Suicide, Suicide Attempts, and Suicidal Ideation


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Suicide, Suicide Attempts, and Suicidal Ideation
E. David Klonsky, Alexis M. May, and Boaz Y. Saffer
Department of Psychology, University of British Columbia, Vancouver, BC V6T 1Z4 Canada; email: [email protected]

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Annu. Rev. Clin. Psychol. 2016. 12:307–30
First published online as a Review in Advance on January 11, 2016
The Annual Review of Clinical Psychology is online at clinpsy.annualreviews.org
This article’s doi: 10.1146/annurev-clinpsy-021815-093204
Copyright c 2016 by Annual Reviews. All rights reserved

Keywords
suicide, suicidal ideation, suicidal behavior, suicide attempts, ideation-to-action framework, three-step theory, 3ST
Abstract
Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-toaction framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.

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Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 DEFINITIONS AND TERMINOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 CHALLENGES FOR RESEARCH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 SOCIODEMOGRAPHIC CORRELATES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 MENTAL DISORDERS AND OTHER CLINICAL CORRELATES . . . . . . . . . . . . . . 312 MOTIVATIONS FOR SUICIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 EVIDENCE-BASED CLINICAL ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 EVIDENCE-BASED CLINICAL INTERVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 EVIDENCE-BASED PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 THE IDEATION-TO-ACTION FRAMEWORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 THE THREE-STEP THEORY OF SUICIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
Step 1. Development of Suicidal Ideation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Step 2. Strong Versus Moderate Ideation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Step 3. Progression from Ideation to Attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 FUTURE DIRECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
INTRODUCTION
Suicidal behavior is a global cause of death and disability. Worldwide, suicide is the fifteenth leading cause of death, accounting for 1.4% of all deaths (WHO 2014). In total, more than 800,000 people die by suicide each year. The annual global age-standardized death rate for 2012 is estimated to be 11.4 per 100,000, and the World Health Organization (WHO) projects this rate to remain steady through 2030 (WHO 2013, 2014).
In addition to suicide deaths, suicidal thoughts and nonfatal suicide attempts also warrant attention. Globally, lifetime prevalence rates are approximately 9.2% for suicidal ideation and 2.7% for suicide attempt (Nock et al. 2008a). Suicide ideation and attempts are strongly predictive of suicide deaths; can result in negative consequences such as injury, hospitalization, and loss of liberty; and exert a financial burden of billions of dollars on society (CDC 2010a; Nock et al. 2008a,b; WHO 2014). Taken together, suicide and suicidal behavior comprise the nineteenth leading cause of global disease burden (i.e., years lost to disability, ill-health, and early death), and the sixth and ninth leading cause of global disease burden among men and women 15 to 44 years of age, respectively (WHO 2008). By any measure, there is urgency to better understand and prevent suicide and suicidal behavior.
DEFINITIONS AND TERMINOLOGY
The use of vague or inconsistent terms and definitions has hindered progress in suicide research and theory. For example, some use the term suicidal behavior as a general term encompassing any suicidal thought or action without taking additional steps to distinguish thoughts from plans, from nonfatal attempts, and from attempts that result in death. Similarly, some use the term self-harm to refer to intentional self-injury without intent to die (i.e., nonsuicidal self-injury behaviors such as superficial skin cutting), whereas others use the term to encompass all intentional self-injurious behaviors regardless of intent to die. Because these different aspects of suicidality and self-injury can have very different prevalence rates, functions, clinical correlates, and outcomes, it is critical to be precise with our use of definitions and terminology.
