Annual AAS Conference 2015

ATLANTA – The suicide-specific intervention known as CAMS, or Collaborative Assessment and Management of Suicidality, provides protection against suicidal events during psychiatric hospitalization and in the first weeks post discharge, according to a study from the Menninger Clinic.

In this study, 52 patients who received CAMS in addition to the Menninger Clinic’s usual very intensive treatment regimen showed significantly greater improvement on measures of depression, suicidal ideation, hopelessness, and psychological flexibility at discharge, compared with 52 propensity-matched controls who receive the same regimen minus the CAMS. And, in the first 6 months after discharge, the CAMS group made half as many suicide attempts as did the controls, Thomas E. Ellis, Psy.D., reported at the annual conference of the American Association of Suicidology.

“We’re thinking that CAMS has some kind of buffering or protective effect in the weeks following discharge, which is the highest-risk period,” said Dr. Ellis, who is director of psychology at the Menninger Clinic and professor of psychiatry at the Baylor College of Medicine, both in Houston.

A total of 4%-7% of all suicides occurring in the United States each year happen in inpatient psychiatric settings. That’s a surprising statistic given that psychiatric hospitalization aims to provide a safe harbor for individuals bent on self-harm. Investigators have identified two sharp peaks of elevated risk of suicide in connection with psychiatric hospitalization: one in the first week after admission, the other in the first week after discharge. CAMS appears to flatten out these peaks, according to the psychologist.

CAMS is an intervention developed by David A. Jobes, Ph.D., professor of psychology at Catholic University in Washington. The intervention often is described as a theoretical framework in which suicide is seen as the primary focus rather than as a symptom. CAMS is nondenominational in terms of its psychotherapeutic orientation: It is being used today by therapists whose approach runs the gamut from psychodynamic to cognitive-behavioral therapy. The emphasis is on helping the patient problem-solve to find alternatives to suicide as a coping response and providing psychotherapy to address underlying vulnerabilities. A key element of CAMS is early assessment via the CAMS Suicide Status Form, which is used for problem identification and treatment planning, Dr. Ellis explained.

In recent years, he and Dr. Jobes have worked to adapt the CAMS approach to the unique setting of the Menninger Clinic. The clinic is a 100-bed private psychiatric hospital that often is seen as “a last chance” for patients who previously have been hospitalized elsewhere for multiple treatment-resistant conditions, often including substance abuse and personality disorders as well as refractory major depression. The average length of stay is 6-7 weeks – “that’s almost unheard of,” he noted – in contrast to the 3- to 7-day hospitalizations that are typical elsewhere.

The 104 study participants had a mean of 1.7 prior suicide attempts. The 52 controls were selected from a pool of 310 suicidal patients on the basis of propensity score matching by age, sex, treatment unit, severity of suicidal ideation, and number of previous suicide attempts. All subjects got the usual Menninger treatment package, which includes medications, group therapy, psychosocial groups, milieu therapy, nursing care, family counseling, vocational counseling, and individual psychotherapy. The only difference was that the individual psychotherapy included CAMS in 52 patients, while the other 52 received their individual psychotherapy from practitioners who were not involved in CAMS.

Both groups showed significant improvement during hospitalization, but the CAMS group showed significantly greater gains on measures of depression, suicidal ideation, and suicidal cognition.

However, when patients were reassessed at 3 and 6 months post discharge, the picture became more complex. The controls showed late improvement in these measures such that by 3 months’ follow-up, there were no longer significant differences between the two groups on measures of suicide ideation intention on the Columbia Suicide Severity Rating Scale, functional impairment on the World Health Organization Disability Assessment Scale, and thoughts of self-harm on the Patient Health Questionnaire-9 (PHQ-9). It’s not that the CAMS group was backsliding, they were in fact remaining stable on these measures post hospitalization while the controls were getting better. For example, depression scores on the PHQ-9 in the CAMS group were 8.8 at discharge, 9.2 at 3 months, and 9.5 at 6 months, in contrast to 13.7, 10.4, and 10.5 in controls.

Three suicide attempts occurred in the CAMS group post discharge at a mean of 53 and median of 57 days, compared with six attempts in controls at a mean of 38 and median 19 days. But while suicide attempts were fewer in number and occurred later in the CAMS group, these favorable outcome trends did not achieve statistical significance, as the study was not powered to look at that relatively infrequent endpoint, Dr. Ellis said.

To his dismay, rehospitalization rates were higher in the CAMS group: 0 versus 3.8% in controls during the first 2 weeks post discharge, but 9.8%, compared with 5.8% at 3 months and 15.4% vs. 7.6% in controls at 6 months.

Those differences are not statistically significant, but “the raw numbers are of concern,” Dr. Ellis said. He added that the rehospitalization data were compiled only quite recently, and he and his coinvestigators are still trying to figure out the explanation. That will be key in achieving their goal, which is to sustain the gains achieved via CAMS during hospitalization and the first few weeks afterward out to 6 months and beyond.

The study was funded by the Menninger Foundation and other nonprofit organizations. Dr. Ellis reported having no financial conflicts.

[email protected]

ATLANTA – The suicide-specific intervention known as CAMS, or Collaborative Assessment and Management of Suicidality, provides protection against suicidal events during psychiatric hospitalization and in the first weeks post discharge, according to a study from the Menninger Clinic.

In this study, 52 patients who received CAMS in addition to the Menninger Clinic’s usual very intensive treatment regimen showed significantly greater improvement on measures of depression, suicidal ideation, hopelessness, and psychological flexibility at discharge, compared with 52 propensity-matched controls who receive the same regimen minus the CAMS. And, in the first 6 months after discharge, the CAMS group made half as many suicide attempts as did the controls, Thomas E. Ellis, Psy.D., reported at the annual conference of the American Association of Suicidology.

“We’re thinking that CAMS has some kind of buffering or protective effect in the weeks following discharge, which is the highest-risk period,” said Dr. Ellis, who is director of psychology at the Menninger Clinic and professor of psychiatry at the Baylor College of Medicine, both in Houston.

A total of 4%-7% of all suicides occurring in the United States each year happen in inpatient psychiatric settings. That’s a surprising statistic given that psychiatric hospitalization aims to provide a safe harbor for individuals bent on self-harm. Investigators have identified two sharp peaks of elevated risk of suicide in connection with psychiatric hospitalization: one in the first week after admission, the other in the first week after discharge. CAMS appears to flatten out these peaks, according to the psychologist.

CAMS is an intervention developed by David A. Jobes, Ph.D., professor of psychology at Catholic University in Washington. The intervention often is described as a theoretical framework in which suicide is seen as the primary focus rather than as a symptom. CAMS is nondenominational in terms of its psychotherapeutic orientation: It is being used today by therapists whose approach runs the gamut from psychodynamic to cognitive-behavioral therapy. The emphasis is on helping the patient problem-solve to find alternatives to suicide as a coping response and providing psychotherapy to address underlying vulnerabilities. A key element of CAMS is early assessment via the CAMS Suicide Status Form, which is used for problem identification and treatment planning, Dr. Ellis explained.

In recent years, he and Dr. Jobes have worked to adapt the CAMS approach to the unique setting of the Menninger Clinic. The clinic is a 100-bed private psychiatric hospital that often is seen as “a last chance” for patients who previously have been hospitalized elsewhere for multiple treatment-resistant conditions, often including substance abuse and personality disorders as well as refractory major depression. The average length of stay is 6-7 weeks – “that’s almost unheard of,” he noted – in contrast to the 3- to 7-day hospitalizations that are typical elsewhere.

The 104 study participants had a mean of 1.7 prior suicide attempts. The 52 controls were selected from a pool of 310 suicidal patients on the basis of propensity score matching by age, sex, treatment unit, severity of suicidal ideation, and number of previous suicide attempts. All subjects got the usual Menninger treatment package, which includes medications, group therapy, psychosocial groups, milieu therapy, nursing care, family counseling, vocational counseling, and individual psychotherapy. The only difference was that the individual psychotherapy included CAMS in 52 patients, while the other 52 received their individual psychotherapy from practitioners who were not involved in CAMS.

Both groups showed significant improvement during hospitalization, but the CAMS group showed significantly greater gains on measures of depression, suicidal ideation, and suicidal cognition.

However, when patients were reassessed at 3 and 6 months post discharge, the picture became more complex. The controls showed late improvement in these measures such that by 3 months’ follow-up, there were no longer significant differences between the two groups on measures of suicide ideation intention on the Columbia Suicide Severity Rating Scale, functional impairment on the World Health Organization Disability Assessment Scale, and thoughts of self-harm on the Patient Health Questionnaire-9 (PHQ-9). It’s not that the CAMS group was backsliding, they were in fact remaining stable on these measures post hospitalization while the controls were getting better. For example, depression scores on the PHQ-9 in the CAMS group were 8.8 at discharge, 9.2 at 3 months, and 9.5 at 6 months, in contrast to 13.7, 10.4, and 10.5 in controls.

Three suicide attempts occurred in the CAMS group post discharge at a mean of 53 and median of 57 days, compared with six attempts in controls at a mean of 38 and median 19 days. But while suicide attempts were fewer in number and occurred later in the CAMS group, these favorable outcome trends did not achieve statistical significance, as the study was not powered to look at that relatively infrequent endpoint, Dr. Ellis said.

To his dismay, rehospitalization rates were higher in the CAMS group: 0 versus 3.8% in controls during the first 2 weeks post discharge, but 9.8%, compared with 5.8% at 3 months and 15.4% vs. 7.6% in controls at 6 months.

Those differences are not statistically significant, but “the raw numbers are of concern,” Dr. Ellis said. He added that the rehospitalization data were compiled only quite recently, and he and his coinvestigators are still trying to figure out the explanation. That will be key in achieving their goal, which is to sustain the gains achieved via CAMS during hospitalization and the first few weeks afterward out to 6 months and beyond.

The study was funded by the Menninger Foundation and other nonprofit organizations. Dr. Ellis reported having no financial conflicts.

[email protected]

ATLANTA – The suicide-specific intervention known as CAMS, or Collaborative Assessment and Management of Suicidality, provides protection against suicidal events during psychiatric hospitalization and in the first weeks post discharge, according to a study from the Menninger Clinic.

In this study, 52 patients who received CAMS in addition to the Menninger Clinic’s usual very intensive treatment regimen showed significantly greater improvement on measures of depression, suicidal ideation, hopelessness, and psychological flexibility at discharge, compared with 52 propensity-matched controls who receive the same regimen minus the CAMS. And, in the first 6 months after discharge, the CAMS group made half as many suicide attempts as did the controls, Thomas E. Ellis, Psy.D., reported at the annual conference of the American Association of Suicidology.

