Suicidal Psychiatric Inpatients Research Articles

Can passive measurement of physiological distress help better predict suicidal thinking?

There has been growing interest in using wearable physiological monitors to passively detect the signals of distress (i.e., increases in autonomic arousal measured through increased electrodermal activity [EDA]) that may be imminently associated with suicidal thoughts. Before using these monitors in advanced applications such as creating suicide risk detection algorithms or just-in-time interventions, several preliminary questions must be answered. Specifically, we lack information about whether: (1) EDA concurrently and prospectively predicts suicidal thinking and (2) data on EDA adds to the ability to predict the presence and severity of suicidal thinking over and above self-reports of emotional distress. Participants were suicidal psychiatric inpatients (n = 25, 56% female, M age = 33.48 years) who completed six daily assessments of negative affect and suicidal thinking duration of their psychiatric inpatient stay and 28 days post-discharge, and wore on their wrist a physiological monitor (Empatica Embrace) that passively detects autonomic activity. We found that physiological data alone both concurrently and prospectively predicted periods of suicidal thinking, but models with physiological data alone had the poorest fit. Adding physiological data to self-report models improved fit when the outcome variable was severity of suicidal thinking, but worsened model fit when the outcome was presence of suicidal thinking. When predicting severity of suicidal thinking, physiological data improved model fit more for models with non-overlapping self-report data (i.e., low arousal negative affect) than for overlapping self-report data (i.e., high arousal negative affect). These findings suggest that physiological data, under certain contexts (e.g., when combined with self-report data), may be useful in better predicting—and ultimately, preventing—acute increases in suicide risk. However, some cautious optimism is warranted since physiological data do not always improve our ability to predict suicidal thinking.

Validation of Visual and Auditory Digital Markers of Suicidality in Acutely Suicidal Psychiatric Inpatients: Proof-of-Concept Study.

BackgroundMultiple symptoms of suicide risk have been assessed based on visual and auditory information, including flattened affect, reduced movement, and slowed speech. Objective quantification of such symptomatology from novel data sources can increase the sensitivity, scalability, and timeliness of suicide risk assessment.ObjectiveWe aimed to examine measurements extracted from video interviews using open-source deep learning algorithms to quantify facial, vocal, and movement behaviors in relation to suicide risk severity in recently admitted patients following a suicide attempt.MethodsWe utilized video to quantify facial, vocal, and movement markers associated with mood, emotion, and motor functioning from a structured clinical conversation in 20 patients admitted to a psychiatric hospital following a suicide risk attempt. Measures were calculated using open-source deep learning algorithms for processing facial expressivity, head movement, and vocal characteristics. Derived digital measures of flattened affect, reduced movement, and slowed speech were compared to suicide risk with the Beck Scale for Suicide Ideation controlling for age and sex, using multiple linear regression.ResultsSuicide severity was associated with multiple visual and auditory markers, including speech prevalence (β=−0.68, P=.02, r2=0.40), overall expressivity (β=−0.46, P=.10, r2=0.27), and head movement measured as head pitch variability (β=−1.24, P=.006, r2=0.48) and head yaw variability (β=−0.54, P=.06, r2=0.32).ConclusionsDigital measurements of facial affect, movement, and speech prevalence demonstrated strong effect sizes and linear associations with the severity of suicidal ideation.

Validation of Visual and Auditory Digital Markers of Suicidality in Acutely Suicidal Psychiatric In-Patients

Multiple symptoms of suicide risk are assessed based on visual and auditory information including flattened affect, reduced movement, and slowed speech. Objective quantification of such symptomatology from unstructured data sources can increase the sensitivity, scalability, and timeliness of suicide risk assessment.

Examining the interpersonal theory of suicide in acutely suicidal psychiatric inpatients

The current study examined hypotheses related to the development of suicidal ideation as directed by the interpersonal theory within a sample of acutely suicidal psychiatric inpatients. Consistent with ideation-to-action models, we distinguished suicidal desire from resolved plans and preparations. Although thwarted belongingness and perceived burdensomeness were correlated with suicidal desire, only perceived burdensomeness was associated with suicidal desire controlling for depression and thwarted belongingness. Depression alone was related to plans and preparations. Findings are interpreted as challenging the mechanisms hypothesis of the interpersonal theory and suggest that alternative conceptualizations of the development of suicidal desire may be warranted.