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The scope of this review precludes a comprehensive discussion of issues of terminology and definition, but we emphasize a few key points. We utilize the definitions provided by the US Centers for Disease Control and Prevention (CDC) (CDC 2015a, Crosby et al. 2011), whereby suicidal self-directed violence is distinguished from self-directed violence with undetermined or nonsuicidal intent. Within the domain of suicidal self-directed violence, suicide is defined as death caused by self-directed injurious behavior with an intent to die as a result of the behavior; suicide attempt is defined as a nonfatal, self-directed, potentially injurious behavior with an intent to die as a result of the behavior even if the behavior does not result in injury; and suicidal ideation is defined as thinking about, considering, or planning suicide. The terms completed suicide, failed attempt, nonfatal suicide, successful suicide, suicidal gesture, and suicide threat are considered pejorative or misleading, and the term parasuicide is considered overly broad and vague and therefore unacceptable by the CDC.
The American Psychiatric Association (APA) has also addressed an important definitional issue with the publication of the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5; Am. Psychiatr. Assoc. 2013). Section III of the DSM-5 includes nonsuicidal self-injury (NSSI) and suicidal behavior disorder as “conditions for further study.” A key reason for proposing a distinct disorder for NSSI was to distinguish the behavior from suicide attempts (i.e., self-harm with intent to die). Although NSSI is strongly correlated with suicide attempts (Klonsky et al. 2013, Wilkinson et al. 2011), the behaviors differ in terms of prevalence (NSSI is more prevalent), frequency (NSSI is often performed dozens or hundreds of times, whereas suicide attempts are typically performed once or a few times), methods (cutting and burning are more characteristic of NSSI, whereas self-poisoning is more characteristic of attempted suicide), severity (NSSI rarely causes medically severe or lethal injuries), and functions (NSSI is performed without intent to die, usually to temporarily relieve overwhelming negative emotion, and sometimes in an effort to avoid suicidal urges) (CDC 2010a, Klonsky 2007, Klonsky & Muehlenkamp 2007, Muehlenkamp 2005, Muehlenkamp & Gutierrez 2004). We believe NSSI has a strong relationship with suicide attempts for two reasons: NSSI correlates with variables, such as depression, known to increase risk for suicidal ideation; and NSSI facilitates habituation to self-inflicted violence and pain, which in turn increases the capacity to attempt suicide (Klonsky et al. 2013).
CHALLENGES FOR RESEARCH
The study of suicide is fraught with many challenges resulting from the nature of suicidality itself, the research practices common to the field over the past several decades, and the complicated cultural meaning of suicide (Goldsmith et al. 2002). Five challenges are detailed in this section.
First, as noted above, the field of suicidology has struggled to establish a set of agreed upon terms over the past 50 years. Although it has become more common for researchers to be clear about the terms they use and their meaning (like we do above), the existing research literature is filled with different terms, which hampers our ability to integrate findings across the various studies published. The field has repeatedly sought to address the issue, including at a meeting hosted in the 1970s by the National Institute of Mental Health (NIMH), and subsequent efforts in the 1990s by multiple organizations including NIMH, the American Association of Suicidology, and the Center for Mental Health Services. These meetings resulted in a seminal article by O’Carroll et al. (1996) that was subsequently revised and updated by Silverman et al. (2007). However, despite these workshops, differences persist in terminology between subfields (e.g., mental health professionals versus school systems versus coroners) and even among mental health professionals and suicidologists (e.g., whether to distinguish NSSI from suicide attempts). Such diversity impedes the ability to combine knowledge from disparate studies and publications and limits the advancement of suicide knowledge and prevention (Posner et al. 2014).
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Second, in part due to the aforementioned inconsistencies in nomenclature, measures of suicidality are numerous and often divergent in their aims and content. For example, assessments of suicide ideation range from simple one- to two-item screenings [e.g., “Did you ever seriously consider suicide?” (CDC 2015b)] to full assessments that capture frequency, severity, planning, communication, and intent (Nock et al. 2007). Though versatility in measurement approaches allows for assessments in different settings and time frames, it also leads to confusion in the literature. For example, the presence of ideation is at times operationalized as fleeting thoughts about suicide and at other times requires heightened severity or frequency. A history of suicide attempt may be determined by a single question (e.g., “Have you ever attempted suicide?”) or may explicitly require intent or a certain degree of lethality. The diverse measurement approaches make it difficult to compare findings and integrate knowledge across studies.