“We’re thinking that CAMS has some kind of buffering or protective effect in the weeks following discharge, which is the highest-risk period,” said Dr. Ellis, who is director of psychology at the Menninger Clinic and professor of psychiatry at the Baylor College of Medicine, both in Houston.

A total of 4%-7% of all suicides occurring in the United States each year happen in inpatient psychiatric settings. That’s a surprising statistic given that psychiatric hospitalization aims to provide a safe harbor for individuals bent on self-harm. Investigators have identified two sharp peaks of elevated risk of suicide in connection with psychiatric hospitalization: one in the first week after admission, the other in the first week after discharge. CAMS appears to flatten out these peaks, according to the psychologist.

CAMS is an intervention developed by David A. Jobes, Ph.D., professor of psychology at Catholic University in Washington. The intervention often is described as a theoretical framework in which suicide is seen as the primary focus rather than as a symptom. CAMS is nondenominational in terms of its psychotherapeutic orientation: It is being used today by therapists whose approach runs the gamut from psychodynamic to cognitive-behavioral therapy. The emphasis is on helping the patient problem-solve to find alternatives to suicide as a coping response and providing psychotherapy to address underlying vulnerabilities. A key element of CAMS is early assessment via the CAMS Suicide Status Form, which is used for problem identification and treatment planning, Dr. Ellis explained.

In recent years, he and Dr. Jobes have worked to adapt the CAMS approach to the unique setting of the Menninger Clinic. The clinic is a 100-bed private psychiatric hospital that often is seen as “a last chance” for patients who previously have been hospitalized elsewhere for multiple treatment-resistant conditions, often including substance abuse and personality disorders as well as refractory major depression. The average length of stay is 6-7 weeks – “that’s almost unheard of,” he noted – in contrast to the 3- to 7-day hospitalizations that are typical elsewhere.

The 104 study participants had a mean of 1.7 prior suicide attempts. The 52 controls were selected from a pool of 310 suicidal patients on the basis of propensity score matching by age, sex, treatment unit, severity of suicidal ideation, and number of previous suicide attempts. All subjects got the usual Menninger treatment package, which includes medications, group therapy, psychosocial groups, milieu therapy, nursing care, family counseling, vocational counseling, and individual psychotherapy. The only difference was that the individual psychotherapy included CAMS in 52 patients, while the other 52 received their individual psychotherapy from practitioners who were not involved in CAMS.

Both groups showed significant improvement during hospitalization, but the CAMS group showed significantly greater gains on measures of depression, suicidal ideation, and suicidal cognition.

However, when patients were reassessed at 3 and 6 months post discharge, the picture became more complex. The controls showed late improvement in these measures such that by 3 months’ follow-up, there were no longer significant differences between the two groups on measures of suicide ideation intention on the Columbia Suicide Severity Rating Scale, functional impairment on the World Health Organization Disability Assessment Scale, and thoughts of self-harm on the Patient Health Questionnaire-9 (PHQ-9). It’s not that the CAMS group was backsliding, they were in fact remaining stable on these measures post hospitalization while the controls were getting better. For example, depression scores on the PHQ-9 in the CAMS group were 8.8 at discharge, 9.2 at 3 months, and 9.5 at 6 months, in contrast to 13.7, 10.4, and 10.5 in controls.

Three suicide attempts occurred in the CAMS group post discharge at a mean of 53 and median of 57 days, compared with six attempts in controls at a mean of 38 and median 19 days. But while suicide attempts were fewer in number and occurred later in the CAMS group, these favorable outcome trends did not achieve statistical significance, as the study was not powered to look at that relatively infrequent endpoint, Dr. Ellis said.

To his dismay, rehospitalization rates were higher in the CAMS group: 0 versus 3.8% in controls during the first 2 weeks post discharge, but 9.8%, compared with 5.8% at 3 months and 15.4% vs. 7.6% in controls at 6 months.

Those differences are not statistically significant, but “the raw numbers are of concern,” Dr. Ellis said. He added that the rehospitalization data were compiled only quite recently, and he and his coinvestigators are still trying to figure out the explanation. That will be key in achieving their goal, which is to sustain the gains achieved via CAMS during hospitalization and the first few weeks afterward out to 6 months and beyond.

The study was funded by the Menninger Foundation and other nonprofit organizations. Dr. Ellis reported having no financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – The potential utility of the medical emergency department as a key venue in which to conduct youth suicide screening is now well established, and a federally funded effort to develop and validate an optimal screening tool designed specifically for this purpose is underway.

Suicide is the second-leading cause of death among 12- to 17-year-olds in the United States. Routine screening for suicide risk in medical EDs would solve a major challenge in preventing these deaths: namely, that adolescents – especially older male teens, who are at highest suicide risk – seldom seek mental health care. Yet, roughly one-third of adolescents visit the ED per year, Cheryl A. King, Ph.D., explained at the annual conference of the American Association of Suicidology.

“They come in for exacerbation of common medical illnesses and sports injuries, but they’re also coming in for things like alcohol poisoning, car accidents, and fistfights,” noted Dr. King, professor of psychology and psychiatry at the University of Michigan, Ann Arbor.

These ED visits offer a particularly good opportunity to screen for suicide risk in adolescent males, who account for 80% of all youth suicides in the United States. Yet, because they are so much less likely than teen girls to share thoughts of suicide, males comprise only 25%-35% of teens hospitalized for suicide risk, she continued.

Dr. King has been a leader in the exploration of the medical ED as a venue for routine screening for high risk for suicidal behavior in adolescents. She and others have shown that such screening is productive. But there’s a problem: ED personnel already feel plenty busy and time crushed without taking on a huge new responsibility. And screening instruments designed to miss few teens at risk will have a high false-positive rate. “I don’t want to set the screen-positive threshold so low that 40% of all youth who come in with a broken thumb that was jammed in a car door screen positive, because then what will the ED physicians say to me? They may not even want to talk to me,” she said.

In an early proof-of-concept study, she and her colleagues developed and tested a high-bar screen, one in which a positive result required self-reported serious suicidal ideation within the past 2 weeks, a suicide attempt within the past month, or co-occurring depression plus alcohol/substance misuse. Applying the screen to 298 adolescents who presented to an ED, the investigators found a 16% screen-positive rate (Acad. Emerg. Med. 2009;16:1234-41).

The investigators went on to survey pools of adolescents and parents as to the acceptability of routine ED screening for suicide risk, and got a thumbs-up from both groups (Ped. Emerg. Care 2012;28:626-32).

Next, Dr. King and her colleagues established that their screening tool actually predicted a high near-term risk for suicidal behavior. In a separate study of 81 adolescents aged 14-19 who were screen positive, 15 (18.5%) engaged in some type of suicidal behavior in the 2 months following their ED visit (J. Child Adolesc. Psychopharmacol. 2015;25:100-8).

Another promising screening tool for use in youths presenting to EDs is the ASQ (Ask Suicide-Screening Questions), a four-question test developed at the National Institute of Mental Health (NIMH). It assesses current thoughts of wishing to die, being better off dead, suicidal ideation, and past attempts (Arch. Pediatr. Adolesc. Med. 2012;166:1170-16); however, the predictive validity of this scale in terms of future suicide attempts has yet to be validated, according to Dr. King.

The clinician-administered Columbia–Suicide Severity Rating Scale has demonstrated predictive validity, but it is likely to prove too comprehensive and time consuming for routine use as a screening tool in the ED. However, several specific items incorporated in the scale – namely, the duration element of the intensity scale score and a lifetime history of nonsuicidal self-injury – showed predictive validity as a streamlined screening tool in a study by Dr. King and her colleagues (Pediatr. Emerg. Care 2015;31:88-94).

The most recent development in ED screening is the National Institute of Mental Health–funded ED-STARS (Emergency Department Screening for Teens at Risk for Suicide) project. Dr. King is a codirector of this multicenter effort to develop the optimal suicide risk screening tool for adolescents in the ED, along with a triage algorithm ED physicians can follow.

The tool being developed is a computerized adaptive screen. Rather than answering a fixed list of screening questions, patients will take a very brief, personalized test administered via computer. The adaptive aspect involves an algorithm in which the next question posed depends upon the individual’s response to the question before. This screening instrument is being paired with the Implicit Association Test developed by investigators at Harvard University, Cambridge, Mass.

ED-STARS is being carried out by the Pediatric Emergency Care Applied Research Network. If the project proves successful, the plan is to extend the screening tool into school settings.

Dr. King’s research efforts are funded by the NIMH. She reported having no relevant financial conflicts.

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

ATLANTA – Among all deaths by suicide, 15%-20% are attributable to a previously undescribed entity that now has a name: acute suicidal affective disturbance, Thomas Joiner, Ph.D., said at the annual conference of the American Association of Suicidology.

“It’s real, it’s fairly common, and it’s extremely dangerous. We think it ranks up there among the most serious of conditions – more likely to result in death than the manic phase of bipolar disorder or schizophrenia, for example,” said Dr. Joiner, who first identified and characterized the condition, named it, plays a pivotal role in ongoing multicenter collaborative research efforts targeting it, and vows to see acute suicidal affective disturbance, or ASAD, included in the DSM-6.

Bruce Jancin/Frontline Medical News

ASAD is a concept compatible with Dr. Joiner’s “Interpersonal Theory of Suicide,” which has taken the field of suicidology by storm. But ASAD , he stressed, is not a theoretical construct.

“ASAD exists as an entity, as a true object in nature that I worry over because it kills people and we can’t diagnose it currently because there’s a gap in the nomenclature. We’re proposing this condition to fill that gap,” explained Dr. Joiner, professor of psychology at Florida State University, Tallahassee.

Roughly 80% of all deaths by suicide can be attributed to a recognized mental health disorder, such as major depressive disorder, the depressive phase of bipolar disorder, anorexia nervosa, schizophrenia, or borderline personality disorder. Dr. Joiner presented highlights of three separate studies now in press – one conducted in Veterans Affairs outpatients, another in high-risk university undergraduates, and a third involving nearly 7,700 Mayo Clinic psychiatric inpatients and more than 3,400 U.S. Army high-risk patients – all of which support the construct validity of ASAD as a distinct entity that correlates negatively with impulsivity and is unrelated to alcohol use disorders or mood disorders.

In addition, Dr. Joiner continued, three different research teams – his own; the Military Suicide Research Consortium, which he codirects; and the U.S. Army STARRS group – have identified subgroups of patients at very high suicide risk who are characterized by ASAD symptoms that are discernible from those of established clinical entities (see list for proposed ASAD criteria).

