Intimate Partner Violence and Suicidality

A recent study in England found an association between intimate partner violence (IPV) and suicidality and self-harm.

Researchers used data from the 2014 Adult Psychiatric Morbidity Survey, a cross-sectional survey of 7,058 adults in England. To analyze the prevalence of IPV, they looked at survey data on past-year and lifetime experiences with physical violence and sexual, economic, and emotional abuse from a partner, in the whole sample and by gender. The researchers then compared past-year non-suicidal self-harm, suicidal thoughts, and suicide attempts among those with and without experiences of IPV. Finally, they examined whether any associations between IPV and suicidality and self-harm were affected by other factors, such as socioeconomic context and experiencing other adversities. 

The analysis found that a fifth (21.4%) of participants reported a lifetime experience of IPV, and 27.2% of women and 15.3% of men had experienced IPV in their lifetime. Women who had experienced IPV were three times more likely to have attempted suicide in the past year than women who had not experienced IPV. They were also more likely to have experienced other adversities, such as financial crises and job loss. Nearly half of the women in the study who were unemployed or unable to work due to sickness or disability had experienced IPV. 

Sexual IPV (any form of sexual assault that takes place in an intimate relationship) was particularly associated with higher rates of suicidality and self-harm. The study found that women were 10 times more likely than men to have experienced sexual IPV. Women who experienced this type of IPV were seven times more likely to have attempted suicide in the past year than their peers.

This study provides evidence to support an association between IPV and suicidality and self-harm among adults. According to the authors, the findings suggest that service providers may want to ask people with a history of self-harm or suicide risk about IPV. Additionally, interventions to reduce IPV may also be protective against self-harm and suicide.

The authors noted that this study was based on cross-sectional data, so it was unable to establish causality in the way a longitudinal study could, since the study did not establish whether suicidal behavior preceded IPV or occurred as a result of it.  The limited sample size prevented the study from fully analyzing factors such as ethnicity and gender identity. The authors also noted that the data was based on self-reporting, so it is possible that participants underreported experiences of IPV, which may be stigmatized.

McManus, S., Walby, S., Barbosa, E. C., Appleby, L., Brugha, T., Bebbington, P. E., Cook, E. A., Knipe, D. (2022). Intimate partner violence, suicidality, and self-harm: A probability sample survey of the general population in England. Lancet Psychiatry, 9(7), 574-583.

Behavioral Health Care Barriers in Rural New York

A recent study examined service providers’ views on behavioral health care delivery barriers in rural New York.

Researchers held focus groups with 206 professionals to explore their perspectives on facilitators and barriers to the delivery of behavioral health care services in 16 rural New York counties. Participants included health, behavioral health care, and social service providers; government officials; law enforcement; first responders; school staff; and clergy.

The study identified several government and regulatory policies that limited participants’ ability to provide effective behavioral health care in rural counties. These included funding algorithms based on population size instead of need as well as “one size fits all” policies that tend to favor urban, population-dense areas over rural, sparsely populated areas with greater need.

Participants also identified a gap in funding for upstream interventions. They reported that challenges in recruiting and retaining staff made it difficult to ensure continuity and quality of services. Participants said turnover rates among rural providers were linked to factors such as higher salaries in urban areas, large caseloads, and stress and burnout.

Despite these challenges, participants shared creative strategies for serving their communities. These included forming outreach teams, using non-traditional venues to meet with clients, and cross-agency collaboration. Participants said the close-knit structure of many rural communities made relationship building very important, especially in the context of behavioral health challenges and cultural beliefs passed down over generations.

This study has some limitations. Participants were recruited from rural New York counties, which may not be representative of rural areas in other parts of the country. Focus group participation was voluntary, so participants may represent the professionals who were most invested in providing behavioral health care services. The race and ethnicity of participants matched the demographics of the counties served (93% White), but the results may not reflect the experiences of other racial and ethnic groups.

Harris, B. R., & Gallant, K. C. (2023). In their own voice: Behavioral health care delivery barriers in rural New York. Journal of Rural Mental Health. Advance online publication.

Pediatric Emergency Department Visit Follow-Up

A recent study examined rates of follow-up outpatient care for children discharged from emergency departments after mental health care visits.

