Risk For Suicidal Thinking Research Articles

Suicidal thoughts are associated with reduced source attribution of emotion.

Approximately 9% of people think about suicide during their lifetime. Suicidal thoughts are consistently associated with perceived failures in emotion regulation. However, factors contributing to these perceptions remain insufficiently clear. New evidence suggests that when people know little about the cause of their emotions (i.e., low source attribution of emotion), they perceive themselves as less successful in regulating them. Therefore, emotion regulation deficits in people with suicidal thoughts might be related to lower knowledge about sources of emotions. We examined this question in two ecological momentary assessment studies (N₁ = 396, N₂ = 195). We found that participants with current suicidal thoughts knew less about the sources of their emotions compared to participants with no suicidal thoughts history (Studies 1 and 2), and even when compared to controls with similar levels of psychiatric symptoms but no history of suicidal thoughts (Study 2). Using language processing, we found that written descriptions of the source of participants' emotions were less concrete among those with suicidal thoughts compared to participants with no suicidal thoughts history. Among suicidal participants, suicidal thoughts were more likely to be present in moments when participants knew less than usual about the source of their negative emotions (Study 2), and low knowledge of the source was associated with more frequent and prolonged suicidal thoughts (Studies 1 and 2). Finally, lower perceived success in emotion regulation mediated the association between source attribution of emotion and the occurrence of suicidal thoughts. Findings suggest that reduced knowledge about the source of negative emotions might increase the risk for suicidal thinking. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

In Case You Haven't Heard…

Individuals with Parkinson's disease may be at significantly higher risk for suicidal thinking and behavior than people without the disease, according to a meta‐analysis published last week in JAMA Neurology. “Patients with [Parkinson's disease] possess multiple risk factors for suicidality, such as advanced age, living with a chronic condition, as well as limitations in physical mobility and functional ability,” wrote Aaron Shengting Mai, M.S., of the National University of Singapore; Yinxia Chao, M.D., Ph.D., of the National Neuroscience Institute Singapore; and colleagues. Efforts at early detection and management of suicidality in patients with Parkinson's can help to reduce patients' risk of death and improve their quality of life, they continued. “Patients with [Parkinson's disease] often experience great psychiatric comorbidity, of which the most prominent is depression,” the researchers wrote. “Depressive mood disorders are the greatest risk factors for both suicidal ideation and suicidal behavior and are present in almost half of patients with Parkinson's.”

Screening for and Responding to Suicidality Among Youth Presenting to a Children's Advocacy Center (CAC).

Youth presenting to a Children's Advocacy Center (CAC) for a forensic interview are at increased risk for suicidality, but no data exist for suicidality or suicide screening and response at the time of the forensic interview. The current study applied a suicide and traumatic stress screening and response protocol, the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), with youth (11-18 years) presenting for a forensic interview to one of 16 participating CAC locations, 2018-2020.46.2% of youth screened for traumatic stress and suicidality (N = 1651) endorsed thoughts of suicide or self-harm in the past two weeks, and 13.6% were assessed as high risk for suicide. High symptoms of traumatic stress increased the risk of suicidal thinking as well as of high risk suicidality. CAC workers, both clinicians and non-clinicians, facilitated screening and provided prevention response. Suicide screening and response at the CAC at the time of the forensic interview appears important and feasible.

Daily-level assessment of the contexts under which seeking social support relates to risk of suicidal thinking.

Perceived social support is a well-established protective factor against suicidal ideation, yet few studies have examined how actually seeking social support relates to suicidal ideation. We investigated the contexts under which social support seeking may be related to greater, or lesser, suicidal ideation. Undergraduates completed ecological momentary assessments up to 6 times daily. Multi-level moderated logistic regressions examined interactions between presence of daily-level support seeking with burdensomeness and loneliness as indicators of same-day and next-day suicidal ideation. Seeking social support was positively associated with same-day, but not next-day reports of suicidal thinking. On days when participants felt burdensome and sought support, they had greater odds of reporting suicidal ideation (OR=1.659, 95% CI=[1.420, 1.938]), compared with days they felt burdensome but did not seek support. There was no effect of burdensomeness on next-day ideation. There was no significant interaction effect between support seeking and loneliness on same-day or next-day ideation. Seeking support and feeling like a burden are associated with a greater likelihood of experiencing suicidal ideation. The current results underscore the importance of equipping at-risk individuals with a toolbelt of a variety of coping skills.

