Development and evaluation of the Clinician Suicide Risk Assessment Checklist

This paper describes the development and evaluation of a new instrument - the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician's competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.

A Qualitative Study of Potential Suicide Risk Factors Among Soldiers Transitioning From Operation Iraqi Freedom/Operation Enduring Freedom

Using qualitative methods, this study explored potential risk factors for suicide, as defined by Joiner's Interpersonal-Psychological Theory of Suicide (IPTS), in a population of Soldiers returning from deployment in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF). Sixty-eight Soldiers participated in semi-structured interviews during the period of transition from deployment to the garrison environment. These Soldiers were asked about changes in perception of pain, experiences of perceived burdensomeness, and lack of belonging. Interviews were transcribed and analyzed. A phenomenological methodology was employed (Creswell, 2006). In response to questions about perception of pain, Soldiers discussed both positive and negative changes in their experience of physical and emotional pain. When asked about experiences of perceived burdensomeness, Soldiers described changes related to deployment, such as injuries and combat related guilt, as well as changes related to transition from combat, including care seeking, reintegration into family and society, and emotional distancing. Regarding the experience of lack of belonging, Soldiers described difficulties related to the deployment, such as combat injuries, leadership roles, and individual differences, as well as difficulties related to reintegration such as symptoms of emotional numbing and distancing. Findings highlight the potential utility of IPTS in exploring both acute and chronic suicide risk factors associated with deployment and transition, as well as potential treatment strategies that may reduce suicide risk in the population of Soldiers during reintegration.

Perceived academic performance, self-esteem and locus of control as indicators of need for assessment of adolescent suicide risk: implications for teachers

Introduction: There is currently a need for research into indicators that could be used by non-clinical professionals working with young people, to inform the need for referral for further clinical assessment of those at risk of suicide. Method: Participants of this repeated measures longitudinal study, were 2603, 2485, and 2246 school students aged 13, 14, and 15, respectively, from 27 South Australian Schools. Results: Perceived academic performance, self-esteem and locus of control are significantly associated with suicidality. Further, logistic regression of longitudinal results suggests that perceived academic performance, over and above self-esteem and locus of control, in some instances, is a good long-term predictor of suicidality. (C) 2004 Published by Elsevier Ltd. on behalf of The Association for Professionals in Services for Adolescents.

Development and evaluation of the Clinician Suicide Risk Assessment Checklist

This paper describes the development and evaluation of a new instrument – the Clinician Suicide Risk Assessment Checklist (CSRAC). The instrument assesses the clinician’s competency in three areas: clinical interviewing, assessment of specific suicide risk factors, and formulating a management plan. A draft checklist was constructed by integrating information from 1) literature review 2) expert clinician focus group and 3) consultation with experts. It was utilised in a simulated clinical scenario with clinician trainees and a trained actor in order to test for inter-rater agreement. Agreement was calculated and the checklist was re-drafted with the aim of maximising agreement. A second phase of simulated clinical scenarios was then conducted and inter-rater agreement was calculated for the revised checklist. In the first phase of the study, 18 of 35 items had inadequate inter-rater agreement (60%>), while in the second phase, using the revised version, only 3 of 39 items failed to achieve adequate inter-rater agreement. Further evidence of reliability and validity are required. Continued development of the CSRAC will be necessary before it can be utilised to assess the effectiveness of risk assessment training programs.