“We intend to put ASAD into DSM-6. We know that’s going to be a battle, and we’re ready for it. We’re determined to fight it,” the psychologist said.

If ASAD were to eventually become a diagnosable condition, the clinical implications would be far-reaching, he observed. It would be a billable entity. Also, its existence in the formal psychiatric nomenclature would alert clinicians to be vigilant regarding ASAD; that’s crucial because recurrences can be lethal, and recognition of the prodromal overarousal symptoms may head off a full-blown crisis.

“If we’re right about ASAD, it would imply that mood disorders and ASAD are distinct, that their onset and remission patterns are different, thus supporting the rationale of suicide-specific treatments like CAMS [collaborative assessment and management of suicidality] and DBT [dialectical behavior therapy]. It would suggest the need for intensive and long-lasting therapies, because a recurrence can cost people their lives,” he continued.

Should ASAD become legitimized as a diagnosis, it would shore up the public health argument in favor of suicide-means restriction as a strategy for forestalling suicidal action.

“ASAD is a time-limited arousal state. You can’t sustain it for more than an hour or a few hours. It’ll abate with the passage of time,” according to Dr. Joiner.

In response to an audience question, he said it’s his clinical impression – not yet supported by data – that the most common comorbid conditions in patients with ASAD are anxiety disorders and personality disorders. Also, ASAD doesn’t appear to be age dependent: “We think it can emerge at any point in the lifespan.”

Dr. Joiner emphasized that many questions regarding ASAD remain unanswered.

“We have a long way to go,” he conceded. “And I’m not talking about years here, I’m talking about decades. The effort is going to be primarily research oriented. It’s a scientific effort. We’ve got to clear the hurdle scientifically, and we haven’t done that yet, although we’ve gotten a start.”

He reported having no financial conflicts regarding his presentation.

Proposed criteria for ASAD

1. A sudden surge in suicidal intent occurring over the course of minutes, hours, or days rather than weeks or months.

2. One or both of two alienation criteria: a) severe social withdrawal defined by extreme disgust with others or perceived liability to others; b) marked self-alienation manifested as self-disgust or the view that one’s selfhood is an onerous burden.

3. The perception that numbers 1 and 2 are hopelessly intractable.

4. At least two of the following manifestations of overarousal: insomnia, nightmares, irritability, agitation.

5. Exclusion criteria: The above is not due to exacerbation of a mood disorder or ingestion of alcohol or another substance.

Source: Dr. Joiner

[email protected]

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

ATLANTA – Don’t – repeat, don’t – use risk assessment tools and scales in an effort to predict future suicide in patients who’ve committed intentional self-harm, Dr. Keith Hawton urged at the annual conference of the American Association of Suicidology.

He noted this isn’t simply a matter of his personal opinion; it’s also a strongly worded recommendation in the current U.K. NICE (National Institute for Health and Care Excellence) guidelines on the long-term management of patients who’ve committed self-harm. The various NICE guidelines, which address numerous areas of medical practice and are used to determine what’s reimbursable through the U.K.’s National Health Service, are famously evidence based and concerned with cost-effectiveness.

The NICE guidelines on management of self-harm further advise: “Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged from hospital.”

“Those are some fairly contentious statements about risk assessment scales. But those statements are based upon review of the evidence about the effectiveness of risk assessment scales,” according to Dr. Hawton, professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

“In our country, hospitals have become obsessed with risk assessment. And usually it seems to be about protecting the organization rather than the patient, because so often the results aren’t linked to risk management, which is what we should be talking about,” he observed.

Dr. Hawton and his colleagues provided some of the evidence that led to the NICE guideline committee’s thumbs-down on the use of suicide risk assessment scales in patients who’ve engaged in intentional self-harm. In a study provocatively titled “The sad truth about the SADPERSONS scale,” he and his coinvestigators essentially dismantled SADPERSONS, a widely used screening tool for suicide risk, concluding that it is without value.

The acronym stands for Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol abuse, Rational thinking loss, Social supports lacking, Organized plan, No spouse, and Sickness. One point is given for each. Patients who score 7-10 are to be hospitalized, and those with a total of 5 or 6 points should be strongly considered for hospitalization.

Dr. Hawton and coinvestigators tracked 126 consecutive patients who were evaluated for self-harm using the SADPERSONS scale in a general hospital emergency department and then followed them for 6 months. SADPERSONS performed miserably in predicting clinical management outcomes, such as admission to a psychiatric hospital or repetition of self-harm within 6 months. Indeed, the test failed to identify 4 of the 5 patients admitted to a psychiatric hospital, 65 of 70 who were referred from the ED to community psychiatric aftercare, and 28 of 31 who repeated self-harm within 6 months. Thus, its sensitivity as a predictor of repetition of self-harm was a lowly 6.6% (Emerg. Med. J. 2014;31:796-8).

And yet, a 32-hospital U.K. national study conducted by Dr. Hawton and others found that SADPERSONS was the most widely used scale in EDs for risk assessment following self-harm (BMJ Open. 2014 May 2;4:e004732 [doi:10.1136/bmjopen-2013-004732]).

“It’s a very crude tool,” Dr. Hawton said. “How it found its way into common use in clinical practice is beyond me.”

[email protected]

ATLANTA– Progress has stalled in understanding the predictors and prevention of suicide, and it’s time for researchers to step up their game, experts agreed at the annual conference of the American Association of Suicidology.

“In the past couple of decades we’ve learned a fair amount about suicidal behavior. However, I think progress has been fairly slow – some might even say a little stagnant – in our pushing things forward and improving our understanding,” Matthew K. Nock, Ph.D., said in the meeting’s opening plenary talk.

He cited a soon-to-be-published meta-analysis led by his post-doctoral fellow Joseph C. Franklin, Ph.D., which evaluated all of the studies of predictors of suicide attempts and completed suicides published during the last 5 decades. The eye opening finding: The predictive odds ratios for the standard risk factors have remained essentially the same – namely, weak – for the past 50 years.

“In general, we’re not getting better in our ability to predict suicidal behavior – and that’s a serious problem for us. We still have enormous gaps in our understanding and in our ability to predict and prevent these outcomes,” declared Dr. Nock, professor of psychology at Harvard University, Boston.

The necessity for a fresh approach to suicide and suicide risk also was emphasized by E. David Klonsky, Ph.D., in his Edwin Shneidman Award Lecture.

“Despite what seems like a very large body of knowledge, suicide rates in the U.S. have increased for numerous consecutive years, and the same is true worldwide,” observed Dr. Klonsky, a psychologist at the University of British Columbia, Vancouver.

“What’s really hard to wrap our heads around is that we’re still only at a 1960s level in our ability to predict suicide. And the main reason for that is our risk factors don’t tell us what we think they do,” he continued.

This was first demonstrated in a 1999 study by Dr. Ronald C. Kessler of Harvard Medical School and coworkers (Arch. Gen. Psychiatry 1999;56:617-26).

They showed that the widely accepted suicide risk factors -- including any mood or anxiety disorder or substance disorders -- are strong predictors of suicidal ideation, but not significant predictors of who will transition from ideation to suicidal action. This finding has subsequently been confirmed by Dr. Nock and others in both adults and adolescents in a massive World Health Organization-sponsored project. Yet to date the concept hasn’t really sunk in broadly in the mental health and medical fields, according to Dr. Klonsky.

In his plenary talk, Dr. Nock focused on four key gaps in the current understanding of how to predict and prevent suicide and outlined how he and others are addressing these needs:

The need for objective markers of suicidal risk: Historically, nearly all patient assessments have relied upon self-report and cross-sectional surveys. That has an obvious limitation, since people are often motivated to conceal their thoughts of suicide. For example, one study found that 78% of patients who died by suicide while in a psychiatric hospital denied suicidal thoughts or intent in their last assessment.

The emerging emphasis is on creating brief computerized tests of memory and reaction time to gain a window into people’s implicit cognitions. Dr. Nock and colleagues have developed one such test, the Implicit Association Test. They had patients who presented to a psychiatric emergency department take the 5-minute word association test and demonstrated that those who scored high for implicit associations between death and suicide were six-fold more likely to make a suicide attempt in the next 6 months (Psychol. Sci. 2010;21:511-7). These findings have since been confirmed by a Canadian group (Psychol. Assess. 2013;25:714-21). The test is available online (www.ImplicitMentalHealth.com) with expert feedback provided as a public education tool and as a means for Dr. Nock and coinvestigators to gather large quantities of data.

Other objective tests for suicide risk that measure physiologic and neural responses to suicide-related stimuli include the Suicide Stroop and Affect Misattribution Procedure.

The need for better predictors of the transition from ideation to attempt: There are a few early leads on such predictors from the WHO dataset and other large studies. These include disorders characterized by aggression, agitation, and/or anxiety, such as conduct disorder, bipolar disorder, and a history of physical or sexual abuse. In a large study in the U.S. Army, the number-one predictor is intermittent explosive disorder.

The need for methods of combining risk factor data: Nearly all studies of suicide risk factors have utilized bivariate analysis -- that is, they examine risk based upon the presence or absence of an individual risk factor, such as a personal history of a mental disorder. But in a study led by Guilherme Borges, Sc.D., of the National Institute of Psychiatry in Mexico City, a group including Dr. Nock showed using National Comorbidity Survey Replication data that by simply together individual risk factors to create a 0-11 scale it became possible to identify a high-risk subgroup consisting of 13.7% of survey participants. This subgroup accounted for 67% of all suicide attempts within the next 12 months (Psychol. Med. 2006;36:1747-57).

The investigators have gone on to validate this approach in more than 108,000 subjects in 21 countries participating in the World Health Organization mental health project (J. Clin. Psychiatry 2010;71:1617-28).

Simple addition of suicidality risk factors, while a big step forward in risk assessment, is still a relatively crude predictive tool. More recently, Dr. Kessler, collaborating with Dr. Nock and others, has developed a much more sophisticated actuarial risk algorithm and applied it to more than 54,000 U.S. Army soldiers hospitalized for psychiatric disorders. They found that subjects who scored in the top 5% in terms of predicted suicide risk accounted for 53% of all suicides that occurred within the next 12 months. The suicide rate in this highest-risk group was massive: 3,624 per 100,000 per year as compared to a background rate of 18.5/100,000/year in the Army overall.

Moreover, nearly one-half of soldiers with a risk score in the top 5% had a 12-month composite adverse outcome, defined as another suicide attempt, death by suicide, accidental death, or psychiatric rehospitalization (JAMA Psychiatry 2015;72:49-57).

