News Type: Weekly Spark Research

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

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. https://doi.org/10.1007/s10964-020-01389-6

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

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. https://doi.org/10.1016/j.psym.2018.09.003
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. https://doi.org/10.1016/j.acap.2021.10.012

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. https://doi.org/10.1016/j.acap.2021.10.012

Ethical Issues in Suicide Prevention Research—Archives of Suicide Research

Racial Differences in Suicide Risk among Adults in Criminal-Legal Systems—BMC Psychiatry

Treatment-Seeking and Suicidality by Suicide Method—JAMA Network Open

Sexual Orientation Hate Crime Laws and Youth Suicide Risk—Psychology, Public Policy, and Law

More Research from 2022

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.

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. https://doi.org/10.1037/law0000360

An evaluation found the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET) program was associated with increased treatment engagement and quality of care and reduced suicide attempts among participants. Run by the Veterans Health Administration, the REACH VET program is designed to facilitate care enhancements for individuals identified by a validated algorithm as being in the top 0.1% for suicide risk.

The study sought to examine whether participation in REACH VET resulted in greater treatment engagement (i.e., more scheduled and completed appointments) and quality of care (e.g., suicide safety plan documentation), as well as reduced acute care needs (fewer inpatient mental health admissions and emergency department visits) and suicide-related behaviors (suicide attempts and deaths).

Researchers compared outcomes of individuals entering REACH VET between March 2017 and December 2018 to a group of individuals identified as high risk prior to the program’s start who would have met the eligibility criteria. They also included a second comparison group of people who would not have been eligible for the program to compare cause-specific mortality using death certificate data.

Participant data came from the Veterans Health Administration Corporate Data Warehouse on 173,313 individuals (93% men, 7% women) with a mean age of 51. 

Results indicated that participation in REACH VET was associated with more completed outpatient appointments, fewer missed appointments, having new suicide safety plans, reduced mental health admissions and emergency department visits, and fewer documented suicide attempts within six months. However, there was no difference between the groups in the proportion of deaths resulting from suicide or other causes within six months.

REACH VET is the first clinical implementation of a validated algorithm to support suicide risk identification in the U.S., carried out in the nation’s largest integrated health system. The findings from this study highlight the value of investment in suicide surveillance, data analytics, and clinical operations to improve health outcomes.

McCarthy, J. F., Cooper, S. A., Dent, K. R., Eagan, A. E., Matarazzo, B. B., Hannemann, C. M., Reger, M. A., Landes, S. J., Trafton, J. A., Schoenbaum, M., & Katz, I. R. (2021). Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment suicide risk modeling clinical program in the Veterans Health Administration. JAMA Network Open, 4(10), e2129900. doi:10.1001/jamanetworkopen.2021.29900

A recent study looked at treatment-seeking and suicidality among people who died by firearm suicide compared to those who died by other suicide methods.

Using data from the National Violent Death Reporting System (NVDRS), researchers studied 234,652 people who died by suicide between 2003 and 2018. Comparing those who died by firearms to those who used other methods, the researchers examined history of mental health or substance use treatment, suicidal thoughts or plans, suicide attempts, and disclosure of suicidal thoughts or plans.

Study participants were mostly male (77.8%) and white (87.8%) with a mean age of 46. In this sample, firearms were the most frequently used suicide method (49.9%), followed by hanging, strangulation, or suffocation (26.7%), and poisoning (15.3%). Most participants were not receiving mental health or substance use treatment when they died, had not sought treatment in their lifetime, did not have a lifetime history of suicidal thoughts or plans or suicide attempts, and had not disclosed suicidal thoughts or plans in the month before they died. Those whose highest level of education was a high school diploma made up the largest percentage of deaths across all methods of suicide.

The analysis found that individuals with a history of mental health or substance use treatment or suicide attempts were significantly less likely to die by firearms than other methods. Those who recently disclosed suicidal thoughts or plans had higher odds of dying by firearms but were not more likely to have a previous history of suicidal thoughts or plans. These findings were consistent for both male and female participants ages 18 to 84. Compared to individuals who died by poisoning, those who died by firearms were significantly more likely to have a history of suicidal thoughts or plans and to have recently disclosed suicidal thoughts or plans. Compared to people who died by hanging, those who used firearms were more likely to have recently disclosed suicidal thoughts or plans.