Lifetime suicide risk in major depression: sex and age determinants

Background: Recent work has demonstrated that the lifetime suicide risk for patients with DSM IV Major Depression cannot mathematically approximate the accepted figure of 15%. Gender and age significantly affect both the prevalence of major depression and suicide risk, Methods: Gender and age stratified calculations were made on the entire population of the USA in 1994 using a mathematical algorithm. Sex specific corrections for under-reporting were incorporated into the design. Results: The lifetime suicide risks for men and women were 7% and 1%, respectively. The combined risk was 3.4%. The male:female ratio for suicide risk in major depression was 10:1 for youths under 25, and 5.6:1 for adults. Conclusions: Suicide in major depression is predominantly a male problem, although complacency towards female sufferers is to be avoided. Diagnosis of major depression is of limited help in predicting suicide risk compared to case specific factors. The male experience of depression that leads to suicide is often not identified as a legitimate medical complaint by either sufferers or professionals. Increasing help-accessing by males is a priority. Clinical implications: Patients with a history of hospitalisation; comorbidity, especially for substance abuse; and who are male, require greater vigilance for suicide risk. It may be that for males che threshold for diagnosing and treating major depression needs to be lowered. Limitations: This research is based on a mathematical algorithm to approximate a life-long longitudinal study that identifies community cases of depression. Our findings therefore rely on the validity of the statistics used. Extrapolation is limited to populations with an actual suicide rate of 17/100,000 or less and a lifetime prevalence of major depression of 17% or more. (C) 1999 Elsevier Science B.V. All rights reserved.

The role of suicide risk in the decision for psychiatric hospitalization after a suicide attempt

BACKGROUND: Suicide prevention can be improved by knowing which variables physicians take into account when considering hospitalization or discharge of patients who have attempted suicide. AIMS: To test whether suicide risk is an adequate explanatory variable for predicting admission to a psychiatric unit after a suicide attempt. METHODS: Analyses of 840 clinical records of patients who had attempted suicide (66.3% women) at four public general hospitals in Madrid (Spain). RESULTS: 180 (21.4%) patients were admitted to psychiatric units. Logistic regression analyses showed that explanatory variables predicting admission were: male gender; previous psychiatric hospitalization; psychiatric disorder; not having a substance-related disorder; use of a lethal method; delay until discovery of more than one hour; previous attempts; suicidal ideation; high suicidal planning; and lack of verbalization of adequate criticism of the attempt. CONCLUSIONS: Suicide risk appears to be an adequate explanatory variable for predicting the decision to admit a patient to a psychiatric ward after a suicide attempt, although the introduction of other variables improves the model. These results provide additional information regarding factors involved in everyday medical practice in emergency settings.

Smoking, depression, and suicide risk in the nursing staff of a Third-Level Hospital

Objective: To determine the association between smoking, depression and suicide risk in the Nursing Staff of a University Hospital. Materials and method: this was a non-experimental, correlational cross-range study with observational analysis carried out between May 2012 and May 2013. We studied 232 nurses of the “Dr. José Eleuterio gonzález” University Hospital. two self-administered scales were applied, one for depression and one for suicide risk. Another hetero-applied scale of nicotine dependency was also used, and the subjects’ socio-demographic records were reviewed. Results: A total of 527,232 nurses were studied. A smoking prevalence of 22.8% (53 subjects), an operational depression prevalence of 15.1% (35 subjects), and a suicide risk of 5.1% (12 subjects) were found. Gender and age, speciically being male and young (mean age 29.2 years) were found to increase the risk of smoking. We also found that those nurses who had a partner and had a higher level of education smoked less compared to those who did not have a partner or had a lower degree of education. there were hospital departments where there was a higher prevalence of smoking, such as Internal Medicine and Shock trauma. No association between smoking and the presence of depression was found. Regarding depression, we found that those nurses who worked in the Department of Pensioners were more likely to develop operational depression than those working in any other department. We also found that the risk of presenting operational depression decreases as age increases. About suicide risk, a statistically signiicant association between smoking and suicide risk was found. We also found an association between operational depression and suicide risk.Conclusions: It is recommended to consider nicotine dependence as a fundamental part of psychopathology assessment because of its strong association with suicide risk. this study emphasizes the complexity of the issue of the comorbidity of smoking and psychopathology and the need to continue research lines.

