Reliability of Suicide Risk Estimates: A Vignette Study.

OBJECTIVE: Suicide risk assessments are obligatory when patients express a death wish in clinical practice. Yet, suicide risk estimates based on unguided risk assessments have been shown to be of low reliability. Since generalizability of previous studies is limited, the current study aimed to assess inter-rater and intra-rater reliability of risk estimates conducted by psychotherapists and psychology students using written case vignettes. METHOD: In total, N = 256 participants (psychology students, psychotherapists) were presented with 24 case vignettes describing patients at either low, moderate, severe or extreme risk of suicide. Participants were asked to assign a level of risk to each single vignette at a baseline assessment and again at a follow-up assessment two weeks later. RESULTS: Risk estimates showed a low inter-rater reliability, both for students (AC1 = .35) and for psychotherapists (AC1 = .44). Intra-rater reliability was moderate for psychotherapists (AC1 = .59) and rather low for psychology students (AC1 = .47). In general, intra- and intra-rater reliability were highest for vignettes displaying "low" and "extreme" risk. CONCLUSIONS: The results highlight that the reliability of unguided suicide risk assessments is questionable. Standardized risk assessment protocols are therefore recommended. Nonetheless, even reliable risk estimation does not imply predictive validity of risk estimates for future suicidal behavior.

Suicide risk estimates have been shown to be of low reliabilitySuicide risk estimates by psychotherapists and students also showed low inter-rater and intra-rater reliability in the current studyReliable risk estimation does not imply predictive validity of risk estimates for future suicidal behavior.

Examining heterogeneity in the affect-regulating function of suicidal ideation: Person-specific analyses in male inpatients with depression.

INTRODUCTION: Men have an increased risk to die by suicide compared to women but are underrepresented in suicide research. To improve individual risk prediction for suicide-related thoughts and behaviors (STBs), risk factors are increasingly being studied at an individual level. The possible affect-regulatory function of suicidal ideation has hardly been investigated ideographically and has not yet been tested in a male sample. METHODS: We investigated the bidirectional associations between suicidal ideation and negative and positive affect in a sample of n = 21 male inpatients with unipolar depression and a history of suicidal ideation both at the group level and at the individual level. Participants underwent an intensive ecological momentary assessment for 6 days with 10 data points per day. RESULTS: We found no evidence for an affect-regulatory function of suicidal ideation at the group level, neither for effects of affect on subsequent suicidal ideation (antecedent affect-regulatory hypothesis) nor for effects of suicidal ideation on subsequent affect (consequence affect-regulatory hypothesis). Person-specific analyses revealed substantial variability in strength and direction of the considered associations, especially for the associations representing the antecedent hypothesis. CONCLUSION: The demonstrated between-person heterogeneity points to the necessity to individualize the investigation of risk factors to enhance prediction and prevention of STBs.

Suicide-specific rumination as a predictor of suicide planning and intent.

BACKGROUND: Suicide-specific rumination (SSR), that is repetitive negative thinking about suicide, has been proposed as a risk factor for suicidal behavior. Yet, few studies have investigated associations between SSR and suicide intent and planning in a longitudinal study design. The purpose of the present study was to investigate the association between SSR, suicide intent, suicide planning and suicide attempts in a sample of adult outpatients undergoing psychotherapy. METHOD: Data from N = 637 patients (58.4% female, 41.6% male; Mage = 35.81, SDage = 13.50, range: 18-79 years) who started therapy at an outpatient clinic were collected. A subsample of n = 335 patients (n = 335; 56,4% female, 43,6% male; Mage = 35.4, SDage = 13.1, range: 18-73 years) also took part in a post-treatment assessment after twelve therapy sessions. RESULTS: SSR differentiated lifetime suicide attempters from suicide ideators. Furthermore, SSR was associated with lifetime suicide attempt status above age, sex, suicide ideation, depression, anxiety, and stress. Finally, SSR served as a prospective predictor of both suicide planning and suicide intent. CONCLUSION: The results emphasize the key role of SSR in understanding the suicidal process.

Sex differences in entrapment in a multinational sample: a network analysis perspective.

