Informacion y Apoyo para los Sobrevivientes del Suicidio: Guia de Recursos del Departamento de Veteran Affairs para las familias que esten lidiando con el suicidio
How to Talk to a Child about a Suicide Attempt in Your Family: Guides Targeting Age Groups 4-8, 9-13 and 14-18
and now also available in Spanish!
Description: This information sheet is intended to serve as a guide for adults to use when talking with a 4-8, 9-13 or 14-18 year-old child about a suicide attempt in the family. It is not intended to replace the advice of a mental health professional. In fact, it may be best to use this along with professional support if you or your child is struggling with how to talk about this difficult topic. It is important to consider the child’s level of development and ability to understand events when deciding how to talk with them about this issue.
Download:
Free Self-Directed Violence Toolkit and Classification System Clipboards!
The free clipboard has the SDVCS Clinical Tool printed right on it for the clinician on the go. The accompanying laminated page with the Classification System makes it easier than ever to use this widely adopted nomenclature.
The purpose of ACE is to help Veterans, their family members and friends learn that they can take the necessary steps to get help. The acronym ACE (Ask, Care, Escort) summarizes the steps needed to take an active and valuable role in suicide prevention.
Annotated Bibliography - Suicide and Traumatic Brain Injury (TBI) - Updated August 2011
This seven (7) page document provides quick and easy reference to the latest in research on Suicide and TBI. Download the bibliography.
Traumatic Brain Injury and Suicide - A Manual for Clinicians and Care Providers
There is a need for more resources that are specifically targeted toward TBI survivors who may be considering suicide. Based upon this need, researchers at the VA VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC) produced this information and resources guide. The target audience is clinicians and care providers working with TBI survivors. Download the 31 page manual.
Traumatic Brain Injury and Suicide Prevention
Easily reproducible brochure for veterans and the family/caregiver - Brochure
Traumatic Brain Injury and Suicide in Veterans and Returning Military Personnel
Recognizing Suicide Risk in Returning Combat Veterans
By Patricia A. Alexander PhD and Lisa A. Brenner, Ph.D ABPP (Rp). This paper suggest that assessing for feelings of burdensomeness, failed belongingness, and acquired ability may be important when evaluating suicide risk. Download the article from Military OneSource.
The Suicide Pocket Guide can be ordered through the local VA Suicide Prevention Coordinator (SPC). This link will take you to a page where the nearest SPC can be found.
Research Projects
Assessment of Cognitive Functioning as it Relates to Risk for Suicide in Veterans with HIV/AIDS
The purpose of this study is to evaluate the potential utility of neuropsychological testing as a key component of suicide risk assessment in Veterans with HIV/AIDS.
Medication overdoses account for substantial numbers of suicide-related behaviors. Non-adherence is a significant issue for those with psychiatric illness.
This study is designed to test the psychometric properties of the Interpersonal Needs Questionnaire (INQ-12) and the Acquired Capability for Suicide Scale (ACSS) in a sample of military veterans, something which has not been done. These measures were developed to assess the constructs of Joiner’s interpersonal psychological theory of suicide. Secondary goals of the study are to determine if values mediate the relationship between reasons for living and suicide risk, and whether participants’ suicidal wish can be categorized as either escaping their problems or influencing other people.
This study will use VHA data toward the ultimate goal of establishing a mechanism by which VA clinicians could access data on Veterans regarding suicidal thoughts and/or behaviors that occurred when they were on active duty, as documented in the Department of Defense Suicide Event Report (DoDSER).
Losing a close friend or family member to death can be an incredibly painful and stressful occurrence. Some bereaved persons may experience additional symptoms associated with a severe and unending type of grief now referred to as prolonged grief (PG). The connection between PG and suicide among Veterans has not been studied, even though Veterans already are at a higher risk for suicide than are other groups.
Through this research we hope to understand which values (e.g., power, achievement, security) and value dimensions (e.g., importance, success) have the strongest impact on suicidality in this population.
This project will determine whether methods drawn from basic science can robustly detect the effects of traumatic brain injury (TBI) and/or post traumatic stress disorder (PTSD) on executive functioning. Although TBI often occurs in the context of a traumatic event, very little research has attempted to disentangle the effects of TBI from PTSD, both of which compromise executive functioning.
This study is designed to test a novel method of measuring avoidance of trauma-related material in combat Veterans with and without PTSD, and to compare this novel behavioral measure of avoidance with other traditional self report measures of avoidance.
Project Summary: The purpose of this study is to compare the effectiveness of the HOME (Home-Based Mental Health Evaluation) intervention with care as usual for Veterans who have transitioned from inpatient to outpatient care. The study consists of four assessments that will gather information on post-discharge treatment engagement, mood related symptoms, and suicidal ideation. See a description of the HOME clinical project.
Research Team: Peter M. Gutierrez PhD, Thomas Joiner PhD, Greg Riccardi PhD, Jon Maner, PhD, Kelly Moroney MA, Karen Gronau, Megan Dwyer, Jetta Hanson MA
Consortium seeks to develop more effective prevention interventions, risk assessment methods, and treatments to decrease suicide in the military.