Hazardous drinking and clinical correlates among suicidal patients receiving psychiatric inpatient care at military medical settings

BackgroundTo describe prevalence and identify clinical correlates of hazardous drinking among suicidal inpatients at military medical settings. MethodData were drawn from the baseline assessment of a multisite randomized controlled trial of Post-Admission Cognitive Therapy (PACT). Participants were military Service members or adult beneficiaries (N = 218) who were admitted to inpatient care following a suicide-related crisis. Hazardous alcohol use in the past year was assessed using the Alcohol Use Disorder Identification Test (AUDIT). ResultsThe average AUDIT score was 6.78 (SD = 7.87), with 28.9% reporting hazardous drinking (scored ≥8 on the AUDIT). Hazardous drinkers were more likely than nonhazardous drinkers to meet diagnosis of Substance Use Disorder (SUD; Odds Ratio [OR] = 5.96, 95% confidence intervals [CI] = 2.13, 16.71). Hazardous drinking was neither associated with measures of suicide ideation nor aborted or interrupted suicide attempt. However, hazardous drinkers had greater risk of having both single (RRR [Relative Risk Ratio] = 2.55, 95% CI = 1.18, 5.50) and multiple actual suicide attempts (RRR = 2.38, 95% CI = 1.06, 5.32) than nonhazardous drinkers. The association between hazardous drinking and single (but not multiple) actual suicide attempt remained significant after controlling for gender, depressive symptoms, hopelessness, Post-Traumatic Stress Disorder, and SUD (adjusted RRR = 2.48, 95% CI = 1.09, 5.65). ConclusionsA history of actual suicide attempt is associated with hazardous alcohol use among suicidal psychiatric inpatients. Assessment of drinking and drug use may inform case conceptualization and treatment of suicide-related behaviors in psychiatric inpatient settings.

Classifying suicidal behavior with resting-state functional connectivity and structural neuroimaging.

About 80% of patients who commit suicide do not report suicidal ideation the last time they speak to their mental health provider, highlighting the need to identify biomarkers of suicidal behavior. Our goal is to identify suicidal behavior neural biomarkers to classify suicidal psychiatric inpatients. Eighty percent of our sample [suicidal (n=63) and non-suicidal psychiatric inpatients (n=65)] was used to determine significant differences in structural and resting-state functional connectivity measures throughout the brain. These measures were used in a random forest classification model on 80% of the sample for training the model. The model built on 80% of the patients had sensitivity=79.4% and specificity=72.3%. This model was tested on an independent sample (20%; n=32) with sensitivity=81.3% and specificity=75.0% for confirming the generalizability of the model. Altered resting-state functional connectivity features from frontal and middle temporal regions, as well as the amygdala, parahippocampus, putamen, and vermis were found to generalize best. This work demonstrates neuroimaging (an unbiased biomarker) can be used to classify suicidal behavior in psychiatric inpatients without observing any clinical features.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths

BackgroundSuicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention.MethodsThematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment.ResultsTwo main themes were identified. The first, ‘A therapy that works’, revealed inpatients’ views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, ‘Concerns about in-patient suicide-focused therapy’, depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients’ whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians.ConclusionsWe conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting.Trial registration numberISRCTN 17890126, Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

Reexamining the Mental Pain-Suicidality Link in Adolescence: The Role of Tolerance for Mental Pain.

