August 2017: Science of Suicidality (SOS)

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August 2017: Science of Suicidality (SOS)

Comparison of Baseline Characteristics between Community-based and Hospital-based Suicidal Ideators and Its Implications for Tailoring Strategies for Suicide Prevention: Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior **

C. H. K. Park, J. W. Lee, S. Y. Lee, J. Moon, S. H. Shim, J. W. Paik, S. G. Kim, S. J. Cho, M. H. Kim, S. Kim, J. H Park, S. You, H. J. Jeon, & Y. M. Ahn.

This article investigated factors distinguishing between populations with suicidal ideation recruited from hospitals and communities.  The authors studied 137 individuals in a hospital-based cohort (HC) and 120 individuals in a community-based cohort (CC) with suicidal ideation obtained from the Korean Cohort for the Model Predicting a Suicide and Suicide-related Behavior (K-COMPASS) study.  They used the Mini International Neuropsychiatric Interview (MINI), Patient Health Questionnaire-9 (PHQ-9), Beck Anxiety Inventory (BAI), Alcohol Use Disorder Identification Test (AUDIT), Barratt Impulsiveness Scale-11 (BIS-11), Early Trauma Inventory Self Report-Short Form (ETISR-SF), Social Relationships Scale (SRS), and Stress Questionnaire for Korean National Health and Nutrition Examination Survey-Short Form (Stress Questionnaire for KNHANES-SF).  They found the HC had more psychiatric diagnoses than the CC.  They found the CC had low socioeconomic status, older age, and live in single households.  The authors recommend, “more clinical support for hospital visitors and more socioeconomic aid for community-dwellers showing suicidality”.

** The Mini International Neuropsychiatric Interview (MINI) was used in this study.  Harm Research Press (the publisher of the Science of Suicidality), Harm Research Institute (the owner of the website on which the Science of Suicidality is published), the editor of the Science of Suicidality, and the owners of Harm Research own or receive royalties from the sale and / or use of the MINI.



Creating Suicide Safety in Schools: A public health suicide prevention program in New York State

P. Breux, D. E. Boccio, & B. S. Brodsky.

This article provides an overview of the Creating Suicide Safety in Schools (CSSS) program and how it was implemented in New York State.  The CSSS is a framework for the integration of suicide prevention best practices based in schools which is focused on the identification of students with risk factors associated with an increase in death by suicide in group populations.  The authors describe the use of staff and faculty training, resiliency and social emotional programs for youth, plans for helping those identified at high risk for death by suicide, postvention plans for after a student dies by suicide, and the involvement of parents and community healthcare providers.  The article describes preliminary findings of a survey following CSSS workshop looking at the acceptability of this model in terms of knowledge, attitudes, sense of empowerment, and perceptions of administrative support.



CSF Apolipoprotein E in attempted suicide

P. Asellus, P. Nordström, A. L. Nordström, & J. Jokinen.

This study investigated whether Apolipoprotein E (ApoE) in cerebrospinal fluid was related to the count of earlier suicide attempts, the potential of reversibility or interruptabilty of the suicide attempt, and violent method of suicide attempt.  The authors studied 41 medication-free suicide attempters from the Karolinska University Hospital using the Beck Suicide Intent Scale (BSIS) and Freeman Intent-to-Die Scale.  Suicide attempts were classified according to violence of method.  They found ApoE levels were significantly negatively correlated to the Freeman Reversibility score.

This study should be repeated with a larger sample and the following comparison groups; 1) healthy controls with no history of suicidality, 2) patients with mental illness, but no history of suicidality, 3) patients with history of only suicidal ideation, and no suicide attempts, and 4) patients with history of suicide attempts, but with no mental illness.  Their finding that first time suicide attempters used a more violent method than those with a history of prior attempt(s) merits further investigation.