Traumatic brain injury is an important medical problem for Veterans. Individuals with traumatic brain injuries are at increased risk for various psychiatric problems, including those associated with suicide. This study seeks to better understand the relationship between these factors.
The purpose of this study is to compare the effectiveness of the SAFE VET (Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment) intervention versus enhanced usual care on Veterans’ suicide attempts, suicide ideation, outpatient mental health or substance abuse treatment, and suicide-related coping. SAFE VET uses a standardized intervention that is specifically adapted for use in the Emergency Department to mitigate suicide risk.
While there is a dearth of evidence-based treatment for co-occurring PTSD and mTBI, it has been suggested that best practices entail treating presenting symptoms (hyperarousal, hypoarousal, emotional reactivity, irritability, depression, anxiety, concentration problems). Yoga may be particularly well-suited to treating returning servicemen as data suggests that core symptoms that develop with a history of trauma exposure, are physiologically based, somatically experienced and often not amenable to change through talking alone. Research suggests that that moment-to-moment awareness of present experience may decrease emotional reactivity and anxiety, and increase the capacity for self-regulation. Mindfulness skills have also been associated with: building resilience in the midst of stress; allowing one to better cope with physical discomfort; decreasing anxiety and depression; decreasing reactivity. An 8-week, 16-session, hatha yoga intervention will be conducted with Veterans to assess the acceptability and feasibility of an intervention in this population. Veterans will be screened and assessed for mental and physical health prior to enrolling in the intervention. Weekly sessions, out of session practice, and weekly assessments will track possible changes in the Veterans quality of life, mental and physical health.
The research team hypothesizes that, similar to other populations, active acupressure treatments will help promote stress resilience, improve cognition and sleep, helping to reduce suicidal ideation and ultimately suicidal behavior. In addition to these potential functional benefits in Veterans, active acupressure is an independent, portable, safe and no-cost (once learned) intervention that is non-pharmacological and therefore has no side effects. The study aims to address a need (reducing military/Veteran suicidality) that has to date gone largely unmet, a need that is also currently a Department of Defense priority.
The purpose of this project is to gather pilot data related to risk factors associated with suicide in Veterans with Human Immunodeficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) and to develop an educational and interventional tool and instructional guide that can be utilized by local and national providers to increase understanding regarding suicide risk assessment.
This proposed project will be the first to replicate a groundbreaking psychological treatment for suicide prevention among those with moderate or severe traumatic brain injury, Window to Hope (WtoH), developed by PI Simpson and colleagues in Sydney, Australia. WtoH has been successfully evaluated in a Randomized Controlled Trial (RCT), in which treated Australian civilians (n=17) with severe TBI recorded significant decreases in hopelessness. The current project aims to (i) undertake the cross-cultural adaptation of the WtoH program; (ii) establish the acceptability and feasibility of WtoH within the VAMC context; and (iii) conduct a RCT within the VAMC to replicate the results from the original trial (efficacy). Deliverables are expected to include an intervention suitable for a larger trial and broader dissemination.
University of Utah National Center for Veterans Studies and American Psychological Association jointly sponsored Military and Veteran Suicide Prevention Clinical Best Practices Consensus Meeting in Washington, DC
Barnes, S.M., Walter, K.H., & Chard, K.M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD? Rehabilitation Psychology, 57, 18-26.
Objective: Research shows that posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI) independently increase suicide risk; however, scant research has investigated whether mTBI increases suicide risk above and beyond the risk associated with PTSD alone. Design: The current research compared suicide risk factors among a matched sample of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) military personnel and veterans with PTSD alone or PTSD and a history of an mTBI. Results: Differences in the assessed risk factors were small and suggest that if PTSD and mTBI are associated with elevations in suicide risk relative to PTSD alone, the added risk is likely mediated or confounded by PTSD symptom severity. Conclusion: This finding highlights the importance of screening and treating military personnel and veterans for PTSD. Future explication of the impact of TBI-related impairments on suicide risk will be critical as we strive to ensure safety and optimize care for our military personnel and veterans.
Bahraini NH, Gutierrez PM, Harwood JEF, Huggins JA, Hedegaard H, Chase M, Brenner LA. (2012). The Colorado Violent Death Reporting System (COVDRS): Validity and Utility of the Veteran Status Variable. Public Health Rep., May/Jun;127(3):304-309.