Study participants were 28,551 children ages 6 to 17 enrolled in Medicaid who visited emergency departments for mental health care between January 2018 and June 2019. The study found that 31.2% of participants received outpatient care within 7 days of discharge and 55.8% received care within 30 days. The most common diagnoses were depressive disorders (39.1%); disruptive, impulse control, and conduct disorders (25.0%); and trauma and stressor-related disorders (14.2%).

Non-Hispanic Black children were less likely than White and Hispanic children to have follow-up visits within seven days of discharge. Children covered under fee-for-service Medicaid were also less likely to receive follow up within seven days. Children who had received mental health outpatient care in the previous year were most likely to receive timely follow-up care after an emergency department visit.

Receiving follow-up care within 30 days of discharge from an emergency department was associated with a 26% decreased risk of return within 5 days of the initial visit. Among all children studied, 26.5% returned to an emergency department for mental health care within six months of their initial visit.

The findings from this study highlight the importance of timely access to mental health services for children following an emergency department discharge. The authors note that children seen in an emergency department are likely to have less severe clinical symptoms and greater family support, which may have affected the outcomes in this study.

Hoffmann, J. A., Krass, P., Rodean, J., Bardach, N. S., Cafferty, R., Coker, T.R., Cutler, G.J., Hall, M., Morse, R. B., Nash, K. A., Parikh, K., Zima, B. T. (2023).  Follow-up After Pediatric Mental Health Emergency Visits. Pediatrics, 15(3). 10.1542/peds.2022-057383

Frailty and Suicide Risk Among Older Adult Veterans

A recent study found frailty was associated with suicide attempt risk among U.S. veterans ages 65 and older.

Study participants were 2,858,876 veterans (mean age 75.4) who received care at U.S. Department of Veterans Affairs (VA) medical centers from October 1, 2011, through September 13, 2013. The sample population was 2.3% female and 97.7% male, 9.0% non-Hispanic Black, 87.8% non-Hispanic White, and 2.6% “other” or unknown ethnicity. Among all participants, 16.6% had diagnosed substance use disorder (SUD) and 6.8% had diagnosed post-traumatic stress disorder (PTSD).

The study integrated databases from VA health care services, Centers for Medicare & Medicaid Services, and other national suicide data. Using suicide attempts through December 31, 2017, as the main outcome measure, researchers analyzed degree of frailty categorized into five levels (nonfrailty; prefrailty; and mild, moderate, and severe frailty).

The researchers found that the risk of suicide attempts was higher in veterans with all levels of frailty compared to those without frailty. Risk of lethal suicide attempts was associated with lower levels of frailty. A total of 8,995 (0.3%) participants had a documented suicide attempt and 5,497 had died by suicide by the end of the study period. The greatest percentage of suicide attempts was found among those with mild or moderate frailty and the smallest percentage among those without frailty. Veterans with prefrailty had the highest cumulative incidence of fatal suicide attempts over time. The risk of any suicide attempt was 48% higher among older veterans with moderate frailty compared to veterans without frailty. The presence of chronic pain, use of durable medical equipment (e.g., motorized wheelchair), lung disease, SUD, PTSD, or other mental health disorder increased the risk of suicide attempts as well as deaths.

The sample for this study was predominantly male (97.7%); women have only recently begun to enter the military in large numbers and are not well represented in the older veteran population. This means caution should be used in generalizing these results to female veterans. The findings may also be less generalizable to people of color, non-veterans, and veterans who do not use VA services. Since frailty was only measured once (at baseline), these results cannot account for the effects of progressive disabilities over time. Nonetheless, this study highlights the importance of assessing and addressing depression and suicidality among frail older adults.

Kuffel, R. L., Morin, R. T., Covinsky, K. E., Boscardin, W. J., Lohman, M. C., Li, Y., Byers, A. L. (2023). Association of frailty with risk of suicide attempt in a national cohort of US veterans aged 65 years or older. JAMA Psychiatry, 80(4): 287-295. doi:10.1001/jamapsychiatry.2022.5144

Screen Time and Suicide Risk Among Emerging Adults

In a new study, researchers examined the association between screen media use and suicide risk among adolescents over a 10-year period, from adolescence to emerging adulthood.

