Introduction

Identifies factors that practitioners consider most important in suicide risk assessment Discusses how to distinguish between chronic and acute risk for suicide Identifies factors that lead to more consistent clinical judgments.

OBJECTIVE: This study examined characteristics of suicides among mental health care users reported between 1996 and 2006 to the Dutch Health Care Inspectorate and the inspectorate's follow-up responses. The aims were to determine whether follow-up was associated with particular characteristics and whether the responses could be improved in accordance with guidelines for treatment of suicidal patients. METHODS: Information about patient and treatment characteristics was collected from a sample of 505 of the 5,483 suicide notifications between 1996 and 2006. The 1996–2005 sample included an equal number of cases to which the inspectorate did and did not respond. The 2006 sample included the first 205 notifications in that year. RESULTS: For 2006 notifications the response rate was 37%. The responses most frequently addressed how and whether the suicide was evaluated and the adequacy of treatment for the psychiatric disorder. A follow-up response was more likely when the suicide involved a young patient or a patient treated in a mental health care setting for less than a year or when the notification was accompanied by the mental health institution's plans for improving its policies. A response was less likely when the patient was discharged from inpatient care in the three months before the suicide. Since 2002 responses have more frequently emphasized the importance of suicide risk assessment, in accordance with guidelines. CONCLUSIONS: The inspectorate might improve its supervision system by placing greater emphasis on addressing suicidal impulses and treating older and chronically suicidal patients and patients soon after inpatient discharge.

To reduce suicides among Veterans, the Department of Veterans Affairs (VA) has designated suicide risk assessments for Veterans who screen positive for depression or post-traumatic stress disorder as a national performance goal. Many VA Medical Centers (VAMCs) are using brief suicidal ideation screens, administered in non-mental health ambulatory care settings, as the first step in the assessment process. To explore Veterans' perceptions of the suicide screening and risk assessment process, the barriers and facilitators to disclosing suicidal thoughts, and perceptions of possible consequences of revealing suicidal thoughts. Investigators recorded one semi-structured interview with each Veteran. Transcripts were analyzed using a modified grounded theory approach. Thirty-four Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans who screened positive for suicidal ideation in non-mental health ambulatory care settings in 2009 and 2010. Veterans accepted the need to assess suicide risk. They increasingly experienced attempts to suppress and avoid thoughts of suicide as burdensome and exhausting. Despite this, Veterans often failed to disclose severe and pervasive suicidal thoughts when screened because: (1) they considered suicidal thoughts as shameful and a sign of weakness; (2) they believed suicidal thoughts were private and not to be divulged to strangers; (3) they worried that disclosure would lead to unwanted hospitalization or medication recommendations; and (4) the templated computer reminder process was perceived as perfunctory and disrespectful. In contrast, admitting and discussing thoughts of suicide with a health provider who focused on building a relationship, demonstrated genuineness and empathy, offered information on the rationale for suicide risk assessment, and used straightforward and understandable language, all promoted trust that resulted in more honest disclosure of suicidal thoughts. In ambulatory care settings, both provider behaviors and system modifications may lead to more honest disclosure of suicidal thoughts.

Suicide is a leading cause of death in the USA. Although factors elevating long-term risk for suicide are known and include bipolar disorder, signs of imminent suicide risk are difficult to study and not well specified. Acute risk determinations must be made to determine the appropriate level of care to safeguard patients. To increase safety among at-risk patients in the short term and to decrease risk over time, psychosocial interventions to prevent suicide have been developed and tested in acute care and outpatient settings. A narrative review of studies of imminent risk factors for suicide, suicide risk decision-making, and psychosocial suicide prevention interventions was conducted. Although some long-term risk factors of suicide have been established, accurate identification of individuals at imminent risk for suicide is difficult. Therefore, prevention efforts targeting individuals at high suicide behavior risk discharging from acute care settings tend to be generic and focus on psychoeducation and supportive follow-up contact. Data regarding the effectiveness of brief interventions (i.e., those not requiring more than one individualized treatment session) are mixed, showing better outcomes in the shorter term and when the incidence of suicidal behavior or ideation is the outcome. With respect to longer-term suicide prevention interventions (i.e., those with a minimum of ten sessions), Dialectical Behavior Therapy has the largest evidence base. To improve suicide prevention efforts, more rigorous study of imminent risk factors and psychosocial interventions is needed. Adaptations specific to individuals with bipolar disorder are possible and needed.

