Suicidal Communication Research Articles

Can profiles of behaviors occurring within 48 h of a suicide attempt predict future severity of suicidal thoughts and reattempt?: An examination of hospitalized patients 12 Months post-discharge

Behavioral warning signs (WS) are near-term changes within individuals, which aid in determining imminent risk for suicide attempts. However, those who attempt suicide differ in their engagement of WS, and it is unclear if these differences relate to future risk of suicidal behavior. Using a sample of 132 adults presenting to a hospital following a suicide attempt, the current study sought to determine if differences in engagement in WS for the index attempt prospectively predicted suicide attempt, frequency of ideation, and intensity of suicide ideation 12 months post discharge. Latent class analyses (LCAs) conducted on 6 behaviors (i.e., alcohol use, nightmares, interpersonal negative life events, suicide communication, risky behavior, low sleep, and high sleep) found a 5-class solution optimally fit the data. One identified class, characterized by engagement in risky behaviors the hours before an attempt differed from other identified classes in terms of risk for future suicidal ideation and behaviors. More specifically, participants in “High Risky Behavior” class had higher rates of 12-month suicide reattempt, significantly more frequent suicide ideation, and significantly worse intensity of suicide ideation during the 12 months following their index attempt compared to participants endorsing typical patterns of WS. These results held when adjusting for various traditional baseline covariates (e.g., depressive symptoms). The current study demonstrates that patterns of behavioral WS may be utilized as their own prognostic indicator of future suicidal ideation and behaviors among high-risk individuals reporting a recent suicide attempt, which can inform post-discharge clinical intervention and prevention efforts.

A Novel Approach for Communication-related to suicidal detection on Twitter using multi-class data

Suicide is a significant issue for public health worldwide since suicide is not something that happens randomly but is influenced by social and environmental variables as well. At the same time, effective early diagnosis and treatment may lead to several positive health and behavioural results. Suicide persists undiagnosed and untreated for many reasons, including denial of sickness and cultural and social disgrace. Through the ubiquity of social media, by expressing opinions, thoughts and everyday struggles with mental health on social media, millions of people are sharing their online identity. As opposed to typical retrospective research that uses self-reported surveys and questionnaires, this study assesses the validity of identifying suicidal symptoms using Twitter tweets that were gathered over more than a year, using a variety of online web-blogging sites as points of reference. For recognizing tweets expressing suicidal thoughts, three sets of characteristics are employed for training the dataset employing base and ensemble classifiers. The Rotation Forest (RF) approach is the preferred baseline, and the Maximum Probability Voting Decision approach is used in seven different labelled classes relating to suicide communication and class demonstrating suicidal thoughts. With the suicidal ideation class scoring 0.76 and the suicidal contents for all seven classes scoring 0.82, this revised model was able to attain an F-measure. To increase awareness of the vocabulary made use of on Twitter to express suicidal thoughts, the findings are summarized by highlighting the predictive principal component of suicide communication in classrooms.

Suicidal Behaviour as an Emerging Factor in Female Victims of Gender-Based Violence within a Relationship: An Exploratory Study.

Intimate partner violence (IPV), in addition to being an important public health problem, is a risk factor for suicidal behaviour (SB). The objective of this study was to explore the risk of suicidal behaviour associated with the different forms of abuse and the consequences derived from it. This exploratory study was conducted on a sample of women who experienced IPV (N = 70) in the Extremadura Region (Spain). Demographic factors, abuse experience, suicidal ideation (SI), suicidal communication (SC), and suicide attempts (SAs) were analysed according to the type of abuse. We found that a very high prevalence of psychological violence (IPVp) was accompanied, in most cases, by some other type of abuse (IPVp+). Additionally, a significant relationship was found between IPV and SB. Logistic regression revealed a greater risk of SI and SA in the IPVp+ group. The results of this study could be useful to healthcare service professionals in preventing suicidal behaviour.

A Psychometric Pilot Study Examining the Functions of Suicidal Communications Using IRT and Factor Analysis.