Objective. Using the Veterans Affairs Beneficiary Identification Record Locator Subsystem (BIRLS) as the criterion database, we evaluated the sensitivity and specificity of the death certificate information in the Colorado Violent Death Reporting System (COVDRS) to determine Veteran status for those who died by suicide. Methods. The study sample consisted of 3,820 individuals aged 18 years and older who died by suicide in Colorado from January 1, 2004, through December 31, 2008. To determine agreement on Veteran status, COVDRS data were submitted to the Veterans Benefits Administration for linkage to the BIRLS using Social Security numbers. Results. Sensitivity and specificity of the Veteran status information on the death certificate were 93.1% (95% confidence interval [CI] 90.7, 95.2) and 91.7% (95% CI 90.5, 92.8), respectively. The overall agreement between the death certificate and the BIRLS on Veteran status was very good (kappa 5 0.76; 95% CI 0.74, 0.79). Conclusions. This study of 3,820 suicide deaths in Colorado demonstrated a high level of agreement between the COVDRS Veteran status variable and the BIRLS. Such findings offer support for using the COVDRS in studying factors associated with suicide in the Veteran population.
Bates MJ, Bradley JC, Bahraini NH, Goldenberg MN. (2012). Clinical Management of Suicide Risk with Military and Veteran Personnel. Chapter in Textbook of Suicide Assessment and Management, 2nd Edition Edited by Simon RI and Hales RE. The American Pyschiatric Publishing, Washington DC, 405-441.
Brausch, A. M. & Gutierrez, P. M. (2010). Differences in non-suicidal self-injury and suicide attempts in adolescents. Journal of Youth and Adolescence, 39(3), 233-244.
As suicide attempts and self-injury remain predominant health risks among adolescents, it is increasingly important to be able to distinguish features of self-harming adolescents from those who are at risk for suicidal behaviors. The current study examined differences between groups of adolescents with varying levels of self-harmful behavior in a sample of 373 high school students with a mean age of 15.04 (SD = 1.05). The sample was 48% female and the distribution of ethnicity was as follows: 35% Caucasian, 37.2% African-American, 16% Multi-ethnic, 9.2% Hispanic, and 2.3% Asian. The sample was divided into three groups: no history of self-harm, non-suicidal self-injury (NSSI) only, and NSSI in addition to a suicide attempt. Differences in depressive symptoms, suicidal ideation, social support, self-esteem, body satisfaction, and disordered eating were explored. Results indicated significant differences between the three groups on all variables, with the no self-harm group reporting the lowest levels of risk factors and highest levels of protective factors. Further analyses were conducted to examine specific differences between the two self-harm groups. Adolescents in the NSSI group were found to have fewer depressive symptoms, lower suicidal ideation, and greater self-esteem and parental support than the group that also had attempted suicide. The clinical implications of assessing these specific psychosocial correlates for at-risk adolescents are discussed.
Brenner LA, Barnes SM. (2012). Facilitating Treatment Engagement During High-Risk Transition Periods: A Potential Suicide Prevention Strategy. American Journal of Public Health, Supplement 1, Vol 102, No. S1
Brenner, L. A., Betthauser, L.M., Homaifar, B. Y., Villarreal, E., Harwood, J. E., Staves, P. J., & Huggins, J. A. (2011). Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among Veterans receiving mental health services. Suicide & Life Threatening Behavior, 41, 416-423.
History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.
Brenner, L.A., Breshears, R.E., Betthauser, L.M., Bellon, K. K., Holman, E., Harwood, J. E., Silverman, M. M., Huggins, J. & Nagamoto, H. T. (2011). Implementation of a suicide nomenclature within two VA healthcare settings. Journal of Clinical Psychology in Medical Settings.
Implementation of a Suicide Nomenclature within Two VA Healthcare Settings Those who work in the field of Veteran’s care, as well as educators, researchers, and professionals providing direct mental health services agree that learning more about and preventing suicide represents a highly critical goal. Yet, up to now, researchers and mental health professionals lacked a shared language for defining suicidal behavior. This study discusses implementation of the Center for Disease Controls’ Self-Directed Violence Classification System (SDVCS) and an accompanying Clinical Tool (CT) at two VA healthcare facilities (in Denver and Grand Junction, CO). Results of this study show that implementing a more unified language is possible, while at the same time highlights some of the challenges and barriers to adoption of this system. This study provides important information regarding implementation of the SDVCS throughout the VA system.
OBJECTIVES:: To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury-4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. STUDY DESIGN:: Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. PARTICIPANTS:: The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. MAIN MEASURES:: For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. RESULTS:: The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. CONCLUSIONS:: The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.
Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2011). Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services. Journal of Head Trauma Rehabilitation, 26(4), 257-264.
This manuscript examines associations between a history of traumatic brain injury (TBI) diagnosis and death by suicide among individuals receiving care within the Veterans Health Administration (VHA). Among VHA users, those with a diagnosis of TBI were at greater risk for suicide than those without this diagnosis. Further research is indicated to identify evidence-based means of assessment and treatment for those with TBI and suicidal behavior.
Breshears, R. E., Brenner, L. A., Harwood, J. E. F., & Gutierrez, P. M. (2010). Predicting suicidal behavior in Veterans with traumatic brain injury: The utility of the Personality Assessment Inventory. Journal of Personality Assessment, 92,349-355.