A third challenge to research is the variability across studies in whether suicidal ideation and attempts are treated as states or traits. In other words, is suicide ideation and attempt better conceptualized as an experience someone has at a moment in time (e.g., studies of ideation or attempts) or as an individual difference variable attached to anyone who has thought about or attempted suicide at least once (e.g., studies of ideators or attempters)? For most, ideation is a relatively rare experience isolated to a particular period of one’s life rather than a chronic experience (Kessler et al. 2012). Similarly, most individuals who attempt suicide only do so once (Kessler et al. 2012). Thus, it may be most accurate to consider suicidality a state and to study it accordingly. However, because previous suicide attempts strongly predict future attempts (Borowsky et al. 2001, O’Connor et al. 2013) and because some ideators, often with early onset, experience persistent ideation (Kessler et al. 2012), there is also reason to view suicidality as a trait-like variable, especially in the context of clinical risk assessment. Different perspectives on this issue imply different research designs and questions, and yield different types of knowledge (e.g., when is an individual at risk versus who is at risk). Unfortunately, the basis for the approach taken is rarely explicitly considered or rationalized in published studies, and knowledge about suicide and suicide risk suffers as a result.
Fourth, even when clear definitions are agreed upon and standardized measures are used, the heavy stigma surrounding suicide can influence reporting. For example, individuals in countries strongly influenced by religions that prohibit suicide may underreport suicide attempts and deaths. It is even possible that individuals with a history of suicidal thoughts or attempts are less likely to identify as such and agree to participate in research studies, although for obvious reasons it would be extremely difficult to recruit a representative sample of suicidal individuals to examine this possibility. Nonetheless, it is likely that cultural differences in the stigma around suicide affect the accuracy of the rates reported in global epidemiological studies (Mars et al. 2014, Nock et al. 2008b).
Finally, the nature of suicidal thoughts and behaviors themselves presents a variety of obstacles for research. To begin with, low base-rate behaviors such as suicide are hard to study for both practical and statistical reasons. Even in high-risk populations, where suicide deaths are more common than in the general population, thousands of participants are needed to obtain reliable results (Goldsmith et al. 2002). Moreover, unlike many other clinically relevant behaviors, such as binge drinking or occurrences of panic attacks, a suicide death precludes the possibility of reporting about the event retrospectively. Instead, examining suicide as an outcome means utilizing large longitudinal studies and psychological autopsy studies. Longitudinal studies present challenges for the inclusion of large sample sizes, comprehensive clinical assessment, and sufficiently frequent assessments so as to ensure that any suicide death that occurs is likely to have been preceded by an assessment relatively close in time. Psychological autopsy studies are limited by their reliance on the memories, knowledge, and interpretations of informants and medical records.
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Because of the difficulty in studying suicide as an outcome, researchers instead often study suicidal thoughts and/or behaviors as proxies for suicide. These behaviors make good research targets because they are strongly related to suicide but occur far more frequently and are thus easier to study. However, these studies have their own practical and ethical limitations. For example, researchers have an ethical responsibility to intervene should they believe a suicide attempt is imminent, which means that researchers often must impact the participants they are studying precisely when, from a scientific perspective, it would be most important to observe and assess the natural course of suicidal thoughts and attempts. In addition, a few studies suggest that suicidal thoughts and behaviors have some different predictors and correlates than suicide death (Daigle 2004, DeJong et al. 2010), which means that studies of suicidal thoughts and behaviors may not fully generalize when it comes to understanding suicide itself. Although these challenges will remain for the foreseeable future, suicide research is also poised to benefit from creative advances in psychological research, including using social networking analysis, ecological momentary assessment, and big data approaches. It will be important for suicidologists to use these and other methodological innovations to combat the challenges inherent to the study of suicide.
SOCIODEMOGRAPHIC CORRELATES
A comprehensive examination of correlates of suicide, suicide attempts, and suicidal ideation is beyond the scope of this review; however, we briefly emphasize some key points. Most notably, suicide rates are not distributed evenly across people or places.