The study participants were part of the Flourishing Families Project, an ongoing, longitudinal study of family life. Data collection took place from 2009-2019. Participants ranged from 12-15 years old (average 13.82) when they were first surveyed. Most participants (67%) came from two-parent families, while 33% came from single-parent families. The sample population was 65% Caucasian, 12% Black, 19% multi-ethnic, and 4% “other.” Sixty-one percent of participants’ mothers and 70% of their fathers had a bachelor’s degree or higher. Annual family incomes ranged from less than $59,000 (18.2%) to $150,000 or more.

Each year of the survey, participants were asked how much time they spent on a typical day watching TV programs (on any device), playing video games (online or offline), talking on a cell phone, texting on a cell phone, and using social networking sites such as Facebook. In the first year of the study, depression was assessed using the 20-item self-report Center for Epidemiological Studies Depression Scale for Children1. In the final year of the study, suicide risk was assessed using the Revised Suicidal Behavior Questionnaire2. By the end of the study, the average age of participants was 23.3 and 7% had a high school education or less, 54% had some college or were currently enrolled, and 385 had a bachelor’s degree or higher.

The study found that boys who played more video games had higher levels of cyber-victimization (e.g., had something embarrassing or mean posted or re-posted about them online) and higher suicide risk. Boys with higher use of media apps that involved reading had higher levels of negative social media use (e.g., compared themselves to others on social media) and the highest suicide risk. Higher use of entertainment apps, social media, and increasing use of video games over time was associated with higher suicide risk for girls. The results of this study suggest that the pattern of social media use over time, not just time spent on social media, is most predictive of suicide risk in emerging adulthood.

While the results of this study are intriguing, they do not establish a causal link between screen media use and suicide risk. The data is based on self-report and does not account for potential mediating factors, including those in the family environment. Suicide risk was not measured at the beginning of the study; some participants may have been at risk prior to the start of the study and there may have been other earlier factors that influenced media use. The families that participated in this study were primarily White, middle-income, well-educated, two-parent families and the findings may not be generalizable to low-income, less-educated, or non-White populations.

Coyne, S. M., Hurst, J. L., Dyer, W. J., Hunt, Q., Schvanaveldt, E., Brown, S., & Jones, G. (2021). Suicide risk in emerging adulthood: Associations with screen time over 10 Years. Journal of Youth and Adolescence, 50(12), 2324-2338.

  1. Weissman, M. M., Orvaschel, H., & Padian, N. (1980). Children’s symptom and social functioning: Self-report scales. Journal of Nervous and Mental Disorders, 168(12),736–740. 10.1097/00005053-198012000-00005
  2. Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and nonclinical samples. Assessment, 8(4), 443–454.10.1177/107319110100800409

Suicide Risk Screening in Adult Primary Care

An expert workgroup has released recommendations on a clinical pathway (i.e., care pathway) for suicide risk screening in adult primary care settings.

Evolving from a public meeting hosted by the National Institute of Mental Health in 2017, the workgroup included researchers and practitioners with expertise in suicide prevention and/or primary care. Their aim was to develop a clinical pathway to assist primary care practices in the screening, assessment, and referral of adult patients at risk for suicide.

Based on a review of the scientific literature and supplementary expert opinion, the workgroup developed three documents: (1) an introduction providing an overview of the purpose of the pathway and recommendations for its use, (2) a flowchart outlining the process and decision points for screening and assessing adult patients for suicide risk, and (3) guidance on how to implement the process.

These workgroup recommendations reflect extensive review of the literature and several iterations of expert discussion over five years. The clinical pathway is a potentially useful tool for medical and social service providers in primary care and a variety of other clinical settings and could be the basis for comprehensive suicide prevention training programs. The authors also reference a similar pathway developed for youth.1,2

The authors acknowledge that the pathway has not been evaluated in a clinical setting and further research is needed to determine its feasibility and usefulness in a clinical setting as well as its effectiveness in preventing suicide. Another limitation is that the workgroup did not include input from patients and others with lived experience.

Ayer, L., Horowitz, L. M., Colpe, L., Lowry, N. J., Ryan, P. C., Boudreaux, E., Little, V., Erban, S., Ramirez-Estrada, S., & Schoenbaum, M. (2022). Clinical pathway for suicide risk screening in adult primary care settings: Special recommendations. Journal of the Academy of Consultation-Liaison Psychiatry, 63(5), 497-510.