Deciphering Suicide and Other Manners of Death Associated with Drug Intoxication: A Centers for Disease Control and Prevention Consultation Meeting Summary

D. M. Stone, K. M. Holland, B. Bartholow, J. E. Logan, W. L. McIntosh, A. Trudeau, & I. R. H. Rockett.

This article provides a summary of a multidisciplinary meeting in March 2015 hosted by the U.S. Centers for Disease Control and Prevention (CDC) to discuss deaths by drug intoxication as they relate to suicide and other manners of death (MOD).  The meeting aimed to identify place-based, individual-level, and system-level factors impacting the classification of MOD and aimed to identify possible solutions to barriers of classification.  The authors report on suggested strategies to aid in classification and the need for continued coordination and collaboration among stakeholders.

This article provides several considerations to researchers or others using data from the National Violent Death Reporting System (NVDRS) due to differences in determining MOD per state law, medical examiner or coroner (ME/C) bias or training, legal implications for the ME/C, and funding constraints.



Disparities in Treatment of Older Adults with Suicide Risk in the Emergency Department

S. A. Arias, E. D. Boudreaux, D. L. Segal, I. Miller, C. A. Camargo, & M. E. Betz.

This study investigated characteristics and treatment received in the emergency department for adults 60 years and older with suicide risk in comparison to younger adults with suicide risk.  The authors studied charts of 800 patients (200 60 years and older, 600 under age 60) who had suicidal ideation in the past 2 weeks and / or had a suicide attempt in the past 6 months, as captured by the Patient Safety Screener, between May 2014 and September 2016.  Patient charts were from the University of Colorado Hospital as part of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study.  Within the group who had a positive suicide screen and were discharged to go home, the authors found only 42% of older adults received a mental health evaluation during their visit compared to 66% of younger adults.  The authors found older adults with recent suicidal ideation or suicide attempt (34%) were less likely than younger adults with similar suicidality (60%) to be referred to resources.

Please note the percentages listed above are from the abstract.  The results section of this article provide slightly different percentages.



Identification and Characteristics of Time-Related Shifts in Suicide-Related Event Frequency During Smoking Cessation Treatment with Varenicline

H. Akimoto, H. Wakiyama, S. Oshima, A. Negishi, K. Ohara, S. Numajiri, M. Okita, S. Ohshima, N. Inoue, & D. Kobayashi.

This study investigated time-related shifts in number of suicide-related events (SRE) during smoking cessation treatment with varenicline (VAR).  The authors investigated cases from the U.S. Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) through the first quarter of 2016.  They found removing effects of smoking history allowed detection of SRE onset signals over a long period from the start of VAR use.  They report the SRE observed during treatment with VAR showed a different expression profile than other central nervous system adverse events (i.e., nausea and abnormal dreams).  The authors recommend careful monitoring of SRE onset during smoking cessation treatment with VAR over the entire treatment period.

A range of Medical Dictionary for Regulatory Activities (MedDRA) terms used in this analysis, including self-injurious ideation (10051154) and self-injurious behavior (10063495), are not necessarily related to suicidality.  This study should be repeated without inclusion of the categories that are not themselves specifically suicidal by definition, as their inclusion may have inflated study results.



Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence **

B. Runeson, J. Odeberg, A. Pettersson, T. Edbom, I. J. Adamsson, & M. Waern.

This article investigated evidence for the use of suicide risk assessment instruments including an assessment of risk of bias and the diagnostic accuracy for future death by suicide and suicide attempt.  The authors identified 21 studies evaluating a total of 15 risk assessment instruments.  They found that most of the suicide risk assessment instruments could not be evaluated for accuracy due to lack of published studies.  The authors report that when looking at suicide attempts 1) the SAD PERSONS Scale had 15% sensitivity and 97% specificity and 2) the Manchester Self-Harm Rule (MSHR) had 97% sensitivity and 20% specificity.  They report ReACT (a modification of MSHR) and the the Sodersjukhuset Self Harm Rule had a similar low specificity of 24% and 17%, respectively.  They report that when looking at death by suicide the Beck Hopelessness Scale had 89% sensitivity and 42% specificity.  Of the suicide risk assessments which could be evaluated the authors found that, “none fulfilled requirements for sufficient diagnostic accuracy.”

The lack of any instruments fulfilling requirements for ‘sufficient diagnostic accuracy’ may be due to the impossibility of accurately predicting death by suicide or suicide attempts in an individual patient as a result of the general, non-linear pattern of suicidality.