For example, high-income countries have higher suicide rates than low- and middle-income countries (LMICs; 12.7 versus 11.2 per 100,000, respectively). LMICs, however, account for over 75% of all suicides worldwide. Suicide rates also differ by gender and age (Nock et al. 2008a; WHO 1999, 2014). Men account for roughly three times the number of suicides than women, and this gender disparity is even greater in high-income countries (WHO 2014). When stratified by age, suicide rates are highest in adults aged 70 and older across both men and women. However, although overall rates of suicide are lower in children and young adults, suicide accounts for a disproportionately large number of deaths in these age ranges. For example, suicide is the second leading cause of death among those 15 to 29 years old, and the leading cause of death among young women aged 15 to 19 (Patton et al. 2009). Notably, sex and age patterns often differ across countries. For example, in high-income countries, middle-aged men have a higher suicide rate than their LMICs counterparts, whereas in LMICs, young adults and elderly women have higher suicide rates compared with young adults and elderly women in high-income countries.
Changes in suicide rates over time also differ across peoples and places (WHO 2014). Between 2000 and 2012, age-standardized suicide rates decreased worldwide by an average of 26%. However, this decrease was far from uniform. For example, during this period suicide rates decreased by 69% among women in Malta but increased by 416% among men in Cyprus. Meaningful variability was even observed between neighboring countries. Whereas Canada experienced an 11% decrease in suicide rates from 2000 to 2012, the United States experienced a 24% increase.
Rates of nonfatal suicidal behavior also differ by region, age, sex, and sexual orientation. For example, the United States has higher rates of suicide ideation (15.6%), plans (5.4%), and attempts (5.0%) than the global average (Nock et al. 2008a). In addition, rates of lifetime suicidal ideation, suicide plans, and suicide attempts are higher in females than males (Kessler et al. 1999; Nock et al. 2008a, 2013) and higher in adolescents than adults (Nock et al. 2008b). It is also recently becoming clear that individuals reporting sexual- or gender-minority orientations (i.e., lesbian,
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gay, bisexual, and transgender) are at increased risk for suicidal ideation and suicide attempts, a trend that appears to hold constant worldwide (Figueiredo & Abreu 2015).
MENTAL DISORDERS AND OTHER CLINICAL CORRELATES
It is often stated that over 90% of individuals who die by suicide have mental disorders (Bertolote & Fleischmann 2002). However, it is also true that the overwhelming majority of individuals with mental disorders—more than 98%—do not die by suicide (Nordentoft et al. 2011). In addition, some mental disorders confer higher risk for suicide than others.
In developed countries, the disorders that most strongly predict a subsequent suicide attempt are bipolar disorder, posttraumatic stress disorder, and major depression; in developing countries, the most predictive disorders are posttraumatic stress disorder, conduct disorder, and drug abuse/dependence (Nock et al. 2009). Importantly, additional analyses of these data showed that the associations between these disorders and suicide attempts are mostly due to the disorders predicting the development of suicidal ideation. When limiting analyses to individuals with suicidal ideation, mental disorders became very weak predictors of suicide attempts. This tendency of potential risk factors to predict suicidal thoughts better than attempts is a key theme that is revisited throughout the remainder of this article.
Besides mental disorders, numerous clinical and psychological variables have been demonstrated to influence suicide risk. A recent paper on the psychology of suicide by O’Connor & Nock (2014; see panel 2) lists more than 30 psychological risk and protective factors. Here, we focus on three psychological variables often considered to be particularly important predictors of suicidal thoughts and attempts: depression (measured as a continuous variable rather than a discrete mental disorder), hopelessness, and impulsivity. Indeed, there is evidence that each of these variables exhibits statistically reliable relationships to measures of suicidality and suicide risk. However, the literature for each of these variables has important nuances. Depression appears to be one of the strongest predictors of suicidal ideation but does not appear to distinguish those who have attempted suicide from those who have experienced suicidal ideation without attempts (May & Klonsky 2016). Hopelessness is well known for demonstrating prospective prediction of suicide and suicide attempts in very-long-term studies; however, the magnitude of prediction in this research is actually quite small, similar to a correlation of about 0.2 (Beck et al. 1989). In addition, like depression, hopelessness is elevated in those who have experienced suicidal ideation but is not higher in attempters compared to ideators (May & Klonsky 2016).