The need for data on imminent risk: Dr. Nock called this the biggest unmet need in suicidology; it’s what clinicians and family members desperately want but don’t have. At present there is “approximately zero data” on how to predict suicidal behavior in the hours, days, or weeks before it occurs, Dr. Nock said. Indeed, Dr. Franklin’s meta-analysis showed that in the past 50 years more than three-quarters of studies examining suicide risk have looked at risk a year or more in the future. Only 2% of studies have looked at risk during the window of the next month or so.

Numerous groups are now looking at real-time patient monitoring using cell phones and smart watches as a means of developing short-term risk predictors. These tools enable investigators to monitor changes in mood, thoughts, behavior, and physiology in large populations in order to see what leads up to a suicide attempt. Dr. Nock’s group is collaborating with information scientists at Massachusetts Intitute of Technology on such projects.

This technology also shows promise for therapeutic intervention. Dr. Franklin and coworkers have developed a brief, game-like mobile app to administer what he calls Therapeutic Evaluative Conditioning. In three soon-to-be-published randomized controlled trials, he has shown that this simple intervention – essentially, playing a game on a cell phone – resulted in reductions of 42%-49% in self-cutting and other nonsuicidal self-injury, 21%-64% reductions in suicidal planning, and 20%-57% decreases in suicidal behaviors, according to Dr. Nock.

Dr. Nock’s research is funded chiefly by the National Institute of Mental Health, the World Health Organization, and the Department of Defense; he reported having no financial conflicts. Dr. Klonsky’s research is largely supported by the American Foundation for Suicide Prevention.

[email protected]

ATLANTA– Progress has stalled in understanding the predictors and prevention of suicide, and it’s time for researchers to step up their game, experts agreed at the annual conference of the American Association of Suicidology.

“In the past couple of decades we’ve learned a fair amount about suicidal behavior. However, I think progress has been fairly slow – some might even say a little stagnant – in our pushing things forward and improving our understanding,” Matthew K. Nock, Ph.D., said in the meeting’s opening plenary talk.

He cited a soon-to-be-published meta-analysis led by his post-doctoral fellow Joseph C. Franklin, Ph.D., which evaluated all of the studies of predictors of suicide attempts and completed suicides published during the last 5 decades. The eye opening finding: The predictive odds ratios for the standard risk factors have remained essentially the same – namely, weak – for the past 50 years.

“In general, we’re not getting better in our ability to predict suicidal behavior – and that’s a serious problem for us. We still have enormous gaps in our understanding and in our ability to predict and prevent these outcomes,” declared Dr. Nock, professor of psychology at Harvard University, Boston.

The necessity for a fresh approach to suicide and suicide risk also was emphasized by E. David Klonsky, Ph.D., in his Edwin Shneidman Award Lecture.

“Despite what seems like a very large body of knowledge, suicide rates in the U.S. have increased for numerous consecutive years, and the same is true worldwide,” observed Dr. Klonsky, a psychologist at the University of British Columbia, Vancouver.

“What’s really hard to wrap our heads around is that we’re still only at a 1960s level in our ability to predict suicide. And the main reason for that is our risk factors don’t tell us what we think they do,” he continued.

This was first demonstrated in a 1999 study by Dr. Ronald C. Kessler of Harvard Medical School and coworkers (Arch. Gen. Psychiatry 1999;56:617-26).

They showed that the widely accepted suicide risk factors -- including any mood or anxiety disorder or substance disorders -- are strong predictors of suicidal ideation, but not significant predictors of who will transition from ideation to suicidal action. This finding has subsequently been confirmed by Dr. Nock and others in both adults and adolescents in a massive World Health Organization-sponsored project. Yet to date the concept hasn’t really sunk in broadly in the mental health and medical fields, according to Dr. Klonsky.

In his plenary talk, Dr. Nock focused on four key gaps in the current understanding of how to predict and prevent suicide and outlined how he and others are addressing these needs:

The need for objective markers of suicidal risk: Historically, nearly all patient assessments have relied upon self-report and cross-sectional surveys. That has an obvious limitation, since people are often motivated to conceal their thoughts of suicide. For example, one study found that 78% of patients who died by suicide while in a psychiatric hospital denied suicidal thoughts or intent in their last assessment.

The emerging emphasis is on creating brief computerized tests of memory and reaction time to gain a window into people’s implicit cognitions. Dr. Nock and colleagues have developed one such test, the Implicit Association Test. They had patients who presented to a psychiatric emergency department take the 5-minute word association test and demonstrated that those who scored high for implicit associations between death and suicide were six-fold more likely to make a suicide attempt in the next 6 months (Psychol. Sci. 2010;21:511-7). These findings have since been confirmed by a Canadian group (Psychol. Assess. 2013;25:714-21). The test is available online (www.ImplicitMentalHealth.com) with expert feedback provided as a public education tool and as a means for Dr. Nock and coinvestigators to gather large quantities of data.

Other objective tests for suicide risk that measure physiologic and neural responses to suicide-related stimuli include the Suicide Stroop and Affect Misattribution Procedure.

The need for better predictors of the transition from ideation to attempt: There are a few early leads on such predictors from the WHO dataset and other large studies. These include disorders characterized by aggression, agitation, and/or anxiety, such as conduct disorder, bipolar disorder, and a history of physical or sexual abuse. In a large study in the U.S. Army, the number-one predictor is intermittent explosive disorder.

The need for methods of combining risk factor data: Nearly all studies of suicide risk factors have utilized bivariate analysis -- that is, they examine risk based upon the presence or absence of an individual risk factor, such as a personal history of a mental disorder. But in a study led by Guilherme Borges, Sc.D., of the National Institute of Psychiatry in Mexico City, a group including Dr. Nock showed using National Comorbidity Survey Replication data that by simply together individual risk factors to create a 0-11 scale it became possible to identify a high-risk subgroup consisting of 13.7% of survey participants. This subgroup accounted for 67% of all suicide attempts within the next 12 months (Psychol. Med. 2006;36:1747-57).

The investigators have gone on to validate this approach in more than 108,000 subjects in 21 countries participating in the World Health Organization mental health project (J. Clin. Psychiatry 2010;71:1617-28).

Simple addition of suicidality risk factors, while a big step forward in risk assessment, is still a relatively crude predictive tool. More recently, Dr. Kessler, collaborating with Dr. Nock and others, has developed a much more sophisticated actuarial risk algorithm and applied it to more than 54,000 U.S. Army soldiers hospitalized for psychiatric disorders. They found that subjects who scored in the top 5% in terms of predicted suicide risk accounted for 53% of all suicides that occurred within the next 12 months. The suicide rate in this highest-risk group was massive: 3,624 per 100,000 per year as compared to a background rate of 18.5/100,000/year in the Army overall.

Moreover, nearly one-half of soldiers with a risk score in the top 5% had a 12-month composite adverse outcome, defined as another suicide attempt, death by suicide, accidental death, or psychiatric rehospitalization (JAMA Psychiatry 2015;72:49-57).

The need for data on imminent risk: Dr. Nock called this the biggest unmet need in suicidology; it’s what clinicians and family members desperately want but don’t have. At present there is “approximately zero data” on how to predict suicidal behavior in the hours, days, or weeks before it occurs, Dr. Nock said. Indeed, Dr. Franklin’s meta-analysis showed that in the past 50 years more than three-quarters of studies examining suicide risk have looked at risk a year or more in the future. Only 2% of studies have looked at risk during the window of the next month or so.

Numerous groups are now looking at real-time patient monitoring using cell phones and smart watches as a means of developing short-term risk predictors. These tools enable investigators to monitor changes in mood, thoughts, behavior, and physiology in large populations in order to see what leads up to a suicide attempt. Dr. Nock’s group is collaborating with information scientists at Massachusetts Intitute of Technology on such projects.

This technology also shows promise for therapeutic intervention. Dr. Franklin and coworkers have developed a brief, game-like mobile app to administer what he calls Therapeutic Evaluative Conditioning. In three soon-to-be-published randomized controlled trials, he has shown that this simple intervention – essentially, playing a game on a cell phone – resulted in reductions of 42%-49% in self-cutting and other nonsuicidal self-injury, 21%-64% reductions in suicidal planning, and 20%-57% decreases in suicidal behaviors, according to Dr. Nock.

Dr. Nock’s research is funded chiefly by the National Institute of Mental Health, the World Health Organization, and the Department of Defense; he reported having no financial conflicts. Dr. Klonsky’s research is largely supported by the American Foundation for Suicide Prevention.

[email protected]

ATLANTA– Progress has stalled in understanding the predictors and prevention of suicide, and it’s time for researchers to step up their game, experts agreed at the annual conference of the American Association of Suicidology.

“In the past couple of decades we’ve learned a fair amount about suicidal behavior. However, I think progress has been fairly slow – some might even say a little stagnant – in our pushing things forward and improving our understanding,” Matthew K. Nock, Ph.D., said in the meeting’s opening plenary talk.

He cited a soon-to-be-published meta-analysis led by his post-doctoral fellow Joseph C. Franklin, Ph.D., which evaluated all of the studies of predictors of suicide attempts and completed suicides published during the last 5 decades. The eye opening finding: The predictive odds ratios for the standard risk factors have remained essentially the same – namely, weak – for the past 50 years.

“In general, we’re not getting better in our ability to predict suicidal behavior – and that’s a serious problem for us. We still have enormous gaps in our understanding and in our ability to predict and prevent these outcomes,” declared Dr. Nock, professor of psychology at Harvard University, Boston.

The necessity for a fresh approach to suicide and suicide risk also was emphasized by E. David Klonsky, Ph.D., in his Edwin Shneidman Award Lecture.

“Despite what seems like a very large body of knowledge, suicide rates in the U.S. have increased for numerous consecutive years, and the same is true worldwide,” observed Dr. Klonsky, a psychologist at the University of British Columbia, Vancouver.

“What’s really hard to wrap our heads around is that we’re still only at a 1960s level in our ability to predict suicide. And the main reason for that is our risk factors don’t tell us what we think they do,” he continued.

This was first demonstrated in a 1999 study by Dr. Ronald C. Kessler of Harvard Medical School and coworkers (Arch. Gen. Psychiatry 1999;56:617-26).

They showed that the widely accepted suicide risk factors -- including any mood or anxiety disorder or substance disorders -- are strong predictors of suicidal ideation, but not significant predictors of who will transition from ideation to suicidal action. This finding has subsequently been confirmed by Dr. Nock and others in both adults and adolescents in a massive World Health Organization-sponsored project. Yet to date the concept hasn’t really sunk in broadly in the mental health and medical fields, according to Dr. Klonsky.