In this study, we investigated the Personality Assessment Inventory's (PAI; Morey, 1991, 2007) Suicide Potential Index (SPI) and Suicide Ideation scale (SUI) as predictors of suicidal behavior (SB) in military Veterans with traumatic brain injury (TBI; N = 154). We analyzed electronic medical records were searched for SB in the 2 years post-PAI administration and data via logistic regressions. We obtained statistical support for the SPI and SUI as predictors of SB. Analyses we performed using receiver operating characteristics suggested an optimal SPI cutoff of > or = 15 for this sample. Findings suggest that SPI and SUI scores may assist in assessing suicide risk in those with TBI, particularly when population-based cutoffs are considered.
Bryan, C.J., Clemans, T.A., & Hernández, A.M. (2012). Perceived burdensomeness, fearlessness of death, and suicidality among deployed military personnel. Personality and Individual Differences, 52, 374-379.
Abstract: The interpersonal-psychological theory of suicide posits that the interaction of three elements is required for lethal suicidal behaviors: the perception that one is a burden on others, the perception that one does not belong, and fearlessness about death combined with high pain tolerance (termed "acquired capability" for suicide). Although an ever expanding research base supports the theory, very limited data exist supporting the theory among military personnel, a group that has experienced a rapid increase in suicides during the past several years. The current study tests the interpersonal-psychological theory in two clinical samples of military personnel while deployed to Iraq: those seeking treatment for mild traumatic brain injury, and those seeking outpatient mental health treatment. In both samples, perceived burdensomeness and acquired capability were significantly associated with suicidality, as was their interaction term. Results partially support the interpersonal-psychological theory of suicide, and indicate that perceptions of burdensomeness combined with fearlessness about death are associated with increased suicidality among deployed military personnel.
Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013 Jan;28(1):13-20.
OBJECTIVE: To identify clinical variables associated with suicidality in military personnel with mild traumatic brain injury (mTBI) while deployed to Iraq. SETTING: Outpatient TBI clinic on a US military base in Iraq. PARTICIPANTS: Military personnel (N = 158) referred to an outpatient TBI clinic for a standardized intake evaluation, 135 (85.4%) who had a diagnosis of mTBI and 23 (14.6%) who did not meet criteria for TBI. MAIN MEASURES: Suicidal Behaviors Questionnaire-Revised, Depression subscale of the Behavioral Health Measure-20, Posttraumatic Stress Disorder Checklist-Military Version, Insomnia Severity Index, self-report questionnaire, and clinical interview addressing TBI-related symptoms. RESULTS: Among patients with mTBI, increased suicidality was significantly associated with depression and the interaction of depression with posttraumatic stress disorder symptoms. Longer duration of loss of consciousness was associated with decreased likelihood for any suicidality. CONCLUSION: Assessment after TBI in a combat zone may assist providers in identifying those at risk for suicidality and making treatment recommendations for service members with mTBI.
Bryan CJ, Hernandez AM, Allison S, Clemans T. Combat exposure and suicide risk in two samples of military personnel. J Clin Psychol. 2013 Jan;69(1):64-77. doi: 10.1002/jclp.21932. Epub 2012 Oct 15.
OBJECTIVE: In light of increased suicidal behaviors among military personnel and veterans since the initiation of combat operations in Afghanistan and Iraq, questions have been raised about the potential causal role of combat. The objective of the current study was to identify any direct or indirect effects of combat exposure on suicide risk through depression symptom severity, posttraumatic stress disorder (PTSD) symptom severity, thwarted belongingness, perceived burdensomeness, and fearlessness about death, consistent with the interpersonal-psychological theory of suicide (Joiner, 2005). METHOD: Structural equation modeling was utilized with two separate samples of deployed military personnel, 1 nonclinical (n = 348; 89.7% male, mean age = 24.50) and 1 clinical (n = 219; 91.8% male, mean age = 27.88), to test the effects of combat exposure on suicide risk. RESULTS: Greater combat exposure was directly associated with fearlessness about death and PTSD symptom severity in both samples, but failed to show either a direct or indirect effect on suicide risk. PTSD symptom severity was strongly associated with depression symptom severity, which in turn was related to suicide risk directly (in the nonclinical sample) or indirectly through low belongingness and perceived burdensomeness (in the clinical sample). CONCLUSIONS: In both samples of deployed active duty military personnel, combat exposure was either unrelated to suicide risk or was too distally related to have a measurable effect. Results do not support the interpersonal-psychological theory's hypothesis that combat exposure should be indirectly related to suicide risk through acquired fearlessness of death.
Davidson, C. L., Babson, K. A., Bonn-Miller, M. O., Souter, T. and Vannoy, S. (2013), The Impact of Exercise on Suicide Risk: Examining Pathways through Depression, PTSD, and Sleep in an Inpatient Sample of Veterans. Suicide and Life-Threat Behavi.
