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INTRODUCTION. The loss of a patient to suicide has an enormous impact on clinicians, but few studies have examined its effects. METHOD. In this retrospective study, we compared clinicians who have and have not experienced a patient suicide using a survey of 2,157 outpatient clinicians from 169 New York clinics to determine differences in their suicide prevention knowledge, practices, training, and self-efficacy. RESULTS. Approximately 25% of the clinician respondents lost patients to suicide; psychiatrists, nurses/nurse practitioners, and those with more years of experience were disproportionately affected. After controlling for these demographic/professional differences, clinicians who had experienced patient suicide reported feeling that they had insufficient training, despite actually having more suicide prevention training, greater knowledge of suicide prevention practices, and feeling more comfortable working with suicidal patients than clinicians who had not lost a patient to suicide. There were no differences in self-efficacy or utilization of evidence-based clinical practices. CONCLUSIONS. Controlling for demographic/professional differences, clinicians who experienced a patient suicide had more training, knowledge, and felt more comfortable working with suicidal patients. It is critical that sufficient training be available to clinicians, not only to reduce patient deaths, but also to help clinicians increase their comfort, knowledge, skill, and ability to support those bereaved by suicide loss.

This PRISMA scoping review explored worldwide research on the delivery of suicide-specific interventions through an exclusive telehealth modality. Research over telehealth modalities with suicidal individuals highlights the importance of facilitating participants' access to treatments despite location and circumstances (e.g., rural, expenses related to appointments, etc.).The review sought evidence of outcomes of trials or projects in which both the patient and therapist attended sessions conjointly and openly discussed suicide over a telehealth modality (e.g., phone, zoom).To explore this topic the authors searched for research trials and quality improvement projects using Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO Social Services Abstracts, and Web of Science on 3/3/2021.Nine different articles were included that each spanned distinct treatments, with eight being research studies and one being a quality improvement project.Publications featuring ongoing or upcoming research in which complete study results were not available did not meet inclusion criteria for this review.Several important research gaps were identified. While this approach has been largely understudied, exclusive telehealth delivery of suicide-specific interventions has great potential for the prevention of suicidality, especially in the era of COVID-19 and beyond.

Background : Behavioral health outpatients are at risk for self-harm. Identifying individuals or combination of risk factors could discriminate those at elevated risk for self-harm. Methods : The study population (N=248,491) included New York State Medicaid-enrolled individuals aged 10 to 64 with mental health specialty clinic visits 11/1/15-11/1/16. Self-harm episodes were defined using ICD-10 codes from emergency department and inpatient visits. Multi-predictor logistic regression models were fit on a subsample of the data and compared to a testing sample based on discrimination performance (Area Under the Curve or AUC). Results : Of N=248,491 patients, 4,224 (1.70%) had an episode of intentional self-harm. Factors associated with increased self-harm risk were age17-25, being female and having recent diagnoses of depression (AOR=4.3, 95%CI: 3.6-5.0), personality disorder (AOR=4.2, 95%CI: 2.9-6.1), or substance use disorder (AOR=3.4, 95%CI: 2.7-4.3) within the last month. A multi-predictor logistic regression model including demographics and new psychiatric diagnoses within 90 days prior to index date had good discrimination and outperformed competitor models on a testing sample (AUC=0.86, 95%CI:0.85-0.87). Limitations : New York State Medicaid data may not be generalizable to the entire U.S population. ICD-10 codes do not allow distinction between self-harm with and without intent to die. Conclusions : Our results highlight the usefulness of recency of new psychiatric diagnoses, in predicting the magnitude and timing of intentional self-harm risk. An algorithm based on this finding could enhance clinical assessments support screening, intervention and outreach programs that are at the heart of a Zero Suicide prevention model.