  1. Brahmbhatt, K., Kurtz, B. P., Afzal, K. I., Giles, L. L., Kowal, E. D., Johnson, K. P., Lanzillo, E., Pao, M., Plioplys, S., Horowitz, L. M., PaCC Workgroup. (2019). Suicide risk screening in pediatric hospitals: Clinical pathways to address a global health crisis. Psychosomatics, 60(1), 1-9.
  2. Horowitz, L. M., Bridge, J. A., Tipton, M. V., Abernathy, T., Mournet, A. M., Snyder, D. J., Lanzillo, E. C., Powell, D., Schoenbaum, M., Brahmbhatt, K., & Pao, M. (2022). Implementing suicide risk screening in a pediatric primary care setting: From research to practice. Academic Pediatrics, 22(2), 217-226.

Suicide Risk Screening in Pediatric Primary Care

A recent study described the implementation of a suicide risk screening protocol in a pediatric primary care setting. The research aimed to determine the feasibility of implementation by measuring acceptability of the screening process to clinic staff, parents, and patients; disruption to workflow; and rates of suicide risk. A secondary study aim was to use the results to develop a clinical pathway (i.e., care pathway) for suicide risk screening in outpatient pediatric settings.

The study was carried out by leaders of a suburban pediatric primary care practice in collaboration with researchers from the National Institute of Mental Health. Participants were 271 patients ages 12 to 25 who were screened for suicidal thoughts and behaviors using the Ask Suicide-Screening Questions (ASQ) tool. Clinic staff received training in suicide epidemiology, risk factors, warning signs, and safety planning, as well as how to administer the ASQ, interpret results, and respond to a positive screen. Following the initial pilot, feedback from staff, parents, and patients was obtained through surveys.

Among the patients screened, 31 (11.4%) were positive for suicide risk with 1 at imminent risk. More than half of patients who screened positive reported a past suicide attempt. Overall, 64% of patients said they had never been asked about suicide before, including the one who was positive for imminent risk. Most parents (74%) were supportive of suicide risk screening at the doctor’s office and 80% indicated that they were somewhat or very comfortable with their child being screened.

All three pediatricians and 73% of nurses in the practice agreed that clinicians should ask patients about suicide risk in medical settings. All nurses reported experiencing discomfort asking direct questions about suicide but that after several patients reported suicidal thoughts, they better understood the importance of screening. After implementation, most clinic staff said that the screening protocol was not disruptive to workflow, were comfortable screening patients for suicide risk, and felt prepared to continue screening. 

This study has limitations that may limit the generalizability of its findings. Participants were not randomly selected and recruited from a single site and therefore may not be representative of the general population of pediatric outpatients and their families. The sample was mostly White and female. Because of the small sample size and relative homogeneity, cultural and ethnic differences in attitudes and beliefs about suicide could not be addressed. The authors also acknowledged that because of the focus on “wellness” visits, the patients may not be representative of those at highest risk. 

Despite its limitations, the results of this study are important and demonstrate that:

  • Suicide risk screening may be acceptable to young patients and their parents.
  • A standard suicide risk screening protocol can be successfully implemented in a pediatric primary care setting without any disruption to normal workflow.
  • Over time, staff may become more comfortable asking direct questions about suicide and realize the importance of screening.
  • Support from leadership, adequate planning and training, frequent feedback and self-monitoring, and willingness to make real time adjustments appear to be key to successfully implementing such a protocol.

The results of this study informed the development of a clinical pathway for youth suicide risk screening in outpatient settings.

Horowitz, L. M., Bridge, J. A., Tipton, M. V., Abernathy, T., Mournet, A. M., Snyder, D. J., Lanzillo, E. C., Powell, D., Schoenbaum, M., Brahmbhatt, K., & Pao, M. (2022). Implementing suicide risk screening in a pediatric primary care setting: From research to practice. Academic Pediatrics, 22(2), 217-226.

Suicide and Known Mental Health Status among Males

In a new study, researchers examined suicide among males across the life span and its association with known mental health conditions.

Using data from the Centers for Disease Control and Prevention’s National Violent Death Reporting System, the researchers analyzed 70,376 suicide deaths from 2016 through 2018. They compared suicide characteristics with and without known mental health conditions among four groups of males (ages 10-17, 18-34, 35-64, and ≥ 65). Data was based on death certificates and coroner/medical examiner and law enforcement reports, and suicide was defined as deaths of persons ≥ 10 years old from intentional self-harm.

