Manges, M. E., Bryan, C. J., Bryan, AB. O., Bauder, C. R., Wastler, H. M. (2023). Suicidal thoughts and behaviors among gender and sexual minorities: Adults ages 25-44 show highest rates of past month suicidal thoughts. Suicide and Life-Threatening Behavior. https://doi.org/10.1111/sltb.13029. The above article, published online on 15 December 2023 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor in Chief, Thomas Joiner, PhD, and Wiley Periodicals LLC on behalf of the American Association of Suicidology. The retraction has been agreed due to errors in the interpretation of the chi-square analysis comparing sexual and gender minorities. Following discovery of the error in interpretation, the authors informed the editorial office and have revised the article with the intent of sharing the corrected results. The correction needed to amend the version of record requires significant alterations to the published article, which requires the journal to issue a retraction. An updated version of this article has been submitted for peer review at Suicide and Life-Threatening Behavior."
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The “pulling-together effect” has been widely studied in the context of large-scale crises, such as wars, natural disasters, epidemics, and pandemics. This study was conducted from November 2020 to June 2021 and suggests a possible association with this effect, as this period may represent one of the most intense phases of the pulling-together effect ever studied in the context of global catastrophes. This study aimed to evaluate the association between life-threatening behavior and satisfaction with social relationships in online psychotherapy patients, which may be related to the pulling-together effect and the COVID-19 pandemic. The clinical sample was composed mostly of females (80%), aged from 21 to 30 years. Patients were selected from the psychotherapy services of five major hospitals in Porto Alegre, a state capital in southern Brazil. Preliminary results indicated that 41 individuals (44%) had some form of life-threatening behavior, and 62 (66%) rated their satisfaction with personal relationships as satisfactory or indifferent. After adjustment for other variables—gender, skin-color, and marital status—satisfaction with social relationships showed a protective effect, reducing life-threatening behavior by 29% (95%CI: 0.59–0.86, p < 0.001). Our results suggest that satisfaction with social relationships was protective against suicidal behavior in the early stages of the pandemic. In this sample, we identified a possible association with the pulling-together effect. The online version contains supplementary material available at 10.1186/s41155-026-00384-3.
Dialectical behavior therapy (DBT) is an empirically supported behavioral treatment for individuals with borderline personality disorder who frequently exhibit life-threatening behavior, such as suicide attempts, nonsuicidal self-injury urges and actions, and suicidal ideation. We provide an overview of the theoretical framework by which DBT conceptualizes these life-threatening behaviors and the principles by which safety planning measures are implemented and maintained throughout treatment. The importance of orienting clients to treatment and obtaining their commitment to decrease life-threatening behavior is reviewed. Relevant strategies associated with risk management and assessment, such as the diary card, chain analysis, solution analysis, phone coaching, and consultation team, are described. The overview concludes with a case example to illustrate the application of these techniques with a DBT client with a long-standing history of engaging in life-threatening behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
This study examines associations between structural minority stress and behavioral health outcomes including suicidal ideation and behaviors, substance use, and sexual risk taking among sexual minority adolescents. Data were analyzed from the 2021 Youth Risk Behavior Survey, which included 3,996 sexual minority adolescents. A series of multi-level binomal logistic models were calculated to examine the association between state equity index and suicidal thoughts and behaviors (ideation, plan, attempt, hospitalization), condom use at last intercourse, and substance use (nicotine vape, marijuana use, illicit drug use). State equity index was associated with lower odds of suicidal ideation and having a plan for suicide in the past year. Similarly, state equity index was also associated with lower odds of vaping nicotine in the past 30-days as well as having condomless sex during last sexual intercourse. Living in a state with more protections for sexual minority and transgender people through state-level policies was generally associated with less risk taking. These results underscore the importance of public policy on potentially severe or life-threatening behaviors - particularly around suicidal ideation and plan and sexual risk taking.