The objective of this quantitative retrospective study is to understand healthcare patterns prior to self-harm, which may inform prevention efforts and identify intervention sites. Medicaid claims within 30, 60, 90, and 365 days prior to hospital-treated self-harm between 11/1/2015 and 11/1/2016 in New York State (N = 7492) were examined. Numbers and proportions were calculated for all service types. Participants were predominately 15-34, female, and White. Most (97%) had prior-year services, 94% outpatient care (73% behavioral health, 90% medical), 69% emergency department (37% behavioral health, 59% medical), and 42% inpatient services (34% behavioral health, 20% medical). About 86% received services within 90 days and 80% within 60 days. Utilization was high within 30 days prior, with 69% having one or more services. Medical services were more common than behavioral health (94% versus 79% in prior year); outpatient (94%) was more common than emergency (69%) and inpatient (42%) care. Given that most patients received health services within 30 days and almost all saw providers within the year prior, the findings indicate that improved prevention efforts within the healthcare system can reduce the incidence of self-harm.

Background The treatment of suicidal patients often suffers owing to a lack of integrated care and standardized approaches for identifying and reducing risk. The National Strategy for Suicide Prevention endorsed the Zero Suicide (ZS) model, a multi-component, system-wide approach to identify, engage, and treat suicidal patients. The ZS model is a framework for suicide prevention in healthcare systems with the aspirational goal of eliminating suicide in healthcare. While the approach is widely endorsed, it has yet to be evaluated in a systematic manner. This trial evaluates two ZS implementation strategies statewide in specialty mental health clinics. Methods/study design This trial is the first large-scale implementation of the ZS model in mental health clinics using the Assess, Intervene, and Monitor for Suicide Prevention (A-I-M) clinical model. Using a hybrid effectiveness-implementation type 1 design, we are testing the effectiveness of ZS implementation in 186 mental health clinics in 95 agencies in New York State. Agencies are randomly assigned to either: “Basic Implementation” (BI; a large group didactic learning collaboratives) or “Enhanced Implementation” (EI; participatory small group learning collaboratives; enhanced consultation for site champions). Primary outcomes include suicidal behaviors, hospitalizations and Emergency Department visits; implementation outcomes include protocol adoption, protocol fidelity and barriers/facilitators to implementation. Discussion This project has the potential to have a significant public health impact by determining the effectiveness of the ZS model in mental health clinics, a setting where suicide attempts and suicides occur at a higher rate than any other healthcare setting. It will also provide guidance on the implementation level required to achieve uptake and sustainability of ZS. Trial registration: N/A.

This article presents a pragmatic approach to assessing and managing suicide risk in children and adolescents. We first present general recommendations for conducting risk assessments with children and adolescents, followed by an algorithm for designating risk. Risk assessment and designation should be based on both distal (i.e., a prior history of self-harm behaviors) and proximal (i.e., suicide ideation, plans, intent, and preparations) predictors of suicide attempt. We then discuss safety planning as an easy-to-implement approach for intervening and managing suicide risk when working with children and adolescents. We end with a case example illustrating the implementation of risk assessment, risk designation, and safety planning with an adolescent client and her mother.

Anxiety and depression co-occur at high rates, and their comorbidity typically creates a more severe clinical presentation then either alone. The effect of comorbid depression appears to vary across anxiety and related disorders. Transdiagnostic treatments present a promising option to improve comorbid conditions by targeting shared factors (e.g., information processing biases). The purpose of this study was to examine the reciprocal effects of secondary depression in transdiagnostic group cognitive behavioral therapy for anxiety (TGCBT). 120 individuals diagnosed with a primary anxiety disorder, 42 of whom had a depressive diagnosis, were enrolled in 12 weeks of TGCBT. Depressed individuals were compared to those without a depressive diagnosis on both clinician-rated and self-reported anxiety and depression following TGCBT. Although depressed individuals scored higher on most indices of anxiety at pre-treatment, both groups improved similarly with some evidence of greater improvement among those with comorbid depression. All individuals improved in self-reported depressive symptoms and comorbid depression improved to subclinical levels. These results posit TGCBT as an effective, efficient option for treating patients with anxiety and comorbid depression.

