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Background: There is need for deeper understanding of the processes by which suicidal thoughts lead to action. Examination of morbid ideation and the emotional sequelae of such ideation that may feed suicide ideation (SI) and attempts (SA) have been limited.Method: Adult psychiatric outpatients (N = 385) were administered the Response to Morbid Ideation Questionnaire (RMI-Q) and measures of SI, suicidal thoughts and behaviors (STB), and other psychiatric symptom severity. We examined (1) incidence and prevalence in mentation of morbid ideations and emotional responses to these ideations, (2) differences in emotional responses between individuals of varying levels of suicide history, and (3) the relationships of different types of morbid ideations and emotional responses with concurrent SI and symptom severity.Results: Morbid ideation was reported by 87.5% of participants and associated with lifetime and concurrent levels of SI/STB. Calm/relieved emotional responses were associated with lifetime and concurrent levels of SI/STB, while negative-valence responses to morbid ideations were associated with concurrent severity of psychopathology.Conclusions: Our results suggest that the role of morbid ideation and its emotional sequelae in the development of suicidal motivation and action deserves further attention and may be a treatment target for suicide risk reduction. [ABSTRACT FROM AUTHOR]

Background: Determining imminent risk of suicide continues to challenge psychiatrists. To this end, we test the clinical utility of a proposed set of diagnostic criteria for the suicide crisis syndrome (SCS) for prediction of imminent suicidal thoughts and behaviors prospectively.Method: One hundred and seventy individuals hospitalized for suicidal thoughts and behaviors (STB) were evaluated within 72 hr of admission with measures assessing symptoms of the proposed SCS, history of STB, current ideation, and depression severity. Four-eight weeks following discharge, STB were reassessed. Associations between SCS and postdischarge attempts were examined using chi-square and logistic regression analyses. The receiver operator characteristic analysis was used to test the optimal number of symptoms required to meet proposed SCS criteria.Results: The syndrome was maximally informative about short-term risk of postdischarge suicide behavior when all criteria were met. The syndrome conferred a sevenfold increase in risk of postdischarge suicide attempt, and significantly improved prediction by standard risk factors, which was null to limited.Conclusions: The SCS diagnostic criteria are supported and appear to describe a clinically meaningful syndrome in a high-risk population. Assessment of SCS may meaningfully improve clinical assessment of imminent suicide risk. Further study is needed to better understand the syndrome and its applicability in low-risk populations. [ABSTRACT FROM AUTHOR]

We examine the interrelations among clinicians' judgment of patients' suicide risk, clinicians' emotional responses, and standard risk factors in the short-term prediction of suicidal thoughts and behaviors. Psychiatric outpatients (n = 153) with a lifetime history of suicide ideation/attempt and their treating clinicians (n = 67) were evaluated at intake. Clinicians completed a standard suicide risk instrument (modified SAD PERSONS scale), a 10-point Likert scale assessment of judgment of patient suicide risk (Clinician Prediction Scale), and a measure of their emotional responses to the patient (Therapist Response Questionnaire-Suicide Form). The Columbia Suicide Severity Rating Scale and the Beck Scale for Suicide Ideation were administered at a one-month follow-up assessment (n = 114, 74.5%). Clinician judgment of risk significantly predicted suicidal thoughts and behaviors at follow-up. Both the standard suicide risk instrument and clinician emotional responses contributed independently to the clinician assessment of risk, which, in turn, mediated their relationships with suicidal thoughts and behaviors. Our findings validate the importance of clinical judgment in assessing suicide risk. Clinical judgment appears to be informed both by concrete risk factors and clinicians' emotional responses to suicidal patients, highlighting emotional awareness as a promising area for research and training. [ABSTRACT FROM AUTHOR]

Background: Non-suicidal self-injury (NSSI) is a risk factor for suicide attempts (SA). Both attachment disturbances and cognitive and emotional problems (e.g., emotional pain) have been associated with SA history. This study sought to determine differential contributions of attachment styles and cognitive and emotional states associated with SA to lifetime NSSI occurrence among adults hospitalized for suicide risk. Sampling and Methods: Adult psychiatric inpatients (n = 200) were assessed for attachment style, cognitive and emotional states, and lifetime NSSI within 72 h of hospitalization. Binary logistic regression and mediation analyses were performed. Results: Preoccupied attachment and emotional pain at admission were independently associated with lifetime NSSI. Emotional pain partially mediated the relationship between preoccupied attachment and lifetime NSSI. Limitations: The cross-sectional nature of the study and the use of a dichotomous (yes/no) measure of NSSI, not specifically designed for its assessment. Conclusions: Preoccupied attachment and emotional pain are associated with NSSI and may be useful targets for assessing risk of NSSI. [ABSTRACT FROM AUTHOR]