The role of impulsivity in suicide is particularly noteworthy because impulsivity has long been conceptualized as a key risk factor for suicide attempts. Indeed, because impulsivity is thought to hasten the transition from thoughts to action, it has often been conceptualized as a critical clinical factor in the progression from suicidal thoughts to attempts (Bryan & Rudd 2006, Mann et al. 1999). However, recent research disputes these long-held clinical beliefs. For example, a recent meta-analysis found that impulsivity is a relatively modest predictor of suicide attempts (Anestis et al. 2014). Other studies find no connection between measures of trait impulsivity and more “impulsive” suicide attempts (e.g., attempts made with little planning or forethought) (Wyder & De Leo 2007). Research has also found that most measures of impulsivity are no higher in suicide attempters than in those who have experienced ideation without attempts (Klonsky & May 2010), although this same study found higher impulsivity in those who have experienced either ideation or attempts compared to those without histories of suicidality.
Taken together, most clinical correlates of suicidality appear to be best conceptualized as correlates of suicidal ideation. These variables appear to predict suicide attempts or deaths only to the extent that they predict ideation. This pattern and its implications are discussed further below in the section titled The Ideation-to-Action Framework.
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MOTIVATIONS FOR SUICIDE
Whereas most studies on suicide focus on correlates, another way to improve suicide knowledge and prevention is to better understand the motivations for suicide attempts. Understanding the most common motivations for suicide attempts can inform conceptual models of suicide and facilitate the development of intervention and prevention programs that are most likely to resonate with and help those at risk. Clinically, identifying the motivation for a specific client’s attempt allows the clinician and the attempter to find alternative solutions that may solve the problem and reduce the likelihood of future attempts. Though a desire to die is, by definition, a motivation common to all suicide attempts, research suggests that individual attempts may be motivated by a myriad of reasons such as escape, communication, altering one’s environment, and dealing with an unbearable state of mind (Brown et al. 2002a, Chapman & Dixon-Gordon 2007, Holden et al. 1998, May & Klonsky 2013, Schnyder et al. 1999).
Different theories of suicide offer different hypotheses about why people attempt suicide. Edwin Shneidman’s (1993) theory of suicide describes psychache (i.e., emotional or psychological pain) as the primary motivator of an attempt. He posits that suicide occurs when an individual’s threshold for tolerating psychological pain is surpassed and that this threshold varies across individuals. Roy Baumeister presents a theory of suicide based on constructs from cognitive, social, and personality psychology. His escape theory suggests that many suicide attempts are motivated by a need to reduce aversive self-awareness (Baumeister 1990). Thomas Joiner’s (2005) interpersonal theory states that two domains, perceived burdensomeness and thwarted belongingness, interact to confer the desire for suicide. Other theories highlight the roles of hopelessness (Abramson et al. 1989), problem-solving (Baechler 1979), impulsivity (Simon et al. 2001), and interpersonal communication (Farberow & Shneidman 1961, Kobler & Stotland 1964, Kreitman 1977) in motivating a suicide attempt.