Self-harm and suicidal ideation are prevalent among adolescents, cause physical and psychosocial disability, and have potentially life-threatening consequences. Dialectical behavioral therapy for Adolescents (DBT-A) is an evidence-based intervention for reducing self-harm. However, few studies have investigated the effectiveness of DBT-A when delivered in routine clinical practice. A follow-up cohort study, based on data from a quality assessment register of DBT-A in child and adolescent mental health services including seven outpatient clinics. Inclusion criteria were ongoing or a history of self-harming behavior the last 6 months; current suicidal behavior; at least 3 criteria of DSM-IV Borderline personality disorder (BPD), or at least the self-destruction criterion of DSM-IV BPD, in addition to minimum 2 subthreshold criteria; and fluency in Norwegian. Participants received 20 weeks of DBT-A consisting of multifamily skills training groups and individual therapy sessions. Outcomes from 41 participants included frequency of self-harm, suicide attempts and hospitalizations caused by self-harm or suicide attempts, assessed pre-, during, and post-treatment by self-report and reviews of the patient's medical records. Suicidal ideation, urge to self-harm and perceived feelings of happiness and sadness were assessed by the patients' diary cards at week 1, 5, 10, 15 and 20 of the treatment program. Participants attended an average of 17.9 (SD = 4.7) individual sessions, 14.7 (SD = 3.4) group-based skills training sessions and 4.6 (SD = 4.1) brief intersession telephone consultations. Moderate to large within-group effect sizes (ES) were found in self-harm from pre-treatment to 1-5 weeks (d = 0.64), 6-10 weeks (d = 0.84), 11-15 weeks (d = 0.99), 16-20 weeks (d = 1.26) and post-treatment (d = 1.68). Nine participants were admitted to hospitalization during DBT-A, whereas five had attempted suicide, but no suicides were completed. No statistically significant changes were found in suicidal ideation, urge to self-harm or perceived feelings of happiness or sadness from pre to post treatment. The findings of the current study are promising as the participants reported considerably reduced self-harm behavior after DBT-A treatment in a child and adolescent mental health outpatient setting.
This study examines psychopathology and personality correlates of non-suicidal self-injury (NSSI) and suicide-related behavior (SRB) in an understudied sample of adolescents who have exhibited behaviors (e.g., delinquent acts, premature high school termination) that place them at-risk for poor psychosocial outcomes. Participants included a predominantly White male sample of 182 adolescents (Mage = 16.82 years). In addition to information about NSSI and SRB histories, participants self-reported various facets of personality and psychopathology on the Personality Assessment Inventory-Adolescent (PAI-A). Logistic regression analyses indicated that the Suicidal Ideation (SUI) scale on the PAI-A was the strongest predictor of both NSSI and SRB history, as it outperformed other relevant PAI-A scales and the Suicide Potential Index (SPI), an aggregate scale that was designed to assess for suicide risk using the PAI for adults. Receiver operating characteristic (ROC) curve analyses were also conducted to determine optimal cutoff scores for significant PAI-A predictors. Findings from the current study can be used to identify NSSI and SRB risk and target these life-threatening behaviors when working with at-risk adolescents.HighlightsPAI-A SUI outperformed other PAI-A variables in predicting NSSI and SRB risk.PAI SPI did not perform as well in adolescents compared to adult samples.Cutoff scores in the current sample were well below those in the PAI-A manual.
Suicide is a leading cause of death worldwide. In 2020, some 12.2 million Americans seriously contemplated suicide, 3.2 million planned suicide attempts, and 1.2 million attempted suicide. Traditionally, the approach to treating suicidal behavior (SB) has been to treat the "underlying" psychiatric disorder. However, the number of diagnoses associated with SB is considerable. We could find no studies describing the range of disorders reported to be comorbid with SB. This narrative review summarizes literature documenting the occurrence of SB across the lifespan and the full range of psychiatric diagnoses, not only BPD and those that comprise MDE, It also describes the relevance of these observations to clinical practice, research, and nosology. The literature searches contained the terms "suicid*" and each individual psychiatric diagnosis and identified 587 studies. We did not include case reports, case series, studies only addressing suicidal ideation or non-suicidal self-injury (NSSI), studies on self-harm, not distinguishing between SB and NSSI and studies that did not include any individuals that met criteria for a specific DSM-5 diagnosis (n = 366). We found that SB (suicide and/or suicide attempt) was reported to be associated with 72 out of 145 diagnoses, although data quality varied. Thus, SB is not exclusively germane to Major Depressive Episode (MDE) and Borderline Personality Disorder (BPD), the only conditions for which it is a diagnostic criterion. That SB co-occurs with so many diagnoses reinforces the need to assess current and past SB regardless of diagnosis, and supports the addition of charting codes to the DSM-5 to indicate current or past SB. It also comports with new data that specific genes are associated with SB independent of psychiatric diagnoses, and suggests that SB should be managed with specific suicide prevention interventions in addition to treatments indicated for co-occurring diagnoses. SB diagnostic codes would help researchers and clinicians document and measure SB's trajectory and response to treatment over time, and, ultimately, help develop secondary and tertiary prevention strategies. As a separate diagnosis, SB would preclude situations in which a potentially life-threatening behavior is not accounted for by a diagnosis, a problem that is particularly salient when no mental disorder is present, as is sometimes the case.