Suicide has a large public health impact. Although effective interventions exist, the many people at risk for suicide cannot access these interventions. Exercise interventions hold promise in terms of reducing suicide because of their ease of implementation. While exercise reduces depression, and reductions in depressive symptoms are linked to reduced suicidal ideation, no studies have directly linked exercise and suicide risk. The current study examined this association, including potential mediators (i.e., sleep disturbance, posttraumatic stress symptoms, and depression), in a sample of Veterans. SEM analyses revealed that exercise was directly and indirectly associated with suicide risk. Additionally, exercise was associated with fewer depressive symptoms and better sleep patterns, each of which was, in turn, related to lower suicide risk.
DelMastro, K., Hellem, T., Kim, N., Kondo, D., Sung, Y. H., & Renshaw, P. F. (2011). Incidence of major depressive episode correlates with elevation of substate region of residence. Journal of Affective Disorders, 129(1-3), 376-379.
BACKGROUND: Major depressive disorder (MDD) is a common disorder that is often associated with suicide. We have recently suggested that elevation may play a role in regional variations in rates of suicide. We hypothesize that there is also a significant correlation between incidence of MDD and elevation of residence. METHODS: The substate estimates from the 2004 to 2006 National Surveys on Drug Use and Health (NSDUH) report from SAMHSA was used to extract substate level data related to percentages of people 18 years or older who experienced serious psychological distress or a major depressive episode in the past year. Mean elevation of each substate region was calculated by averaging the weighted elevations of its relevant counties. Average elevation for United States counties was calculated using the Shuttle Radar Topography Mission (SRTM) elevation dataset. Pearson correlation coefficients were computed to investigate the association between average substate elevation and rate of serious psychological distress or major depressive episode. RESULTS: There was a significant correlation between percentage of people experiencing serious psychological distress in the past year in a substate region and that substate region's mean elevation (r=0.18; p=0.0005), as well as between the percentage of people having at least one major depressive episode in the past year in a substate region and that substate region's mean elevation (r=0.27; p0.0001). CONCLUSIONS: Elevation appears to be a significant risk factor for MDD. Further studies are indicated to determine whether the increased incidence of depression with increased elevation may be due to the hypoxic effects on subjects with MDD.
Dennehy, E. B., Marangell, L. B., Allen, M. H., Chessick, C., Wisniewski, S. R., & Thase, M. E. (2011). Suicide and suicide attempts in the Systematic Treatment Enhancement Program for bipolar disorder (STEP-BD). 133, 423-427.
BACKGROUND: The current report describes individuals with bipolar disorder who attempted or completed suicide while participating in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study. METHODS: Baseline and course features of individuals with suicide events are described. RESULTS: Among the 4360 people with bipolar disorder enrolled, 182 individuals made 270 prospectively observed suicidal acts, including 8 completed suicides. This represents a suicide rate of .014 per 100 person years in STEP-BD, which included frequent clinical visits, evidence based care, and standardized assessment at each patient contact. Approximately 1/3 of those who attempted suicide had more than one attempt during study participation. Those who completed suicide tended to do so early in study participation, and half of them did so on their first attempt. LIMITATIONS: While this study is limited to description of individuals and precipitants of completed suicides and attempts in STEP-BD, further analyses are planned to explore risk factors and potential interventions for prevention of suicidal acts in persons with bipolar disorder. CONCLUSIONS: Persons with bipolar disorder are at high risk for suicide. Overall rates of suicide events in STEP-BD were lower than expected, suggesting that the combination of frequent clinical visits (i.e., access to care), standardized assessment, and evidence-based treatment were helpful in this population.
Freedenthal, S., Lamis, D. A., Osman, A., Kahlo, D. & Gutierrez, P. M. (2011). Evaluation of the psychometric properties of the Interpersonal Needs Questionnaire-12 in samples of men and women. Journal of Clinical Psychology, 67(6), 609-623.
This study analyzed the psychometric properties of the Interpersonal Needs Questionnaire-12 (INQ-12; Van Orden, Witte, Gordon, Bender, & Joiner, 2008a), designed to test Joiner's interpersonal-psychological theory of suicide. Study participants included 785 U.S. undergraduates (58.6% female; 77.2% White; ages 18-25). Confirmatory bifactor analyses discerned a general factor for overall distress, while also supporting separate subfactors for perceived burdensomeness and thwarted belongingness. The scale's factor structure did not vary by gender, and internal consistency reliability was strong among the male and female samples. Correlational analyses supported the scale's content validity. Overall, the analyses preliminarily support continued use of the INQ-12.
Gutierrez, P. M. (2010). The accidental suicidologist. In M. Pompili (Ed.), Suicide in the words of suicidologists (pp. 87-90). New York, NY: Nova Science Publishers, Inc.
Gutierrez, P. M., & Brenner, L. A. (2011). Helping military personnel/veterans and families manage stress reactions and navigate reintegration. In A. Palmo, W. Weikel & D. Borsos (Eds.), Foundations of mental health counseling, fourth edition (pp. 280-286). Springfield, IL: Charles C. Thomas.
Gutierrez PM, Freedenthal S, Wong JL, Osman A, Norizuki T. Validation of the Suicide Resilience Inventory-25 (SRI-25) in Adolescent Psychiatric Inpatient Samples. J Pers Assess. 2012 Jan;94(1):53-61.