Self-report depressive symptoms do not directly predict suicidality in nonclinical individuals: Contributions toward a more psychosocial approach to suicide risk

Although suicidality is associated with mental illness in general and depression in particular, many depressed individuals do not attempt suicide and some individuals who attempt to or do die by suicide do not present depressive symptoms. This article aims to contribute to a more psychosocial approach to understanding suicide risk in nonclinical populations. In advocating a psychosocial perspective rather than a depression-focused approach, this article presents four diverse studies that demonstrate sampling and measurement invariance in findings across different populations and specific measures. Study 1 tests the mediation effects of 2 interpersonal variables, thwarted belongingness and perceived burdensomeness, in the association between depressive symptoms and recent suicidality. Studies 2 and 3 evaluate the contribution of hopelessness and psychache, beyond depressive symptoms, to suicidality. Study 4 tests the contribution of life events behind depressive symptoms, and other relevant sociodemographic and clinical variables, to the estimation of “future suicidality.” Overall, results demonstrate that depressive symptoms do not directly predict suicidality in nonclinical individuals, but that other psychosocial variables mediate the association between depressive symptoms and suicidality or predict suicidality when statistically controlling for depressive symptoms. The article contributes to understanding some of the nonpsychopathological factors that potentially link depressive symptoms to suicide risk and that might themselves contribute to suicidality, even when controlling for depressive symptoms.

The moderating effect of gender on the relationship between coping and suicide risk in a Portuguese community sample of adults

Background and aims(s): The study evaluated the contribution of coping strategies, based on the Toulousiane conceptualization of coping, to the prediction of suicide risk and tested the moderating effect of gender, controlling for depressive symptoms. Method: A two-time data collection design was used. A community sample of 195 adults (91 men and 104 women) ranging in age from 19 to 65 years and living in several Portuguese regions, mostly in Alentejo, participated in this research. Results: Gender, depressive symptoms, control, and withdrawal and conversion significantly predicted suicide risk and gender interacted with control, withdrawal and conversion, and social distraction in the prediction of suicide risk. Coping predicted suicide risk only for women. Conclusions: Results have important implications for assessment and intervention with suicide at-risk individuals. In particular,the evaluation and development of coping skills is indicated as a goal for therapists having suicide at-risk women as clients.

Religion and the risk of suicide: longitudinal study of over 1 million people

Background: Durkheim’s seminal historical study demonstrated that religious affiliation reduces suicide risk, but it is unclear whether this protective effect persists in modern, more secular societies.

Aims: To examine suicide risk according to Christian religious affiliation and by inference to examine underlying mechanisms for suicide risk. If church attendance is important, risk should be lowest for Roman Catholics and highest for those with no religion; if religiosity is important, then ‘conservative’ Christians should fare best.

Method: A 9-year study followed 1 106 104 people aged 16–74 years at the 2001 UK census, using Cox proportional hazards models adjusted for census-based cohort attributes.

Results: In fully adjusted models analysing 1119 cases of suicide, Roman Catholics, Protestants and those professing no religion recorded similar risks. The risk associated with conservative Christians was lower than that for Catholics (HR = 0.71, 95% CI 0.52–0.97).

Conclusions: The relationship between religious affiliation and suicide established by Durkheim may not pertain in societies where suicide rates are highest at younger ages. Risks are similar for those with and without a religious affiliation, and Catholics (who traditionally are characterised by higher levels of church attendance) do not demonstrate lower risk of suicide. However, religious affiliation is a poor measure of religiosity, except for a small group of conservative Christians, although their lower risk of suicide may be attributable to factors such as lower risk behaviour and alcohol consumption.

Spatial distribution of suicide in Queensland, Australia

Background: There has been a lack of investigation into the spatial distribution and clustering of suicide in Australia, where the population density is lower than many countries and varies dramatically among urban, rural and remote areas. This study aims to examine the spatial distribution of suicide at a Local Governmental Area (LGA) level and identify the LGAs with a high relative risk of suicide in Queensland, Australia, using geographical information system (GIS) techniques.---------- Methods: Data on suicide and demographic variables in each LGA between 1999 and 2003 were acquired from the Australian Bureau of Statistics. An age standardised mortality (ASM) rate for suicide was calculated at the LGA level. GIS techniques were used to examine the geographical difference of suicide across different areas.---------- Results: Far north and north-eastern Queensland (i.e., Cook and Mornington Shires) had the highest suicide incidence in both genders, while the south-western areas (i.e., Barcoo and Bauhinia Shires) had the lowest incidence in both genders. In different age groups (≤24 years, 25 to 44 years, 45 to 64 years, and ≥65 years), ASM rates of suicide varied with gender at the LGA level. Mornington and six other LGAs with low socioeconomic status in the upper Southeast had significant spatial clusters of high suicide risk.---------- Conclusions: There was a notable difference in ASM rates of suicide at the LGA level in Queensland. Some LGAs had significant spatial clusters of high suicide risk. The determinants of the geographical difference of suicide should be addressed in future research.