** The Suicidality Module (Module B) of the Mini International Neuropsychiatric Interview (MINI) was one of the assessments included in this analysis.  Harm Research Press (the publisher of the Science of Suicidality), Harm Research Institute (the owner of the website on which the Science of Suicidality is published), the editor of the Science of Suicidality, and the owners of Harm Research own or receive royalties from the sale and / or use of the MINI.



Precision medicine for suicidality: from universality to subtypes and personalization

A. B. Niculescu, H. Le-Niculescu, D. F. Levey, P. L. Phalen, H. L. Dainton, K. Roseberry, E. M. Niculescu, J. O. Niezer, A. Williams, D. L. Graham, T. J. Jones, V. Venugopal, A. Ballew, M. Yard, T. Gelbart, S. M. Kurian, A. Shekhar, N. J. Schork, G. E. Sandusky, & D. R. Salomon.

This article investigated blood gene expression biomarkers for suicidality which are not specific to a particular psychiatric diagnosis or gender.  The authors identified a “Top Dozen” list of candidate biomarkers and a more thorough list of 148 candidate biomarkers.  They found subtypes and personalized approaches by gender and diagnosis permitted enhanced precision of predictions for different universal biomarkers.  Further, the authors provide information on which individual biomarkers are targeted by existing drugs used to treat suicidality (e.g., lithium and clozapine).

The authors’ finding that the phenotypic measures of anxiety, mood, and suicide risk factors (not including suicidal ideation) were more precise predictors than the blood biomarkers alone merit further investigation.  Their assumption that, “Suicide occurs maladaptively in the face of negative life events, with the individual who commits suicide being vulnerable due to a psychiatric illness and addictions, misperceiving circumstances and/or overreacting in an impulsive manner.” merits further investigation.  This study needs to be replicated in larger samples using a wider array of questions to assess the presence of suicidality and allowing for more than only 3 phenotypes of suicidality.  For example, some have theorized there are 12 distinct suicidality disorders phenotypes, which contain the 3 phenotypes used in this study.



Psychoneurometric assessment of dispositional liabilities for suicidal behavior: phenotypic and etiological associations

N. C. Venables, J. R. Yancey, M. D. Kramer, B. M. Hicks, R. F. Krueger, W. G. Iacono, T. E. Joiner, & C. J. Patrick.

This article investigates genetic and phenotypic associations of threat sensitivity (THT) and disinhibition (DIS) with suicidal behavior in adult twins.  The authors studied 444 identical and fraternal twins (107 female dizygotic [DZ], 122 female monozygotic [MZ], 101 male DZ, and 114 male MZ) recruited from an urban community using a psychological-scale measure of fearlessness / fear, physiological indicators of reactivity to aversive pictures, measures of disinhibitory tendencies, indicators of brain response from lab performance tasks, items from a structured interview, and items from the questionnaire protocols.  They report DIS and THT each contributed to prediction of suicidality when assessed as composites of scale and neurophysiological indicators.  The authors report “twin-modeling analyses revealed that a high percentage of the predictive association for each psychoneurometric trait (83% for THT, 68% for DIS) was attributable to genetic variance in common with suicidality.”

This article fails to provide demographic or other basic data on the individuals in the study.  For example, the article does not state how many of the participants experienced suicidality as captured by any of their measurements.  The reader does not know if 10%, 25%, 50%, or more of the study participants experienced suicidality.  This percentage of overall suicidality in the study would impact the generalizability of the study findings.

There was no interval constancy in the measures of suicidality used in this study. They used different look-back timeframes in assessing suicidality (e.g. in the “past 2 weeks”, ‘current’, and ‘lifetime’) and determined whether the THT or DIS measures were related to the presence of any suicidality within these various look-back timeframes.  The lack of interval constancy within the phenomena being predicted, casts serious doubt on the predictive utility of the measures of THT or DIS used in this study.  This study should be repeated to determine whether the differences in look-back timeframes for suicidality impacted the study results.