BackgroundArtificial intelligence has the potential to innovate current practices used to detect the imminent risk of suicide and to address shortcomings in traditional assessment methods.ObjectiveIn this paper, we sought to automatically classify short segments (40 milliseconds) of speech according to low versus imminent risk of suicide in a large number (n=281) of telephone calls made to 2 telehealth counselling services in Australia.MethodsA total of 281 help line telephone call recordings sourced from On The Line, Australia (n=266, 94.7%) and 000 Emergency services, Canberra (n=15, 5.3%) were included in this study. Imminent risk of suicide was coded for when callers affirmed intent, plan, and the availability of means; level of risk was assessed by the responding counsellor and reassessed by a team of clinical researchers using the Columbia Suicide Severity Rating Scale (=5/6). Low risk of suicide was coded for in an absence of intent, plan, and means and via Columbia suicide Severity Scale Ratings (=1/2). Preprocessing involved normalization and pre-emphasis of voice signals, while voice biometrics were extracted using the statistical language r. Candidate predictors were identified using Lasso regression. Each voice biomarker was assessed as a predictor of suicide risk using a generalized additive mixed effects model with splines to account for nonlinearity. Finally, a component-wise gradient boosting model was used to classify each call recording based on precoded suicide risk ratings.ResultsA total of 77 imminent-risk calls were compared with 204 low-risk calls. Moreover, 36 voice biomarkers were extracted from each speech frame. Caller sex was a significant moderating factor (β=–.84, 95% CI –0.85, –0.84; t=6.59, P<.001). Candidate biomarkers were reduced to 11 primary markers, with distinct models developed for men and women. Using leave-one-out cross-validation, ensuring that the speech frames of no single caller featured in both training and test data sets simultaneously, an area under the precision or recall curve of 0.985 was achieved (95% CI 0.97, 1.0). The gamboost classification model correctly classified 469,332/470,032 (99.85%) speech frames.ConclusionsThis study demonstrates an objective, efficient, and economical assessment of imminent suicide risk in an ecologically valid setting with potential applications to real-time assessment and response.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12622000486729; https://www.anzctr.org.au/ACTRN12622000486729.aspx

Thirty-three brief case histories of suicidal patients were given to 19 experienced crisis workers for 7-point ratings of short- and long-term suicide risk. The ratings revealed considerable variability, raising questions about the reliability of such global assessments of suicidality. The most consistently rated cases were selected to operationally define "mild," "moderate," and "high" risk. Thus, each level was "anchored" by several vignettes. It was hoped that these anchor points would lead to more uniform future ratings among crisis workers. The correlation between short- and long-term risk ranged from near zero for some vignettes to as high as .82 (median = .46), demonstrating the need to rate both separately. Long-term risk was more difficult to rate, as demonstrated by a larger number of cases judged to be unrateable because of "insufficient information" (94 vs. 53 rater-case combinations). When the anchor vignettes were provided as a guide to the same sample of crisis workers, their ratings of suicide risk, as expected, showed significantly improved consistency.