In this study, we reexamine the mental pain-suicidality link in adolescence, by focusing on mental pain tolerance as a critical factor in explaining youth suicidal behavior. In a series of three studies, participants completed measures of mental pain (tolerance and intensity), emotional regulation, depression, and suicidality. Study 1 included a nonclinical sample of 183 Israeli adolescents. Study 2 included a nonclinical sample of 139 Israeli adolescents, who completed additional measures of self-esteem, optimism, mindfulness, meaning in life, positive affectivity, and life satisfaction. Study 3 included suicidal psychiatric inpatients (N=24), nonsuicidal psychiatric inpatients (N=24), and nonclinical adolescents (N=24). In Study 1, mental pain tolerance was significantly associated with depression, suicidality, and emotion-regulation skills. In Study 2, mental pain tolerance was significantly associated with measures of psychological resources. In Study 3, we found that suicidal psychiatric inpatients reported significantly lower levels of mental pain tolerance than nonsuicidal psychiatric inpatients and nonclinical adolescents. No significant group difference was found in the reported intensity of mental pain. Findings imply that mental pain tolerance may be a better indicator for suicidal behavior during adolescence than reported pain intensity.

Violence victimization and perpetration in relation to fearlessness about death in suicidal psychiatric inpatients

PurposeThe interpersonal theory of suicide proposes that fearlessness about death, one aspect of the capability for suicide, may explain men’s greater risk for death by suicide. The purpose of this paper is to examine whether violence perpetration and victimization would mediate the relation of gender with fearlessness about death in suicidal psychiatric inpatients.Design/methodology/approachThe current study used a cross-sectional survey design in a sample of 196 psychiatric inpatients admitted for suicide risk.FindingsMen endorsed greater fearlessness about death compared to women. The relation of gender with fearlessness about death was partially mediated by violence perpetration, but not victimization. Violence perpetration may play a more central role in the development of fearlessness about death, the capability for suicide, and the transition from suicide ideation to action compared to violence victimization.Research limitations/implicationsThe current study was cross-sectional and not able to definitively answer questions about the development of the capability for suicide. Future research must examine how fearlessness about death evolves over time.Practical implicationsSuicide risk assessment should include history of violence perpetration, as this may better identify those who may be at greater risk for suicide due to greater fearlessness about death.Originality/valueThe current study adds to the growing literature that aims to understand variables that explain the transition from suicide ideation to action.

Post-Admission Cognitive Therapy (PACT) for the Prevention of Suicide in Military Personnel With Histories of Trauma

To date, no inpatient evidence-based psychotherapeutic interventions have been developed for suicidal individuals with psychological trauma. Therefore, we have adapted, refined, implemented, and pilot-tested an inpatient-based cognitive behavioral therapy protocol, named Post-Admission Cognitive Therapy (PACT), for the prevention of suicide. This article briefly describes the theoretical and research underpinnings for PACT, components of the treatment protocol, and clinical challenges. A case study of a traumatized military service member hospitalized following a suicide attempt is presented. Baseline and follow-up assessment data show general improvements in suicide ideation, depression, hopelessness, and Post Traumatic Stress Disorder symptomatology over time. While the data for the presented case appears promising, the efficacy of PACT remains unknown and is currently under investigation in a randomized controlled trial. Recommendations for clinicians and students who deliver care to suicidal psychiatric inpatients are provided.

Collaborative assessment and management of suicidality at Menninger (CAMS-M): An inpatient adaptation and implementation

In this article, the authors describe CAMS-M, a novel approach to working therapeutically with suicidal psychiatric inpatients, with the goal of reducing the likelihood of future suicidal crises. CAMS-M, developed at The Menninger Clinic, is an adaptation of the Collaborative Assessment and Management of Suicidality (CAMS), a novel framework with promising early research findings in outpatient settings (Jobes, 2006). Here, we provide a detailed description of CAMS-M, describe how it differs from CAMS in its original form, and discuss issues around implementation in a hospital setting. We conclude that CAMS-M holds considerable promise in risk management and therapeutic intervention with suicidal patients in the inpatient environment.