A Standard Protocol for the Clinical Management of Suicidal Thoughts and Behavior: Implications for the Suicide Prevention Narrative.

The last several decades have witnessed growing and converging evidence from randomized controlled trials (RCT’s) that an identifiable set of simple clinical management strategies are effective for those at risk for suicidal thinking and/or suicide attempts. The current article offers a brief review of clinical strategies supported by RCT’s targeting suicidality as “commonalities of treatments that work” and related recommendations for use in the delivery of care for suicidal individuals in generic fashion, regardless of any particular treatment, theoretical orientation, or intervention perspective. The article includes eight recommendations that can be easily adapted across the full range of clinical contexts, institutional settings, and delivery systems, recommendations that help frame a broader clinical narrative for suicide prevention. Recommendations cut across five identifiable domains or clinical strategies for the delivery of care: (1) informed consent discussion that identifies risks of opting out of care and emphasizes the importance of shared responsibility and a collaborative process, (2) an explanatory model that emphasizes the importance of individual self-management skills and targeting the causes of suicide rather than describing suicidality as a function of mental illness, (3) the importance of proactively identifying barriers to care and engaging in targeted problem-solving to facilitate treatment adherence, (4) a proactive and specific plan for management of future suicidal episodes, and (5) reinforcing the importance of taking steps to safeguard lethal means and facilitate safe storage of firearms.

Sleep influences daily suicidal ideation through affective reactivity to interpersonal events among high-risk adolescents and young adults.

Identifying proximal risk factors for suicidal ideation that are modifiable and relevant for adolescents and young adults is critical for suicide prevention. This study used an intensive monitoring approach to examine whether objectively- and subjectively- measured sleep characteristics predict next-day suicidal ideation occurrence and intensity through affective reactivity to interpersonal events in young people at high risk for suicide. Participants included 59 (13-23 years; 76% White; 75% female) adolescents and young adults undergoing intensive outpatient program treatment for depression and suicidality. Participants completed daily ratings of suicidal ideation, sleep quality, and affective reactivity to positive and negative interpersonal events for up to 3 months (M = 56 days, SD = 24.13). Actigraphy captured behavioral sleep duration and timing. Multilevel modeling was used to evaluate within-person fluctuations in sleep and affective reactivity as predictors of suicidal ideation, and multilevel mediation tested the indirect effects of sleep on suicidal ideation via affective reactivity to interpersonal events. Results indicate significant indirect effects of objectively measured sleep duration and subjective sleep quality on next-day suicidal ideation via affective reactivity to negative and positive interpersonal events, respectively. Shorter-than-usual sleep predicted the presence and intensity of next-day suicidal ideation via heightened affective reactivity to negative interpersonal events. Worse sleep quality than usual predicted next-day suicidal ideation via reduced affective reactivity to positive interpersonal events. Affectivity reactivity is a proximal mechanism through which sleep indices may influence risk for suicidal thinking on a daily basis. Findings highlight the utility of targeting sleep and emotion regulation in suicide prevention among adolescents and young adults at high-risk for suicide.

Dose-dependent opposite effects of nortriptyline on affective-like behavior in adolescent rats: Comparison with adult rats

Antidepressant drugs elicit different behavioral and neurochemical responses with age. In fact, the use of antidepressants during adolescence is associated with an increased risk of suicidal thinking, being the best pharmacological treatment during this critical period a matter of constant debate in terms of its risk-benefit outcome. In this regard, the present study compared the effects of nortriptyline (3–10 mg/kg, 7 days) on regulating different aspects of affective-like behavior by screening adolescent and adult Sprague-Dawley rats through several consecutive tests (forced-swim, open field, sucrose preference). Brains were later collected to evaluate hippocampal neurogenesis and mBDNF protein content as potential molecular correlates of the observed behavioral responses. The main results in adolescent rats showed that nortriptyline induced dose-dependent opposite effects: while 3 mg/kg decreased immobility and increased mBDNF (indicative of an antidepressant-like response), 10 mg/kg decreased exploratory time in the open field and mBDNF (suggestive of an anxiogenic-like response). These effects were not associated with changes in neurogenesis regulation. In adult rats, nortriptyline failed to modulate affective-like behavior or the neuroplasticity markers evaluated at the doses tested. In conclusion, clear behavioral and neurochemical differences were observed between adolescent and adult rats in response to nortriptyline treatment. Interestingly, while nortriptyline displayed an antidepressant-like potential at the lowest dose examined in adolescence, a higher dose shifted these results towards a negative outcome, thus reinforcing the need to extreme caution when considering this treatment for our younger population.