Background Research has documented significant associations between life stress, especially interpersonal stress, and suicidal ideation in adolescents. Little is known about variables that explain the association between interpersonal stress and suicidal ideation. Methods The present study evaluated a conceptual model in which interpersonal stress (chronic and episodic) predicted suicidal ideation indirectly via thwarted belongingness and perceived burdensomeness among 180 inpatients (65.0% girls) ages 12–17 years ( M =14.72, SD=1.49). Non-interpersonal stress was also examined to determine whether the model was specific to interpersonal stress or common to stress in general. Results Structural equation modeling identified a significant indirect effect of chronic interpersonal stress on suicidal ideation via perceived burdensomeness. Episodic interpersonal stress was significantly correlated with thwarted belongingness and suicidal ideation, but was not a significant predictor of suicidal ideation in a model that controlled for depressive and anxious symptoms. No significant associations were found between non-interpersonal stress and suicidal ideation. Limitations Adolescents were the sole informant source, data on psychiatric diagnoses were not available, and the optimal time interval for examining stress remains unclear. The cross-sectional study design prevents conclusions regarding directionality. Conclusions These findings highlight the role of chronic interpersonal stress in suicidal ideation in adolescents, as well as the potential promise of perceived burdensomeness as a target for programs designed to prevent or reduce suicidal ideation.

IMPORTANCE: Suicidal behavior is a major public health problem in the United States. The suicide rate has steadily increased over the past 2 decades; middle-aged men and military veterans are at particularly high risk. There is a dearth of empirically supported brief intervention strategies to address this problem in health care settings generally and particularly in emergency departments (EDs), where many suicidal patients present for care. OBJECTIVE: To determine whether the Safety Planning Intervention (SPI), administered in EDs with follow-up contact for suicidal patients, was associated with reduced suicidal behavior and improved outpatient treatment engagement in the 6 months following discharge, an established high-risk period. DESIGN, SETTING, AND PARTICIPANTS: Cohort comparison design with 6-month follow-up at 9 EDs (5 intervention sites and 4 control sites) in Veterans Health Administration hospital EDs. Patients were eligible for the study if they were 18 years or older, had an ED visit for a suicide-related concern, had inpatient hospitalization not clinically indicated, and were able to read English. Data were collected between 2010 and 2015; data were analyzed between 2016 and 2018. INTERVENTIONS: The intervention combines SPI and telephone follow-up. The SPI was defined as a brief clinical intervention that combined evidence-based strategies to reduce suicidal behavior through a prioritized list of coping skills and strategies. In telephone follow-up, patients were contacted at least 2 times to monitor suicide risk, review and revise the SPI, and support treatment engagement. MAIN OUTCOMES AND MEASURES: Suicidal behavior and behavioral health outpatient services extracted from medical records for 6 months following ED discharge. RESULTS: Of the 1640 total patients, 1186 were in the intervention group and 454 were in the comparison group. Patients in the intervention group had a mean (SD) age of 47.15 (14.89) years and 88.5% were men (n = 1050); patients in the comparison group had a mean (SD) age of 49.38 (14.47) years and 88.1% were men (n = 400). Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. The SPI+ was associated with 45% fewer suicidal behaviors, approximately halving the odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI, 0.33-0.95, P = .03). Intervention patients had more than double the odds of attending at least 1 outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71; P

Suicide is a serious public health concern in the US, especially for those served in outpatient behavioral health. Over the past decade, there has been a dramatic increase in US suicide rates, and a significant proportion of those dying by or attempting suicide were treated in outpatient behavioral healthcare within the prior year. In response, the US Action Alliance released the National Strategy for Suicide Prevention in 2012, a key tenet of which is the “Zero Suicide” (ZS) model. ZS provides resources for administrators and providers to create a systematic approach to quality improvement for suicide prevention in healthcare systems via seven essential elements (Lead, Train, Identify, Engage, Treat, Transition, Improve). In this paper, we describe the ZS model, as well as our operationalization of the model in an NIMH-funded study in ~170 free-standing New York State outpatient behavioral health clinics, serving >80,000 patients. This study is the largest implementation and evaluation of the ZS approach ever conducted in outpatient behavioral health. Evaluation of ZS implementation in “real-world” clinical settings will provide crucial insight regarding broader dissemination and inform how to best adopt empirically-supported care for suicidal patients in outpatient behavioral health, thereby reducing tragic and preventable loss of life.