Background: The concept of entrapment has been highlighted as a transdiagnostic element that manifests itself in disorders such as depression, anxiety, and suicidal ideation. Although research has been conducted in different contexts independently, a comprehensive multi-country study to assess gender differences in entrapment through network analysis has not yet been carried out. The objective of this study was to evaluate the entrapment network in men and women at the multinational level. Methods: A sample of 2,949 participants, ranging in age from 18 to 73 years from six countries (Germany, Iran, Spain, Slovakia, El Salvador, and Peru), was considered. They completed the entrapment scale. A network analysis was performed for both men and women to identify the connectivity between indicators and the formation of clusters and domains, in addition to the centrality assessment in both sex groups. Results: The study findings revealed the presence of a third domain focused on external interpersonal entrapment in the network of men and women. However, in relation to the interconnectivity between domains, variations were evidenced in both networks, as well as in centrality, it was reported that men present a greater generalized entrapment in various aspects of life, while women tend to experience a more focused entrapment in expressions of intense emotional charge. Conclusion: The multinational study identified variations in the structure of entrapment between genders, with three domains (internal, external, and external-interpersonal) and differences in the interaction of indicators and groupings, as well as discrepancies in centrality.

Implicit measures of suicide vulnerability: Investigating suicide-related information-processing biases and a deficit in behavioral impulse control in a high-risk sample and healthy controls.

OBJECTIVE: Relevant implicit markers of suicidal thoughts and behaviors (STBs) have only been studied in isolation with mixed evidence. This is the first study that investigated a suicide attentional bias, a death-identity bias and a deficit in behavioral impulsivity in a high-risk sample and healthy controls. METHOD: We administered the Death Implicit Association Test, the Modified Suicide Stroop Task, and a Go/No-Go Task to inpatient suicide ideators (n = 42), suicide attempters (n = 40), and community controls (n = 61). RESULTS: Suicide ideators and attempters showed a suicide attentional bias and a death-identity bias compared to healthy controls. Ideators and attempters did not differ in these implicit information-processing biases. Notably, only attempters were more behaviorally impulsive compared to controls; however, ideators and attempters did not significantly differ in behavioral impulsivity. Moreover, implicit scores were positively intercorrelated in the total sample. CONCLUSION: In line with the Cognitive Model of Suicide, ideators and attempters display suicide-related information processing biases, which can be considered as implicit cognitive markers of suicide vulnerability. Furthermore, attempters have elevated levels of behavioral impulsiveness. These results are highly relevant in the context of crisis intervention strategies and warrant further research.

Torn between living or dying-analyses of influencing factors on suicide ambivalence and its longitudinally impact on suicidal ideation and behavior in a high-risk sample.

INTRODUCTION: Findings on the role of suicide ambivalence, an individual's wish to live (WL), and wish to die (WD) in the development of suicidality have been heterogenous. The main goal of this study was to examine associations of these constructs within the past week with sociodemographic factors and to longitudinally investigate their predictive power for suicidal ideation (SI) and suicide attempts (SA). METHODS: N = 308 patients (54% female; M = 36.92 years, SD = 14.30), admitted to a psychiatric ward due to suicidality, were assessed for all constructs after admission, after six, nine, and 12 months. Data were analyzed with univariate fixed-effect models and lagged mixed-effect regression models. RESULTS: Decreased, WL increased post-baseline. Gender showed no significant link to ambivalence, WD, and WL. Ambivalence and WD correlated negatively with age and positively with depressiveness. More participants in a relationship showed a WL compared with single/divorced/widowed participants. More single participants or those in a relationship showed ambivalence than divorced/widowed participants. More single participants showed a WD than participants in a relationship/divorced/widowed. Longitudinally, ambivalence and WD predicted SI and SA. CONCLUSION: The findings underscore the importance of taking suicide ambivalence and WD into account in risk assessment and treatment.

Suicidal ambivalence: A scoping review.