Interoceptive Abnormalities and Suicidality: A Systematic Review

Dysfunction of interoception (i.e., difficulties sensing the physiological state of one's own body) is increasingly linked to different mental health disorders and suicidal outcomes. The aim of this study was to systematically review the literature on the association between suicidality and interoception, as well as identify potential confounders and mediators of the relationship. We conducted a systematic review of four databases, allowing for critical examination of the role of different measures of interoception (accuracy, sensibility, awareness, cognitive/emotional evaluation) across the suicide continuum (ideation, plans, attempts, deaths). The search strategy identified 22 studies (14,988 participants). Preliminary but limited evidence was found for impaired interoceptive accuracy among those reporting suicide attempt histories. We found evidence of interoceptive sensibility disturbances across the suicide continuum, including experiences of not trusting one’s own body sensations and impaired abilities to sustain and control attention to such sensations. Consistent evidence was also reported for disturbances related to cognitive and emotional evaluations of interoceptive sensations. The latter was particularly pronounced for those reporting suicide attempts, relative to those reporting suicidal thinking or planning alone. Overall, this review’s results suggest that interoceptive abnormalities are potentially important indicators of risk for suicidal thinking, intentions, and behaviors. However, due to the inconsistent adjustment for variables of interest, and cross-sectional designs, it is unclear whether interoceptive changes and disturbances have a direct role, or whether the association is explained and mediated by key third variables (e.g. depression, disordered eating, emotional dysregulation). We discuss the implications with respect to suicidal risk and therapeutic interventions.

Financial Strain, Suicidal Thoughts, and Suicidal Behavior Among US Military Personnel in the National Guard.

Background: Although financial strain is an identified risk factor for suicide among US military personnel, research is limited regarding the specific dimensions of financial strain that confer the greatest risk. Aims: The present study examined the associations among multiple indicators of financial strain, suicide ideation, and suicide attempts in a sample of US National Guard personnel, a high-risk subgroup of the US military. Method: National Guard personnel from Utah and Idaho (n = 997) completed an anonymous online self-report survey. Weighted univariate and multivariate logistic regression was used to test hypothesized associations. Results: Lifetime history of suicide ideation was significantly more common among participants reporting recent income decrease, credit problems, and difficulty making ends meet, even when adjusting for other covariates. Lifetime history of suicide attempt was significantly associated with recent foreclosure or loan default, credit problems, and difficulty making ends meet, but only in univariate analyses. Recent credit problems were the only financial strain indicator that significantly predicted a history of suicide attempt among participants with a history of suicide ideation. Limitations: The present study includes self-report methodology and cross-sectional design. Conclusion: Although multiple indicators of financial strain are associated with increased risk for suicidal thinking among National Guard military personnel, credit problems had the strongest association with suicide attempts.

