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Introduction: Identifying the Patients Most at Risk for Suicide Beyond Suicidal Ideation

Philippe Courtet, MD, PhD

Published: June 28, 2017

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.

Assessment of Suicidal Ideation and Behavior: Report of the International Society for CNS Clinical Trials and Methodology Consensus Meeting

Phillip B. Chappell, Michelle Stewart, Larry Alphs, Franco DiCesare, Sarah DuBrava, Jill Harkavy-Friedman, Pilar Lim, Sian Ratcliffe, Morton M. Silverman, Steven D. Targum, and Stephen R. Marder

Cognitive Control Deficits Differentiate Adolescent Suicide Ideators From Attempters

Jeremy G. Stewart, Catherine R. Glenn, Erika C. Esposito, Christine B. Cha, Matthew K. Nock, and Randy P. Auerbach

Contributing Factors and Mental Health Outcomes of First Suicide Attempt During Childhood and Adolescence: Results From a Nationally Representative Study

Hugo Peyre, Nicolas Hoertel, Coline Stordeur, Gaële Lebeau, Carlos Blanco, Kibby McMahon, Romain Basmaci, Cédric Lemogne, Frédéric Limosin, and Richard Delorme

Self-Reported Reasons for Not Receiving Mental Health Treatment in Adults With Serious Suicidal Thoughts

S. Janet Kuramoto-Crawford, Beth Han, and Richard T. McKeon

Objectively Assessed Sleep Variability as an Acute Warning Sign of Suicidal Ideation in a Longitudinal Evaluation of Young Adults at High Suicide Risk

Rebecca A. Bernert, Melanie A. Hom, Naomi G. Iwata, and Thomas E. Joiner


Identifying the Patients Most at Risk for Suicide Beyond Suicidal Ideation

This month’s Focus on Suicide section, available at PSYCHIATRIST.COM, highlights contemporary views in suicide research. First, a panel of experts proposes consensus statements regarding assessment of suicidal ideation and behavior in clinical trials. Two articles provide important perspectives on strategies that rely on objective markers for improving the detection of subjects who are at short-term risk of suicidal behavior. Two other studies focus on populations for whom development of preventive strategies is needed. The articles in this section represent major contributions in addressing the risk of suicide in young people.

Suicidal ideation and behaviors are too often exclusion criteria in clinical trials, although research on suicidal risk is needed. Chappell et al highlight consensus agreements dealing with nomenclature, assessment of suicidal ideation and behaviors across different patient populations, statistical issues and design of clinical trials, and strengthened public health approaches to deal with suicidal ideation and behaviors.

According to the Centers for Disease Control and Prevention, suicide is the second leading cause of death in US adolescents. Rates of attempted suicides in youngsters are markedly high. Because suicidal ideation is even more common, it is critical to identify factors that predict the transition from ideation to suicide attempt. Studies by Bernert et al and Stewart et al aimed to identify reliable, objective markers of short-term risk, specifically, risk of suicide attempt among adolescents with suicidal ideation and increase in suicidal ideation in high-risk adolescents. Bernert et al reported that self-reported insomnia and nightmares and actigraphically assessed sleep variability may represent acute warning signs of suicidal ideation. In this longitudinal study, 50 participants who were prescreened from 4,847 undergraduates and who presented a high risk of suicide were prospectively assessed at 3 timepoints during a 21-day observation period. Notably, actigraphic and subjective sleep parameters predicted acute increase of suicidal ideation independent of depressed mood. Moreover, sleep variability outperformed depressive symptoms in predicting suicidal ideation. This is of great interest because both sleep and suicidal ideation are symptoms of depression, which is a major condition associated with adolescent suicide risk, as revealed by Peyre and coworkers in another article in this section.

Bernert and colleagues are inviting researchers to study in depth the relationship between sleep disruption and emotion regulation deficits. As a matter of fact, Stewart et al reported that adolescent attempters, especially those with multiple attempts, exhibit pronounced cognitive control deficits in the context of emotional stimuli in comparison to ideators. To identify factors associated with the transition from suicidal ideation to act, the authors assessed interference to suicide-related, negative, and positive words using the Suicide Stroop Task in 109 adolescents with recent suicidal ideation or suicide attempts. As Stewart and colleagues point out, reduced Stroop Task performance has been suggested to be associated with suicidal behavior. However, questions of its specificity as a suicide marker, and whether the cognitive control deficits are general or related to the stimulus valence, are raised. Examining interference for emotional stimuli may thus improve clinical detection of adolescents who are at greatest risk of suicide attempts. Sleep disturbances, actigraphy, and cognitive control, then, have the potential to expand the clinical armamentarium that may help improve detection of the highest-risk individuals.

Studies by Peyre et al and Kuramoto-Crawford et al represent strong contributions that should lead to improvement of prevention strategies. Peyre et al examined a rarely investigated but important issue: What are the main contributors to early onset suicidal behavior, and what is the prognosis of these patients who initiated their history of suicide attempts during childhood or adolescence? Thanks to the opportunity to use data from the large (N = 34,653) nationally representative US adult sample (National Epidemiologic Survey on Alcohol and Related Conditions), they found a significant increase in the incidence of first suicide attempt between 12 and 13 years. They further demonstrated that suicide attempts during childhood were more strongly related to childhood maltreatment, while suicide attempts during adolescence were more strongly associated to depression. It should be pointed out that a wide range of traumatic events and types of childhood maltreatment were examined, but the assessment of familial history of psychiatric disorder did not consider suicidal behavior. This study provides particularly important preventative perspectives. First, it emphasizes the current large-scale effort aimed at protecting children worldwide ( Second, in reporting that subjects who attempted suicide during childhood had a particularly high risk for multiple suicide attempts, bipolar disorder, and panic disorders, the study should foster efforts in care and close follow-up of young suicide attempters, which are too often neglected.

Another key issue is insufficient mental health care in adults with serious suicidal thoughts. Kuramoto-Crawford et al examined self-reported reasons for not receiving mental health treatment among 8,400 adults with past-year serious suicidal thoughts (National Surveys on Drug Use and Health participants). It is important for clinicians to note that the majority of suicidal adults did not feel the need for treatment. Among those who felt the need, multiple barriers were identified, the first being the inability to afford it. Stigma and not knowing where to go for treatment were also frequently reported by suicidal adults. Sociodemographic correlates of reporting no perceived need for mental health treatment were male sex, age of 50 years or older, being from an ethnic minority, and being a nonmetropolitan resident. Of note, these factors are mainly related to social exclusion, which considerably increases suicidal risk. Consequently, it is important to help individuals with serious suicidal thoughts to recognize their problem and to inform them about the benefits of receiving professional mental health treatment.

Further, identifying contributors to suicidal behavior that are frequent, and less stigmatized, such as the sleep disturbances reported by Bernert et al, may be helpful in offering good therapeutic options to these patients in primary care.

Philippe Courtet, MD, PhD

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