Spatial clusters of suicide in Australia

Background: Understanding the spatial distribution of suicide can inform the planning, implementation and evaluation of suicide prevention activity. This study explored spatial clusters of suicide in Australia, and investigated likely socio-demographic determinants of these clusters. Methods: National suicide and population data at a statistical local area (SLA) level were obtained from the Australian Bureau of Statistics for the period of 1999 to 2003. Standardised mortality ratios (SMR) were calculated at the SLA level, and Geographic Information System (GIS) techniques were applied to investigate the geographical distribution of suicides and detect clusters of high risk in Australia. Results: Male suicide incidence was relatively high in the northeast of Australia, and parts of the east coast, central and southeast inland, compared with the national average. Among the total male population and males aged 15 to 34, Mornington Shire had the whole or a part of primary high risk cluster for suicide, followed by the Bathurst-Melville area, one of the secondary clusters in the north coastal area of the Northern Territory. Other secondary clusters changed with the selection of cluster radius and age group. For males aged 35 to 54 years, only one cluster in the east of the country was identified. There was only one significant female suicide cluster near Melbourne while other SLAs had very few female suicide cases and were not identified as clusters. Male suicide clusters had a higher proportion of Indigenous population and lower median socio-economic index for area (SEIFA) than the national average, but their shapes changed with selection of maximum cluster radii setting. Conclusion: This study found high suicide risk clusters at the SLA level in Australia, which appeared to be associated with lower median socio-economic status and higher proportion of Indigenous population. Future suicide prevention programs should focus on these high risk areas.

Not in all Walks of Life? : Social Differences in Suicide Mortality

In Finland, the suicide mortality trend has been decreasing during the last decade and a half, yet suicide was the fourth most common cause of death among both Finnish men and women aged 15 64 years in 2006. However, suicide does not occur equally among population sub-groups. Two notable social factors that position people at different risk of suicide are socioeconomic and employment status: those with low education, employed in manual occupations, having low income and those who are unemployed have been found to have an elevated suicide risk. The purpose of this study was to provide a systematic analysis of these social differences in suicide mortality in Finland. Besides studying socioeconomic trends and differences in suicide according to age and sex, different indicators for socioeconomic status were used simultaneously, taking account of their pathways and mutual associations while also paying attention to confounding and mediatory effects of living arrangements and employment status. Register data obtained from Statistics Finland were used in this study. In some analyses suicides were divided into two groups according to contributory causes of death: the first group consisted of suicide deaths that had alcohol intoxication as one of the contributory causes, and the other group is comprised of all other suicide deaths. Methods included Poisson and Cox regression models. Despite the decrease in suicide mortality trend, social differences still exist. Low occupation-based social class proved to be an important determinant of suicide risk among both men and women, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set. High relative suicide mortality among the unemployed during times of economic boom suggests that selective processes may be responsible for some of the employment status differences in suicide. However, long-term unemployment seems to have causal effects on suicide, which, especially among men, partly stem from low income. In conclusion, the results in this study suggest that education, occupation-based social class and employment status have causal effects on suicide risk, but to some extent selection into low education and unemployment are also involved in the explanations for excess suicide mortality among the socially deprived. It is also conceivable that alcohol use is to some extent behind social differences in suicide. In addition to those with low education, manual workers and the unemployed, young people, whose health-related behaviour is still to be adopted, would most probably benefit from suicide prevention programmes.