In his plenary talk, Dr. Nock focused on four key gaps in the current understanding of how to predict and prevent suicide and outlined how he and others are addressing these needs:

The need for objective markers of suicidal risk: Historically, nearly all patient assessments have relied upon self-report and cross-sectional surveys. That has an obvious limitation, since people are often motivated to conceal their thoughts of suicide. For example, one study found that 78% of patients who died by suicide while in a psychiatric hospital denied suicidal thoughts or intent in their last assessment.

The emerging emphasis is on creating brief computerized tests of memory and reaction time to gain a window into people’s implicit cognitions. Dr. Nock and colleagues have developed one such test, the Implicit Association Test. They had patients who presented to a psychiatric emergency department take the 5-minute word association test and demonstrated that those who scored high for implicit associations between death and suicide were six-fold more likely to make a suicide attempt in the next 6 months (Psychol. Sci. 2010;21:511-7). These findings have since been confirmed by a Canadian group (Psychol. Assess. 2013;25:714-21). The test is available online (www.ImplicitMentalHealth.com) with expert feedback provided as a public education tool and as a means for Dr. Nock and coinvestigators to gather large quantities of data.

Other objective tests for suicide risk that measure physiologic and neural responses to suicide-related stimuli include the Suicide Stroop and Affect Misattribution Procedure.

The need for better predictors of the transition from ideation to attempt: There are a few early leads on such predictors from the WHO dataset and other large studies. These include disorders characterized by aggression, agitation, and/or anxiety, such as conduct disorder, bipolar disorder, and a history of physical or sexual abuse. In a large study in the U.S. Army, the number-one predictor is intermittent explosive disorder.

The need for methods of combining risk factor data: Nearly all studies of suicide risk factors have utilized bivariate analysis -- that is, they examine risk based upon the presence or absence of an individual risk factor, such as a personal history of a mental disorder. But in a study led by Guilherme Borges, Sc.D., of the National Institute of Psychiatry in Mexico City, a group including Dr. Nock showed using National Comorbidity Survey Replication data that by simply together individual risk factors to create a 0-11 scale it became possible to identify a high-risk subgroup consisting of 13.7% of survey participants. This subgroup accounted for 67% of all suicide attempts within the next 12 months (Psychol. Med. 2006;36:1747-57).

The investigators have gone on to validate this approach in more than 108,000 subjects in 21 countries participating in the World Health Organization mental health project (J. Clin. Psychiatry 2010;71:1617-28).

Simple addition of suicidality risk factors, while a big step forward in risk assessment, is still a relatively crude predictive tool. More recently, Dr. Kessler, collaborating with Dr. Nock and others, has developed a much more sophisticated actuarial risk algorithm and applied it to more than 54,000 U.S. Army soldiers hospitalized for psychiatric disorders. They found that subjects who scored in the top 5% in terms of predicted suicide risk accounted for 53% of all suicides that occurred within the next 12 months. The suicide rate in this highest-risk group was massive: 3,624 per 100,000 per year as compared to a background rate of 18.5/100,000/year in the Army overall.

Moreover, nearly one-half of soldiers with a risk score in the top 5% had a 12-month composite adverse outcome, defined as another suicide attempt, death by suicide, accidental death, or psychiatric rehospitalization (JAMA Psychiatry 2015;72:49-57).

The need for data on imminent risk: Dr. Nock called this the biggest unmet need in suicidology; it’s what clinicians and family members desperately want but don’t have. At present there is “approximately zero data” on how to predict suicidal behavior in the hours, days, or weeks before it occurs, Dr. Nock said. Indeed, Dr. Franklin’s meta-analysis showed that in the past 50 years more than three-quarters of studies examining suicide risk have looked at risk a year or more in the future. Only 2% of studies have looked at risk during the window of the next month or so.

Numerous groups are now looking at real-time patient monitoring using cell phones and smart watches as a means of developing short-term risk predictors. These tools enable investigators to monitor changes in mood, thoughts, behavior, and physiology in large populations in order to see what leads up to a suicide attempt. Dr. Nock’s group is collaborating with information scientists at Massachusetts Intitute of Technology on such projects.

This technology also shows promise for therapeutic intervention. Dr. Franklin and coworkers have developed a brief, game-like mobile app to administer what he calls Therapeutic Evaluative Conditioning. In three soon-to-be-published randomized controlled trials, he has shown that this simple intervention – essentially, playing a game on a cell phone – resulted in reductions of 42%-49% in self-cutting and other nonsuicidal self-injury, 21%-64% reductions in suicidal planning, and 20%-57% decreases in suicidal behaviors, according to Dr. Nock.

Dr. Nock’s research is funded chiefly by the National Institute of Mental Health, the World Health Organization, and the Department of Defense; he reported having no financial conflicts. Dr. Klonsky’s research is largely supported by the American Foundation for Suicide Prevention.

[email protected]

ATLANTA – One-third of a large sample of male state prison inmates reported some level of suicidal ideation in the first-ever study to examine the applicability of Joiner’s interpersonal theory of suicide in a correctional setting.

That’s a high rate, especially since the study participants hadn’t been red-flagged by prison officials for any indication of increased suicidality. By comparison, studies conducted in the general population outside of a prison setting have placed the prevalence of suicidal ideation at 2%-10%, Jon Mandracchia, Ph.D., noted at the annual conference of the American Association of Suicidology.

His study earned the Young Investigator of the Year Award from the American Foundation for Suicide Prevention.

Bruce Jancin/Frontline Medical News

Suicide is a serious problem in correctional settings. According to the Bureau of Justice Statistics, suicide is the number-one cause of death in jails, accounting for 29% of all mortality in that setting. In prisons, suicide accounts for 6.2% of all deaths, making it the fourth most common cause of mortality, said Dr. Mandracchia of the University of Southern Mississippi, Hattiesburg.

Prison officials realize suicide is a major problem. Guards, nurses, and other staff have been trained to be on the lookout for suicidality and are quick to ask inmates if they’ve been thinking about harming themselves, but the answer is virtually always no.

“Prison is a harsh place. You can’t live in prison if you’re seen as a potential victim or target by other inmates,” Dr. Mandracchia said. “You’re not going to admit to anything that might possibly be perceived as weakness, whether it’s true or just in your mind.”

The interpersonal theory of suicide, introduced by Thomas Joiner, Ph.D., a decade ago, has generated enormous interest among suicide researchers because of its simplicity and ready testability. Indeed, much of this year’s AAS conference was devoted to studies examining the theory’s validity in various populations.

The theory holds that, for suicide attempts to occur, three elements are necessary. In Dr. Joiner’s terminology, an individual must simultaneously experience thwarted belongingness and perceived burdensomeness, which together generate suicidal ideation. To move from ideation to action, however, a third component must be present: acquired capability, the ability to overcome the powerful, innate urge to survive. Acquired capability is often achieved through desensitization to trauma or pain.

Prison is an environment rife with thwarted belongingness and perceived burdensomeness. Prisoners are removed from their family and friends, hence the thwarted belongingness. They also often feel that they’ve become a burden to their family because they’re not providing income and often ask their families for money to buy snacks. Moreover, they are constantly reminded that they are a burden on society. Dr. Mandracchia hypothesized that, if the interpersonal theory of suicide is valid in a prison population, then prisoners who score high on measures of thwarted belongingness and perceived burdensomeness should have the highest levels of suicidal ideation.

That’s exactly what he found in his study of 399 male inmates in Mississippi state prisons. For his measurement tools, he used the Beck Scale for Suicide Ideation and the Interpersonal Needs Questionnaire, which features separate scales to look at perceived burdensomeness and thwarted belongingness. In addition, he employed the Center for Epidemiological Studies Depression Scale and the hopelessness scale from the Depression Hopelessness Suicide Screening Form, a tool developed specifically for use in criminal offenders. He measured inmates’ levels of depression and hopelessness to be able to control for those two factors in his analysis, since they are traditionally viewed as risk factors for suicide but aren’t central to the Joiner model.

Dr. Mandracchia found a strong dose-response effect between thwarted belongingness and perceived burdensomeness and suicidal ideation among the inmates, all of whom participated in the study voluntarily. Inmates who scored in the top tertiles for both thwarted belongingness and perceived burdensomeness had the greatest amount of suicidal ideation, while those in the middle tertiles had mid-range levels of suicidal ideation on the Beck scale.

Dr. Mandracchia highlighted several practical implications of the study findings in terms of suicidality assessment and management in prison populations. For example, instead of asking inmates, “How are you feeling?” and “Are you thinking of hurting yourself?” as prison staff routinely do now, they should instead be on the lookout for inmates who complain that they are a burden to their family or feel particularly isolated. This ought to reduce the traditionally extremely high false-positive and false-negative rates for detection of suicidality in correctional institutions, he said.

In terms of implications for management, Dr. Mandracchia said that he is trying to convince prison officials to limit their use of suicide watch.

“They don’t know what else to do, so when they’re concerned about someone they remove them and lock them in isolation until they’re safe. That’s often counterproductive. It takes the inmates away from their support system,” he said.

Mental health professionals working in prison settings also could try to boost inmates’ sense of belongingness, perhaps by encouraging them to join one of the prosocial groups that exist in prisons. Staying in touch with friends and family by writing letters is another means of increasing belongingness. Perceived burdensomeness can be addressed through cognitive behavioral therapy aimed at helping inmates gain a more accurate picture of how much of a burden they are to others, Dr. Mandracchia added.

He is planning a longitudinal study to identify measures that predict actual future suicidal behavior among prison inmates, but acknowledged there are challenges to doing this work.

“When you start doing mental health research in prisons, you quickly realize that no one wants you there. Not the staff, not the inmates,” he said.

Dr. Mandracchia reported having no financial conflicts regarding this study, which was conducted free of commercial support.

[email protected]

ATLANTA – One-third of a large sample of male state prison inmates reported some level of suicidal ideation in the first-ever study to examine the applicability of Joiner’s interpersonal theory of suicide in a correctional setting.

That’s a high rate, especially since the study participants hadn’t been red-flagged by prison officials for any indication of increased suicidality. By comparison, studies conducted in the general population outside of a prison setting have placed the prevalence of suicidal ideation at 2%-10%, Jon Mandracchia, Ph.D., noted at the annual conference of the American Association of Suicidology.

His study earned the Young Investigator of the Year Award from the American Foundation for Suicide Prevention.

Bruce Jancin/Frontline Medical News

Suicide is a serious problem in correctional settings. According to the Bureau of Justice Statistics, suicide is the number-one cause of death in jails, accounting for 29% of all mortality in that setting. In prisons, suicide accounts for 6.2% of all deaths, making it the fourth most common cause of mortality, said Dr. Mandracchia of the University of Southern Mississippi, Hattiesburg.