Notwithstanding its empirical status and strong recommendation in clinical practice guidelines, cognitive behavioral therapy (CBT) continues to be delivered infrequently and with low fidelity on the clinical front lines. Recently, organized efforts and policies within the public sector to disseminate and implement CBT and other evidence-based psychotherapies have yielded encouraging results and provided optimism for bridging the research-to-practice-gap. Following from these efforts, the current article examines the initial impact and experience of the implementation of an individualized approach to CBT training and treatment within the Kaiser Permanente health care system. Initial training outcomes, including changes in general and specific competencies, were assessed using divergent assessment methods within the initial cohort of therapists undergoing training. Initial patient outcomes, including changes in depression and anxiety, were assessed among patients receiving treatment from therapists in training. Results revealed training in and implementation of CBT-D was associated with overall large improvements in therapist competencies and in clinically significant improvements in both depression and anxiety among patients. Findings from the initial phase of dissemination and implementation within a large private system provide support for, and extend recent findings related to, the feasibility and effectiveness of training in and implementation of CBT-D in a real-world context.

Attentional fixation is a cognitive process characterized by a narrowing of attention on and preoccupation with suicide as the only solution to one’s problems. The present study sought to investigate the experience of attentional fixation on suicide by establishing the psychometric properties of the Attentional Fixation on Suicide Experiences Questionnaire (AFSEQ) in a sample of 64 patients who recently attempted suicide. The AFSEQ evidenced strong psychometric properties, including good internal consistency and construct validity through moderate correlations with measures of suicidal ideation, depressive symptoms, and suicide-relevant cognitive distortions. In addition, an exploratory factor analysis of the AFSEQ identified two factors: Cognitive Dysfunction and Cognitive Stuckness. Results suggest the AFSEQ is a reliable method for assessing the experience of attentional fixation in relation to suicide. We propose future research to further examine attentional fixation as a proximal risk factor for suicidal behavior.

Context: Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force. Evidence acquisition: Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included. Evidence synthesis: Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings. Conclusions: This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives. (Am J Prev Med 2014;47(3S2):S209–S215) & 2014 American Journal of Preventive Medicine

Enhancing the ability to cope with suicidal thoughts, urges, and crises is a key component of therapeutic work with suicidal patients. Suicide-related coping can serve as a treatment target, can provide an additional component in the evaluation of suicidal patients, and can serve as an outcome in randomized controlled trials for the prevention of suicide. However, to date, psychometrically sound measures to assess suicide-related coping are lacking. The aim of this study was to examine the psychometric properties of a new measure, the Suicide-Related Coping Scale (SRCS). Adult patients who were either admitted to a psychiatric inpatient unit (n = 97) or an Emergency Department (n = 232) for suicide-related concerns were enrolled in this study. All were administered the SRCS at baseline and at one month. Factor analyses and internal consistency analyses were conducted. Additional measures were administered to assess convergent and divergent validity. Factor analysis of the SRCS revealed two factors, internal and external coping strategies. The SRCS had high internal consistency, good convergent validity and was sensitive to change. Suicide-related coping is a promising construct as measured by the SRCS to assess suicide-related coping in both clinical practice and trials.

OBJECTIVE Progress bringing evidence-based practice (EBP) to community behavioral health (CBH) has been slow. This study investigated feasibility, acceptability, and fidelity outcomes of a program to implement transdiagnostic cognitive therapy (CT) across diverse CBH settings, in response to a policy shift toward EBP. METHOD Clinicians (n = 348) from 30 CBH programs participated in workshops and 6 months of consultation. Clinician retention was examined to assess feasibility, and clinician feedback and attitudes were evaluated to assess implementation acceptability. Experts rated clinicians' work samples at baseline, mid-, and end-of-consultation with the Cognitive Therapy Rating Scale (CTRS) to assess fidelity. RESULTS Feasibility was demonstrated through high program retention (i.e., only 4.9% of clinicians withdrew). Turnover of clinicians who participated was low (13.5%) compared to typical CBH turnover rates, even during the high-demand training period. Clinicians reported high acceptability of EBP and CT, and self-reported comfort using CT improved significantly over time. Most clinicians (79.6%) reached established benchmarks of CT competency by the final assessment point. Mixed-effects hierarchical linear models indicated that CTRS scores increased significantly from baseline to the competency assessment (p < .001), on average by 18.65 points. Outcomes did not vary significantly between settings (i.e., outpatient vs. other). CONCLUSIONS Even clinicians motivated by policy-change rather than self-nomination may feasibly be trained to deliver a case-conceptualization driven EBP with high levels of competency and acceptability. (PsycINFO Database Record