BACKGROUND: Suicidal ambivalence is considered a characteristic condition of suicidal individuals. At the same time, there is a lack of a uniform definition, conception and assessment of suicidal ambivalence. On this background, the current scoping review aims to explore the extent, range, and nature of research activity on suicidal ambivalence and to summarize research findings. METHODS: A systematic literature search was conducted in four different databases (PubMed, Psychinfo, Web of Science, and Google Scholar) using an array of search terms (e.g., ambivalence, internal suicide debate, reasons for living and reasons for dying, wish to live and wish to die). RESULTS: In total, 28 articles published between 1977 and 2023 were included in the scoping review. The study situation lacks a clear definition, conceptualization and operationalization of suicidal ambivalence. Nonetheless, suicidal ambivalence is a common experience in persons contemplating suicide and suicidal ambivalence seems to be present before, during and after a suicide attempt. Suicidal ambivalence is associated with diverse markers of negative/positive mental health as well as suicidal ideation and behavior. CONCLUSION: Results point to the relevance of suicidal ambivalence. At the same time, there are large gaps in knowledge about the development, impact and therapeutic responsiveness of suicidal ambivalence.

Suicide Crisis Syndrome: A systematic review.

BACKGROUND: The objective of this systematic review is to describe the scientific evidence for the Suicide Crisis Syndrome (SCS), a presuicidal cognitive and affective state consisting of five symptomatic dimensions: entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The aim of this article is to summarize the emerging literature on the SCS and to assess the extent to which a uniform syndrome can be assumed. METHODS: A systematic literature search was conducted in three different databases (PubMed, PsycInfo, and Google Scholar) using the search terms "Suicide Crisis Inventory," "Suicide Crisis Syndrome," "Narrative Crisis Model of Suicide," and "Suicide Trigger State." RESULTS: In total, 37 articles from 2010 to 2022 were identified by search criteria. Twenty-one articles published between 2017 and 2022 were included in the systematic review. All but three studies were conducted in the United States and examined clinical samples of adult high-risk psychiatric in- and outpatients. Sample sizes ranged from N = 170 to 4846. The findings confirm the unidimensional structure of the proposed disorder and support the predictive validity for short-term suicidal behavior above and beyond suicidal ideation. CONCLUSION: Despite the promising predictive validity of the SCS, a precise prediction of future suicidal behavior remains difficult.

[Utilization of Outpatient Psychotherapy and Outpatient Psychiatric Treatment by Men and Women after Inpatient Treatment due to Suicide Attempt or Acute Suicidal Crisis]. / Inanspruchnahme ambulanter Psychotherapie und ambulanter psychiatrischer Behandlung von Männern und Frauen nach stationärer Behandlung aufgrund eines Suizidversuchs oder akuter suizidaler Krise.

OBJECTIVE: The strongest predictor of suicide attempts is a previous suicide attempt. Individuals hospitalized for suicidal ideation and behavior face an increased risk of suicide following discharge. This study investigates the extent to which outpatient treatment services are utilized the first 6 months after discharge and whether men and women differ in this regard. METHOD: The study examines data of 124 individuals (with suicide attempts (lifetime), 59.7% female) on the use of outpatient treatment services in the 6 months after inpatient treatment. RESULTS: 37.9% (N=47) of individuals reported not having used any treatment services at all. Men were significantly less likely to make use of the services. CONCLUSION: Members of a group with an increased risk of suicide, to a large extent, fail to make use of outpatient treatment services. Discharge management should increasingly focus on (gender-specific) barriers and pave the way for treatment in outpatient.

Understanding suicidal ideation-a network analysis of the Interpersonal Needs Questionnaire.

INTRODUCTION: Identifying various interacting risk factors for suicidality is important to develop preventive measures. The Interpersonal-Psychological Theory of Suicidal Behavior (IPTS) postulates suicidal ideation resulting from the occurrence of Perceived Burdensomeness (PB) and Thwarted Belongingness (TB). Suicidal behavior ultimately occurs if people have a Capability for Suicide. In past studies, the validity of TB was often not empirically confirmed, questioning which of the aspects of TB are central and related to suicidal ideation and whether applied measurement methods adequately capture the construct. METHOD: Using a sample of 3,404 individuals from different clinical and nonclinical settings, 30% (1,023) of whom reported suicidal ideation, two network analyses were conducted on the Interpersonal Needs Questionnaire (INQ) and a variable mapping suicidal ideation. RESULTS: Analyses revealed that some items of the INQ were not related to suicidal ideation and the most central items did not have the strongest associations to suicidal ideation. CONCLUSION: Based on these results, a shortened version of the INQ with the four items that showed the strongest associations with suicidal ideation in the network analyses was suggested.