Prison officials realize suicide is a major problem. Guards, nurses, and other staff have been trained to be on the lookout for suicidality and are quick to ask inmates if they’ve been thinking about harming themselves, but the answer is virtually always no.

“Prison is a harsh place. You can’t live in prison if you’re seen as a potential victim or target by other inmates,” Dr. Mandracchia said. “You’re not going to admit to anything that might possibly be perceived as weakness, whether it’s true or just in your mind.”

The interpersonal theory of suicide, introduced by Thomas Joiner, Ph.D., a decade ago, has generated enormous interest among suicide researchers because of its simplicity and ready testability. Indeed, much of this year’s AAS conference was devoted to studies examining the theory’s validity in various populations.

The theory holds that, for suicide attempts to occur, three elements are necessary. In Dr. Joiner’s terminology, an individual must simultaneously experience thwarted belongingness and perceived burdensomeness, which together generate suicidal ideation. To move from ideation to action, however, a third component must be present: acquired capability, the ability to overcome the powerful, innate urge to survive. Acquired capability is often achieved through desensitization to trauma or pain.

Prison is an environment rife with thwarted belongingness and perceived burdensomeness. Prisoners are removed from their family and friends, hence the thwarted belongingness. They also often feel that they’ve become a burden to their family because they’re not providing income and often ask their families for money to buy snacks. Moreover, they are constantly reminded that they are a burden on society. Dr. Mandracchia hypothesized that, if the interpersonal theory of suicide is valid in a prison population, then prisoners who score high on measures of thwarted belongingness and perceived burdensomeness should have the highest levels of suicidal ideation.

That’s exactly what he found in his study of 399 male inmates in Mississippi state prisons. For his measurement tools, he used the Beck Scale for Suicide Ideation and the Interpersonal Needs Questionnaire, which features separate scales to look at perceived burdensomeness and thwarted belongingness. In addition, he employed the Center for Epidemiological Studies Depression Scale and the hopelessness scale from the Depression Hopelessness Suicide Screening Form, a tool developed specifically for use in criminal offenders. He measured inmates’ levels of depression and hopelessness to be able to control for those two factors in his analysis, since they are traditionally viewed as risk factors for suicide but aren’t central to the Joiner model.

Dr. Mandracchia found a strong dose-response effect between thwarted belongingness and perceived burdensomeness and suicidal ideation among the inmates, all of whom participated in the study voluntarily. Inmates who scored in the top tertiles for both thwarted belongingness and perceived burdensomeness had the greatest amount of suicidal ideation, while those in the middle tertiles had mid-range levels of suicidal ideation on the Beck scale.

Dr. Mandracchia highlighted several practical implications of the study findings in terms of suicidality assessment and management in prison populations. For example, instead of asking inmates, “How are you feeling?” and “Are you thinking of hurting yourself?” as prison staff routinely do now, they should instead be on the lookout for inmates who complain that they are a burden to their family or feel particularly isolated. This ought to reduce the traditionally extremely high false-positive and false-negative rates for detection of suicidality in correctional institutions, he said.

In terms of implications for management, Dr. Mandracchia said that he is trying to convince prison officials to limit their use of suicide watch.

“They don’t know what else to do, so when they’re concerned about someone they remove them and lock them in isolation until they’re safe. That’s often counterproductive. It takes the inmates away from their support system,” he said.

Mental health professionals working in prison settings also could try to boost inmates’ sense of belongingness, perhaps by encouraging them to join one of the prosocial groups that exist in prisons. Staying in touch with friends and family by writing letters is another means of increasing belongingness. Perceived burdensomeness can be addressed through cognitive behavioral therapy aimed at helping inmates gain a more accurate picture of how much of a burden they are to others, Dr. Mandracchia added.

He is planning a longitudinal study to identify measures that predict actual future suicidal behavior among prison inmates, but acknowledged there are challenges to doing this work.

“When you start doing mental health research in prisons, you quickly realize that no one wants you there. Not the staff, not the inmates,” he said.

Dr. Mandracchia reported having no financial conflicts regarding this study, which was conducted free of commercial support.

[email protected]

ATLANTA – One-third of a large sample of male state prison inmates reported some level of suicidal ideation in the first-ever study to examine the applicability of Joiner’s interpersonal theory of suicide in a correctional setting.

That’s a high rate, especially since the study participants hadn’t been red-flagged by prison officials for any indication of increased suicidality. By comparison, studies conducted in the general population outside of a prison setting have placed the prevalence of suicidal ideation at 2%-10%, Jon Mandracchia, Ph.D., noted at the annual conference of the American Association of Suicidology.

His study earned the Young Investigator of the Year Award from the American Foundation for Suicide Prevention.

Bruce Jancin/Frontline Medical News

Suicide is a serious problem in correctional settings. According to the Bureau of Justice Statistics, suicide is the number-one cause of death in jails, accounting for 29% of all mortality in that setting. In prisons, suicide accounts for 6.2% of all deaths, making it the fourth most common cause of mortality, said Dr. Mandracchia of the University of Southern Mississippi, Hattiesburg.

Prison officials realize suicide is a major problem. Guards, nurses, and other staff have been trained to be on the lookout for suicidality and are quick to ask inmates if they’ve been thinking about harming themselves, but the answer is virtually always no.

“Prison is a harsh place. You can’t live in prison if you’re seen as a potential victim or target by other inmates,” Dr. Mandracchia said. “You’re not going to admit to anything that might possibly be perceived as weakness, whether it’s true or just in your mind.”

The interpersonal theory of suicide, introduced by Thomas Joiner, Ph.D., a decade ago, has generated enormous interest among suicide researchers because of its simplicity and ready testability. Indeed, much of this year’s AAS conference was devoted to studies examining the theory’s validity in various populations.

The theory holds that, for suicide attempts to occur, three elements are necessary. In Dr. Joiner’s terminology, an individual must simultaneously experience thwarted belongingness and perceived burdensomeness, which together generate suicidal ideation. To move from ideation to action, however, a third component must be present: acquired capability, the ability to overcome the powerful, innate urge to survive. Acquired capability is often achieved through desensitization to trauma or pain.

Prison is an environment rife with thwarted belongingness and perceived burdensomeness. Prisoners are removed from their family and friends, hence the thwarted belongingness. They also often feel that they’ve become a burden to their family because they’re not providing income and often ask their families for money to buy snacks. Moreover, they are constantly reminded that they are a burden on society. Dr. Mandracchia hypothesized that, if the interpersonal theory of suicide is valid in a prison population, then prisoners who score high on measures of thwarted belongingness and perceived burdensomeness should have the highest levels of suicidal ideation.

That’s exactly what he found in his study of 399 male inmates in Mississippi state prisons. For his measurement tools, he used the Beck Scale for Suicide Ideation and the Interpersonal Needs Questionnaire, which features separate scales to look at perceived burdensomeness and thwarted belongingness. In addition, he employed the Center for Epidemiological Studies Depression Scale and the hopelessness scale from the Depression Hopelessness Suicide Screening Form, a tool developed specifically for use in criminal offenders. He measured inmates’ levels of depression and hopelessness to be able to control for those two factors in his analysis, since they are traditionally viewed as risk factors for suicide but aren’t central to the Joiner model.

Dr. Mandracchia found a strong dose-response effect between thwarted belongingness and perceived burdensomeness and suicidal ideation among the inmates, all of whom participated in the study voluntarily. Inmates who scored in the top tertiles for both thwarted belongingness and perceived burdensomeness had the greatest amount of suicidal ideation, while those in the middle tertiles had mid-range levels of suicidal ideation on the Beck scale.

Dr. Mandracchia highlighted several practical implications of the study findings in terms of suicidality assessment and management in prison populations. For example, instead of asking inmates, “How are you feeling?” and “Are you thinking of hurting yourself?” as prison staff routinely do now, they should instead be on the lookout for inmates who complain that they are a burden to their family or feel particularly isolated. This ought to reduce the traditionally extremely high false-positive and false-negative rates for detection of suicidality in correctional institutions, he said.

In terms of implications for management, Dr. Mandracchia said that he is trying to convince prison officials to limit their use of suicide watch.

“They don’t know what else to do, so when they’re concerned about someone they remove them and lock them in isolation until they’re safe. That’s often counterproductive. It takes the inmates away from their support system,” he said.

Mental health professionals working in prison settings also could try to boost inmates’ sense of belongingness, perhaps by encouraging them to join one of the prosocial groups that exist in prisons. Staying in touch with friends and family by writing letters is another means of increasing belongingness. Perceived burdensomeness can be addressed through cognitive behavioral therapy aimed at helping inmates gain a more accurate picture of how much of a burden they are to others, Dr. Mandracchia added.

He is planning a longitudinal study to identify measures that predict actual future suicidal behavior among prison inmates, but acknowledged there are challenges to doing this work.

“When you start doing mental health research in prisons, you quickly realize that no one wants you there. Not the staff, not the inmates,” he said.

Dr. Mandracchia reported having no financial conflicts regarding this study, which was conducted free of commercial support.

[email protected]

ATLANTA– A landmark study of newspaper coverage of suicides provides empirical support for media guidelines aimed at minimizing the likelihood of suicide clusters among college students.

“Given the prevalence of suicide on college campuses, and the associated risk of suicide contagion and clustering, it’s imperative that colleges develop effective and comprehensive postvention programs,” Madelyn S. Gould, Ph.D., said at the annual conference of the American Association of Suicidology.

According to the Centers for Disease Control and Prevention, suicide is the No. 2 cause of death among college students, with roughly 1,100 completed suicides occurring annually, noted Dr. Gould, professor of epidemiology in psychiatry at Columbia University, New York, and the New York State Psychiatric Institute.

Suicide contagion is the process by which direct or indirect knowledge of one suicide facilitates subsequent suicide. Dr. Gould was the lead investigator in a national study that examined the role of newspaper coverage of suicide as a contributor to suicide clusters among 13- to 20-year-olds. The retrospective, population-based, case-control study included 48 communities in which suicide clusters occurred during 1988-1996 – before the arrival of social media. The control group consisted of 95 matched communities in which a youth suicide was not followed by a suicide cluster.

The key finding: The more sensational the newspaper coverage of suicides as evidenced by a greater number of stories, front page placement, and more details about the suicidal individual and act, the greater the likelihood of subsequent suicide clusters (Lancet Psychiatry 2014;1:34-43).