The questions used to assess suicidality combined multiple suicidality phenomena into one question.  Because of this, the authors are unable to dis-aggregate the suicidality phenomena now to clearly show what relationship exists between THT and DIS on the one side and each suicidality phenomenon on the other side.  This study should be repeated using one question to assess each individual suicidality phenomenon in order to determine if the THT or DIS are still ‘predictive’ of individual suicidality phenomena.



Suicidality and associated risk factors in outpatients attending a general medical facility in rural Kenya **

L. Ongeria, C. E. McCulloch, T. C. Neylanc, E. Bukusi, S. B. Macfarlane, C. Othieno, A.K. Ngugi, & S. M. Meffert.

This article investigated potential risk factors for suicidal ideation and suicide attempts in low-and-middle-income-countries (LMICs).  The authors studied 394 general medical outpatients in rural Kenya using the Socio-Economic Survey–SEARCH instrument, Mini International Neuropsychiatric Interview (MINI) version 5.0, Trauma History Questionnaire (THQ), Conflict Tactic Scale (CTS), and WHOQOL-BREF.  They found 17% of patients had lifetime history of suicide attempt, while 4% had made a suicide attempt in the past month.  The authors found 20% of patients had suicidal ideation in the past month.  They report patients who met criteria for Major Depressive Disorder (MDD) were 19 times [CI: 4.56, 79.05] more likely to report suicidal ideation compared to those without MDD (adjusted odds ratio 12.15 [CI: 2.66, 55.49]).

The finding that 18% of patients with suicidal ideation in the past month had also made a suicide attempt in the past month merits further investigation.

** The Mini International Neuropsychiatric Interview (MINI) was used in this study.  Harm Research Press (the publisher of the Science of Suicidality), Harm Research Institute (the owner of the website on which the Science of Suicidality is published), the editor of the Science of Suicidality, and the owners of Harm Research own or receive royalties from the sale and / or use of the MINI.



Suicide and suicide attempts among women in the Manitoba Mothers and Fetal Alcohol Spectrum Disorder cohort: a retrospective matched analysis using linked administrative data

D. Singal, M. Brownell, D. Chateau, E. Wall-Wieler, S. Longstaffe, A. Hanlon-Dearman, & L. L. Roos.

This study retrospectively investigated death by suicide rates before, during, and after pregnancy between women who had given birth to children with Fetal Alcohol Spectrum Disorder (FASD) and women who had given birth to children without FASD.  The authors studied 2,799 women who had given birth between April of 1984 and March of 2012 in Manitoba Province, Canada (702 had children with FASD and 2,097 matched controls who had children without FASD) to determine the count and timing of suicide attempts or death by suicide using ICD coding in medical records.  They found the FASD group had 1) a higher death by suicide rate (adjusted RR 6.20 [95% confidence interval (CI) 2.36–16.31]); 2) a higher attempted suicide rate after the postpartum period (adjusted RR 4.62 [95% CI 2.53–8.43]); and 3) a higher count of suicide attempts after the postpartum period (adjusted RR 3.92 [95% CI 2.30–6.09]).

Given these high rates of suicide attempts and death by suicide in mothers of a child with FASD, it may be prudent to routinely assess suicidality in all mothers with children with FASD.



Survey of Australian dermatologists’ perceptions and experiences with isotretinoin-induced depression and suicide

S. Rea, S. Tucker, V. Frittelli, & R. Gunnarsson.

This letter to the editor reports on a survey investigating dermatologists’ experiences and perceptions with isotretinoin-induced depression and suicide in acne patients.  The authors surveyed 73 dermatological clinicians (64 consultant dermatologists and 9 dermatology registrars) at the 48th Australasian College of Dermatologists Annual Scientific Meeting Acne Symposium.  They report 78% of respondents saw patients with acne who were treated with isotretinoin later developed depressive symptoms.  The authors further report 32% of respondents witnessed patients with acne become suicidal or died by suicide while on isotretinoin.  They recommend educating dermatologists on DSM criteria for MDD and implementing screening tools to monitor for potential mental health side effects of oral isotretinoin.

Dermatologists should monitor suicidality in patients taking oral isotretinoin throughout their course of treatment.


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