Resilience has been associated with a markedly decreased chance for risky behaviors following a trauma or other negative life event. This study examined the factor structure and psychometric properties of a self-report measure of resilience, the Suicide Resilience Inventory-25 (SRI-25; Osman et al., 2004 ), among psychiatric inpatient adolescents. In Study 1, we conducted confirmatory factor analysis to provide additional empirical support for the structure and invariance of the 3-factor model of the SRI-25 in youth samples, ages 14 to 17 years (N = 152 boys, 220 girls). Scale reliability analyses provided good evidence for internal consistency reliability of scores on the SRI-25 total and scales. In Study 2 (N = 30 boys, 40 girls), we presented data in support for the concurrent validity (i.e., known groups) of scores on the SRI-25. Additionally, we identified potential correlates for the SRI-25 total scale scores.
Haas, A. P., Eliason, M., Mays, V. M., Mathy, R. M., Cochran, S. D., D'Augelli, A. R. et al. (Silverman, M. M.) (2010). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58, 10-51.
Despite strong indications of elevated risk of suicidal behavior in lesbian, gay, bisexual, and transgender people, limited attention has been given to research, interventions or suicide prevention programs targeting these populations. This article is a culmination of a three-year effort by an expert panel to address the need for better understanding of suicidal behavior and suicide risk in sexual minority populations, and stimulate the development of needed prevention strategies, interventions and policy changes. This article summarizes existing research findings, and makes recommendations for addressing knowledge gaps and applying current knowledge to relevant areas of suicide prevention practice.
Homaifar, B. Y., Bahraini, N.H., Silverman, M.M., Brenner, L.A.. (2012). Executive Functioning as a Component of Suicide Risk Assessment: Clarifying its Role in Standard Clinical Applications. Journal of Mental Health Counseling, 34(2), 110-120.
Clinically, because executive dysfunction (e.g., impulsivity, insight, thinking process) is often thought of in the context of those with traumatic brain injuries and other neurologic conditions, its formal assessment has historically been seen as the domain of those who assess and treat patients with neurologic disease. However, mental health counselors (MHCs) could benefit from learning how executive functioning relates to suicide risk assessment and coping strategies. Assessment of executive functions can be incorporated in routine clinical practice without the need for formal neuropsychological measures or other time-consuming procedures. In fact, during standard clinical assessment, mental health professionals often informally assess components of executive functioning such as impulsivity, insight, and thinking processes. This article highlights aspects of executive functioning with which MHCs may already be familiar and demonstrates their clinical utility in enhancing assessment and management of suicide-related thoughts and behaviors.
Homaifar BY, Brenner LA, Forster JE, Nagamoto H. Traumatic brain injury, executive functioning, and suicidal behavior: A brief report. Rehabil Psychol. 2012 Nov;57(4):337-41.
Objective: The aim of this pilot study was to explore the relationship between executive dysfunction and suicidal behavior in two groups of participants: (Group 1, n = 18) veterans with traumatic brain injury (TBI) and a history of at least one suicide attempt (SA), and (Group 2, n = 29) veterans with TBI and no history of SA. Controlling for the severity of TBI, it was hypothesized that participants in Group 1 would perform more poorly than those in Group 2 on measures of executive functioning. Design: The primary outcome variable was decision making as assessed by performance on the Iowa Gambling Task (IGT). Secondary outcome variables included laboratory-measured impulsivity as measured by the Immediate and Delayed Memory Test (IMT/DMT), abstract reasoning as measured by the Wisconsin Card Sorting Test (WCST), and aggression as measured by the Lifetime History of Aggression (LHA) scale. Results: Among those in Group 1, time between TBI and first suicide attempt postinjury varied widely (months to nearly 30 years). Only the WCST perseverative errors score differed significantly between individuals with and without histories of one or more suicide attempts (SAs). Conclusion: Suggestions for future study of SA among those with TBI are provided. When working with individuals with TBI, clinicians are encouraged to incorporate suicide risk assessment into their practice. Augmenting this process with a measure of perseveration may be beneficial. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
Jobes, D. A., Comtois, K., Brenner, L.A. & Gutierrez, P.M. (2011). Clinical trial feasibility studies of the collaborative assessment and management of suicidality (CAMS). In R. O'Connor, S. Platt & J. Gordon (Eds.), International handbook of suicide prevention research, policy, and practice. (pp. 383-400). West Sussex, United Kingdom: John Wiley & Sons Ltd.
Kim, N., Mickelson, J. B., Brenner, B. E., Haws, C. A., Yurgelun-Todd, D.A., & Renshaw, P.F. (2011). Altitude, Gun Ownership, Rural Areas, and Suicide. American Journal of Psychiatry,168(1), 49-54.