Despite important differences in suicide presentation and risk among ethnic and sexual minority groups, cultural variations have typically been left out of systematic risk assessment paradigms. A new self-report instrument for the culturally competent assessment of suicide, the Cultural Assessment of Risk for Suicide (CARS) measure, was administered to a diverse sample of 950 adults from the general population. Exploratory factor analysis yielded a 39-item, 8-factor structure subsumed under and consistent with the Cultural Theory and Model of Suicide (Chu, Goldblum, Floyd, & Bongar, 2010), which characterizes the vast majority of cultural variation in suicide risk among ethnic and sexual minority groups. Psychometric properties showed that the CARS total and subscale scores demonstrated good internal consistency, convergent validity with scores on other suicide-related measures (the Suicide Ideation Scale, the Beck Depression Inventory suicide item, and the Beck Hopelessness Scale), and an ability to discriminate between participants with versus without history of suicide attempts. Regression analyses indicated that the CARS measure can be used with a general population, providing information predictive of suicidal behavior beyond that of minority status alone. Minorities, however, reported experiencing the CARS cultural risk factors to a greater extent than nonminorities, though effect sizes were small. Overall, results show that the CARS items are reliable, and the instrument identifies cultural suicide risk factors not previously attended to in suicide assessment. The CARS is the first to operationalize a systematic model that accounts for cultural competency across multiple cultural identities in suicide risk assessment efforts.

This article considers the role that assessment of suicidal ideation may have in short-term prediction of suicide. Suicide risk assessment is a multifactorial process and it is assumed that assessment of suicidal ideation is one component. Denial that suicidal ideation has any useful role in risk assessment fails to allow for the marked ongoing short-term variability in severity of intent, which is a common feature of the suicidal state of mind. It is concluded that the assessment of suicidal ideation, provided it is carried out correctly and applied appropriately, should continue to be regarded as a central component of the overall prediction process. A 'two-take' approach to short-term risk assessment and mitigation is proposed that takes variability in severity of intent into account and includes anticipatory treatment planning for any problems that may occur in the near future.

Standards for assessing and managing suicide risk were developed and incorporated into a guidance manual for general practitioners. The effects of the manual on opinions and practice were evaluated using a quasi-experimental controlled before/after design, comparing participating general practitioners with others who did not use the manual. Thirty four general practitioners participated over a six-month period. The intervention group showed changes in perceptions, with increased satisfaction with their own methods and in their recognition and assessment of suicide risk. Their practice changed, with increased recording of relevant factors in notes. The comparison group did not change in these ways. It is concluded that general practitioners' practice and opinions in assessing and managing suicide risk were significantly improved using a minimal intervention. Given the importance of the topic and the small size of this study, further research is needed, examining changes in professional practice, knowledge and attitudes.

Topic:This article will briefly review screening for depression andsuicidal ideation in primary care and school-based clinics, with a focus onin-depth screening for imminent suicide risk, developing a safety plan, andincorporating handoffs to urgent and emergency mental health care personnel.The article will cover current definitions of levels of suicidal risk andclinic-based protocols for a team approach to adolescents in crisis.Purpose:To provide primary care and behavioral health nurses withevidence-based suicide risk screening and assessment tools and bestpractices for using them in patient-centered encounters with adolescentswith suicidal thinking or behavior.Sources used:Journal articles, books, and reports.Conclusion:Past studies have shown that many individuals who died by suicide hadseen a primary care provider in the 30 days prior to their deaths. Nurses inprimary care settings should develop clinic-based protocols for screeningall adolescents for suicide risk, developing safety plans, and providingsuicidal youth and families with monitoring, appropriate referrals,follow-up, and support.

ObjectivesDetermining the risk for suicide is a difficult endeavour. Clinical guidance in the UK explicitly advises against using risk assessment tools and scales to determine suicide risk. Based on Freedom...

Lowered eye blink rate may be a clinically useful indicator of acute, imminent, and severe suicide risk. Diminished eye blink rates are often seen among individuals engaged in heightened concentration on a specific task that requires careful planning and attention. Indeed, overcoming one's biological instinct for survival through suicide necessitates premeditation and concentration; thus, a diminished eye blink rate may signal imminent suicidality. This article aims to spur research and clinical inquiry into the role of eye blinks as an indicator of acute suicide risk. Literature relevant to the potential connection between eye blink rate and suicidality was reviewed and synthesized. Anecdotal, cognitive, neurological, and conceptual support for the relationship between decreased blink rate and suicide risk is outlined. Given that eye blinks are a highly observable behavior, the potential clinical utility of using eye blink rate as a marker of suicide risk is immense. Research is warranted to explore the association between eye blink rate and acute suicide risk.