Exposure to Police Violence Linked to Suicide Risk, Psychosis

Back to table of contents Previous article Next article Professional NewsFull AccessExposure to Police Violence Linked to Suicide Risk, PsychosisTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:11 Jan 2019https://doi.org/10.1176/appi.pn.2019.1a9AbstractPeople of color and members of sexual minorities are more likely to experience police violence.Experiencing police violence is associated with a higher risk for suicide attempts, suicidal thinking, and psychotic experiences, according to a study published in JAMA Network Open. The study, which was based on a cross-sectional, general population survey of 1,000 residents of Baltimore and New York City from October through December 2017, also suggests that people of color and sexual minorities are more likely to experience police violence.In their research, Jordan E. DeVylder, Ph.D., an associate professor in the Graduate School of Social Services at Fordham University, and colleagues evaluated data from the Survey of Police-Public Encounters II. This survey asks about experiences with police violence over the past 12 months. The types of police violence included physical violence with a weapon, physical violence without a weapon, psychological violence (threats, intimidation, and more), sexual violence, and neglect (not responding to calls for assistance, responding too late, and more) (see chart). The survey respondents were also asked to report psychological distress (including feelings of hopelessness, agitation, and depression), suicidal thinking, suicide attempts, and psychotic experiences.In addition, the researchers determined risk according to race/ethnicity, sexual orientation/identity, and age. Compared with non-Hispanic whites, people of color had more than a fourfold increased risk of experiencing police violence with a weapon and more than a threefold increased risk of experiencing the other forms of police violence. Those who identified as homosexual or bisexual had nearly a twofold increased risk of psychological violence. Most exposures occurred among people aged 44 years or younger.DeVylder told Psychiatric News that some of the data surprised him.“There is a narrative in the media that [police violence] affects a lot of urban communities, especially those of color, so we did expect the data to reflect that. [But] the prevalence of police violence was [still] higher than I expected it to be, especially among the subgroups,” DeVylder said. “One group that stood out that I want to research further is transgender people. They were a small subset of only six, but four of the six had some kind of victimization with a weapon by a police officer.”Physical violence with a weapon and sexual violence were associated with the greatest increase in risk for suicide attempts, suicidal thinking, and psychotic experiences. Physical violence with a weapon was associated with more than a sevenfold increase for suicide attempts, nearly a threefold increase in risk for suicidal thinking, and more than a fourfold increase in risk for having psychotic experiences. Sexual violence was associated with more than a sixfold increase in risk for suicide attempts and psychotic experiences and nearly a fourfold increase in risk for suicidal thinking. Physical and sexual violence were associated with greater distress than the other forms of police violence.Jordan DeVylder, Ph.D., noted that four of the six transgender people in the study had experienced police violence with a weapon, indicating a need for further study of police violence against them.DeVylder noted that police neglect may also take a toll on mental health.“If you’re living in a place perceived as unsafe, and [you feel that] when you call for help, it might not come, it’s distressing,” DeVylder said. In their paper, DeVylder and his colleagues called attention to the broad effects of police violence in the United States.“Police violence constitutes a public health problem that is important to address because of the expanse of its potential mental health consequences and the limited attention it has received from policymakers and researchers. [Our] findings suggest the need for clinicians to be attuned to the prevalence of police violence among patient populations, especially racial/ethnic minorities, males, young adults, and economically disadvantaged individuals.”DeVylder encouraged psychiatrists to consider whether their patients have been affected by police violence. “Along with all the other social and environmental risks you think about, keep in mind that this could be happening to the people you work with and it’s affecting their mental health. It’s a problem that needs to be addressed in a way that’s sensitive to the difficult nature of these experiences,” DeVylder said.This study was supported by the University of Maryland School of Social Work and Fordham University. ■“Association of Exposure to Police Violence With Prevalence of Mental Health Symptoms Among Urban Residents in the United States” can be accessed here. ISSUES NewArchived

Antiepileptic drugs and suicide-related outcomes in bipolar disorder: A descriptive review of published data.

Introduction:In January 2008 the US Food and Drug Administration issued a warning to healthcare professionals about the potential for an increased risk of suicidal thinking and behavior associated with antiepileptic drugs (AEDs). Given that AEDs are important for treating bipolar disorder (BD), a better understanding of suicide-related events is necessary.Methods:A PubMed search was performed using the following search terms: anticonvulsant OR valpro* OR carbamazepine OR lamotrigine OR oxcarbazepine OR topiramate AND bipolar AND suicid*. The objective was to identify published investigations reporting rate and/or risk data of suicide-related outcomes in BD patients treated with AED monotherapy.Results:The search identified 323 reviewable citations, with 13 of these studies (4.0%) being reviewed. Valproate was studied most often, and lithium treatment was frequently used as a reference group. Carbamazepine and lamotrigine had small treatment exposure durations. Suicide attempts and suicide deaths were studied the most; a few trials investigated suicidal thinking and/or hospitalizations for suicidal behavior. Suicide attempt rates occurred in the following order: no treatment > carbamazepine > valproate > lithium, while suicide death rates were: no treatment > valproate > lithium > carbamazepine. For valproate, the risk of suicide attempts and suicide death appeared higher than lithium, but lower than no treatment.Discussion:Investigating suicide-related events for AEDs in BD is difficult; more data are necessary for valproate, carbamazepine, and lamotrigine. An improved understanding of AED treatment and suicide-related events in BD may help pharmacists become more effective at supporting their patients with BD.