Interestingly, and perhaps unfortunately, most instruments designed to assess suicide motivations have been developed with little regard for the theoretical work described above. Early efforts to assess motivations for suicide were carried out by John Bancroft and colleagues in the 1970s. Potential motivations for overdoses were generated by researchers and study participants, resulting in a list of 14 possible reasons (Bancroft et al. 1976, 1979). Twenty years later, Ronald Holden and collaborators (1998) used these items to construct the Reasons for Attempting Suicide Questionnaire. Shortly thereafter, Marsha Linehan and colleagues (Brown et al. 2002a) included reasons for self-injurious behavior as part of their Parasuicide History Interview. More recently, the Inventory of Motivations for Suicide Attempts (IMSA; May & Klonsky 2013) was developed. Unlike for previous measures, development of the IMSA was informed by prevailing theories of suicide, and the IMSA consists of nine scales assessing motivations emphasized by these different theories.
Some important lessons can be drawn from studies utilizing the above measures. Across both rationally and empirically derived measures, two superordinate dimensions of attempt motivations arise (Brown et al. 2002a, Holden & DeLisle 2006, May & Klonsky 2013, May et al. 2016). The first represents internal (self-oriented) motivations, such as hopelessness, extreme emotional pain, a need to escape, and other distressing emotional or cognitive states. The second domain captures communication (other-oriented) motivations, such as a desire to communicate with, influence, or seek help from others. The fact that multiple independent lines of inquiry converge on these two factors increases confidence in the validity and clinical utility of these domains.
Internal motivations for suicide, particularly overwhelming pain and hopelessness, are more often endorsed than communication motivations. Numerous studies find that a majority of suicide attempters report internal motivations (Brown et al. 2002a, Hjelmeland et al. 2002, Holden et al.
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1998, May & Klonsky 2013, May et al. 2016), and to our knowledge there are no exceptions. A smaller subset of participants report communication motivations, almost always in addition to, rather than instead of, internal motivations. Importantly, the types of motivations endorsed have implications for the type of suicide attempt made. Relative to internal motivations, communication motivations appear to be protective. For example, among a sample of undergraduates and outpatients with recent attempts, greater endorsement of communication motivations was associated with lower suicidal intent and a greater likelihood the attempt would be interrupted, whereas greater internal reasons were correlated with a greater desire to die (May & Klonsky 2013). These findings are consistent with earlier studies reporting that internal reasons were correlated with higher intent and preparation, whereas communication motivations were not (Hjelmeland et al. 2002, Holden et al. 1998).
A possible explanation for this pattern is that the presence of socially oriented motivations signifies a continued connection to people, a desire to maintain these relationships, and thus a continued investment in living. This connection to people may counterbalance a desire to die, whereas the absence of communication motivations may signify less connection and thus less ambiguity about the desire to die. In addition, individuals who attempt suicide with communication motivations, particularly help-seeking, may be more interested and engaged in the treatment options that are often offered postattempt. It is important to remember that all research on suicide motivations has been conducted with suicide attempters who survived, limiting our knowledge of whether these same motivations generalize to suicide decedents.
EVIDENCE-BASED CLINICAL ASSESSMENT
Suicide research and prevention require accurate evaluation of suicide phenomena. Therefore, reliable, valid, and comprehensive assessments are essential. For in-depth reviews of such measures, including scope and psychometric properties, see Brown (2001), Goldston (2003), and Nock et al. (2008c). Here we summarize some of the more widely used and better-validated measures.
The Suicide Attempt and Self-Injury Interview (SASII; Linehan et al. 2006a), formerly the Parasuicide History Interview (Linehan et al. 1989), is a structured interview composed of 31 items designed to assess the intent, context, and topography of nonsuicidal and suicidal behaviors. The SASII subscales were factor-analytically derived using three medium-sized cohorts. The SASII demonstrates excellent internal consistency and high interrater reliability (Linehan et al. 2006a), and has been repeatedly used in samples with borderline personality disorder (Brown et al. 2002b, Crowell et al. 2012, Harned et al. 2010).