Background: Anhedonia-impairment related to the experience of pleasure-has been identified as a potential risk factor for suicide, with some mixed findings. The current study sought to clarify the role of acuity of anhedonia in the relationship between anhedonia and suicidal thoughts and behaviors by comparing acutely and chronically anhedonic subjects on severity of suicidal ideation (SI) and suicide attempt (SA) history.Methods: Psychiatric outpatients (N = 395) were administered the Columbia Suicide Severity Rating Scale, the Beck Scale for Suicidal Ideation and a modified version of the Snaith-Hamilton Pleasure Scale (SHPS); SI measures were readministered at a 1-month follow-up (N = 289, 73%). Participants were classified as acutely anhedonic, chronically anhedonic and nonanhedonic based on their responses to the SHPS at initial assessment.Results: Controlling for symptoms of anxiety and depression, acute anhedonia was cross-sectionally and prospectively associated with greater severity of SI compared to the nonanhedonic group; no differences in severity of SI were found between the chronically anhedonic and nonanhedonic group at either time point. Anhedonia grouping was not associated with SA history.Conclusion: Changes in capacity to experience pleasure may be more informative of near-term SI than typically low pleasure levels. Future investigation should focus on the relationship between acute anhedonia and imminent suicidal behavior. [ABSTRACT FROM AUTHOR]

Background: Mental health professionals have a pivotal role in suicide prevention. However, they also often have intense emotional responses, or countertransference, during encounters with suicidal patients. Previous studies of the Therapist Response Questionnaire-Suicide Form (TRQ-SF), a brief novel measure aimed at probing a distinct set of suicide-related emotional responses to patients found it to be predictive of nearterm suicidal behavior among high suicide-risk inpatients. The purpose of this study was to validate the TRQ-SF in a general outpatient clinic setting. Methods: Adult psychiatric outpatients (N = 346) and their treating mental health professionals (N = 48) completed self-report assessments following their first clinic meeting. Clinician measures included the TRQ-SF, general emotional states and traits, therapeutic alliance, and assessment of patient suicide risk. Patient suicidal outcomes and symptom severity were assessed at intake and one-month follow-up. Following confirmatory factor analysis of the TRQ-SF, factor scores were examined for relationships with clinician and patient measures and suicidal outcomes. Results: Factor analysis of the TRQ-SF confirmed three dimensions: (1) affiliation, (2) distress, and (3) hope. The three factors also loaded onto a single general factor of negative emotional response toward the patient that demonstrated good internal reliability. The TRQ-SF scores were associated with measures of clinician state anger and anxiety and therapeutic alliance, independently of clinician personality traits after controlling for the state- and patient-specific measures. The total score and three subscales were associated in both concurrent and predictive ways with patient suicidal outcomes, depression severity, and clinicians' judgment of patient suicide risk, but not with global symptom severity, thus indicating specifically suicide-related responses. Conclusion: The TRQ-SF is a brief and reliable measure with a 3-factor structure. It demonstrates construct validity for assessing distinct suicide-related countertransference to psychiatric outpatients. Mental health professionals' emotional responses to their patients are concurrently indicative and prospectively predictive of suicidal thoughts and behaviors. Thus, the TRQ-SF is a useful tool for the study of countertransference in the treatment of suicidal patients and may help clinicians make diagnostic and therapeutic use of their own responses to improve assessment and intervention for individual suicidal patients. [ABSTRACT FROM AUTHOR]

Background: Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients. Methods: The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated. Results: Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI. Conclusion: Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior. [ABSTRACT FROM AUTHOR]