Masculinity and suicidal thinking.

Males feature prominently in suicide statistics, but relatively little work has been done to date to explore whether endorsement of dominant masculinity norms heightens the risk of or is protective against suicidal thinking. This paper aimed to further knowledge in this area. We used baseline data from 13,884 men (aged 18-55) in the Australian Longitudinal Study on Male Health (Ten to Men) cohort. These men filled in self-complete questionnaires in 2013/14 which covered a range of topics, including conformity to dominant masculinity norms and suicidal thinking. We conducted logistic regression analyses to estimate the strength of association between these two variables. After controlling for other key predictors of suicidal thinking, one characteristic of dominant masculinity-self-reliance-stood out as a risk factor for suicidal thinking (AOR 1.33; 95% CI 1.25-1.42). It suggests that one particular element of dominant masculinity-being self-reliant-may place men at increased risk of suicidal thinking. This finding resonates with current theories of how suicidal thinking develops and leads to action. It also has implications for the full gamut of suicide prevention approaches that target males in clinical settings and in the general population, and for our broader society. Further work is needed, however, to confirm the direction of the relationship between self-reliance and suicidality, and to unpack the means through which self-reliance may exert an influence.

Suicidal thoughts and emotion competence

ABSTRACTBackground. During deployment and upon returning home, veterans experience emotional challenges that test their social and psychological adaptation and place them at risk for suicidal thinking. Individual variability in skill-based capacity to adaptively perceive, understand, correctly use, and manage emotions (called emotional competence) may play a role in the development of psychological suffering and suicidal thinking. Based on research in healthy and clinical samples, poor emotional competence was predicted to be associated with suicidal thinking among returning veterans. Method. Participants were selected from the W. F. Caveness Vietnam Head Injury Study (VHIS) registry, which in the late 1960s began prospectively assessing 1221 veterans). The study sample was composed of veterans examined between 2003 and 2006 and included 185 participants who at the time of assessment with the Beck Depression Inventory (BDI) did (N= 46) or did not endorse (N= 139) suicidal thinking then or during the previous two weeks and received performance-based measures of emotional competence (Mayer–Salovey–Caruso Emotional Intelligence Test; MSCEIT, Version 2.0) and theory of mind. MSCEIT subtests and theory of mind tasks were condensed via principal component analysis: Component 1 (Emotion Processing) included use, understand, and manage emotions tasks, and Component 2 (Emotion Perception) included perceive emotions. Results. Veterans endorsing suicidal thoughts showed poorer emotion processing whereas emotion perception and theory of mind tasks did not show significant group effects. In addition, veterans who endorsed thoughts of suicide were deployed at a younger age, had lower education, and tended to report more negative experiences in social interactions upon return to the United States. Conclusions. The capacity to understand, use, and manage emotionally charged stimuli and situations may represent risk factors for suicidal thinking among veterans.

Peer Victimization Mediates the Impact of Maternal Depression on Risk for Suicidal Ideation in Girls but not Boys: A Prospective Study.

Although children of depressed mothers are at an increased risk for suicidal thinking, little is known about the potential mechanisms by which this occurs. The present study is the first to our knowledge to utilize a prospective design with the goal of examining whether the impact of maternal depression on children's risk for suicidal ideation is mediated by children's levels of overt and relational peer victimization. Participants were 203 mother-child pairs recruited from the community. The age range of the children was 8 to 14 years old (50.2 % girls). Mothers either met criteria for a major depressive disorder (MDD) during their child's lifetime (n = 96) or had no lifetime diagnosis of any DSM-IV mood disorder and no current Axis I diagnosis (n = 107). At the baseline assessment, diagnostic interviews were used to assess mothers' and children's histories of MDD and children completed a self-report measure of peer victimization. Follow-up assessments were conducted at 6, 12, 18, and 24 months after the initial assessment during which time interviewers assessed for the occurrence of suicidal ideation in the children. Utilizing a mediated moderation model, we found significant indirect pathways from maternal depression to children's suicidal ideation through both relational and overt forms of peer victimization among girls, but not among boys. The current study suggests that peer victimization may constitute one of the potential mechanisms by which daughters of depressed mothers are at increased risk for suicidal thinking.

