A preliminary investigation of the relationship between internalized stigma, experiential avoidance, and suicidal thoughts and behaviors in college students.

Objective: Examine the relationship between internalized stigma, experiential avoidance (EA), and suicidal thoughts and behaviors (STBs) in a sample of college students, and explore whether EA accounts for part of the relationship between internalized stigma, EA, and STBs.Participants: College students (N=78) completed online questionnaires about demographic information, internalized stigma, EA, and STBs.Results: A simple mediation model evaluated the indirect effect of internalized stigma on STBs through EA, controlling for the presence of a mental health disorder diagnosis. Results: Internalized stigma, STBs, and EA were all positively correlated. EA partially mediated the relationship between internalized stigma and STBs.Conclusion: Despite decades of research and prevention efforts, STBs remain a pervasive problem. There is an urgent need to identify modifiable predictors of STBs. Internalized stigma is a risk factor for STBs, and recent research suggests EA might be a mechanism linking internalized stigma and STBs. Our findings suggest EA might represent a modifiable mechanism of change in the context of both anti-stigmatization and suicide prevention programs.

Emotion dysregulation, help-seeking attitudes, and posttraumatic stress disorder symptoms: A structural equation model.

Objective: Most college students have experienced an adverse event in their lifetime, yet help-seeking rates remain low. This study seeks to understand psychological factors that might contribute to delays in treatment initiation among trauma-affected students. Participants: Our sample consisted of 531 undergraduate students of which 27% scored above the clinical cutoff for PTSD using the PTSD Checklist for DSM-5 (PCL-5). Methods: This cross-sectional study explored relationships among help-seeking attitudes, emotion dysregulation, and PTSD symptoms using structural equation modeling. Results: Findings demonstrated that individuals with more severe emotion dysregulation had more severe PTSD symptoms and held more negative attitudes toward seeking help. Conclusions: Individuals who are the most in need of treatment hold attitudes that may impede help-seeking. We discuss clinical implications and ways college counseling centers can maximize outreach and programming efforts to increase treatment initiation and engagement.

Do Coping Strategies Differentially Mediate the Relationship Between Emotional Closeness and Complicated Grief and Depression?

Although complicated grief (CG) following the death of a loved one has traditionally been viewed as avoidance-driven, recent research implicates approach behavior. Researchers have investigated how coping styles predict CG; however, emotional closeness remains unexamined. This study investigated the differential relationship of approach- and avoidance-focused coping on CG and depressive symptoms. Bereaved adults (n = 340) completed questionnaires about their loss, coping styles, CG, and depression. Results suggest that approach-, but not avoidance-, focused coping mediates the relationship of emotional closeness on CG, while emotional closeness of the relationship had no direct impact on depressive symptoms. This suggests closeness of the relationship plays a unique role in CG.

Finding mental health providers in the United States: a national survey and implications for policy and practice.

BACKGROUND: Research suggests that a major barrier to mental health treatment is not knowing where to go for services, yet little is known about the specific steps people take to find treatment. AIMS: To (1) understand the process people would undertake if they decided they needed mental health treatment and (2) examine how well the process that current non-treatment-seeking individuals describe matches that used by individuals currently in treatment. METHODS: Adults recruited online via Amazon's Mechanical Turk (N = 669) answered questions about finding a mental health provider. Participants who had (N = 167) and had not (N = 502) seen a mental health provider in the past month were compared. RESULTS: Both groups indicated they would rely on Internet searches and recommendations of family, friends and physicians to find mental health providers. The order in which participants indicated they would use each step was similar across groups as was participants' confidence these steps would help them find a provider. Differences emerged in the factors each group indicated were important to their selection of a provider. CONCLUSIONS: Results can inform mental health providers and policy makers regarding the importance of clear and informative online mental health information, including thorough information about appropriate mental health providers.

Predictors of Treatment Satisfaction Among Adolescents Following an Intensive Cognitive-Behavioral Intervention for Panic Disorder.