Background: We have developed the Suicide Crisis Inventory (SCI) to evaluate the intensity of the Suicidal Crisis Syndrome, an acute state hypothesized to precede suicide attempt. The psychometric properties of the SCI, including predictive validity for suicidal behavior (SB), were assessed.Methods: Adult psychiatric patients (n = 201) hospitalized for high suicide risk were assessed. Logistic regression models assessed the SCI's predictive validity for SB in the 4-8 weeks following hospital discharge and its incremental predictive validity over traditional risk factors (n = 137, 64% f/u rate). Internal structure, reliability, convergent and discriminant validity, and state versus trait properties were also assessed.Results: The SCI had excellent internal consistency (Cronbach's α 0.970). The SCI total score at discharge predicted short-term SB with 64% sensitivity 88% specificity (OR = 13, P = .003) at its optimal cut score. In a test of its incremental predictive validity, SCI total score at discharge improved prediction of SB over traditional risk factors (Chi-squared 5.597, P = .024, model P = .001), with AOR 2.02 (P = .030). The SCI admission versus discharge test-retest reliability and score distributions showed it to be an acute state measure.Conclusion: The SCI was predictive of future SB in high-risk psychiatric inpatients during the crucial weeks following their hospital discharge. Further validation in diverse patient populations is needed. [ABSTRACT FROM AUTHOR]

Background: Suicide remains poorly understood and unpredictable. Addressing this challenge, this study examined the independent contributions of several research domain criteria (RDoC) constructs in relation to suicidality in patients hospitalized for acute suicide risk. Specifically, we examined anhedonia, anxiety/entrapment, and attachment disturbances, reflecting disturbances in reward processes, negative valence systems, and social processes, respectively.Methods: Anhedonia, anxiety, entrapment, and fearful attachment, were assessed quantitatively in 135 adults hospitalized for suicidality. Current suicidality and suicidal history were assessed with the Columbia Suicide Severity Rating Scale. Bivariate analyses (with significance threshold of p<.01 to account for multiple comparisons) and multivariate models examined relationships between symptom dimensions and severity of suicidal ideation (SI). We also assessed differences between patients with a history of suicide attempt and those who exhibited only suicidal ideations.Results: Using bivariate analyses all symptoms except for fearful attachment correlated robustly with SI (r =.37-0.50, p<.001). However, when using multivariate analyses, only anhedonia (β=.28, p=.01) and entrapment (β=.19, p=.03) were independently associated with SI across the entire sample. No functional domain measures differed between patients with history of suicide attempt versus ideation only.Limitations: The reliance on self-report data and a cross-sectional design.Conclusions: Disturbances in reward and threat processing may represent independent factors in the development of suicidal ideation in this high suicide risk cohort. Future studies should assess their role as risk factors. [ABSTRACT FROM AUTHOR]

Background: Suicide attempts (SA) after psychiatric hospitalization continue to be a major cause of morbidity. Implicit measures may enhance our ability to assess suicide risk. In this context, we describe the first use of the Suicide Opinion Questionnaire (SOQ) to identify post-discharge suicide attempters. Methods: Adult psychiatric inpatients admitted for suicidality (N = 91) were administered a battery of measures including the SOQ, and forty were reached and reassessed for SA at two months post-discharge. Exploratory factor analysis (EFA) on items associated with suicidality was performed to identify latent constructs. Linear discriminant analysis (LDA) was used to optimize factor combination for suicide identification. Results were compared with explicit measures of suicidality, and logistic regression was used to control for other risk factors. Finally, a simplified 9-item scale was derived from the results and its performance compared to that of the linear discriminant function. Results: Twenty items differed between patients with and without SA at intake or follow-up. EFA on these identified two factors: suicide attempters indicated greater acceptability and less moral condemnation of suicide. The LDA-derived discriminant function and 9-item scale was significantly sensitive and specific for post-discharge SA. Conclusions: Attitudes of acceptability and lack of condemnation toward suicide may constitute an implicit measure of suicidality that could contribute to risk assessment in a high-risk population. [ABSTRACT FROM AUTHOR]

Background: The greatly increased risk of suicide after psychiatric hospitalization is a critical problem, yet we are unable to identify individuals who would attempt suicide upon discharge. The Suicide Trigger Scale v.3 (STS-3), was designed to measure the construct of an affective ‘suicide trigger state’ hypothesized to precede a suicide attempt (SA). This study aims to test the predictive validity of the STS-3 for post-discharge SA on a high-risk psychiatric-inpatient sample. Methods: The STS-3, and a psychological test battery measuring suicidality, mood, impulsivity, trauma history, and attachment style were administered to 161 adult psychiatric patients hospitalized following suicidal ideation (SI) or SA. Receiver Operator Characteristic and logistic regression analyses were used to assess prediction of SA in the 6-month period following discharge from hospitalization. Results: STS-3 scores for the patients who made post-discharge SA followed a bimodal distribution skewed to high and low scores, thus a distance from median transform was applied to the scores. The transformed score was a significant predictor of post-discharge SA (AUC 0.731), and a subset of six STS-3 scale items was identified that produced improved prediction of post-discharge SA (AUC 0.814). Scores on C-SSRS and BSS were not predictive. Patients with ultra-high (90th percentile) STS-3 scores differed significantly from ultra-low (10th percentile) scorers on measures of affective intensity, depression, impulsiveness, abuse history, and attachment security. Conclusion: STS-3 transformed scores at admission to the psychiatric hospital predict suicide attempts following discharge among the high-risk group of suicidal inpatients. Patients with high transformed scores appear to comprise two clinically distinct groups; an impulsive, affectively intense, fearfully attached group with high raw STS-3 scores and a low-impulsivity, low affect and low trauma-reporting group with low raw STS-3 scores. These groups may correspond to low-plan and planned suicide attempts, respectively, but this remains to be established by future research. [ABSTRACT FROM AUTHOR]