The risk of suicide is higher for patients with colorectal cancer (crc) than for the general population. Given known differences in morbidity and sites of recurrence, we sought to compare the predictors of suicide for patients with colon cancer and with rectal cancer. Using the U.S. Surveillance, Epidemiology, and End Results database, adult patients with confirmed adenocarcinoma of the colon or rectum during 1973-2009 were identified. Parametric and nonparametric tests were used to assess selected variables, and Cox proportional hazards regression models were used to determine predictors of suicide. The database identified 187,996 patients with rectal cancer and 443,368 with colon cancer. Compared with the rectal cancer group, the colon cancer group was older (median age: 70 years vs. 67 years; p < 0.001) and included more women (51% vs. 43%, p < 0.001). Suicide rates were similar in the colon and rectal cancer groups [611 (0.14%) vs. 337 (0.18%), p < 0.001]. On univariate analysis, rectal cancer was a predictor of suicide [hazard ratio (hr): 1.26; 95% confidence interval (ci): 1.10 to 1.43]. However, after adjusting for clinical and pathology factors, rectal cancer was not a predictor of suicide (hr: 1.05; 95% ci: 0.83 to 1.33). In the colon cancer cohort, independent predictors of suicide included older age, male sex, white race, and lack of primary resection. The aforementioned predictors, plus metastatic disease, similarly predicted suicide in the rectal cancer cohort. The suicide risk in crc patients is low (<0.2%), and no difference was found based on location of the primary tumour. Sex, age, race, distant spread of disease, and intact primary tumour were the main predictors of suicide among crc patients. Further studies and interventions are needed to target these high-risk groups.

Suicide risk assessment is predominantly based on assessing current/recent suicidal ideation and past suicidal behavior. However, suicidal ideation and lifetime suicide attempt are poor predictors of imminent suicide risk or crisis. The acute suicidal affective disturbance inventory-lifetime (ASADI-L) was developed to assess symptoms of acute suicidal affective disturbance, which includes a drastic increase in suicidal intent, perceptions of social and/or self-alienation, hopelessness, and overarousal. However, the ASADI-L has not yet been validated in a Korean population. Also, the ASADI-L has only been validated for people who experience a drastic increase in suicidal intention over the course of hours or days (i.e., the acute suicidal intention group) and not validated for those who experience suicidal intention for a longer period (i.e., the non-acute suicidal intention group). Thus, the aims of this study were to (1) validate the ASADI-L in a sample of Korean community adults; and (2) compare clinical characteristics of the acute and non-acute suicidal intention groups. Among 1,675 community adults, data from 682 participants who reported a lifetime drastic increase in suicidal intent were analyzed. Results indicated that the ASADI-L has relevant reliability, validity, and a unidimensional factor structure. The acute suicidal intention group had higher ASAD symptoms as well as clinical symptoms than the non-acute group, but the two groups did not differ in history of suicide attempt. Overall, these findings suggest that the ASADI-L is a valid measure of acute and non-acute suicidal affective disturbance among Korean adults. Further investigation of the differences in acute and non-acute suicide risk is warranted.

Background: Communicating the objective meaning of the cut-off criteria for high-risk among suicide risk assessment tools is challenging because they measure different aspects of suicide risk. This study aimed to provide comparable scores among widely used suicide assessment instruments by using test linking.Methods: Linking was performed using the equipercentile method with the data of 400 adults. Then, for an independent sample of 165 adults, the validity of linking was tested by providing an overall percent agreement of group classification.Results: Linking results indicated that the score of 4 on the C-SSRS corresponded to 8 on the DSI-SS and 16 on the SBQ-R, respectively. The overall percent agreement of group classification based on the cutoff score of 4 on the C-SSRS was high in both scales, supporting the validity of linking.Conclusions: The study results provide comparable criteria for the high-risk group among the three measures. Mental health practitioners could utilize our results in identifying people at high suicide risk.