Background: Suicide prevention, an important public health issue, relies on suicidal communications to identify and intervene with those at risk. Scant research tests explicit theories of suicidal communication impeding applications to prevention science. The current study pilots a new measure assessing the functions of suicidal communications using factor analysis and item response theory. Methods: MTurk workers (n = 898) completed an anonymous survey. The original scale included 35 items refined using exploratory and confirmatory factor analysis, bifactor modeling, and item response theory. Results: The initial EFA identified a two-correlated-factor solution. The two-correlated-factor and unidimensional models yielded a poor fit. A bifactor model yielded a borderline to acceptable fit. The final four items were identified using a bifactor model and item response theory graded response models capturing ambivalence resolution defined as behaviors aimed to aid in suicide decision making. The final model yielded an excellent fit: 𝝌2(2) = 1.81, CFI (1.00), TLI (1.00), RMSEA (0.00), and SRMR (0.01). Conclusions: There may be one function of suicidal communications. Disclosure may elicit connection and reasons for living that serve as barriers to suicide and resolve ambivalence. Key limitations include convenience sampling and limited validity measures. Future research should partner with participants to improve scale and theory development efforts.

Can you See and Hear How Bad I Feel Right Now? - Self-Injury and Suicidal Communication in Borderline Personality Disorder - A Secondary Analysis

Non-suicidal self-injurious behavior (NSSV) and suicide attempts are well-known features of borderline personality disorder; communicative behavior is poorly studied. Differences between patients with and without NSSV as well as differences in current suicide attempts regarding suicidal communication and NSSV were investigated.In a secondary analysis, data on current and anamnestic NSSV, suicide attempts, suicidal communication, and clinical symptomatology of 87 inpatients were studied.Patients with and without current NSSV did not differ in anamnestic but did differ in current suicide attempts and suicidal communication. In regard to the current inpatient stay, it was observed that patients with and without suicide attempts differed considerably in the variables NSSV (100 vs. 32.5 %) and suicidal communication (71.4 vs. 7.5 %).Current self-injury and suicidal communication are highly significant for risk assessment of current suicidality.

Automated Monitoring of Suicidal Adolescents’ Digital Media Use: Qualitative Study Exploring Acceptability Within Clinical Care

BackgroundMonitoring linguistic cues from adolescents’ digital media use (DMU; ie, digital content transmitted on the web, such as through text messages or social media) that could denote suicidal risk offers a unique opportunity to protect adolescents vulnerable to suicide, the second leading cause of death among youth. Adolescents communicate through digital media in high volumes and frequently express emotionality. In fact, web-based disclosures of suicidality are more common than in-person disclosures. The use of automated methods of digital media monitoring triggered by a natural language processing algorithm offers the potential to detect suicidal risk from subtle linguistic units (eg, negatively valanced words, phrases, or emoticons known to be associated with suicidality) present within adolescents’ digital media content and to use this information to respond to alerts of suicidal risk. Critical to the implementation of such an approach is the consideration of its acceptability in the clinical care of adolescents at high risk of suicide.ObjectiveThrough data collection among recently suicidal adolescents, parents, and clinicians, this study examines the current context of digital media monitoring for suicidal adolescents seeking clinical care to inform the need for automated monitoring and the factors that influence the acceptance of automated monitoring of suicidal adolescents’ DMU within clinical care.MethodsA total of 15 recently suicidal adolescents (aged 13-17 years), 12 parents, and 10 clinicians participated in focus groups, qualitative interviews, and a group discussion, respectively. Data were recorded, transcribed, and analyzed using thematic analysis.ResultsParticipants described important challenges to the current strategies for monitoring the DMU of suicidal youth. They felt that automated monitoring would have advantages over current monitoring approaches, namely, by protecting web-based environments and aiding adolescent disclosure and support seeking about web-based suicidal risk communication, which may otherwise go unnoticed. However, they identified barriers that could impede implementation within clinical care, namely, adolescents’ and parents’ concerns about unintended consequences of automated monitoring, that is, the potential for loss of privacy or false alerts, and clinicians’ concerns about liability to respond to alerts of suicidal risk. On the basis of the needs and preferences of adolescents, parents, and clinicians, a model for automated digital media monitoring is presented that aims to optimize acceptability within clinical care for suicidal youth.ConclusionsAutomated digital media monitoring offers a promising means to augment detection and response to suicidal risk within the clinical care of suicidal youth when strategies that address the preferences of adolescents, parents, and clinicians are in place.

Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample

Clinical assessments are a primary method for ascertaining suicide risk, yet the language used across measures is inconsistent. The implications of these discrepancies for adolescent responding are unknown, which is troubling as multiple research areas (i.e. on culture, mental health language, and suicide communication) indicate individuals from varying sociodemographic backgrounds may communicate differently regarding mental health concerns. The aims of the current study are to investigate whether a geographically diverse sample of adolescents respond differently to directly and indirectly phrased suicide attempt questions (i.e. directly phrased includes the term 'suicide' and indirectly asks about suicidal behavior without using 'suicide'), and to examine whether sociodemographic factors and history of mental health service usage relate to endorsement differences. Participants were N = 5909 adolescents drawn from the Emergency Department Screening for Teens at Risk for Suicide multi-site study. The lifetime suicide attempt was assessed with two items from an adapted version of the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008): (1) a directly phrased question asking about 'suicide attempts' and (2) an indirectly phrased question providing the definition of an attempt. An adolescent majority (83.7%) consistently reported no lifetime suicide attempt across items, 10.1% consistently reported one or more lifetime attempts across items, and 6.2% of adolescents responded discordantly to the items. Multivariable models indicated multiple demographic and mental health service variables significantly predicted discordant responding, with a notable finding being that father/stepfather education level at or below high school education predicted endorsing only the direct question.

Effectiveness of Brief Educational Training on Medical Students' Attitude toward Suicide Prevention.

Objectives Medical students are future physicians, and their attitude toward suicide attempters can impact outcome of patient management and quality of care. This study aimed to assess the effects of brief educational intervention on medical students' attitude toward suicide prevention. Materials and Methods The prospective study was conducted at a tertiary care center in northwestern India. The total enumeration method was employed to recruit 243 medical students. Attitude toward suicide prevention scale was applied before and after three hours’ training on management of suicide attempters and strategies for suicide prevention. Statistical Analysis Mean, median, standard deviation, frequencies, and percentages were calculated through descriptive statistics. Mean values were compared before and after the intervention through paired sample student's t -test. Chi-square test or Fischer exact test was used to compare categorical variables and p ≤ 0.05 was set for level of significance. Results Ten out of 14 attitudinal statements were significantly more favorable after imparting brief training on suicide prevention and management of suicide attempters. They reported lesser resentment, more responsible efforts, with greater competence and positive expectation associated with working for suicidal patients. They agreed on the need for multidisciplinary efforts for effective suicide prevention. After the intervention, they considered the possibility of suicidal ideas emerging due to the need for help, not for the purpose of attention-seeking, and instead of considering suicidal communication as individual's choice, they agreed on substantial preventability of suicide with comprehensive management. Their misconceptions were resolved to a greater extent. Conclusion Brief educational intervention was found effective in improving their attitude toward suicide prevention. The medical curriculum should incorporate regular educational programs, suicide prevention and comprehensive assessment, and management of suicide attempters.

Exposure to Early Life Adversity and Interpersonal Functioning in Attempted Suicide.

BackgroundEarly life adversity (ELA) may lead to an increased risk for mental health problems including suicidal behavior. ELA alters biological stress systems that affect behavior and control within the individual that in turn will affect interpersonal behavior. Strained relations and interpersonal conflicts leading to rejection and isolation have been shown to be factors for suicidal behavior. Difficulties in interpersonal relationships are a common reason for seeking help in psychiatric care. In the present study, we examined relationship between different types of interpersonal problems and adverse childhood experiences in patients with a recent suicide attempt.MethodThe study included 181 recent suicide attempters. We assessed early life adversity and specific interpersonal problems by using the Karolinska Interpersonal Violence Scale and the Inventory of Interpersonal problems respectively.ResultsSuicide attempters with high levels of early life adversity expressed a more socially avoidant, non-assertive, and exploitable personal style even after adjustment for comorbidities with personality disorder and substance use disorder.ConclusionsPatients with a recent suicide attempt with high levels of early life adversity tend to isolate themselves, of being introvert, and having difficulties to open up and confide in others. They report low self-confidence and self-esteem and problems with feeling and expressing anger. These behaviors complicate interaction with others and make establishment of solid relationships more difficult. In regards to detection of suicidal communication and treatment of suicidal patients, this may lead to misinterpretations and difficulties to fully benefit from treatment given or for professionals to provide the appropriate treatment. Clinicians should closely investigate the presence of early life adversity in suicidal patients and pay attention to their personal style and their difficulties in interpersonal exchange.