Validation of the Farsi version of the Suicide Ideation and Behavior Scale.

Objective: Suicide ideation and suicide attempts are prevalent in Farsi speaking populations. The present study aimed at validating the Farsi version of the Suicide Ideation and Behavior Scale (SIBS). Methods: Reliability and validity of the Farsi version of the SIBS were established in a highly burdened Afghan student sample (N = 279). Internal consistency, convergent and discriminant validity were investigated, and confirmatory factor analysis was conducted. Results: The Farsi version of the SIBS was shown to have a unidimensional structure with excellent internal consistency, as well as good convergent and divergent validity. Discussion: The results suggest that the SIBS is a brief, reliable, and valid measure of current suicidal ideation and behavior that can be used in Farsi speaking populations.

Metacognitions about suicidal thoughts.

BACKGROUND: Rumination about suicide has recently been identified as a risk factor for suicidal behavior. According to the metacognitive model of emotional disorders, the activation and maintenance of rumination is dependent on specific metacognitive beliefs. On this background, the current study is concerned with the development of a questionnaire to assess suicide-specific positive and negative metacognitive beliefs. METHODS: Factor structure, reliability and validity of the Scales for Suicide-related Metacognitions (SSM) were investigated in two samples comprised of participants suffering from lifetime suicide ideation. Participants of sample 1 (N = 214; 81.8% female; Mage = 24.9, SDage = 4.0) took part in a single assessment using an online survey. Participants of sample 2 (N = 56; 71.4% female; Mage = 33.2, SDage = 12.2) took part in two online assessments within a two week time-period. To establish convergent validity questionnaire-based assessments of suicidal ideation, general and suicide specific rumination and depression were used. Furthermore, it was analyzed whether suicide-related metacognitions predict suicide-specific rumination cross-sectionally and prospectively. RESULTS: Factor analyses revealed a two-factor structure of the SSM. Results indicated good psychometric properties, and provided evidence for construct validity and stability of the subscales. Positive metacognitions predicted concurrent and prospective suicide-specific rumination beyond the effect of suicide ideation and depression and rumination predicted concurrent and prospective negative metacognitions. CONCLUSION: Taken together the results provide initial evidence that the SSM is a valid and reliable measure of suicide-related metacognitions. Furthermore, findings are in line with a metacognitive conceptualization of suicidal crises and provide first indications of factors that might be relevant for the activation and maintenance of suicide-specific rumination.

Psychometric properties of an innovative smartphone application to investigate the daily impact of hypoglycemia in people with type 1 or type 2 diabetes: The Hypo-METRICS app.

INTRODUCTION: The aim of this study was to determine the acceptability and psychometric properties of the Hypo-METRICS (Hypoglycemia MEasurement, ThResholds and ImpaCtS) application (app): a novel tool designed to assess the direct impact of symptomatic and asymptomatic hypoglycemia on daily functioning in people with insulin-treated diabetes. MATERIALS AND METHODS: 100 adults with type 1 diabetes mellitus (T1DM, n = 64) or insulin-treated type 2 diabetes mellitus (T2DM, n = 36) completed three daily 'check-ins' (morning, afternoon and evening) via the Hypo-METRICs app across 10 weeks, to respond to 29 unique questions about their subjective daily functioning. Questions addressed sleep quality, energy level, mood, affect, cognitive functioning, fear of hypoglycemia and hyperglycemia, social functioning, and work/productivity. Completion rates, structural validity, internal consistency, and test-retest reliability were explored. App responses were correlated with validated person-reported outcome measures to investigate convergent (rs>±0.3) and divergent (rs<±0.3) validity. RESULTS: Participants' mean±SD age was 54±16 years, diabetes duration was 23±13 years, and most recent HbA1c was 56.6±9.8 mmol/mol. Participants submitted mean±SD 191±16 out of 210 possible 'check-ins' (91%). Structural validity was confirmed with multi-level confirmatory factor analysis showing good model fit on the adjusted model (Comparative Fit Index >0.95, Root-Mean-Square Error of Approximation <0.06, Standardized Root-Mean-square Residual<0.08). Scales had satisfactory internal consistency (all ω≥0.5), and high test-retest reliability (rs≥0.7). Convergent and divergent validity were demonstrated for most scales. CONCLUSION: High completion rates and satisfactory psychometric properties demonstrated that the Hypo-METRICS app is acceptable to adults with T1DM and T2DM, and a reliable and valid tool to explore the daily impact of hypoglycemia.