The Self-Injurious Thoughts and Behaviors Interview (SITBI), developed by Nock et al. (2007), is another structured interview that comprehensively assesses both nonsuicidal and suicidal selfharming behaviors. The SITBI’s 169 items assess characteristics associated with NSSI, suicidal ideation, plans, gestures, and attempts including their frequency, severity, methods used, function, perceived cause, and age of onset. The SITBI was developed and has been primarily used with adolescent samples (Barrocas et al. 2012, Janis & Nock 2008, Nock et al. 2007), where it has been found to have strong psychometric properties, including high interrater and test-retest reliability, and has demonstrated concurrent validity by overlapping with established measures of NSSI, suicide ideation, and suicide attempts ( Janis & Nock 2008, Nock et al. 2007).
The Scale for Suicide Ideation (SSI; Beck et al. 1979) is a long-standing semi-structured interview assessing the presence, frequency, and severity of suicidal thoughts using 21 items. The SSI has been found to have high internal consistency and test-retest reliability (Beck et al. 1979, 1997) and strong concurrent validity (Beck et al. 1979, 1985, 1997), and it is one of the few clinicianadministered measures to have been shown to predict suicide attempts. Specifically, participants
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who obtained scores at or greater than 3 on the SSI were found to be seven times more likely to attempt suicide over a ten-year period than those who scored less than 3 (Brown et al. 2000). A more recently developed semi-structured interview, the Columbia-Suicide Severity Rating Scale (CSSRS; Posner et al. 2008, 2011), has also demonstrated predictive validity. The C-SSRS assesses lifetime presence of suicide ideation, plans, intensity of ideation, and attempts as well as NSSI, and it has been shown to predict suicide attempts during a 24-week follow-up period (Posner et al. 2011).
A variety of self-report measures assessing constructs related to suicide (such as depression and hopelessness) and aspects of suicidality (ideation, intent, lethality) have been developed over the past 40 years. However, only a few of these measures have been shown to predict future suicide attempts. The Beck Hopelessness Scale (Beck et al. 1974) assesses participants’ sense of hopelessness using 20 true-or-false items. Psychiatric outpatients who obtained scores at or above 9 on the Beck Hopelessness Scale were found to be 11 times more likely to die by suicide than were outpatients scoring 8 or below. Question nine on the Beck Depression Inventory-II (Beck et al. 1961, 1996) assessing suicidal thoughts/wishes has demonstrated sensitivity to future suicide attempts in three psychiatric samples (Beck et al. 1990, Brown et al. 2000, Oquendo et al. 2004). Patients scoring at or above 2 on this question were found to be 6.9 times more likely to die by suicide than those who scored below 2 (Brown et al. 2000). Similarly, baseline scores obtained by a psychiatric sample on the 25-item Adult Suicidal Ideation Questionnaire (Reynolds 1991), a measure of the frequency of suicidal ideation, predicted suicide attempts over a three-month period (Osman et al. 1999).
Virtually all clinical interviews and self-report measures rely on participants self-disclosing information regarding their past suicide attempts and current suicidal thoughts and plans. Suicide, however, is an extremely personal and sensitive subject that is often stigmatized and difficult to discuss. In response to these challenges, objective measures free of reporting biases have been developed to assess suicide risk. One such measure is the death/suicide implicit association test (IAT) developed by Nock et al. (2010). Administering the death/suicide IAT to patients in an emergency department revealed that the death/suicide IAT correctly distinguished participants admitted following a suicide attempt from those who were admitted for reasons other than a suicide attempt. Furthermore, and critically, performance on the death/suicide IAT predicted future suicide attempts, over and above both the patients’ own predictions and clinicians’ predictions of the likelihood of future suicide attempts (Nock et al. 2010). The death/suicide IAT therefore is promising for predicting suicide attempts, although further study of these findings and their clinical utility is required.
EVIDENCE-BASED CLINICAL INTERVENTION
Suicidal thoughts and behaviors remain difficult to treat. Unfortunately, no gold-standard, highly effective treatments exist. However, some treatments have better evidence than others for reducing suicidal thoughts and behaviors, and we summarize these below. We specifically focus on clinical interventions that target individuals at risk for suicide and that seek to reduce suicidal thoughts and behaviors; we address community-level suicide prevention efforts separately in a subsequent section.