Study participants who died by firearm suicide were less likely to seek mental health treatment or to have attempted suicide compared to those who died by other methods, suggesting many likely died on their first attempt. These individuals may be less likely to be identified through evidence-based suicide interventions that take place in mental health care settings. Those who died by firearms were also more likely to have disclosed suicidal thoughts or plans to someone in the month before their death, but they were not more likely to have a history of suicidal thoughts or plans. These findings highlight the need for more universal prevention strategies to raise awareness of suicide risk factors, warning signs, and prevention strategies in the general population. Among potential upstream interventions, the authors note safe storage of firearms is associated with decreased firearms suicide. To increase their effectiveness, they recommend programs that promote safe storage practices reflect the language and culture of firearms owners.

Limitations of this study include the homogeneity of the sample and the lack of specifics about the mental health services used and the nature and recipients of suicidal disclosure. Individuals who did disclose thoughts or plans represented a small subset of those who used firearms, an indication that disclosure is rare. During the study, the dataset expanded from 6 states in 2003 to 32 states in 2018. The earlier data account for a disproportionate number of deaths in this sample and may not represent more recent socio-demographic trends or changes.

Bond, A. E., Bandel, S. L., Rodriguez, T. R., Anestis, J. C., Anestis, M. D. (2022). Mental health treatment seeking and history of suicidal thoughts among suicide decedents by mechanism, 2003-2018. JAMA Network Open, 5(3): e222101. doi:10.1001/jamanetworkopen.2022.2101

Research shows that adults in the criminal-legal system have higher rates of suicide and behavioral health disorders than the general population. There are also documented racial differences in experiences of criminal processing and access to behavioral health care. However, few studies have looked at whether this population’s suicide risk varies by race. To fill that gap, researchers conducted a study to identify risk factors for suicide among adults involved in the criminal-legal system and to find out if there were differences in suicide risk based on race.

The sample for this study was 16,849 adults with recent criminal-legal involvement who were enrolled in a statewide behavioral health treatment program, Indiana Recovery Works, between October 2015 and March 2018. Participants only included those who identified as either White or Black. The group was predominantly White and male with an average age of 35. Suicide risk was determined by clinicians using the Adult Needs and Strengths Assessment (ANSA) tool. Researchers carried out analyses to model suicide risk overall and within each of the racial groups and to identify differences between them. 

The initial analyses revealed that one in five individuals had suicide risk, a majority had a primary diagnosis of substance use disorder and a primary mental health diagnosis, and a small percentage had a history of self-harm. Black participants were significantly older, had lower suicide risk and higher criminal behavior risk, and were more likely to have mental health or substance use diagnoses. White participants were more likely to have a co-occurring diagnosis, evidence of self-harm, and prior substance use episodes, and were more likely to be female and have worse scores on the domains of life functioning, strengths, and behavioral health needs. The secondary analyses found no evidence of differences in suicide risk between the groups based on race alone.

It is important to note that the study participants had already been identified as needing behavioral health treatment and therefore may have had higher suicide risk than the general population and others in the criminal-legal system. Without a behavioral health diagnosis or participation in treatment, additional or different risk factors may have been found, particularly since Black and White disparities have been found in both access to treatment and the likelihood of incarceration. All study participants were referred to treatment based on clinical diagnosis, which may have been influenced by implicit clinician bias (i.e., an association outside conscious awareness that lead to a negative evaluation of a person or group on the bias of irrelevant characteristics such as race or gender¹).

Nonetheless, these findings suggest that adults with behavioral health disorders and recent experience in the criminal-legal system experience risk factors for suicide similar to those in the general population. The association of substance use and co-occurring behavioral health disorders with suicide risk is particularly important given the current opioid epidemic. As the authors note, these findings highlight the need for more investigation on how criminal-legal involvement may worsen suicide risk.

Lawson, S. G., Lowder, E. M., & Ray, B. (2022). Correlates of suicide risk among Black and White adults with behavioral health disorders in criminal-legal systems. BMC Psychiatry, 22(163). doi: 10.1186/s12888-022-03803-8

1. Fitzgerald, C., & Hurst, S. (2017.) Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1). doi: 10.1186/s12910-017-0179-8