It is difficult to predict who will end their life by suicide, but often possible to prevent a suicide. To succeed with suicide prevention within healthcare, a clinical practice is required that includes more than assessing signs of psychiatric disease. Assessments of suicide risk must include the patient's own perspective and narrative, as well as life-threatening behavior and reasons to live. Cooperation with relatives is necessary to understand the whole picture, and alternative behavior in situations where life seems impossible to endure should be the long-term goal of all suicide prevention.
Self-injurious behavior (SIB) is common in prisons, but a small subset of episodes involves extreme medical severity, atypical methods, and striking psychiatric complexity. This retrospective mixed-methods study aimed to identify and describe "extreme" SIB within a large U.S. state prison system and to characterize its medical, behavioral, and contextual features. We reviewed 5.5 years of critical incident reports and, from all self-harm-related events, identified 85 episodes that met an a priori definition of extreme SIB, including clear risk of death or disfigurement, ingestion or insertion of foreign bodies or toxic substances, targeting of the face, eyes, or genitals, bizarre or psychotic features, and/or use of multiple severe methods in a single episode. Quantitative coding documented that most incidents (80%) involved life-threatening medical risk, nearly half (49%) featured ingestion or insertion of foreign objects or toxic substances, over one third (35%) targeted the face, eyes, or genitals, and 41% combined more than one severe method; altered mental states or bizarre behavior were described in 59% of events. Thematic analysis of staff narratives highlighted massive blood loss, unusual instruments and body insertion, symbolic attacks on identity and sexuality, "method stacking," and altered mental states, often in the context of segregation, disciplinary action, or adverse legal news. Extreme SIB appears to be a low base-rate but high-impact phenomenon that concentrates psychiatric morbidity, medical cost, and institutional disruption, and is often poorly matched to standard custodial responses. The findings support the need for specialized forensic assessment, clinical management, and policy responses for this subgroup.
Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.
Penetrating cardiac injury (PCI) is rare and life-threatening, with complications that include hemorrhage, tamponade, arrhythmia, and cardiac arrest. Needle insertion into the heart is infrequently reported; to our knowledge, only one case of recurrent self-insertion has been described. A 29-year-old man with bipolar I disorder and a prior sternotomy for foreign-body removal presented after a second suicide attempt within two years, having self-inserted multiple needles through the chest and abdomen. Chest radiography showed three metallic densities in the left hemithorax and one in the abdominal wall. Transthoracic echocardiography demonstrated a linear metallic echo within the left ventricle (LV) near the apex. Computed tomography confirmed three metallic densities in the left thorax, one penetrating the LV to a depth of 30 mm. Median sternotomy was performed, and one needle was removed from the LV. After recovery, the patient was transferred to a psychiatric hospital for further inpatient treatment. Intentional cardiac injury by needle insertion is extremely rare and poses diagnostic and therapeutic challenges. Early imaging and prompt surgery are essential to reduce morbidity and mortality. A multidisciplinary plan, including psychiatric evaluation and follow-up, is required to prevent fatal outcomes and recurrence. This study describes the successful management of a penetrating cardiac injury in a patient with a prior sternotomy.
Postictal psychosis (PIP) is a serious, often unrecognized complication of epilepsy. Early diagnosis and intervention can prevent life-threatening outcomes. We report the case of a 26-year-old woman with childhood-onset frontal lobe epilepsy who attempted suicide, during a postictal psychotic episode, several days after undergoing inpatient video-EEG monitoring. This case presents a real-world scenario with clear guidelines for the on-call neurologist who will need to accurately diagnose and confidently manage PIP with psychotropic medications. Moreover, this case may stimulate discussion about the complex relationship between epilepsy and psychosis.