Social Media and Suicide: A Validation of Terms to Help Identify Suicide-related Social Media Posts

ABSTRACT Background Communication plays an important role in the prevention of suicide, a leading cause of death in the United States. Prior research suggests people who die by suicide often communicate their intent to more than one member of their social network. The ubiquity of social media in modern society means an individual’s social network may be larger than ever before, which has contributed to a proliferation of colloquial terms and phrases to describe suicide. Aims The present study collected and validated suicide-related terms from the U.S. English language in 2018–2019. By validating clinical and lay terms with people on the front lines of suicide prevention, the study provides a necessary foundation for lexical analyses of suicide communication on social media. Method 98 terms related to suicide were collected from online, academic, and other sources. Mental health professionals and members of the electronic mailing list of the American Association of Suicidology were asked to validate terms. Results The survey validated common terms used to communicate about suicide. Limitations The lexicon did not capture international phrases. It also did not document less direct language, such as expressions of emotion.

Validation of the Suicidal Behavior Exposure Scale in First Responders.

Background: First responders (e.g., emergency medical technicians, firefighters) may be at higher suicide risk than the general population due to frequent exposure to suicidal behaviors of others. Aims: We aimed to confirm the factor structure, scale reliability, and convergent validity of a new measure of suicidal exposure, the Suicidal Behaviors Exposure Scale, in first responders. Method: Using a cross-sectional web-based survey, we recruited 862 participants (81.3% male, mean age = 40.23, SD = 11.88) from a national database and southeastern state-based organization of first responders. Results: Confirmatory factor analysis resulted in a generally poor fit for the three-factor structure (exposure to suicidal communication, indirect exposure to suicide attempts/deaths, direct exposure to suicide attempts/deaths). However, good scale reliability and convergent validity were demonstrated. Limitations: The cross-sectional design, a convenience sample, and the low percentage of women comprise the limitations of this study. Conclusion: The Suicidal Behavior Exposure Scale requires additional development and validation before use in a first-responder sample. Future work should also examine other aspects of reliability and validity, namely, measurement invariance across groups and time.

Forms of suicide communication are not associated with five-factor personality

PurposeUS age-adjusted suicide rates increased by 33 per cent from 1999 to 2017 (Hedegard et al., 2018). Communications about suicide and death are a commonly cited warning sign (SPRC, 2014) and are foundational to the vast majority of risk assessment, prevention and intervention practices. Suicidal communications are critically understudied despite their implications for prevention and intervention practices. The purpose of this study is to examine the association between five factor model personality traits and forms of suicidal communications.Design/methodology/approachA sample of 154 people admitted to emergency psychiatry for suicide ideation or attempt completed self-report measures about their suicide ideation and behavior. Kruskal–Wallis ANOVA examined differences between five-factor model personality domains and forms of communications.FindingsThere were no significant differences; however, two nonsignificant trends related to indirect or non-communication and extraversion and openness emerged.Research limitations/implicationsFuture studies should focus on using more nuanced measures of dimensional personality and suicidal communications.Originality/valueThis study is the first to examine differences in the Five-Factor Model personality traits and suicidal communications.

Epistemic Justice and the Struggle for Critical Suicide Literacy

ABSTRACT The concept of suicide literacy is currently used to describe a perceived deficit in public knowledge about suicide that is directly related to specific health actions and outcomes. It thereby fulfils an important function in determining the way health education and communication are constructed as a problem in suicide prevention policy and practice. In this work, I examine the incongruities produced by operationalisation of the concept of suicide literacy and the way it preserves structural inequities in epistemic practice. Drawing on the concept of epistemic injustice, I contend that the routine social and material practices of suicide prevention education and communication aimed at advancing suicide literacy restrict certain testimonial and hermeneutical activities, resulting in the silencing of alternative interpretations and expressions of suicide. Because these practices prevent critical thinking, help maintain professional privilege and hide complicity with potentially harmful practices they are ethically and politically significant. The uptake of wide-ranging epistemic contributions must be paramount in order to connect multiple perspectives and build knowledge. In order to create a more democratic approach to suicide prevention education and communication that cultivates critical dialogue and promotes social and political agency and change, new ways of thinking about suicide literacy are required.