Time to end the black box on antidepressants?

When the Food and Drug Administration (FDA) put a black‐box warning on antidepressants 10 years ago, it was because of a risk of suicidal thinking in young people — the very symptom for which the medications are indicated. There were immediate concerns that patients wouldn't get needed treatment, that doctors would be discouraged from prescribing, and that the worst of unintended consequences — increased suicides — would follow.

Mindfulness tempers the impact of personality on suicidal ideation

The Five Factor Model (FFM) domains of neuroticism and extraversion have consistently been related to suicidal ideation, such that individuals high in neuroticism or low in extraversion are at greater risk for suicidal thinking. The relationship between mindfulness and suicidal thoughts has not been empirically investigated in relation to personality. However, mindfulness has been shown to moderate the relationship between neuroticism and depression (Barnhofer, Duggan, & Griffith, 2011). The current study examined the relationship of the FFM domains, mindfulness, and suicidal ideation, and tested whether mindfulness would moderate the relationship between FFM domains and suicidal thinking. Results indicated that mindfulness weakened the relationship between neuroticism and suicidal ideation. Additionally, a strong negative relationship between suicidal ideation and extraversion was present at low levels of mindfulness. The possible importance of incorporating mindfulness practices in the prevention of suicidal thinking is discussed.

CVS to phase out tobacco sales, launch smoking cessation program

Calling the decision "simply the right thing to do for the good of our customers and our company," CVS Caremark will stop selling all tobacco products at its more than 7,600 CVS/pharmacy locations by October 1. The February 5 announcement came a week after the U.S. Surgeon General issued renewed warnings about tobacco use on the 50th anniversary of the Surgeon General's landmark report linking smoking and poor health.

Ketamine for Treatment-Resistant Depression: Ready or Not for Clinical Use?

(Reprinted with permission from the American Journal of Psychiatry 2013; 170(10):1079–1081)

Control strategies and suicidal ideation in older primary care patients with functional limitations.

Failure to adapt to limitations in control may place older adults at risk for suicidal behavior. The present study examined the relation between control strategies, depressive symptoms, and suicidal ideation in older adults with health-related limitations. Cross-sectional study of 50 older adult (aged 65-94) primary care patients with health-related limitations. Compensatory primary control strategies characterized by seeking help from others were associated with lower levels of suicidal ideation, independent of depressive symptoms. Selective primary control strategies (e.g., persistence) were also associated with reduced suicidal ideation independent of depressive symptoms, but only when a low level of compensatory primary control strategies was endorsed. Selective secondary control strategies were associated with higher suicidal ideation, whereas compensatory secondary control strategies (e.g., goal disengagement) were unrelated in this sample after controlling for covariates. Findings demonstrate that primary care patients with functional limitations who are not striving to meet their goals, either through persistence or by seeking help from others, are at elevated risk of suicidal thinking.

Suicidal Thinking and Behavior Among Youth Involved in Verbal and Social Bullying: Risk and Protective Factors

To identify risk and protective factors associated with thinking about or attempting suicide among youth involved in verbal and social bullying. We analyzed data on 130,908 students in the sixth, ninth, and twelfth grades responding to the 2010 Minnesota Student Survey. Among students involved in frequent bullying (once a week or more during the past 30 days), we compared those who did and did not report suicidal ideation or a suicide attempt during the past year. Separate analyses were conducted for perpetrators only, victims only, and bully-victims. Overall, 6.1% of students reported frequent perpetration only, 9.6% frequent victimization only, and 3.1% both. Suicidal thinking or a suicide attempt was reported by 22% of perpetrators only, 29% of victims only, and 38% of bully-victims. In logistic regression models controlling for demographic and other risk and protective factors, a history of self-injury and emotional distress were risk factors that cross-cut the three bullying involvement groups. Physical abuse, sexual abuse, a mental health problem, and running away from home were additional risk factors for perpetrators only and victims only. Parent connectedness was a cross-cutting protective factor, whereas stronger perceived caring by friends and by nonparental adults were additional protective factors for some groups. A range of risk and protective factors were associated with suicidal ideation and a suicide attempt among youth involved in verbal and social bullying. Findings may assist in identifying youth at increased risk for suicidal thinking and behavior and in promoting key protective factors.