The analysis found 40% of all males had a history of known mental health conditions. Males with known mental health conditions were more likely to have a history of suicidal thoughts and/or suicide attempts. Among those recently released from an institution (10% of participants), those with a known mental health condition were more likely to have been released from a psychiatric hospital, while those without a known mental health condition were more likely to have been released from jail/prison.

Males without a history of known mental health conditions were more likely to have had a recent or impending crisis, such as eviction/home loss, relationship problems, or criminal/legal problems; live in a rural area; have disclosed suicidal thoughts or suicide attempts; used firearms as a suicide method; and have been recently released from jail/prison. 

Among males 65 and older, physical health problems also appeared to be a risk factor for suicide. Substance use was common in both groups but more likely in those with known mental health conditions.

This study helps shed light on risk factors for suicide among males across the life span with and without known mental health conditions. The findings highlight the importance of a comprehensive approach to suicide prevention, including strategies to reduce the impact of social stressors and provide supportive environments, especially in cases of substance misuse or access to firearms.

Unlike previous research of its kind, this study used medical records or other official documents to determine mental illness rather than interviews with family members, which may be less objective and subject to bias. However, it is possible that some individuals with mental health conditions were undiagnosed. The authors note that non-White, lower educated, and rural males were less likely to have had a known mental health condition, which may reflect disparities in access to mental health care.

As of 2018, data in the National Violent Death Reporting System was only available for 39 states, reflecting 72% of the U.S. population and Puerto Rico, so the data used in this study was not national in scope. Also, routine assessments of substance use are not standard across jurisdictions and not all substances are routinely screened for.

Fowler, K. A., Kaplan, M. S., Stone, D. M., Zhou, H., Stevens, M. R., Simon, T. R. (2022). Suicide among males across the lifespan: An analysis of differences by known mental health status. American Journal of Preventive Medicine, 63(3), 419–422.

Sexual Orientation Hate Crime Laws and Youth Suicide Risk

State laws that aim to prevent hate crimes related to sexual orientation may help reduce suicide among high-school-aged youth, suggests a recent study.

Using data from the Youth Risk Behavior Survey (YRBS), researchers examined suicide attempts among youth in states with hate crime laws that explicitly name sexual minorities as a protected population, states that do not include them as a protected group, and states without any hate crime laws. They found there were 62,274 past-year suicide attempts among youth in the study, with an overall prevalence of 8.6 %. The estimated prevalence of suicide attempts among youth who identified as gay or lesbian (25.7%), bisexual (27.1%), or questioning (18.5%) was considerably higher than among their heterosexual peers (6.3%).

The study found that including sexual minorities as a protected group in state-level hate crime laws reduced suicide attempt rates among youth by a small but significant percentage compared to state laws that did not include them as a protected group. The reduction in suicidal behaviors did not differ in magnitude between lesbian, gay, bisexual, or questioning and heterosexual respondents, suggesting that the passage of hate crime laws related to sexual orientation may benefit all youth. Reductions in suicide attempts were larger among questioning and bisexual youth compared to their gay or lesbian peers. Youth outcomes in states with hate crime laws that lacked specific protections for sexual minority populations did not differ from states without any hate crime legislation.

Experiencing social stigma, discrimination, and associated stress can increase suicide risk and mental health challenges among youth who identify as LGBTQIA+. This study highlights the potential benefit of state legislation that specifically names sexual minority populations as a protected group. Enactment of such legislation may be an indicator of a more supportive political environment which, in turn, may lessen actual or perceived stigma and victimization.

This study has some limitations. The identification of sexual and gender identity was based on a self-report survey, and it is likely that some respondents might have been reluctant to disclose this information. The authors noted that the validity of questions exploring sexual preferences have been questioned due to variability in the interpretation of the question. Also, the language and provisions of hate crime laws differ across states, making it difficult to establish a direct link between the legislation and behavioral outcomes.

Despite its limitations, the results of this study are intriguing. There have been few studies of the impact of legislation and public policy on individual suicide-related behavior. The results of this study highlight the need for further research on this topic.

Prairie, K., Kivisto, A. J., Gray, S. L., Taylor, N., & Anderson, A. M. (2022). The association between hate crime laws that enumerate sexual orientation and adolescent suicide attempts. Psychology, Public Policy, and Law. Advance online publication.