No studies to date examine predictors of treatment satisfaction following intensive cognitive-behavioral therapy interventions among adolescents. Given the challenges to treatment adherence among adolescents, and the promise intensive interventions hold for providing rapid symptom relief and increasing access to care, data examining adolescents' satisfaction with intensive programs are needed. Twenty-four adolescents (ages 12-17) with panic disorder received an eight-day intensive cognitive-behavioral therapy intervention. Pre-treatment characteristics and clinical outcome variables were examined as predictors of satisfaction at post-treatment and three-months follow-up. Multiple regression analyses revealed that higher levels of overall symptom interference at baseline and greater reductions in agoraphobic fear during treatment predicted greater treatment satisfaction at post-treatment. Only satisfaction at post-treatment significantly predicted treatment satisfaction at follow-up, highlighting the potential influence of treatment satisfaction on long-term perceptions of treatment. Considerations for fostering treatment satisfaction in the context of intensive interventions are discussed.

Emotion regulation difficulties are associated with nightmares and suicide attempts in an adult psychiatric inpatient sample.

Although many studies have examined potential moderators of the relation between nightmares and suicide, few have examined emotion regulation, particularly utilizing severe populations such as psychiatric inpatients. The present study sought to investigate whether emotion regulation difficulties are associated with nightmares and suicide attempts in an inpatient sample. We included 2,683 psychiatric inpatients ranging from 18 to 81 years (M = 34.35, SD = 14.70). Nightmare frequency, emotion regulation difficulties, and their interaction predicted previous suicide attempts. Limitations include the homogeneity and cross-sectional nature of the sample. Suggestions for future study are discussed.

Managing post-sexual assault suicide risk.

Suicidal ideation and suicidal behavior are common after experiencing a sexual assault. Therefore, it is imperative to assess for and manage suicidal ideation using evidence-based techniques after a sexual assault medical forensic examination (SAMFE). We assessed factors associated with higher suicidal ideation identified in a post-SAMFE mental health screening conducted over the phone and strategies to manage suicide risk. We also discuss three case examples and unique considerations when assessing post-SAMFE suicide risk. It was found that among individuals who completed a post-SAMFE screen, individuals who have been previously hospitalized for a mental health problem, who had higher acute stress symptoms, and who were homeless reported more suicidal ideation than those without those histories or symptom presentations. No matter the risk factors for suicidal ideation post-SAMFE, it is essential to screen all individuals post-SAMFE due to their high risk for suicidal ideation and death by suicide.

Conducting Research with Individuals at Risk for Suicide: Protocol for Assessment and Risk Management.

OBJECTIVE: Suicide prediction, prevention, and intervention are urgent research areas. One barrier for research with high-risk populations is limited resources to manage risk in a research setting. We describe using the University of Washington Risk Assessment Protocol (UWRAP) to assess and manage suicide risk during phone-administered eligibility assessments in two clinical trials. METHOD: Study 1 (N = 151) recruited suicidal adults who were not engaged in mental health treatment and Study 2 (N = 135) recruited suicidal adults who used alcohol to regulate emotions. Pre- and postassessment ratings of stress, urge to harm self, urge to use drugs/alcohol, and intent to harm self were compared and strategies to manage increased suicide risk following screening interviews were implemented, as indicated. RESULTS: In both studies, average postassessment ratings were significantly lower than pre-assessment. A minority of participants reported higher ratings on one or more domains; however, following more thorough suicide risk assessment, risk was appropriately managed by providing low-level interventions (e.g., validation). CONCLUSIONS: Suicide risk in research involving community participants can be managed by using appropriate risk protocols.

Factors related to suicide's unpredictability: a qualitative study of adults with lived experience of suicide attempts.