Attachment and need to belong as moderators of the relationship between thwarted belongingness and suicidal ideation.

BACKGROUND: In the Interpersonal Theory of Suicide, thwarted belongingness is presented as a main predictor for suicidal ideation. Studies only partially support this prediction. The aim of this study was to examine whether the heterogenous results are due to moderating effects of attachment and the need to belong on the association between thwarted belongingness and suicidal ideation. METHODS: Four hundred forty-five participants (75% female) from a community sample aged 18 to 73 (M = 29.90, SD = 11.64) filled out online questionnaires about romantic attachment, their need to belong, thwarted belongingness, and suicidal ideation cross-sectionally. Correlations and moderated regression analyses were conducted. RESULTS: The need to belong significantly moderated the relationship between thwarted belongingness and suicidal ideation and was associated with higher levels of anxious attachment and avoidant attachment. Both attachment dimensions were significant moderators of the relationship between thwarted belongingness and suicidal ideation. CONCLUSION: Anxious and avoidant attachment as well as a high need to belong are risk factors for suicidal ideation in people with thwarted belongingness. Therefore, attachment style and need to belong should both be considered in suicide risk assessment and therapy.

[Need of Help and Social Support of Parents with a Mental Disorder]. / Hilfsbedarf und soziale Unterstützung bei psychisch erkrankten Elternteilen mit minderjährigen Kindern.

Studies could already show that parents with a mental disorder have a high need for social support but the use of offered help is scarce. The main goal of this study was therefore to assess the need of help as well as the extent of social support of parents with mental illness. N = 100 psychiatric inpatients (49 % female) with underaged children were assessed for need of help, use of help and social support. 99 % of patients reported to have received help. 53 % of patients reported to have further need for social support. 36 % of patients reported a below-average extent of social support. There were sociodemographic differences in the extent of social support. Even though, parents with mental illness make use of offered help, they do not experience social support in the extent that they need it. This underlines the high need as well as the importance of social support for parents with mental illness.

Phenotyping suicidal ideation and behavior: Comparing clinical characteristics and future suicide attempts between suicidal subtypes in two clinical samples.

OBJECTIVES: To further validate the concept of suicidal subtypes distinguished by indicators of suicidal thinking and behavior with regard to clinical characteristics and past and future suicide attempts. METHODS: Psychiatric inpatients were assessed (study 1: ecological momentary assessments in 74 depressed inpatients with suicidal ideation; study 2: clinical assessments in 224 inpatients after a suicide attempt and over a 12-month follow-up period). Subtypes were identified using latent profile analysis (based on indicators of real-time suicide ideation) and latent class analysis (based on features of past suicide ideation and suicide attempt characteristics). Comparisons between subtypes included clinical characteristics (depression, suicidal ideation, trait impulsivity, childhood trauma) as well as past (study 1) and future (study 2) suicide attempts. RESULTS: Suicidal subtypes emerged that are characterized by suicidal ideation means and stability and features of past suicidal behavior (four in study 1, three in study 2). The subtypes differed in terms of depression/suicidal ideation, but not in terms of trait impulsivity/childhood trauma. Although not significant, the subtypes "high-stable" and "low-moderate stable" reported multiple re-attempts more frequently during follow-up than the "low-stable" subtype in study 2. CONCLUSION: Differences in clinical variables (and by trend in future suicide attempts) clearly point to the clinical relevance of suicidal subtypes (with variability of suicidal thoughts playing a particularly important role).