Insomnia Symptoms and Suicide-Related Ideation in U.S. Army Service Members

ABSTRACT Background: Insomnia has been identified as a key risk factor for suicide, though most studies have been limited to global measures of these constructs. The aim of the present study was to evaluate the link between insomnia symptoms and five different aspects of suicide-related ideation. Participants: 1,160 active U.S. Army service members (719 male; Mage = 31.2; SDage = 8.62). Methods: As part of an archival analysis, retrospectively assessed insomnia, depression, anxiety symptoms, as well as suicide-related ideation, were evaluated. Suicide-related ideation was assessed in terms of: thoughts of death, thoughts of suicide, suicidal plan, suicidal intent, and suicidal communication. Results: Subjects with clinically significant insomnia symptoms were 3.5 times more likely to report any suicide-related ideation, and approximately 3 times more likely to report thoughts of death and thoughts of suicide. More frequent nocturnal awakenings (i.e., waking up three or more times during a single night) were associated with a greater likelihood of reporting thoughts of death or suicide, whereas greater middle insomnia (i.e., waking up and having difficulty getting back to sleep) was associated with lower odds of experiencing thoughts of suicide, suicidal plan, and suicidal intent. Conclusions: A more refined delineation of insomnia and suicide-related ideation may serve to clarify the nature of the association, and potentially offer some clues as to the underlying mechanisms. With regard to potential clinical implications, the results support that careful assessment of insomnia symptoms, suicide-related ideation, and their respective subtypes, is important and may influence how we estimate risk for suicide.

A Preliminary Validation of the Suicidal Behavior Exposure Scale.

Research on suicide contagion has suggested that exposure to suicide-related thoughts and behaviors of others promotes one's personal risk for suicide. However, our understanding of the role suicidal exposure plays in the development of suicide risk is underdeveloped. This limited understanding may be due, in part, to the lack of a validated measure of exposure to suicidal behavior. The present study aimed to develop and validate a comprehensive self-report instrument of exposure to suicidal behaviors. Using two independent convenience samples of undergraduate students, exploratory structural equation modeling (ESEM) was performed on a newly developed measure of suicidal exposure. Data supported a three-factor model of suicidal exposure: exposure to suicidal communication, direct exposure to suicide deaths and attempts, and indirect exposure to suicide deaths and attempts. Each factor demonstrated positive bivariate associations with depressive symptoms, posttraumatic stress disorder symptoms, suicide ideation, and suicide attempt history, suggesting convergent validity. Analyses demonstrated generally acceptable internal consistency. This instrument will facilitate the study of suicidal exposure. Further validation of this scale, with attention to its reliability and invariance across gender and other demographic variables in clinically relevant samples, will be important for advancing the assessment of suicidal exposure and understanding its relation to suicide risk.

Suicide Ideation and Behavior as Risk Factors for Subsequent Suicide in Schizophrenia: A Nested Case–Control Study

To investigate suicide ideation and behavior as risk factors for suicide in schizophrenia during varying time periods. Cases were 84 patients who died by suicide within 5years from diagnosis in a source population of patients discharged for the first time from psychiatric hospitals in Stockholm County, Sweden, with a schizophrenia spectrum diagnosis. One control was individually matched with each suicide case. Data were retrieved from clinical records in a blind fashion. Thoughts of death, thoughts of suicide, suicide plan, and suicide attempt during varying time periods were investigated as risk factors for subsequent completed suicide. In adjusted analyses, thoughts of suicide, suicide plan, and suicide attempt were significantly associated with subsequent completed suicide in the following year. The highest suicide risk was found within a year following suicide attempt (adjusted OR 9.9, 95% confidence interval 2.5-39.0). The association between suicide ideation and behavior and subsequent suicide declined over time. Several types of suicide ideation and behavior were associated with suicide, and the association was stronger for suicidal behavior. The clinical significance of suicidal communication appears highest during the following month or/and year. Many suicides occurred without recorded short-term suicidal communication.

Linguistic Research on Specific Features of Suicidal Communication—Past, Present, and Future

Linguistic Research on Specific Features of Suicidal Communication—Past, Present, and Future

Assessing Suicide Risk and Emotional Distress in Chinese Social Media: A Text Mining and Machine Learning Study.