Factors distinguishing adolescents who experienced a precipitating event in the week preceding a suicidal crisis from those who did not were examined. Among 130 suicidal inpatients (mean age = 15.01 years), those who experienced a precipitating event reported significantly lower depressive symptom scores, better perceived problem solving, less suicidal intent, and a lower rate of prior suicide attempts than those without a precipitating event. Levels of trait impulsivity, suicidal ideation, and current attempt status did not differentiate groups. Findings provide preliminary evidence consistent with at least two possible pathways to a suicidal crisis. Clinical implications and future directions are discussed.

In this study, we set out to extend empirical research on the Life-Death Implicit Association Test (IAT) by administering the measure to an adult psychiatric inpatient population with suicidal ideation. We sought to examine its association with other suicide-relevant measures and to determine whether it adds predictive utility beyond that offered by other measures of suicide risk. The IAT was administered (N = 124) at biweekly intervals as part of an assessment battery at an inpatient facility for complex, treatment resistant psychiatric disorders (average length of stay: approximately 6 weeks). Multiple regression procedures were utilized to examine relationships among the measures and their predictive utility with respect to suicidal ideation at discharge. Consistent with prior research with other populations, significant associations were found between IAT performance and explicit (self-report and interview) measures of suicide risk. Moreover, the IAT was found to predict suicidal ideation at discharge above and beyond number of prior suicide attempts and admission scores on measures of depression, suicidal ideation, and hopelessness. Change in IAT performance over the course of treatment was observed. The IAT shows promise as an addition to explicit measures conventionally used to estimate suicide risk in psychiatric patients. These findings are consistent with a cognitive vulnerability model of suicide risk.

OBJECTIVE The current study examines the predictive validity of the Beck Depression Inventory (BDI) suicide item for death by suicide and suicide attempts. METHOD The study included 2 samples: (1) 5,200 psychiatric outpatients who were evaluated between 1975 and 1995 and followed prospectively for up to 20 years (all psychiatric diagnoses based on DSM-III and DSM-III-R), and (2) 119 patients who, between 2000 and 2004, participated in a randomized controlled trial of outpatient Cognitive Therapy for Suicide Prevention after a suicide attempt and were followed for 18 months (all psychiatric diagnoses based on DSM-IV-TR). All patients completed structured diagnostic interviews, as well as the BDI and Scale for Suicide Ideation. RESULTS Cox regression models demonstrated that the BDI suicide item significantly predicted both deaths by suicide (Wald χ(2)1 = 35.67; P < .001 [N = 5,200]) and repeat suicide attempts (Wald χ(2)1 = 8.82; P < .01 [N = 119]), with each successive rating on the item conferring greater risk. Using receiver operating characteristic (ROC) curves, optimal cutoff scores of 1 and above for suicide and 2 and above for suicide attempts were identified as providing the best balance between sensitivity and specificity. CONCLUSIONS The BDI suicide item is associated with both risk of repeat suicide attempts and death by suicide. The use of the item as a brief, efficient screen for suicide risk in routine clinical care is recommended. Clinicians would then conduct a comprehensive suicide risk assessment in response to a positive screen. Future research examining the item's performance in other at-risk groups (ie, older adults, adolescents, inpatients, etc) is encouraged.

Five versions of the Interpersonal Needs Questionnaire (INQ), a self-report measure of perceived burdensomeness and thwarted belongingness, have been used in recent studies (including 10-, 12-, 15-, 18-, and 25-items). Findings regarding the associations between perceived burdensomeness, thwarted belongingness, and suicidal ideation using different versions have been mixed, potentially due to differences in measurement scales. This study evaluated factor structure, internal consistency, and concurrent predictive validity of these five versions in three samples. Samples 1 and 2 were comprised of 449 and 218 undergraduates, respectively; Sample 3 included 114 adolescent psychiatric inpatients. All versions demonstrated acceptable internal consistency. The 10-item version and 15-item version demonstrated the best, most consistent model fit in confirmatory factor analyses. Both perceived burdensomeness and thwarted belongingness consistently predicted concurrent suicidal ideation on the 10-item INQ only. Future research should consider using the 15-item or 10-item versions.