Suicide is the second-leading cause of death among adolescents. Sexual minority individuals are at a higher risk of suicide and attempted suicide, but a precise and systematic evaluation of this risk among sexual minority youths has not been documented to our knowledge. To examine the risk of attempted suicide among sexual minority adolescents, differentiating for each sexual minority group. Electronic databases (PubMed, Embase, and PsycINFO) were searched for articles published through April 30, 2017, with the following search terms: heterosexual, homosexual, bisexual, transgender, adolescents, teens, and attempted suicide. Studies that reported attempted suicide in sexual minority adolescents compared with heterosexual peers were included. Thirty-five studies satisfied criteria for inclusion of 764 records identified. Pooled analyses were based on odds ratios (ORs), with relevant 95% CIs, weighting each study with inverse variance models with random effects. Risk of publication bias and analysis of heterogeneity through univariable and multivariable meta-regressions were also rated. The evaluation of increased odds of attempted suicide among sexual minority youths compared with heterosexual peers. Thirty-five studies reported in 22 articles that involved a total of 2 378 987 heterosexual and 113 468 sexual minority adolescents (age range, 12-20 years) were included in the analysis. Sexual minority youths were generally at higher risk of attempted suicide (OR, 3.50; 95% CI, 2.98-4.12; c2 = 3074.01; P < .001; I2 = 99%). If estimated in each sexual minority group, the OR was 3.71 in the homosexual group (95% CI, 3.15-4.37; c2 = 825.20; P < .001; I2 = 97%) and 4.87 in the bisexual group (95% CI, 4.76-4.98; c2 = 980.02; P < .001; I2 = 98%); transgender youths were described as an individual group in only 1 study, which reported an OR of 5.87 (95% CI, 3.51-9.82). Meta-regressions weighted for the study weight highlighted that the presence of young participants (12 years old) was associated with heterogeneity in the bisexual group, whereas the year of sampling was associated with heterogeneity in the whole group when combined with other covariates. Our findings suggest that youths with nonheterosexual identity have a significantly higher risk of life-threatening behavior compared with their heterosexual peers. Public awareness is important, and a careful evaluation of supportive strategies (eg, support programs, counseling, and destigmatizing efforts) should be part of education and public health planning.
Prior research has documented shared heritable contributions to non-suicidal self-injury (NSSI) and suicidal ideation (SI) as well as NSSI and suicide attempt (SA). In addition, trauma exposure has been implicated in risk for NSSI and suicide. Genetically informative studies are needed to determine common sources of liability to all three self-injurious thoughts and behaviors, and to clarify the nature of their associations with traumatic experiences. Multivariate biometric modeling was conducted using data from 9526 twins [59% female, mean age = 31.7 years (range 24-42)] from two cohorts of the Australian Twin Registry, some of whom also participated in the Childhood Trauma Study and the Nicotine Addiction Genetics Project. The prevalences of high-risk trauma exposure (HRT), NSSI, SI, and SA were 24.4, 5.6, 27.1, and 4.6%, respectively. All phenotypes were moderately to highly correlated. Genetic influences on self-injurious thoughts and behaviors and HRT were significant and highly correlated among men [rG = 0.59, 95% confidence interval (CI) (0.37-0.81)] and women [rG = 0.56 (0.49-0.63)]. Unique environmental influences were modestly correlated in women [rE = 0.23 (0.01-0.45)], suggesting that high-risk trauma may confer some direct risk for self-injurious thoughts and behaviors among females. Individuals engaging in NSSI are at increased risk for suicide, and common heritable factors contribute to these associations. Preventing trauma exposure may help to mitigate risk for self-harm and suicide, either directly or indirectly via reductions in liability to psychopathology more broadly. In addition, targeting pre-existing vulnerability factors could significantly reduce risk for life-threatening behaviors among those who have experienced trauma.
The present study evaluated whether adverse childhood experiences (ACEs) are significantly and independently associated with six key outcomes in the Polish general population: (1) lifetime suicide attempt, (2) self-mutilation, (3) potential problem drinking, (4) use of street drugs, (5) visiting a psychologist/psychotherapist, and (6) visiting a psychiatrist. We also investigated whether ACEs explain a significant proportion of variability in generalized self-efficacy. Six hundred and fifty-nine individuals completed the ACE Study questionnaire (physical, verbal, and sexual abuse; neglect; select family dysfunctions) and three additional questions [ACE (13) questionnaire]: witnessing (1) a family member's suicide attempt or (2) death due to any cause except completed suicide, and (3) a stranger's death due to any cause (e.g., traffic accident). Generalized self-efficacy was assessed with the Generalized Self-Efficacy Scale. The likelihood of lifetime use of street drugs, potential problem drinking, and visiting a psychologist/psychotherapist and psychiatrist increased as ACE and ACE (13) score increased. As compared to scores of < 4, ACE (13) scores of ≥ 4 were associated with a 10.8-fold increased likelihood of self-mutilation, a 3.26-fold increased likelihood of potential problem drinking, a 5.72-fold increased likelihood of visiting a psychologist/psychotherapist, and a 6.71-fold increased likelihood of visiting a psychiatrist. ACE (13) score explained 1.2% of the variability in generalized self-efficacy. The present study identified a strong association between childhood adversity and increased likelihood of lifetime self-mutilation, potential problem drinking, visiting a psychologist/psychotherapist, and visiting a psychiatrist. Generalized self-efficacy may be an important target for secondary intervention following childhood adversity.