Association of polymorphisms of the serotonergic pathways with clinical traits of impulsive-aggression and suicidality in adolescents: A multi-center study

Objectives. Suicidal behaviour runs in families. This study evaluated association between common polymorphisms in the serotonergic and adrenergic candidate genes (HTR2A, 5HTTLPR, and MAOA) and suicidality, psychopathology and aggression in adolescents. Methods. Four groups of adolescents were included: Suicidal (N=35) and non-suicidal (N=30) psychiatric inpatients, suicide attempters admitted to three psychiatric emergency rooms (N=51) and a community-based control group (N=95). All were genotyped and underwent psychological assessment for relevant endophenotypes and plasma serotonin content (p5HT) was measured. Results. Homozygosity for the T allele of the HTR2A 102T/C polymorphism was associated with lower impulsivity (P=0.03) and aggression (P=0.01) compared to TC carriers. Low activity MAOA genotypes were associated with suicidality (P=0.04). No association was found between p5HT level and the examined polymorphisms. Conclusions. Our findings are in line with the associations described in adult suicidal population. Further studies are needed to evaluate the gene × environmental interactions in larger samples in an attempt to clarify the possible role of genetic factors in pediatric suicidal and impulsive-aggressive behaviour.

Substance-induced suicidal admissions to an acute psychiatric service: Characteristics and outcomes

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients

Family Functioning in Suicidal Inpatients With Intimate Partner Violence

Intimate partner violence (IPV) is commonly bidirectional with both partners perpetrating and being victims of aggressive behaviors. In these couples, family dysfunction is reported across a broad range of family functions: communication, intimacy, problem solving, expression or control of anger, and designation of relationship roles. This study reports on the perceived family functioning of suicidal inpatients. In this descriptive, cross-sectional study of adult suicidal inpatients, participants completed assessments of recent IPV and family functioning. Recruited patients were between 18 and 65 years of age and English fluent, had suicidal ideation, and were living with an intimate partner for at least the past 6 months. Intimate partner violence was assessed using the Conflict Tactics Scale-Revised, and family functioning was measured using the McMaster Family Assessment Device. The study was conducted from August 2004 through February 2005. In 110 inpatients with suicidal ideation and IPV, family functioning was perceived as poor across many domains, although patients did report family strengths. Gender differences were not found in the overall prevalence of IPV, but when the sample was divided into good and poor family functioning, women with poorer family functioning reported more psychological abuse by a partner. For both genders, physical and psychological victimization was associated with poorer family functioning. Among psychiatric inpatients with suicidal ideation, IPV occurred in relationships characterized by general dysfunction. Poorer general family functioning was associated with the perception of victimization for both genders. The high prevalence of bidirectional IPV highlights the need for the development of couples treatment for this population of suicidal psychiatric inpatients.

Adolescent Perceptions of a Suicide Prevention Group on an Inpatient Unit

The purpose of this study was to present a psychoeducational suicide prevention group for psychiatrically hospitalized suicidal adolescents, and explore participant perceptions of the strengths and weaknesses of this group therapy experience using archival data. Over the course of approximately three years, 250 adolescents admitted to a psychiatric inpatient unit attended the suicide prevention group. Almost all adolescents indicated that they learned something helpful in the group that would keep them from attempting suicide in the future. The creation of a “Reasons To Live List” was reported as most helpful by adolescents while the creation of a “Safety List” was deemed least helpful. However, some differences did emerge as a function of history of prior suicidal behavior. Recommendations for future treatment research with suicidal adolescent psychiatric inpatients are offered.

Psychiatric nurses’ response to suicidal psychiatric inpatients: struggling with self and sufferer

Research on nurses' responses to suicidal patients is sparse. The purpose of this secondary analysis of qualitative data from interviews with 19 nurses employed in Norway was to describe nurses' responses to suicidal psychiatric inpatients. Thematic analyses revealed four themes: 'struggling with discernment of self and sufferer'; 'reconciling inner dialogue'; 'opening up while envisioning self from sufferer'; and 'revisioning the meaning of life revealed over time'. The main theme was 'struggling with self and sufferer'. While these findings reveal existential issues and self reflections of psychiatric nurses' struggle with the suffering of suicidal patients, they also contribute to a methodological debate. Further research is needed to examine nurses' responses to suicidal patients in various settings and to develop secondary analysis of qualitative data.