OBJECTIVE: The authors recently observed a correlation between state altitude and suicide rate in the United States, which could be explained by higher rates of gun ownership and lower population density in the intermountain West. The present study evaluated the relationship between mean county and state altitude in the United States and total age-adjusted suicide rates, firearm-related suicide rates, and non-firearm-related suicide rates. The authors hypothesized that altitude would be significantly associated with suicide rate. METHOD: Elevation data were calculated with an approximate spatial resolution of 0.5 km, using zonal statistics on data sets compiled from the National Geospatial-Intelligence Agency and the National Aeronautics and Space Administration. Suicide and population density data were obtained through the Centers for Disease Control and Prevention (CDC) WONDER database. Gun ownership data were obtained through the CDC's Behavioral Risk Factor Surveillance System. RESULTS: A significant positive correlation was observed between age-adjusted suicide rate and county elevation (r=0.51). Firearm (r=0.41) and non-firearm suicide rates (r=0.32) were also positively correlated with mean county elevation. CONCLUSIONS: When altitude, gun ownership, and population density are considered as predictor variables for suicide rates on a state basis, altitude appears to be a significant independent risk factor. This association may be related to the effects of metabolic stress associated with mild hypoxia in individuals with mood disorders.
Kirschner, K. L., Mukherjee, D., Gittler, M., Brenner, L.A., & Kelly, J. P. (2011). Setting limits: The threat of violence in the health care setting. The American Academy of Physical Medicine and Rehabilitation, 3, 68-72.
Knox KL, Stanley B, Currier GW, Brenner LA, Ghahramanlou-Holloway M, Brown GK. An emergency based brief intervention for veterans at risk for suicide (SAFE VET). Am J Public Health. 2012;102(S1):S33 – S37.
Reducing deaths from veteran suicide is a public health priority for veterans who receive their care from the Department of Veterans Affairs (VA) and those who receive services in community settings. Emergency departments frequently function as the primary or sole point of contact with the health care system for suicidal individuals; therefore, they represent an important venue in which to identify and treat veterans who are at risk for suicide. We describe the design, implementation and initial evaluation of a brief behavioral intervention for suicidal veterans seeking care at VA emergency departments. Initial findings of the feasibility and acceptability of the intervention suggest it may be transferable to diverse VA and non-VA settings, including community emergency departments and urgent care centers.
Muehlenkamp, J. J., Cowles, M. L., & Gutierrez, P.M. (2010). Validity of the self-harm behavior questionnaire with diverse adolescents. Journal of Psychopathology and Behavioral Assessment, 32, 236-245.
Suicide and non-suicidal self-injurious behavior (NSSI) continue to be significant health problems for adolescents. Although there are many instruments available to assess self-harm behaviors, few have been validated for use with adolescents, and even fewer have been validated for use with different racial/ethnic groups. The Self-Harm Behavior Questionnaire (SHBQ) assesses NSSI, suicidal ideation, suicide threats, and past suicide attempts. Data from 1,386 racially/ethnically diverse adolescents (57.5% minority) were collected to examine the validity of the SHBQ in this age group. Analyses supported the four-factor structure, revealed the SHBQ is internally consistent, and provided evidence for convergent validity within Caucasian, African American, and Hispanic adolescents. However, slight differences were noted. Overall, the findings suggest the SHBQ is a useful assessment tool appropriate for use with Caucasian, African American, and Hispanic adolescents.
Ribeiro JD, Pease JL, Gutierrez PM, Silva C, Bernert RA, Rudd MD, Joiner TE Jr. Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military. J Affect Disord. 2012 Feb;136(3):743-50.
Background: Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms.
Methods: Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311).
Results: In support of a priori hypotheses, self-reported insomnia symptoms were crosssectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Selfreported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled.
Limitations: The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk. Conclusions: These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.
Rings JA, Alexander PA, Silvers VN, Gutierrez PM. (2012). Adapting the Safety Planning Intervention for Use in a Veterans Psychiatric Inpatient Group Setting. Journal of Mental Health Counseling, 34(2), 95-109.
The Department of Veterans Affairs (VA) recently has adopted the Safety Planning Intervention (SPI; Stanley & Brown, 2011), a brief collaborative intervention, for use with veterans who are at high risk of suicide. The SPI is a hierarchical list of strategies for veterans to use in coping with a suicidal crisis. Its developers recommended that it be used with individual psychiatric inpatients working toward discharge, but its utility in a group format has not previously been addressed. This article describes the facilitation of a safety planning group with psychiatric inpatients at a large urban VA medical center. It depicts each step in the safety plan and offers case examples, anecdotal support, and specific considerations for its use in groups. Directions for further research are also discussed.
Schmitz WM Jr, Allen MH, Feldman BN, Gutin NJ, Jahn DR, Kleespies PM, Quinnett P, Simpson S. Preventing Suicide through Improved Training in Suicide Risk Assessment and Care: An American Association of Suicidology Task Force Report Addressing Serious Gaps in U.S. Mental Health Training. Suicide Life Threat Behav. 2012 Jun;42(3):292-304. doi: 10.1111/j.1943-278X.2012.00090.x. Epub 2012 Apr 11.