Trapped in my inner prison-Cross-sectional examination of internal and external entrapment, hopelessness and suicidal ideation.

BACKGROUND: Within the integrated motivational-volitional model of suicidal behavior, entrapment that consecutively leads to hopelessness is considered as a proximal risk factor for suicidal ideation. Entrapment can refer to both external and internal circumstances whereby results of recent studies indicate that internal entrapment plays a more important role than external entrapment in the development of suicidal ideation. It has been considered that to escape internal entrapment might be more complicated than to change external circumstances. However, it remains unclear whether the greater effect of internal entrapment on suicidal ideation is due to greater feelings of hopelessness. Therefore, the aim of this study was to address this research gap and to examine the effects of internal and external entrapment on hopelessness and suicidal ideation. METHODS: N = 454 participants from a community sample (75% female) aged between 18 and 73 years (M = 29.91, SD = 11.56) conducted a cross-sectional online survey. All participants were assessed for suicidal ideation, hopelessness, and internal as well as external entrapment. Pearson product-moment correlations and two mediation analyses were conducted. RESULTS: All constructs were significantly correlated. For both internal and external entrapment, an effect on suicidal ideation was found. Both effects were partially mediated by hopelessness, this mediation was larger for external entrapment. The completely standardized indirect effect used to compare the mediation models was larger for external entrapment than for internal entrapment. CONCLUSIONS: Hopelessness mediated the association between external entrapment as well as internal entrapment and suicidal ideation. This effect was larger for external entrapment.

The Mereology of Depression-Networks of Depressive Symptoms during the Course of Psychotherapy.

(1) Background: Research has shown that it is important to examine depressive symptoms in the light of the mereology (the ratio between one symptom and the whole disorder). The goal of this study was to examine changes in the symptom interrelations of patients undergoing cognitive behavioral therapy treatment (CBT) via network analyses. (2) Method: Outpatients with depressive symptoms (N = 401) were assessed with the Beck Depression Inventory three times (pretreatment, after 12 sessions, and post-treatment) during CBT. Gaussian graphical models were used to estimate the relationships among symptoms. (3) Results: The severity of depressive symptoms significantly decreased over the course of therapy, but connectivity in the networks significantly increased. Communities of symptoms changed during treatment. The most central and predictable symptom was worthlessness at baseline and after 12 sessions, and loss of energy and self-dislike at post-treatment. (4) Conclusion: The results indicate that the severity of depressive symptoms decreased during cognitive behavior therapy, while network connectivity increased. Furthermore, the associations among symptoms and their centrality changed during the course of therapy. Future studies may investigate individual differences and their impact on the planning of psychotherapeutic treatment.

Association of real-time assessed mood, affect and suicidal ideation in psychiatric inpatients with unipolar depression.

Previous research provided preliminary support of a potential reinforcing effect of suicidal ideation demonstrating reduced negative affect and increased positive affect after thinking about suicide. The present study therefore sought to investigate the role of mood and affect as a proximal risk factor of suicidal ideation in a high-risk sample. Seventy-four psychiatric inpatients (72% female) with unipolar depression and current and/or lifetime suicidal ideation aged 18 to 85 years (M = 37.6, SD = 14.3) took part in an ecological momentary assessment (EMA) over 6 days. Multilevel analyses were calculated. Analyses revealed negative valence of mood and low positive affect to be predictors of subsequent intensity of suicidal ideation (active, passive) as well as predictors of change in suicidal ideation (active, passive) since the last measurement. High negative affect only predicted intensity of passive suicidal ideation. Suicidal ideation (active, passive) was prospectively associated with subsequent negative valence of mood and lower positive affect as well as with higher intensity of negative affect. Suicidal ideation (active, passive) also predicted the change in valence of mood, positive affect and negative affect since the last measurement. Mood and affect should be taken into account as important proximal risk factors of active and passive suicidal ideation. The results do not support the idea of a reinforcing effect of suicidal ideation. In fact, they show a pattern of reduced subsequent positive affect, negative valence of mood and increased negative affect. Replication studies with larger samples and longer EMA follow-ups are needed.