BackgroundEarly identification and intervention are imperative for suicide prevention. However, at-risk people often neither seek help nor take professional assessment. A tool to automatically assess their risk levels in natural settings can increase the opportunity for early intervention.ObjectiveThe aim of this study was to explore whether computerized language analysis methods can be utilized to assess one’s suicide risk and emotional distress in Chinese social media.MethodsA Web-based survey of Chinese social media (ie, Weibo) users was conducted to measure their suicide risk factors including suicide probability, Weibo suicide communication (WSC), depression, anxiety, and stress levels. Participants’ Weibo posts published in the public domain were also downloaded with their consent. The Weibo posts were parsed and fitted into Simplified Chinese-Linguistic Inquiry and Word Count (SC-LIWC) categories. The associations between SC-LIWC features and the 5 suicide risk factors were examined by logistic regression. Furthermore, the support vector machine (SVM) model was applied based on the language features to automatically classify whether a Weibo user exhibited any of the 5 risk factors.ResultsA total of 974 Weibo users participated in the survey. Those with high suicide probability were marked by a higher usage of pronoun (odds ratio, OR=1.18, P=.001), prepend words (OR=1.49, P=.02), multifunction words (OR=1.12, P=.04), a lower usage of verb (OR=0.78, P<.001), and a greater total word count (OR=1.007, P=.008). Second-person plural was positively associated with severe depression (OR=8.36, P=.01) and stress (OR=11, P=.005), whereas work-related words were negatively associated with WSC (OR=0.71, P=.008), severe depression (OR=0.56, P=.005), and anxiety (OR=0.77, P=.02). Inconsistently, third-person plural was found to be negatively associated with WSC (OR=0.02, P=.047) but positively with severe stress (OR=41.3, P=.04). Achievement-related words were positively associated with depression (OR=1.68, P=.003), whereas health- (OR=2.36, P=.004) and death-related (OR=2.60, P=.01) words positively associated with stress. The machine classifiers did not achieve satisfying performance in the full sample set but could classify high suicide probability (area under the curve, AUC=0.61, P=.04) and severe anxiety (AUC=0.75, P<.001) among those who have exhibited WSC.ConclusionsSC-LIWC is useful to examine language markers of suicide risk and emotional distress in Chinese social media and can identify characteristics different from previous findings in the English literature. Some findings are leading to new hypotheses for future verification. Machine classifiers based on SC-LIWC features are promising but still require further optimization for application in real life.

Clinical Prediction of Suicide and Undetermined Death: A Pseudo-Prospective Clinical and Medico-Legal Study of Substance Abusers.

This study examines aspects of prediction of suicide and death of undetermined intent. We investigated all consecutive, autopsied patients between 1993 and 1997 who had been in contact with the Addiction Centre in Malmö from 1968 onwards. The staff was asked, shortly after autopsy but before they knew of the manner of death, if they thought the patient had committed suicide. The case records were blindly evaluated, and toxicological autopsy findings for alcohol in blood samples investigated. The specificity of prediction was 83% and significantly more often correct than the sensitivity, which was only 45% for suicide and for suicide/death of undetermined intent (93% versus 39%). Suicidal communication was more often considered non-serious before death of undetermined intent than before suicide. The former could be predicted by ideation but not by suicide attempt reported in case records, unlike suicide, which was predicted by both. The undetermined group also showed higher levels of alcohol in the blood at autopsy. We concluded that more serious clinical investigation of suicidal feelings, which may be hidden and not taken seriously, and treatment of alcohol use disorders with active follow-up appear urgent in the efforts to prevent suicide.

The communication of suicidal intentions: a meta-analysis.

Among the myths that are often cited about suicide is that 'people who talk about killing themselves rarely die by suicide', but the evidence seems to contradict this statement. The aim of this study was to conduct a meta-analysis of studies reporting a prevalence of suicide communication (SC), and to examine the diagnostic accuracy of SC towards suicide in case-control reports. Eligible studies had to examine data relative to completed suicides and report the prevalence of SC. Data relative to sample characteristics, study definition, modality and recipient of the SC were coded. We included 36 studies, conducted on a total of 14 601 completed suicides. The overall proportion of SC was 44.5% [95% confidence interval (CI) 35.4-53.8], with large heterogeneity (I 2 = 98.8%) and significant publication bias. The prevalence of SC was negatively associated with the detection of verbal communication as the sole means of SC and, positively, with study methodological quality. Based on seven case-control studies, SC was associated with an odds ratio of 4.66 for suicide (95% CI 3.00-7.25) and was characterized by sufficient diagnostic accuracy only if studies on adolescents were removed. Available data suggest that SC occurs in nearly half of subjects who go on to die by suicide, but this figure is likely to be an underestimate given the operational definitions of SC. At present, SC seems associated with overall insufficient accuracy towards subsequent suicide, although further rigorous studies are warranted to draw definite conclusions on this issue.