There are twice as many suicides as homicides in the United States, and the suicide rate is rising. Suicides increased 12% between 1999 and 2009. Mental health professionals often treat suicidal patients, and suicide occurs even among patients who are seeking treatment or are currently in treatment. Despite these facts, training of most mental health professionals in the assessment and management of suicidal patients is surprisingly limited. The extant literature regarding the frequency with which mental health professionals encounter suicidal patients is reviewed, as is the prevalence of training in suicide risk assessment and management. Most importantly, six recommendations are made to address the longstanding insufficient training within the mental health professions regarding the assessment and management of suicidal patients.
Selby, E. A., Anestis, M. D., Bender, T. W., Ribeiro, J. D, Nock, M. K., Rudd, et al. (Gutierrez, P.M.) (2010). Overcoming the fear of lethal injury: Evaluating suicide in the military through the lens of the interpersonal-psychological theory of suicide. Clinical Psychology Review, 30, 298-307.
Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.
Swogger, M. T., Walsh, Z., Homaifar, B. Y., Caine, E. D., & Conner, K. R. (2011). Predicting self- and other-directed violence among discharged psychiatric patients: the roles of anger and psychopathic traits. Psychological Medicine. Jul 18:1-9.
BACKGROUND: We examined the extent to which trait anger and psychopathic traits predicted post-discharge self-directed violence (SDV) and other-directed violence (ODV) among psychiatric patients.MethodParticipants were 851 psychiatric patients sampled from in-patient hospitals for the MacArthur Violence Risk Assessment Study (MVRAS). Participants were administered baseline interviews at the hospital and five follow-up interviews in the community at approximately 10-week intervals. Psychopathy and trait anger were assessed with the Psychopathy Checklist: Screening Version (PSC:SV) and the Novaco Anger Scale (NAS) respectively. SDV was assessed during follow-ups with participants and ODV was assessed during interviews with participants and collateral informants. Psychopathy facets and anger were entered in logistic regression models to predict membership in one of four groups indicating violence status during follow-up: (1) SDV, (2) ODV, (3) co-occurring violence (COV), and (4) no violence. RESULTS: Anger predicted membership in all three violence groups relative to a non-violent reference group. In unadjusted models, all psychopathy facets predicted ODV and COV during follow-up. In adjusted models, interpersonal and antisocial traits of psychopathy predicted membership in the ODV group whereas only antisocial traits predicted membership in the COV group. CONCLUSIONS: Although our results provide evidence for a broad role for trait anger in predicting SDV and ODV among discharged psychiatric patients, they suggest that unique patterns of psychopathic traits differentially predict violence toward self and others. The measurement of anger and facets of psychopathy during discharge planning for psychiatric patients may provide clinicians with information regarding risk for specific types of violence.
Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.
INTRODUCTION: There is an urgent need to define the neurobiological and cognitive underpinnings of suicidal ideation and behavior in veterans with traumatic brain injury (TBI). Separate studies implicate frontal white matter systems in the pathophysiology of TBI, suicidality, and impulsivity. We examined the relationship between the integrity of major frontal white matter (WM) systems on measures of impulsivity and suicidality in veterans with TBI. METHODS: Fifteen male veterans with TBI and 17 matched healthy controls (HC) received clinical ratings, measures of impulsivity and MRI scans on a 3T magnet. Diffusion tensor imaging (DTI) data for the genu and cingulum were analyzed using Freesurfer and FSL. Correlations were performed for fractional anisotropy (FA) (DTI) values and measures of suicidality and impulsivity for veterans with TBI. RESULTS: Significantly decreased in FA values in the left cingulum (P = 0.02), and left (P = 0.02) and total genu (P = 0.01) were observed in the TBI group relative to controls. Measures of impulsivity were significantly greater for the TBI group and total and right cingulum FA positively correlated with current suicidal ideation and measures of impulsivity (P <0.03). CONCLUSION: These data demonstrate a significant reduction in FA in frontal WM tracts in veterans with mild TBI that was associated with both impulsivity and suicidality. These findings may reflect a neurobiological vulnerability to suicidal risk related to white matter microstructure.
Project Summary: The intent of the clinical demonstration project, Home-Based Mental Health Evaluation (HOME) is to enhance the VA infrastructure for ensuring that Veterans with recent suicidal crises receive the care they need during the often difficult transition from psychiatric inpatient hospitalization to home. This is accomplished by calling the Veteran within 24 business hours of the Veteran’s discharge from the inpatient unit to assess safety and review the safety plan and discharge plan. Then, a HOME clinician will meet the Veteran in the home environment to review and revise aftercare plans and will follow-up with them weekly by phone to assess risk and encourage treatment engagement. The primary goal of the HOME project is to increase engagement with aftercare and decrease the risk of suicide during this time of transition and elevated suicide risk. The HOME demonstration project is being conducted at the Denver and Salt Lake City VAMCs. See a description of the HOME research project.
Suicide Attempt Survivor Family Resource Guide