Dialectical behavior therapy (DBT; Linehan 1993) is a multimodal treatment that combines behavioral and acceptance-based strategies. DBT was developed for populations with extensive histories of self-injurious and suicidal behaviors, and it has been primarily used and studied in samples with borderline personality disorder. Randomized controlled trials (RCTs) have found that patients who received DBT engaged in less self-harm (suicidal intent not always assessed
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or reported; Koons et al. 2001; Linehan et al. 1991, 1993; van den Bosch et al. 2005; Verheul et al. 2003), attempted suicide less often (Linehan et al. 2006b), and experienced improvements in disability and quality of life (Carter et al. 2010).
Another treatment, cognitive therapy for suicide prevention (CT-SP; Brown et al. 2002a), is based on Beck’s cognitive theory (Beck 1976). CT-SP views suicide as resulting from patients’ sense of hopelessness and dysfunctional automatic thoughts. CT-SP therefore focuses on mitigating hopelessness, evaluating and challenging the accuracy of patients’ assumptions, and providing patients with coping strategies and problem-solving skills. RCTs have found that patients who received CT-SP experienced greater reductions in suicidal thoughts (Slee et al. 2008) and made fewer suicide attempts at 6-month (Evans et al. 1999) and 18-month (Brown et al. 2005) follow-up.
The collaborative assessment and management of suicide risk (CAMS; Jobes 2006) is a relatively new treatment of suicidal behavior. CAMS uses a collaborative, nonjudgmental approach and focuses on developing a strong therapeutic patient relationship as the basis for working with patients to design and implement a treatment plan. Studies have found that CAMS can quickly reduce suicidality broadly defined ( Jobes et al. 2005) and that treatment gains are sustained at 50 days (Ellis et al. 2012). An RCT found CAMS to be effective in treating suicidal ideation and that CAMS patients had continued to improve 12 months after treatment (Comtois et al. 2011). These studies suggest that CAMS might be an effective treatment for suicidal ideation. Additional and larger CAMS trials are currently under way.
EVIDENCE-BASED PREVENTION
Treatments for suicidality tend to focus on individual and/or group modalities. However, some key approaches to suicide prevention can be implemented at the level of the community or government. These approaches include means restriction, physician education, and school-based programs.
There may be no more effective approach to suicide prevention than to reduce access to means on a large scale. Access to firearms in the United States represents a prime example. Firearms are the leading cause of suicide death in the United States, and laws regulating the availability of firearms vary by state. In two important studies, Anestis and colleagues found that laws restricting access to handguns, such as those requiring permits, registration, licenses, background checks, and gun locks, were associated not only with reductions in suicides by handgun, but also with lower suicide rates overall (Anestis & Anestis 2015, Anestis et al. 2015). In addition, evidence indicates that states with higher self-reported gun ownership have higher rates of firearm suicide as well as overall suicide (Miller et al. 2007). These patterns are not due to an association of gun ownership with mental health or suicidal thoughts; in fact, there is no relationship of gun ownership to either mental health or suicidal thoughts, and the relationship between gun ownership and suicide persists after controlling for these variables (Betz et al. 2011, Hemenway & Miller 2002, Miller et al. 2009).
Means restriction applies beyond the United States and beyond firearms. For example, when particularly lethal pesticides became a common method of suicide in Sri Lanka, regulations restricting the availability of these pesticides resulted in a halving of the overall suicide rate (Gunnell et al. 2007). A similar story took place in the United Kingdom. Up until the 1950s, domestic gas came from coal and included 10% to 20% carbon monoxide. During this time, gas inhalation was the leading method of suicide. Starting in the late 1950s and through the 1970s, natural gas, which contains very little carbon monoxide, was introduced, and its use became increasingly common. As the carbon monoxide levels in domestic gas decreased between the 1950s and 1970s, rates of suicide by carbon monoxide poisoning as well as overall suicide rates decreased substantially (Kreitman 1976).
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Suicide, Suicide Attempts, and Suicidal Ideation