Follow-up services are an important component of a comprehensive, national strategy for suicide prevention. Increasing our knowledge of effective follow-up care has been identified as an Aspirational Goal by The National Action Alliance for Suicide Prevention's Research Prioritization Task Force.Several recent comprehensive reviews informed the selection of studies included in this brief review. Studies of follow-up services that reported significant effects for the outcomes of death by suicide, suicide attempts, or suicidal ideation were included.Although there is a paucity of research in this area, promising paradigms that have demonstrated effectiveness in preventing suicide and suicide attempts and reducing suicidal ideation will be discussed. The major limitations of the literature in this area include numerous methodological flaws in the design and analyses of such studies and the lack of replication of studies with positive findings.This paper identifies several breakthroughs that would be helpful for advancing this area of research and describes a comprehensive research pathway for achieving both short- and long-term research objectives.

Few studies have examined the relation between suicide-related behaviors and Borderline Personality Disorder (BPD) in adolescent samples. The current study investigated the incremental validity of BPD relative to Major Depressive Disorder (MDD) for suicide-related behaviors in a psychiatric sample of adolescents at the cross-sectional level of analysis. The sample included N = 156 consecutive admissions (55.1% female; M age = 15.47; SD = 1.41), to the adolescent treatment program of an inpatient treatment facility. Of the sample 19.2% (n = 30) met criteria for BPD on the Child Interview for DSM-IV Borderline Personality Disorder and 39.1% (n = 61) met criteria for MDD on the Computerized Diagnostic Interview Schedule for Children–IV. Results showed that BPD conferred additional risk for suicidal ideation and deliberate self-harm. Our findings support the clinical impression that BPD should be evaluated in inpatient samples of adolescents either through intake interviews or more structured assessments. Suicide and related behaviors are an important public health concern, particularly in the adolescent population, where these behaviors are highly prevalent. Most recent data indicate that suicide is the fifth leading cause of death among individuals ages 5 to 14 and the third leading cause of death among individuals ages 15 to 24 in the United States (Xu, Kochanek, Murphy, & Tejada-Vera, 2010). Given the costs both in terms of lost productivity (Corso, Mercy, Simon, Finkelstein, & Miller, 2007) and the emotional trauma suffered by surviving family, friends, and communities (Crosby & Sacks, 2002), the identification of early markers of suicide-related behaviors to aid in prevention and intervention efforts is important. Psychiatric diagnostic status is one method of identifying adolescents who may be at risk for suicide-related behaviors, considering that studies

Little is known about the role of chronic stress in youth suicidal behaviors. This study examined the relations between specific domains of chronic stress and suicidal behaviors among 131 inpatient youth (M age = 15.02 years) who completed measures of stress, suicidal ideation, suicide attempt, and suicide intent. After controlling for demographics, diagnostic status, past history of attempt, and life event stress, the predictors of suicidal ideation were chronic stress in family relationships, close friendship, and physical health. Chronic close friendship stress also predicted suicide intent among attempters after controlling for covariates. No domain robustly predicted the presence of an attempt or moderated the relation between life event stress and suicidal behaviors. These findings highlight the role of certain domains of chronic stress in suicidal ideation and suicide intent.

The present study examined the unique and interactive effects of stress and problem-solving skills on suicidal behaviors among 102 inpatient adolescents. As expected, life event stress and chronic stress each significantly predicted suicidal ideation and suicide attempt. Problem solving significantly predicted suicidal ideation, but not suicide attempt. Problem solving moderated the associations between life event stress and suicidal behaviors, as well as between chronic stress and suicidal ideation, but not chronic stress and suicide attempt. At high levels of stress, adolescents with poor problem-solving skills experienced elevated suicidal ideation and were at greater risk of making a nonfatal suicide attempt. The interactive effects decreased to non-significance after controlling for depressive symptoms and hopelessness. Clinical implications are discussed.