Context As a group, comorbid anxiety disorders among depressed persons have consistently been found to increase risk of suicide attempt (SA). Growing evidence supports the link between panic attacks (PAs) and suicidality, but prospective evidence is limited and the nature of the linkage remains unclear. The positive-feedback model of suicide suggests that PAs eliciting catastrophic cognitions may drive SA. Objective To prospectively examine the relationship between PAs, panic symptoms and suicidality in individuals meeting DSM-IV criteria for past-year major depressive episodes in a large epidemiological study. Methods In data on 2,864 participants of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) wave 1 and 2 surveys with depressive disorders, the associations of PAs and panic symptoms with subsequent suicidal ideation (SI) and SAs were assessed using logistic regression. Results Past-year PAs in wave 1 significantly increased odds for subsequent SI and attempt in the 3-year follow-up interval; however, in multivariate analyses, PAs were not a significant predictor, but PAs featuring fear of dying were. Further, among subjects with PAs, fear of dying during a PA increased the odds of subsequent SA sevenfold, even after controlling for comorbid disorders, demographic factors, and other PA symptoms. Conclusion PAs characterized by prominent morbid catastrophic cognitions may mediate the transition to SIs and SAs in subjects with depressive episodes. Presence of these symptoms in clinical settings may serve as a warning sign for future suicidality. [ABSTRACT FROM AUTHOR]

Background: Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians' emotional responses to them have not been examined. Methods: Clinicians' responses to their patients when last seeing them prior to patients' suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups. Results: Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/ avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients. Conclusions: Clinicians' emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians' emotional responses to suicidal patients and suicide risk. [ABSTRACT FROM AUTHOR]

Background: Suicide has been linked to intense negative affect. However, little is known about the range of affects experienced by suicidal persons, or the separate effects of affect valence and intensity. We examine a novel self- report scale, the 17-item Affective Intensity Rating Scale (AIRS), and its relation to suicidality in a high-risk sample. Methodology/Principal Findings: Patients presenting with suicidality were recruited from the Emergency Department in a large urban hospital, and completed a battery of assessments there. Structure of the AIRS was assessed using Maximum Likelihood Factor Analysis with Oblimin rotation. Convergent and divergent validity were assessed by regressing AIRS subscales against Brief Symptom Inventory subscales. Relation to suicidality was assessed by regression of suicide attempt status against scale and subscale scores, and individual items and two-way item interactions, along with significant clinical and demographic factors. 176 subjects were included in analyses. Three reliable subscales were identified within the AIRS measure: positive feelings towards self, negative feelings towards self, and negative feelings towards other. Only individual AIRS items associated significantly with suicide attempt status; strong 'feelings of love' associated positively with actual suicide attempt, while 'feelings of calm' and 'positive feelings towards self' associated negatively. Interaction analyses suggest 'calm' moderates the association of 'love' with suicide attempt. Conclusions/Significance: Factor analysis of the AIRS is consistent with a circumplex model of affect. Affective dimensions did not predict suicidal behavior, but intense feelings of love, particularly in the absence of protective feelings of calm or positive self-view associated with current attempt. [ABSTRACT FROM AUTHOR]

The article discusses a research study on the association of panic attacks with panic symptoms to suicidal tendencies among patients with major mood disorder (MDD). Data used was the National Epidemiologic Survey on Alcohol and Related Conditions from 2001-2002 and the assessment of suicide attempts, suicidal ideation and suicide attempts with panic attack through the adjusted odd ratios (AORs). Results showed the strong association of panic attacks with high risk of suicidal ideations.