Dr. Gould highlighted what she considers a seminal study led by Dr. Thomas Niederkrotenthaler of the Medical University of Vienna. The investigators analyzed the content of nearly 500 suicide-related Austrian print media articles and demonstrated that while sensational and/or repetitive coverage of suicides was associated with a subsequent increase in suicide, stories about mastery-of-crisis – that is, articles about individuals with suicidal ideation who adopted coping strategies other than suicidal behavior when faced with adverse circumstances – were associated with a decreased suicide rate (Br. J. Psychiatry 2010;197:234-43). Dr. Niederkrotenthaler calls it “the Papageno effect,” after a lovesick character in Mozart’s opera “The Magic Flute” whose planned suicide is averted by three child spirits who remind him of alternatives to death.

Dr. Gould noted that emotions also can be spread through the social media, as was made evident by the Facebook’s News Feed Experiment. In this massive study, investigators in Facebook’s research department manipulated the emotional content of the Facebook News Feed for 689,003 Facebook members. When exposure to friends’ positive emotional content in their news feed was reduced, subjects produced fewer positive and more negative posts. When exposure to negative content in the news feed was reduced, the result was more positive and fewer negative posts (Proc. Natl. Acad. Sci. USA 2014;11:8788-90).

The Higher Education Mental Health Alliance has disseminated a comprehensive suicide postvention guide for colleges. It includes specific recommendations aimed at limiting suicide contagion on campuses. The guide includes recommended media guidelines in the wake of suicide, emphasizes the importance of addressing common and counterproductive myths about suicide, and provides tips on how to shape students’ desire to “do something” in the aftermath of a student suicide while at the same time balancing that constructive urge against the needs of mourners.

Guidance regarding how to encourage responsible social networking in the aftermath of a suicide is available from the Suicide Prevention Research Center, Dr. Gould continued.

Up to half of college students with suicidal ideation choose not to share that information with anyone.

“There are a lot of vulnerable students on campuses. Consider implementing the American Foundation for Suicide Prevention’s anonymous online Interactive Screening Program,” she said.

Dr. Gould’s suicide cluster study was funded by the National Institute of Mental Health and the American Foundation for Suicide Prevention. She reported receiving royalties as coauthor of the Columbia-Suicide Severity Rating Scale.

[email protected]

ATLANTA– A landmark study of newspaper coverage of suicides provides empirical support for media guidelines aimed at minimizing the likelihood of suicide clusters among college students.

“Given the prevalence of suicide on college campuses, and the associated risk of suicide contagion and clustering, it’s imperative that colleges develop effective and comprehensive postvention programs,” Madelyn S. Gould, Ph.D., said at the annual conference of the American Association of Suicidology.

According to the Centers for Disease Control and Prevention, suicide is the No. 2 cause of death among college students, with roughly 1,100 completed suicides occurring annually, noted Dr. Gould, professor of epidemiology in psychiatry at Columbia University, New York, and the New York State Psychiatric Institute.

Suicide contagion is the process by which direct or indirect knowledge of one suicide facilitates subsequent suicide. Dr. Gould was the lead investigator in a national study that examined the role of newspaper coverage of suicide as a contributor to suicide clusters among 13- to 20-year-olds. The retrospective, population-based, case-control study included 48 communities in which suicide clusters occurred during 1988-1996 – before the arrival of social media. The control group consisted of 95 matched communities in which a youth suicide was not followed by a suicide cluster.

The key finding: The more sensational the newspaper coverage of suicides as evidenced by a greater number of stories, front page placement, and more details about the suicidal individual and act, the greater the likelihood of subsequent suicide clusters (Lancet Psychiatry 2014;1:34-43).

Dr. Gould highlighted what she considers a seminal study led by Dr. Thomas Niederkrotenthaler of the Medical University of Vienna. The investigators analyzed the content of nearly 500 suicide-related Austrian print media articles and demonstrated that while sensational and/or repetitive coverage of suicides was associated with a subsequent increase in suicide, stories about mastery-of-crisis – that is, articles about individuals with suicidal ideation who adopted coping strategies other than suicidal behavior when faced with adverse circumstances – were associated with a decreased suicide rate (Br. J. Psychiatry 2010;197:234-43). Dr. Niederkrotenthaler calls it “the Papageno effect,” after a lovesick character in Mozart’s opera “The Magic Flute” whose planned suicide is averted by three child spirits who remind him of alternatives to death.

Dr. Gould noted that emotions also can be spread through the social media, as was made evident by the Facebook’s News Feed Experiment. In this massive study, investigators in Facebook’s research department manipulated the emotional content of the Facebook News Feed for 689,003 Facebook members. When exposure to friends’ positive emotional content in their news feed was reduced, subjects produced fewer positive and more negative posts. When exposure to negative content in the news feed was reduced, the result was more positive and fewer negative posts (Proc. Natl. Acad. Sci. USA 2014;11:8788-90).

The Higher Education Mental Health Alliance has disseminated a comprehensive suicide postvention guide for colleges. It includes specific recommendations aimed at limiting suicide contagion on campuses. The guide includes recommended media guidelines in the wake of suicide, emphasizes the importance of addressing common and counterproductive myths about suicide, and provides tips on how to shape students’ desire to “do something” in the aftermath of a student suicide while at the same time balancing that constructive urge against the needs of mourners.

Guidance regarding how to encourage responsible social networking in the aftermath of a suicide is available from the Suicide Prevention Research Center, Dr. Gould continued.

Up to half of college students with suicidal ideation choose not to share that information with anyone.

“There are a lot of vulnerable students on campuses. Consider implementing the American Foundation for Suicide Prevention’s anonymous online Interactive Screening Program,” she said.

Dr. Gould’s suicide cluster study was funded by the National Institute of Mental Health and the American Foundation for Suicide Prevention. She reported receiving royalties as coauthor of the Columbia-Suicide Severity Rating Scale.

[email protected]

ATLANTA– A landmark study of newspaper coverage of suicides provides empirical support for media guidelines aimed at minimizing the likelihood of suicide clusters among college students.

“Given the prevalence of suicide on college campuses, and the associated risk of suicide contagion and clustering, it’s imperative that colleges develop effective and comprehensive postvention programs,” Madelyn S. Gould, Ph.D., said at the annual conference of the American Association of Suicidology.

According to the Centers for Disease Control and Prevention, suicide is the No. 2 cause of death among college students, with roughly 1,100 completed suicides occurring annually, noted Dr. Gould, professor of epidemiology in psychiatry at Columbia University, New York, and the New York State Psychiatric Institute.

Suicide contagion is the process by which direct or indirect knowledge of one suicide facilitates subsequent suicide. Dr. Gould was the lead investigator in a national study that examined the role of newspaper coverage of suicide as a contributor to suicide clusters among 13- to 20-year-olds. The retrospective, population-based, case-control study included 48 communities in which suicide clusters occurred during 1988-1996 – before the arrival of social media. The control group consisted of 95 matched communities in which a youth suicide was not followed by a suicide cluster.

The key finding: The more sensational the newspaper coverage of suicides as evidenced by a greater number of stories, front page placement, and more details about the suicidal individual and act, the greater the likelihood of subsequent suicide clusters (Lancet Psychiatry 2014;1:34-43).

Dr. Gould highlighted what she considers a seminal study led by Dr. Thomas Niederkrotenthaler of the Medical University of Vienna. The investigators analyzed the content of nearly 500 suicide-related Austrian print media articles and demonstrated that while sensational and/or repetitive coverage of suicides was associated with a subsequent increase in suicide, stories about mastery-of-crisis – that is, articles about individuals with suicidal ideation who adopted coping strategies other than suicidal behavior when faced with adverse circumstances – were associated with a decreased suicide rate (Br. J. Psychiatry 2010;197:234-43). Dr. Niederkrotenthaler calls it “the Papageno effect,” after a lovesick character in Mozart’s opera “The Magic Flute” whose planned suicide is averted by three child spirits who remind him of alternatives to death.

Dr. Gould noted that emotions also can be spread through the social media, as was made evident by the Facebook’s News Feed Experiment. In this massive study, investigators in Facebook’s research department manipulated the emotional content of the Facebook News Feed for 689,003 Facebook members. When exposure to friends’ positive emotional content in their news feed was reduced, subjects produced fewer positive and more negative posts. When exposure to negative content in the news feed was reduced, the result was more positive and fewer negative posts (Proc. Natl. Acad. Sci. USA 2014;11:8788-90).

The Higher Education Mental Health Alliance has disseminated a comprehensive suicide postvention guide for colleges. It includes specific recommendations aimed at limiting suicide contagion on campuses. The guide includes recommended media guidelines in the wake of suicide, emphasizes the importance of addressing common and counterproductive myths about suicide, and provides tips on how to shape students’ desire to “do something” in the aftermath of a student suicide while at the same time balancing that constructive urge against the needs of mourners.

Guidance regarding how to encourage responsible social networking in the aftermath of a suicide is available from the Suicide Prevention Research Center, Dr. Gould continued.

Up to half of college students with suicidal ideation choose not to share that information with anyone.

“There are a lot of vulnerable students on campuses. Consider implementing the American Foundation for Suicide Prevention’s anonymous online Interactive Screening Program,” she said.

Dr. Gould’s suicide cluster study was funded by the National Institute of Mental Health and the American Foundation for Suicide Prevention. She reported receiving royalties as coauthor of the Columbia-Suicide Severity Rating Scale.

[email protected]

ATLANTA – The strongest evidence to date that brief psychological therapy is effective in reducing repetition of acts of self-harm comes from a new Cochrane Collaboration meta-analysis.

Current guidelines on management of self-harm provided by the United Kingdom’s National Institute for Health and Care Excellence (NICE) state that psychological therapy “may” prevent recurrent self-harm, but this guidance relied upon limited evidence. The new Cochrane Collaboration review, based on 18 randomized controlled trials, greatly strengthens support for that conclusion, Dr. Keith Hawton said at the annual meeting of the American Association of Suicidology.

Bruce Jancin/Frontline Medical News

“And I’ve got to add, of course, that psychological therapy may be at least as effective in terms of other important outcomes,” observed Dr. Hawton, lead author of the soon-to-be published Cochrane meta-analysis. Dr. Hawton is professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

The meta-analysis included 11 randomized trials of brief psychological therapy or treatment as usual in adults in which the primary outcome was repetition of self-harm during 6 months of follow-up. There were 146 such events in 663 patients who underwent psychological therapy, compared with 176 events in 640 controls, for an adjusted 43% relative risk reduction.

In 10 trials featuring 12 months of follow-up, some of which were also included in the 6-month analysis, there were 263 events in 1,101 psychotherapy recipients, compared with 308 events in 1,131 controls. That translates into a statistically significant 20% relative risk reduction favoring brief psychotherapy.

Depression scores at last follow-up were significantly lower in the psychotherapy recipients, compared with treatment as usual. So were hopelessness and suicidal ideation scores.