Purpose: In recent decades, suicide prevention initiatives have increased substantially, yet the suicide rate has continued to rise, and suicide deaths are still generally perceived as unexpected. This study sought to identify factors that might account for this discrepancy by focusing on the exhibition of suicide warning signs. Methods: Qualitative interviews were conducted with 15 adults [mean age = 36 (SD = 14), 93% female] who had attempted suicide at least once in their lifetime. Results: A disconnect between participants and their environment emerged as a central theme. Many expressed ambivalence about whether they wanted others to intervene before their attempts, resulting in either expression or inhibition of warning signs. Regardless of whether they wanted their attempt to be predictable, most participants expressed disappointment if they perceived a lack of intervention before their attempt. In some cases, this disappointment exacerbated distress and may have contributed to the attempt itself. Participants also expressed difficulty disclosing their suicidal ideation to others. Thus, even if they wanted help, participants were unsure how to effectively attain it. Conclusions: Findings underscore the complexity of predicting and preventing suicide; however, engaging individuals with lived experience in these efforts facilitates greater understanding toward outreach and intervention approaches.

Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide.

INTRODUCTION: Suicide is a major public health problem and its human, emotional, and economic costs are significant. Individuals in rural areas are at highest risk for suicide. However, telemedicine services are typically not rendered to individuals who are actively suicidal. The goals of the current study were to identify the risks of using telemedicine for mental healthcare from the perspective of licensed mental health providers and to determine factors associated with the use of telemedicine with patients who are at high risk for suicide. METHODS: A total of 52 licensed mental health providers were recruited online through several professional organization listservs and targeted emails. Providers completed online questionnaires regarding demographics, caseload of suicidal patients, perceived risks for using telemedicine with patients at risk for suicide, attitudes towards telemedicine, and use of telemedicine with patients at risk for suicide. RESULTS: Three key perceived risks associated with using telemedicine were identified, including assessment, lack of control over patient, and difficulties triaging patients if needed. It was also found that individuals who had more positive attitudes towards telemedicine, younger providers, and more experienced providers were more likely to use telemedicine with patients who are at high risk for suicide. DISCUSSION: To our knowledge, this is the first study to examine the perceived risks and use of telemedicine with patients at high risk for suicide. It is essential to continue this line of research to develop protocols for the provision of evidence-based therapy via telemedicine for this high-risk group.

Examining components of emotion regulation in relation to sleep problems and suicide risk.

BACKGROUND: Sleep has emerged as an important factor in elevated risk for suicide and suicidal behaviors; however, the mechanisms accounting for this relationship are poorly understood. Emotion regulation is a well-established correlate of self-injurious behaviors; however, the broad construct has recently been shown to provide limited predictive utility. More nuanced investigations into the processes involved in emotion regulation may address this gap. This study sought to examine the mediating role of emotion regulation between sleep disturbances and suicide risk, as well as to evaluate a moderated mediation model in which down- and up-regulation of emotions would moderate this mediation. METHODS: Participants were 972 adults recruited from a crowdsourcing website (Amazon's Mechanical Turk) who completed self-report questionnaires regarding nightmares, suicide risk, and emotion regulation. RESULTS: Emotion regulation mediated the direct effect of nightmares on suicide risk and suicide attempts. Downregulation of negative affect moderated the mediation of nightmares on suicide risk more clearly than upregulation of positive affect, and neither component of emotion regulation exhibited moderated mediation in the suicide attempt model. LIMITATIONS: Generalizability of our findings from an online community sample will need to be established with replication in other samples. Additionally, we used cross-sectional measures in our mediation models. CONCLUSIONS: Downregulation of negative emotions may be particularly salient in relation to the severity of suicide risk and, as a result, relative deficits in this area should be considered when making risk determinations.

Suicidal ideation among adults with a recent sexual assault: Prescription opioid use and prior sexual assault.

