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Ambivalence About Living and the Risk for Future Suicide Attempts: A Longitudinal Analysis

Bruce Naherniak, MD; Joanna Bhaskaran, MA; Jitender Sareen, MD; Yunqiao Wang, MA; and James M. Bolton, MD

Published: March 7, 2019

Article Abstract

Objective: While suicidal ideation is a recognized risk factor for future suicidal behavior, clinicians often subtype ideation in an effort to further clarify risk. This study referred to the SAFE (Suicide Assessment Form in Emergency Psychiatry) database to examine individuals who were assessed for suicidal ideation in the emergency department (ED) to determine whether ideation subtypes (active desire for death versus ambivalence about living) differentially predicted future suicide attempt.

Methods: Participants were individuals presenting to psychiatric services in the ED between January 1, 2009, and December 31, 2013, at 2 hospitals in Manitoba, Canada. People presenting with suicidal ideation were subtyped as having either ambivalence about living or active suicidal ideation. These presentations were examined as predictors of suicide attempt (defined by the Columbia Classification Algorithm for Suicide Assessment scale) within 6 months in regression models that adjusted for confounders.

Results: Of the 5,655 individuals presenting to the ED during the study, 158 (3.1%) presented again within 6 months with a suicide attempt. Individuals presenting with ambivalence about living showed more than a doubling in risk for future suicide attempts (odds ratio [OR] = 2.57, 95% CI = 1.64-4.02, P < .001). Active suicidal ideation also predicted attempts (defined by the within 6 months, with more than a tripling of risk compared to people who were not suicidal at baseline (OR = 3.75, 95% CI = 2.61-5.34, P < .001).

Conclusions: Psychiatric presentations to the ED often include suicidal ideation. Both active suicidal ideation and ambivalence about living are concerning presentations associated with risk of attempt within 6 months. Clinicians should be mindful that differentiating between active suicidal ideation and ambivalence about living may downplay the severity of the latter presentation.

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