Nine suicides occurred among 1,169 patients randomized to psychotherapy, vs. 15 in 1,185 controls. Although this represents a 34% relative risk reduction, the difference wasn’t significant, because suicide was such a rare event, even in these high-risk patients who – as documented in the Multicentre Study of Self Harm in England – have a 50-fold greater risk of death by suicide in the year following a self-harm event than the risk in the general population.

“This illustrates the problem in using suicide as an outcome, even when you stack up a lot of studies,” Dr. Hawton noted.

The trials in the meta-analysis were conducted throughout the world, so “treatment as usual” in the control arm varied from study to study. But even in the United Kingdom, where the NICE guidelines state that all self-harm patients who present to a hospital should receive a psychosocial assessment, including an evaluation of their needs and risks, a 32-hospital study showed that only 60% of self-harm patients actually get such an assessment, the psychiatrist said.

A variety of forms of brief psychological therapy for self-harm were employed in the randomized trials. Most involved short-term cognitive-behavioral therapy, problem-solving therapy, or dialectical behavior therapy. Components shared by the various regimens included engagement; a careful examination of the process associated with an individual’s self-harm; problem-solving; cognitive therapy to address the patient’s problems, thoughts, images, and core beliefs; and ongoing monitoring of depression, hopelessness, and thoughts of self-harm.

“The self-harm population is very heterogeneous. There’s a wide range of problems and needs. Brief psychological therapy isn’t suitable for all patients. We’ve estimated that about 30% could benefit from this approach,” according to Dr. Hawton.

Based in part upon the Cochrane Collaboration analysis, the local directors of health services across England and Wales recently have received guidance that brief psychological therapy is to be made available routinely to patients seen by self-harm mental health programs, he added.

Self-harm is defined in the United Kingdom as intentional nonfatal self-poisoning or self-injury regardless of the degree of suicidal intent.

Looking ahead, Dr. Hawton cited several developments that show promise as potential new therapies for self-harm patients.

“Mindfulness has achieved great success in recent years, particularly based on very impressive impacts in people with relapsing depression. This is clearly an area that’s going to be developed in relation to the self- harm population. In fact, there is already work going on,” he said.

Similarly, randomized studies are underway evaluating ketamine and its analogs for acute suicidality based upon the highly favorable results reported in treating severe depression.

Internet and mobile telephone–based interventions for self-harm patients are “proliferating” at the moment, Dr. Hawton said.

“One of the issues is how to individualize therapy through these approaches,” he noted.

Dr. Hawton’s research is funded by the National Institute for Health Research. He reported having no financial conflicts.

[email protected]

ATLANTA – The strongest evidence to date that brief psychological therapy is effective in reducing repetition of acts of self-harm comes from a new Cochrane Collaboration meta-analysis.

Current guidelines on management of self-harm provided by the United Kingdom’s National Institute for Health and Care Excellence (NICE) state that psychological therapy “may” prevent recurrent self-harm, but this guidance relied upon limited evidence. The new Cochrane Collaboration review, based on 18 randomized controlled trials, greatly strengthens support for that conclusion, Dr. Keith Hawton said at the annual meeting of the American Association of Suicidology.

Bruce Jancin/Frontline Medical News

“And I’ve got to add, of course, that psychological therapy may be at least as effective in terms of other important outcomes,” observed Dr. Hawton, lead author of the soon-to-be published Cochrane meta-analysis. Dr. Hawton is professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

The meta-analysis included 11 randomized trials of brief psychological therapy or treatment as usual in adults in which the primary outcome was repetition of self-harm during 6 months of follow-up. There were 146 such events in 663 patients who underwent psychological therapy, compared with 176 events in 640 controls, for an adjusted 43% relative risk reduction.

In 10 trials featuring 12 months of follow-up, some of which were also included in the 6-month analysis, there were 263 events in 1,101 psychotherapy recipients, compared with 308 events in 1,131 controls. That translates into a statistically significant 20% relative risk reduction favoring brief psychotherapy.

Depression scores at last follow-up were significantly lower in the psychotherapy recipients, compared with treatment as usual. So were hopelessness and suicidal ideation scores.

Nine suicides occurred among 1,169 patients randomized to psychotherapy, vs. 15 in 1,185 controls. Although this represents a 34% relative risk reduction, the difference wasn’t significant, because suicide was such a rare event, even in these high-risk patients who – as documented in the Multicentre Study of Self Harm in England – have a 50-fold greater risk of death by suicide in the year following a self-harm event than the risk in the general population.

“This illustrates the problem in using suicide as an outcome, even when you stack up a lot of studies,” Dr. Hawton noted.

The trials in the meta-analysis were conducted throughout the world, so “treatment as usual” in the control arm varied from study to study. But even in the United Kingdom, where the NICE guidelines state that all self-harm patients who present to a hospital should receive a psychosocial assessment, including an evaluation of their needs and risks, a 32-hospital study showed that only 60% of self-harm patients actually get such an assessment, the psychiatrist said.

A variety of forms of brief psychological therapy for self-harm were employed in the randomized trials. Most involved short-term cognitive-behavioral therapy, problem-solving therapy, or dialectical behavior therapy. Components shared by the various regimens included engagement; a careful examination of the process associated with an individual’s self-harm; problem-solving; cognitive therapy to address the patient’s problems, thoughts, images, and core beliefs; and ongoing monitoring of depression, hopelessness, and thoughts of self-harm.

“The self-harm population is very heterogeneous. There’s a wide range of problems and needs. Brief psychological therapy isn’t suitable for all patients. We’ve estimated that about 30% could benefit from this approach,” according to Dr. Hawton.

Based in part upon the Cochrane Collaboration analysis, the local directors of health services across England and Wales recently have received guidance that brief psychological therapy is to be made available routinely to patients seen by self-harm mental health programs, he added.

Self-harm is defined in the United Kingdom as intentional nonfatal self-poisoning or self-injury regardless of the degree of suicidal intent.

Looking ahead, Dr. Hawton cited several developments that show promise as potential new therapies for self-harm patients.

“Mindfulness has achieved great success in recent years, particularly based on very impressive impacts in people with relapsing depression. This is clearly an area that’s going to be developed in relation to the self- harm population. In fact, there is already work going on,” he said.

Similarly, randomized studies are underway evaluating ketamine and its analogs for acute suicidality based upon the highly favorable results reported in treating severe depression.

Internet and mobile telephone–based interventions for self-harm patients are “proliferating” at the moment, Dr. Hawton said.

“One of the issues is how to individualize therapy through these approaches,” he noted.

Dr. Hawton’s research is funded by the National Institute for Health Research. He reported having no financial conflicts.

[email protected]

ATLANTA – The strongest evidence to date that brief psychological therapy is effective in reducing repetition of acts of self-harm comes from a new Cochrane Collaboration meta-analysis.

Current guidelines on management of self-harm provided by the United Kingdom’s National Institute for Health and Care Excellence (NICE) state that psychological therapy “may” prevent recurrent self-harm, but this guidance relied upon limited evidence. The new Cochrane Collaboration review, based on 18 randomized controlled trials, greatly strengthens support for that conclusion, Dr. Keith Hawton said at the annual meeting of the American Association of Suicidology.

Bruce Jancin/Frontline Medical News

“And I’ve got to add, of course, that psychological therapy may be at least as effective in terms of other important outcomes,” observed Dr. Hawton, lead author of the soon-to-be published Cochrane meta-analysis. Dr. Hawton is professor of psychiatry and director of the Centre for Suicide Research at the University of Oxford (England).

The meta-analysis included 11 randomized trials of brief psychological therapy or treatment as usual in adults in which the primary outcome was repetition of self-harm during 6 months of follow-up. There were 146 such events in 663 patients who underwent psychological therapy, compared with 176 events in 640 controls, for an adjusted 43% relative risk reduction.

In 10 trials featuring 12 months of follow-up, some of which were also included in the 6-month analysis, there were 263 events in 1,101 psychotherapy recipients, compared with 308 events in 1,131 controls. That translates into a statistically significant 20% relative risk reduction favoring brief psychotherapy.

Depression scores at last follow-up were significantly lower in the psychotherapy recipients, compared with treatment as usual. So were hopelessness and suicidal ideation scores.

Nine suicides occurred among 1,169 patients randomized to psychotherapy, vs. 15 in 1,185 controls. Although this represents a 34% relative risk reduction, the difference wasn’t significant, because suicide was such a rare event, even in these high-risk patients who – as documented in the Multicentre Study of Self Harm in England – have a 50-fold greater risk of death by suicide in the year following a self-harm event than the risk in the general population.

“This illustrates the problem in using suicide as an outcome, even when you stack up a lot of studies,” Dr. Hawton noted.

The trials in the meta-analysis were conducted throughout the world, so “treatment as usual” in the control arm varied from study to study. But even in the United Kingdom, where the NICE guidelines state that all self-harm patients who present to a hospital should receive a psychosocial assessment, including an evaluation of their needs and risks, a 32-hospital study showed that only 60% of self-harm patients actually get such an assessment, the psychiatrist said.

A variety of forms of brief psychological therapy for self-harm were employed in the randomized trials. Most involved short-term cognitive-behavioral therapy, problem-solving therapy, or dialectical behavior therapy. Components shared by the various regimens included engagement; a careful examination of the process associated with an individual’s self-harm; problem-solving; cognitive therapy to address the patient’s problems, thoughts, images, and core beliefs; and ongoing monitoring of depression, hopelessness, and thoughts of self-harm.

“The self-harm population is very heterogeneous. There’s a wide range of problems and needs. Brief psychological therapy isn’t suitable for all patients. We’ve estimated that about 30% could benefit from this approach,” according to Dr. Hawton.

Based in part upon the Cochrane Collaboration analysis, the local directors of health services across England and Wales recently have received guidance that brief psychological therapy is to be made available routinely to patients seen by self-harm mental health programs, he added.

Self-harm is defined in the United Kingdom as intentional nonfatal self-poisoning or self-injury regardless of the degree of suicidal intent.

Looking ahead, Dr. Hawton cited several developments that show promise as potential new therapies for self-harm patients.

“Mindfulness has achieved great success in recent years, particularly based on very impressive impacts in people with relapsing depression. This is clearly an area that’s going to be developed in relation to the self- harm population. In fact, there is already work going on,” he said.

Similarly, randomized studies are underway evaluating ketamine and its analogs for acute suicidality based upon the highly favorable results reported in treating severe depression.

Internet and mobile telephone–based interventions for self-harm patients are “proliferating” at the moment, Dr. Hawton said.

“One of the issues is how to individualize therapy through these approaches,” he noted.

Dr. Hawton’s research is funded by the National Institute for Health Research. He reported having no financial conflicts.

[email protected]