic regression analysis indicated that severe depression was associated with a higher likelihood of having a suicide plan or attempt.Conclusion:The findings of this study suggest that public health strategies focusing on the systematic identification of patients with increased depression severity and the implementation of evidence-based depression treatments are relevant for minimizing and preventing suicidal behavior among general practice patients with chronic health conditions.

Suicidal ideation among elderly homecare patients

To identify the prevalence, correlates, and one-year naturalistic course of suicidal ideation in a representative sample of elderly adults newly admitted to visiting nurse homecare. Five hundred and thirty-nine participants (aged > or =65), newly initiating homecare for skilled nursing services, were interviewed with the Structured Clinical Interview for DSM-IV (SCID-IV) and measures of depression severity, medical comorbidity, functional status, and social support. Participants were classified as having no suicidal ideation in the past month, passive ideation, active ideation, or active ideation with poor impulse control or suicide plan. Fifty-seven participants (10.6%) reported passive and six (1.2%) reported active suicidal ideation. Higher depression severity, greater medical comorbidity, and lower subjective social support were independently associated with the presence of any level of suicidal ideation. At one year, suicidal ideation persisted for 36.7% of those with ideation at baseline, and the incidence of suicide ideation was 5.4% The high prevalence, persistence, and incidence of suicidal ideation in medically ill home healthcare patients underscore the relevance of this population for suicide prevention efforts. The clinical and psychosocial factors associated with suicidal ideation in this underserved, high-risk population are potentially modifiable, and thus useful targets for suicide prevention interventions.

Prevalence and outcomes of occult suicidality in a multiethnic emergency department population

Study objectives: Because suicide completers frequently visit the emergency department (ED) for reasons other than suicide before their death, we sought to establish the prevalence of occult suicidality in patients seeking treatment for routine, nonpsychiatric problems in the ED. Methods: A prospective cohort of waiting room patients recruited during random time blocks in a large, urban ED were screened with an anonymous, computerized mental health assessment for a tripartite construct of suicidality: passive ideation, frequent thoughts of death and being "better off dead"; active ideation, specific thoughts about self-harm; and serious intent, defined as an endorsement of the statement "I am planning to kill myself." Patients younger than 18 years, with mental status impairment, or with a psychologic chief complaint were excluded. Results: Passive ideation was endorsed by 184 of 1,590 patients (11.6%), whereas 143 (8.4%) patients acknowledged active thoughts about killing themselves and 31 (1.6%) patients acknowledged imminent plans to kill themselves. Black patients were most likely and Hispanic patients least likely to endorse passive and active suicidal ideation, respectively (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1 to 2.1; OR 0.50; 95% CI 0.34 to 0.73, respectively). Patients reporting both ideation and serious intent were demographically similar to all other ED patients with similar reasons for visit. Fully 97% of 184 ideators screened positive for 1 or more mood, anxiety, or substance-related disorders, and 30% of serious intent patients endorsed problems in all 3 axis I domains. Of 31 actively suicidal patients, 24 remained undetected, receiving neither psychiatric diagnoses nor referral; only 6 patients had any mention of suicidality on the index ED record. None of the 31 patients expressing suicidal intent died within 3 months of enrollment, but 4 returned within 60 days, having made serious attempts; all survived. Conclusion: Occult suicidality is common in ambulatory ED patients presenting for nonpsychiatric problems but may be unmasked with a simple screen during routine ED evaluation.

Toward a New Definition of Suicidality? Are We Prone to Fregoli's Illusion?

Subjects with Fregoli’s illusion recognize a number of different people as differing in appearance, but they have the delusional belief that all of them are in fact the same familiar person (Sims, 1995). Do we suicidologists tend to behave as if we were experiencing this illusion when recognizing a number of our patients or clients, usually differing in cognitive and behavioral aspects of suicidality, as the same familiar person? Do we have a tendency to investigate, manage, or treat them as if they were in fact a single suicidal case? Are we consistent enough in defining suicidality in our cases? Is there sufficient external validity present in our definitions of suicidality? Can one’s definition of suicidality be sent as a letter across the Pacific and be really understood as written when mailed or does the message in the bottle somehow get lost? In their famous paper, O’Carroll et al. (1996) stated: “Suicidology finds itself confused and stagnated for lack of a standard nomenclature.” Their paper proposed a nomenclature for suicide-related behavior in the hope of improving communications, advancing suicidological research, and improving the efficacy of clinical interventions. Of course, they were not the first. Nor were Beck et al. (1974) the first ones to develop a classification scheme for suicidal behavior differentiating between the suicidal idea, the suicide attempt, and the completed suicide. Interestingly, each of the three types was further specified by certainty of the rater, lethality, intent to die, mitigating circumstances, and method used. Unfortunately, neither these nor any other classification efforts have been widely adopted. Why? Is Fregoli that resistant? In the mid-1980s, the Centers for Disease Control (CDC) published the Operational Criteria for the Determination of Suicide – OCDC (Rosenberg et al., 1988). Suicide was defined in terms of three components: death as the results of injury (yes), self-inflicted (yes), and intentionally inflicted (by self), which were seen as essential elements distinguishing suicide from death due to natural causes (no; no; not applicable), accidental death (yes; no; not applicable), and homicide (yes; yes; by others). Interestingly, this was not to constitute a classification scheme; rather, they established a clear definition of the evidential component elements that are necessary for a certification of suicide, thus guiding coroners as to the kind of death-scene evidence to be sought and considered in cases of possible suicide. The OCDC undoubtedly represents a good basis for a nomenclature. However, in the same way as various suicidality states are not attributable to one single cause, they are similarly not presenting themselves in a single way. Presentations of suicidality are traditionally divided into various forms of suicidal ideation (from passive ideation to active suicidal thoughts with plans and clear intent or even threat), various forms of suicidal behavior (from parasuicides and deliberate self-harm to suicidal attempts with corresponding suicidal intent), and the completed suicide. Classical definitions have defined suicide as a deliberate act of selfdestruction resulting in death; as a conscious self-directed act intended to lead to death; or a willful self-inflicted lifethreatening act resulting in death (Retterstol, 1993). In other words, classical definitions tend to stress intent of selfdestructiveness, an act that is self-directed and life-threatening, and that will be fatal. Similar to the OCDC, the above three components can be proposed as essential elements distinguishing completed suicide from other suiciderelated behaviors (not necessary fatal) and non-suicide related deaths, too: 1. intention (yes; no) and 2. act of self-destruction (yes; no) 3. death (yes; no).