Plasma serotonin levels and suicidal behavior in adolescents

To evaluate the relationship between plasma serotonin (p5-HT) levels and psychometric measures in suicidal adolescents vs. controls, 211 adolescents from three sites in Israel were divided into four groups: suicidal psychiatric inpatients (n=35); non-suicidal psychiatric inpatients (n=30); adolescents referred to the emergency room (ER) due to a suicide attempt (n=51); and a community-based control group from 4 high schools in the same catchment areas (n=95). All were interviewed and assessed for violence, aggression, depression, impulsivity, anger, anxiety, and p5-HT. p5-HT levels were significantly lower in the control group compared to all other groups. A significant negative correlation was found between p5-HT level and suicidal behavior severity among the suicidal inpatients. p5-HT did not discriminate between the psychiatric diagnostic categories and was significantly lower in ER violent compared to non-violent subjects. Gender, depression, and anger were associated with suicidal behavior in all four groups. Beck Depression Inventory (BDI) scores together with p5-HT levels discriminated between healthy controls and other groups. p5-HT level in combination with some of the psychometric scales may serve as a safe and inexpensive peripheral marker of psychopathology, and may help to differentiate between sub-populations of suicidal adolescents. The biological mechanism behind the serotonin dysregulation in suicidal adolescents requires further investigation.

Suicidal Tendencies and Body Image and Experience in Anorexia nervosa and Suicidal Female Adolescent Inpatients

Background: The aim of this study was to assess the relationship between body image and suicidal tendencies in anorexia nervosa (AN). Methods: Three groups of hospitalized female adolescents – nonsuicidal AN, suicidal psychiatric and nonsuicidal psychiatric patients, as well as a community control group with no psychiatric disturbances were compared with regard to suicidal tendencies (in the form of attitudes to life and death), body image and experience, depression and anxiety. Results: The AN and suicidal patients showed less attraction to but more repulsion by life, and more attraction to and less repulsion by death compared with the other two groups. The AN and suicidal patients were also different from either one or both control groups in showing more negative attitudes and feelings towards their bodies, lower sensitivity to body clues, less body control, and elevated depression and anxiety. These between-group differences in suicidal tendencies were retained after controlling for age, body mass index, the different body image dimensions, anxiety and depression. Conclusions: Our findings suggest that female AN inpatients with no evidence of overt suicidal behavior demonstrate elevated suicidal tendencies that are similar to those of suicidal psychiatric inpatients. These self-destructive tendencies are highly associated with a pervasive sense of disturbance of body image and experience.

The meaning of suicidal psychiatric inpatients' experiences of being treated by physicians.

Twenty-one psychiatric inpatients who had thought about, expressed a wish to, or even attempted to commit suicide narrated their experiences of receiving treatment from physicians. The interview texts were transcribed and interpreted using a phenomenological-hermeneutic method inspired by the philosophy of Ricoeur. Two main themes and eight themes were found. Participating Approach: being with the patients, listening to patients without prejudice, trusting each other, respecting patients' integrity; and Observing Approach: leaving patients to themselves, listening to patients with prejudice, mistrusting each other, not respecting patients' integrity. These findings were interpreted in the light of the writings of Hegel, Buber and Cissna and Sieburg. The suicidal patients expressed their need for confirmation in their interaction with physicians, that is they needed to meet with respect and interest when staying in the hospital with suicidal thoughts or after suicidal attempts.

Physicians' Stories about Suicidal Psychiatric Inpatients

Fourteen Norwegian, three Danish, and two Swedish physicians employed at a Norwegian psychiatric hospital narrated their lived experiences in caring for suicidal psychiatric inpatients. The interview text was transcribed and interpreted using a phenomenological-hermeneutics method, inspired by Ricoeur's philosophy. Two main themes were found: Power Over, i.e. Communicating with the patients; Not accepting one's own mortality; Not accepting one's own vulnerability; Not accepting one's own fallibility; Being rejected by the patients; and Power To, Deep communicating with the patients; Accepting one's own mortality; Accepting one's own vulnerability; Accepting one's own fallibility; Being trusted by the patients. These findings were pondered in the light of Cissna's and Sieburg's writings about confirming. The study emphasizes the importance to physicians of confronting their own strong and frightening feelings about mortality, vulnerability and fallibility in order to confirm suicidal psychiatric patients during interactions with them, when in hospital after suicide thoughts and attempts.