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Focus on Suicide

Suicidal Behavior: Measurement and Mechanisms

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

Suicidal Behavior: Measurement and Mechanisms

This issue of Focus on Suicide brings us new data about risk assessment, with 2 articles examining the utility of rating scales for assessment of suicidal behavior. Youngstrom et al conduct a careful comparison of 3 suicide rating scales: the Columbia Suicide Severity Rating Scale (C-SSRS), the Suicide Tracking Scale (STS), and the Sheehan Suicidality Tracking Scale (S-STS). While the scales did comparably in 2 broad categories, suicidal ideation and suicide attempts, the study suggests that some subtypes of suicidal behavior/ideation are not captured as well by the S-STS. This may be considered a detail; however, 3 of the “behaviors” in the C-SSRS, aborted attempt, interrupted attempt, and preparatory acts, would not be considered suicidal behaviors at all using other frameworks and potentially would not be captured. At least 1 study (Mundt et al1) has suggested that membership in these subcategories of suicidal behavior does predict suicide attempts, and thus these subcategories may have clinical significance. Confirmation by other groups would be instructive. Of course, what is always missing in cross-sectional analyses of clinical assessments is the profile of the individual who dies by suicide, which interestingly was one of the outcomes in a study by Green et al. Using the suicide item of the Beck Depression Inventory, they found that the suicide item predicts both future attempts and suicide death with impressive hazard ratios. Unfortunately, the positive and negative predictive values for this one item will limit its utility in the clinic, but this study does support the notion that sensitive and specific screeners, perhaps with more items, can be built.

Just a few months ago, a paper by Case and Deaton2 underscoring the devastating trend for suicide and poisoning deaths among US white middle-aged individuals showed that in the United States alone, close to a million lives were lost to these causes. Indeed, some 3 years ago, the National Institute of Mental Health launched a campaign to raise awareness regarding rises in suicides in this cohort with a call to research action. In this issue, Bhaskaran and colleagues show not only that overdoses resulting in intensive care unit admission are common, but also that they are often due to ingestion of multiple substances, a trend that appears to be increasing. We know that suicide and poisoning are crucially preceded by psychiatric disorders, including substance use disorders, but the paucity of data regarding the link between substance and alcohol abuse and suicide is tragic. In October, the World Health Organization held a meeting in Geneva to devise a strategy for increasing the knowledge base about this relationship. The timely article by Hung et al in this issue shows that those admitted with alcohol use disorders, who quite likely represent the most severe end of the spectrum, have hugely elevated standardized mortality ratios for death not only by suicide, but by other causes as well. These findings again document the underappreciated fact that the illnesses that we treat are indeed fatal, and not just because of suicide, but also because they worsen outcomes of other diseases, possibly through nonadherence or more direct effects of brain disorders on health (exercise, nutrition, etc).

The increase in deaths by suicide in the middle-aged group may be due to other subtle effects of psychiatric conditions, and Szanto and coworkers examine this possibility. Assessing suicide attempters for neurocognitive differences compared to psychiatric controls, they note that attempters were more resistant to framing effects, potentially making them less able to reframe problems in a more positive light after a given problem is initially presented from a negative standpoint (eg, the presentation of a cancer treatment as having a 50% chance of failure being reframed as having a 50% chance of success). Whether this type of neurocognitive bias leads attempters to have difficulty in evaluating their choices and problem-solving in real life has yet to be shown, but it is a conceptually powerful way of understanding what happens in the suicidal mind.


1. Mundt JC, Greist JH, Jefferson JW, et al. Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. J Clin Psychiatry. 2013;74(9):887-893. PubMed doi:10.4088/JCP.13m08398

2. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. PNAS Web site. Updated September 17, 2015. Accessed November 9, 2015.

Maria A. Oquendo, MD

Editor’s Note: We encourage authors to submit papers for consideration as a part of our Focus on Suicide section. Please contact Maria A. Oquendo, MD, at

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Volume: 76

Quick Links: Depression (MDD) , Suicide


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