INTRODUCTION: Sexual assault (SA) is common, and recent sexual assault is associated with suicidal ideation and prescription opioid (PO) use. PO use is also associated with increased risk of suicidal ideation. The current study examined suicidal ideation among adults seeking medical and psychological follow-up care after a SA medical forensic examination based on PO use and prior SA. METHODS: Adults (n = 60) who received a SA medical forensic exam at the emergency room within 120 h of a SA were invited to receive medical and psychological follow-up care, which included a questionnaire about current mental health symptoms. RESULTS: Results from a linear regression model revealed that more acute stress symptoms were associated with higher suicidal ideation. Further, there was a significant association between PO use and suicidal ideation among those with a prior SA such that those with a prior SA and who used POs reported more severe suicidal ideation than those with a prior SA who did not use POs. CONCLUSIONS: Routine screening at the emergency department for PO use and prior SA may help prevention efforts for suicide among adults who recently experienced SA.

Comparing brief interventions for suicidal individuals not engaged in treatment: A randomized clinical trial.

BACKGROUND: Non-treatment-engaged individuals experiencing suicidal thoughts have been largely overlooked in the intervention literature, despite reviews suggesting most individuals who die by suicide were not in treatment immediately prior to their death. Most intervention studies recruit individuals from treatment providers, potentially neglecting those individuals who are not already engaged in services. These individuals clearly represent a group in need of additional empirical attention. METHODS: A randomized clinical trial was conducted to compare a single-session dialectical behavior therapy skills-based intervention to a relaxation training control condition. Ninety-three non-treatment-engaged subjects participated in a single in-person assessment, received one of the intervention protocols, and completed follow-up phone interviews for three months including measures of suicidal ideation, emotion dysregulation, and coping skills, as well as other relevant assessments. RESULTS: Both conditions reported significantly reduced levels of suicidal ideation, depression, and anxiety; however, analyses revealed no significant differences between conditions on the main outcome measures of suicidal ideation, emotion dysregulation, skills use, depression, or anxiety. LIMITATIONS: The two interventions may have been too similar to permit detection of differential effects with this sample size. Specifically, the control condition may have been too active and there may have been stylistic overlap by providers who delivered both interventions. CONCLUSIONS: Encouragingly, half of subjects contacted other mental health services during the follow-up period. Although the two interventions under investigation did not yield differential results, the significant changes in important domains across interventions suggest that brief interventions may hold promise for this difficult-to-reach population.

Relations Between Nonsuicidal Self-Injury and Suicide Attempt Characteristics in a Sample of Recent Suicide Attempters.

BACKGROUND: Although nonsuicidal self-injury (NSSI) is known to be associated with increased risk of death by suicide and suicide attempts, minimal research has focused on comparing recent suicide attempters with and without NSSI on suicide attempt characteristics (frequency and severity of suicide attempts). Understanding how NSSI impacts suicide attempt characteristics can help providers to enhance their assessment and treatment strategies so as to prevent future suicidal behaviors. AIMS: The present study investigated the extent to which a history of NSSI was related to the frequency and severity of suicide attempts in a sample of recent suicide attempters. METHOD: Participants included 171 adult patients who presented to the hospital within 24 hr of a suicide attempt. Information about their suicide attempts and NSSI was gathered using self-report questionnaires and interviews. RESULTS: Suicide attempters with a history of NSSI reported significantly more suicide attempts and more suicide attempts requiring medical attention, after controlling for important clinical covariates. CONCLUSION: NSSI was uniquely associated with suicide attempt characteristics, highlighting the importance of NSSI in suicide assessment, prevention, and treatment efforts.

Single-session dialectical behavior therapy skills training versus relaxation training for non-treatment-engaged suicidal adults: a randomized controlled trial.