Religion is a salient aspect of patient background in treatment (The psychology of religion and coping: Theory, research, practice; Guilford Press). However, research investigating the role of religion in suicide is lacking and inconsistent (Journal of Religion and Health, 57, 2478-2499). The current study (1) clarifies the association between religious identity and fearlessness about death in a psychiatric sample and (2) tests whether religious identity moderates the association between fearlessness about death and suicidal ideation. Participants were 155 patients seeking treatment in a partial hospital program. Religious identity was assessed using the Identities in Treatment Scale (The Behavior Therapist). Fearlessness about death was assessed with two relevant items from the acquired capability with rehearsal for suicide scale (Psychological Assessment, 28, 1452-1464), as in prior studies (Suicide & Le-Threatening Behavior, 50, 1230-1240; Journal of Affective Disorders Reports, 12, 100492). Fearlessness about death interacted with religious identity to predict suicidal ideation, b = 0.47, 95% C.I. [0.02, 0.91], p = 0.042. Conditional effects showed that greater fearlessness about death was associated with greater suicidal ideation among non-religious patients, b = -0.56, 95% C.I. [-0.88, -0.24], p = 0.001, but not in religious patients, b = -0.09, 95% C.I. [-0.41, 0.22], p = 0.559. Our results suggest that fearlessness about death is a risk factor for suicidal ideation, but only among those who do not identify as religious. Results from this study inform theories of suicide and elucidate the influence of religious identity on links among suicide risk factors and suicide-related outcomes.
Introduction Posttraumatic stress disorder (PTSD) may develop after exposure to stressful or life-threatening events and is linked to suicidal behavior. Personality is hypothesized to be a mediator of this risk though assessing factors influencing such findings has been difficult due to the psychiatric comorbidities of the disorder. Objective The aim of the study was to examine the relationship between personality and suicidal behavior in people with PTSD. Method This was a cross-sectional study with 67 participants diagnosed with PTSD who completed a structured interview (SCID-II), and an inventory (NEO-FFI) to gather personality characteristics. Data were collected and analyzed through statistical software, and the investigation period ranged from August 2020 to July 2021. Results Extraversion was correlated with suicide attempts, borderline traits predicted the number of these, and a negative relationship was found between conscientiousness and the same variable. Schizotypal traits were also positively correlated to self-harm. Extraversion, schizoid, borderline, and obsessive-compulsive traits were more likely to be diagnosed with either depressive and/or anxious disorders. Extraversion's association with suicidal attempts is inconsistent with previous studies, although the correlation of borderline traits with the same variable complies with existing knowledge. Schizotypal traits and their link with self-harm may be a novelty for this line of research, although the connection between extraversion, schizoid, borderline, and obsessive-compulsive traits along with depressive and anxious disorders echoes current literature. Conclusion Certain characteristics of personality are related to suicidal behavior in individuals with PTSD.
During a trial, standardization can lock in a treatment that researchers learn is flawed and may be ineffective. In such cases, researchers typically decide between two options, continue the trial and monitor for iatrogenic effects or stop the trial. When faced with this dilemma while testing an adaptation of motivational interviewing to address suicidal ideation, our research team considered a third option, to correct the flaws in the intervention and study the effect on outcome. We explored the rationale for and against changing an intervention mid-trial and progressed through a series of steps to determine whether we should change the intervention, ultimately deciding to make changes and examine their impact. We developed a procedure that researchers can use to determine whether they should change an intervention during a trial, how to implement the changes, and how to redesign their study. When faced with evidence that a treatment is ineffective, researchers should consider changing the intervention and examining the effects of the changes on outcome. Such decisions may be particularly relevant in trials examining life-threatening outcomes. Making and studying these changes may increase the potential for the study to identify a treatment that produces a desired outcome.
Suicidal ideation and behavior are among the most severe psychiatric presentations, warranting emergency room visits and psychiatric admission for higher levels of care. In the United States, suicide rates continue to climb, especially in younger patients, and the continued psychosocial stressors of the COVID-19 pandemic may further exacerbate this crisis. Suicidal ideation and behavior are core features of a major depressive episode, but there are limited treatment options to rapidly redress these life-threatening symptoms. Racemic ketamine and its S-enantiomer, esketamine, are N-methyl-D-aspartate receptor antagonists and glutamate modulators that have robust antidepressant efficacy in treatment-resistant major depressive disorder and bipolar depression. Additionally, both ketamine and esketamine have demonstrated rapid-acting antisuicidal efficacy in major mood disorders. In August 2020, this culminated in a first-in-class approval of Spravato® (intranasal esketamine) for the treatment of major depressive disorder with acute suicidal ideation and behavior. In this article, we review the literature in support of the antisuicidal efficacy of ketamine and esketamine.