BACKGROUND: Individuals who are not engaged in treatment are commonly overlooked in the design of intervention trials targeting suicidal populations as a result of recruitment methodology that requires individuals to be referred from their current provider. In fact, research suggests that the majority of individuals who die by suicide have not been in contact with mental health services in the year before their death. METHODS/DESIGN: A randomized controlled trial of two brief, one-session interventions for adults who are not engaged in mental health treatment. Inclusion criteria include 1) 18 years or older, 2) experiencing suicidal ideation in the past week, 3) have not received mental health treatment in the month prior to screening, 4) living within commuting distance to the research office, and 5) willing to consent to recording and assessment. Exclusion criteria are 1) non-English speaking and 2) significant cognitive impairment. Recruitment takes place in the community via flyers, radio, and online advertisements. Interested individuals are screened via telephone and those who are eligible attend a one-time in-person assessment and intervention appointment. During this appointment, they are randomized to a single-session intervention in which they are presented with either dialectical behavior therapy skills or supportive discussion and instruction in relaxation. Following the in-person appointment, participants complete three follow-up interviews via telephone at one-week, four-weeks, and twelve-weeks post-intervention. The primary outcomes are suicidal ideation, emotion dysregulation, and skills use. Secondary outcomes include depression, anxiety, self-efficacy, and treatment utilization. Exploratory outcomes are suicidal and intentionally self-injurious behaviors. Intent-to-treat analyses will be conducted on primary and secondary outcomes. DISCUSSION: Suicidal individuals who are not engaged in mental health treatment are an understudied and significantly at-risk group for death by suicide. A better understanding of this population, targeted efforts to recruit and engage these individuals, and developing effective interventions for this group are critical areas for investigation in the field that this trial seeks to address. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02236325 ; Date of registration: 05-Sept-2014.

Suicide-Bereaved Individuals' Attitudes Toward Therapists.

BACKGROUND: Suicide-bereaved individuals represent an important group impacted by suicide. Understanding their experiences following the suicide of a loved one is an important research domain, despite receiving limited attention. Although suicide-bereaved individuals may benefit from mental health treatment, their attitudes toward therapy and therapists are poorly understood. AIMS: The present study aimed to understand the extent to which bereaved individuals' attitudes toward therapy and therapists are impacted by whether their loved one was in therapy at the time of death. METHOD: Suicide-bereaved individuals (N = 243) from the United States were recruited to complete an online survey about their experience with and attitudes toward therapy and therapists following the suicide of a loved one. RESULTS: Bereaved individuals whose loved one was in therapy at the time of death (N = 48, 19.8%) reported more negative and less positive attitudes toward the treating therapist than those whose loved one was not in therapy at the time of death (N = 81, 33.3%) or whose loved one was never in therapy/the deceased's therapy status was unknown (N = 114, 46.9%). CONCLUSION: The deceased's involvement with a therapist appears to be an important factor impacting the experience of bereaved individuals and should be considered when attempting to engage these individuals in postvention.

An open pilot feasibility study of a brief dialectical behavior therapy skills-based intervention for suicidal individuals.

This open trial sought to develop and evaluate the preliminary feasibility and effectiveness of a brief, one-time, dialectical behavior therapy skills-based intervention with specific focus on ensuring acceptability to nontreatment-seekers. Treatment-seeking and nontreatment-seeking suicidal individuals were recruited successfully from the community. Both groups found the intervention valuable. Suicide ideation was significantly lower at the 1-month follow-up, while use of the specific skills taught in the intervention increased significantly across time points. These results suggest that the intervention is both acceptable to the target population and that it has potential effectiveness as an intervention for individuals experiencing suicidal ideation.

The prevalence and correlates of sexual risk behaviors and sexually transmitted infections in outpatients with borderline personality disorder.

This study examined the prevalence and correlates of sexual risk behaviors and sexually transmitted infections (STIs) in two samples of outpatients with borderline personality disorder (BPD), including suicidal BPD women (n = 99) and opiate-dependent BPD men and women (n = 125). High rates of sexual risk behaviors and STIs were found, particularly in the opiate-dependent BPD sample. Compared with suicidal BPD outpatients, opiate-dependent BPD outpatients reported higher rates of past-year sexual activity, commercial sex work, and lifetime hepatitis, as well as a greater number of lifetime sex partners. Substance use and demographic characteristics (age, sex, and marital status) were associated with higher rates of sexual risk behaviors and/or STIs, whereas cognitive-behavioral factors and indicators of psychiatric impairment were not. These findings point to a clear need for interventions aimed at decreasing sexual risk behaviors among individuals with BPD.