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Background Near-term risk factors for suicidal behavior, referred to as ‘warning signs’ (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. Methods Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). Results Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. Conclusions The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

IntroductionThe increase in the suicide mortality rate among middle-aged adults in the United States (US) has been well documented. Aside from a few studies from the United Kingdom, it is unclear whether the suicide mortality rate trend in the US is also occurring in other developed countries. Accordingly, we aimed to compare the suicide mortality rate trends over the past 30 years in the US to a country in the European Union–Lithuania.MethodsJoinpoint regression analyses were performed to identify secular trends in the gender-specific age-standardized suicide mortality rate among individuals 15 + years of age, as well as middle-aged adults (45–54 years of age), and suicide mortality rate ratio for men-to-women.ResultsAge-standardized suicide mortality rates among middle-aged adults in the US increased annually, on average, by 0.89% (95% CI: 0.66%, 1.12%) among men and 1.21% (95% CI: 0.75%, 1.66%) among women between 1990 and 2019. In contrast to the US, there was an overall downward trend in the suicide mortality rates among middle-aged adults in Lithuania across the study period. The average annual percent change in the suicide mortality rate ratio for men-to-women were not statistically significant for either country.ConclusionThe suicide mortality rate trend in the US does not appear to be an indicator of an upcoming global trend, but rather should be regarded as a cautionary example of what other countries should strive to avoid.

BackgroundDespite decades of research to better understand suicide risk and to develop detection and prevention methods, suicide is still one of the leading causes of death globally. While large-scale studies using real-world evidence from electronic health records can identify who is at risk, they have not been successful at pinpointing when someone is at risk. Personalized social media and online search history data, by contrast, could provide an ongoing real-world datastream revealing internal thoughts and personal states of mind.ObjectiveWe conducted this study to determine the feasibility and acceptability of using personalized online information-seeking behavior in the identification of risk for suicide attempts.MethodsThis was a cohort survey study to assess attitudes of participants with a prior suicide attempt about using web search data for suicide prevention purposes, dates of lifetime suicide attempts, and an optional one-time download of their past web searches on Google. The study was conducted at the University of Washington School of Medicine Psychiatry Research Offices. The main outcomes were participants’ opinions on internet search data for suicide prediction and intervention and any potential change in online information-seeking behavior proximal to a suicide attempt. Individualized nonparametric association analysis was used to assess the magnitude of difference in web search data features derived from time periods proximal (7, 15, 30, and 60 days) to the suicide attempts versus the typical (baseline) search behavior of participants.ResultsA total of 62 participants who had attempted suicide in the past agreed to participate in the study. Internet search activity varied from person to person (median 2-24 searches per day). Changes in online search behavior proximal to suicide attempts were evident up to 60 days before attempt. For a subset of attempts (7/30, 23%) search features showed associations from 2 months to a week before the attempt. The top 3 search constructs associated with attempts were online searching patterns (9/30 attempts, 30%), semantic relatedness of search queries to suicide methods (7/30 attempts, 23%), and anger (7/30 attempts, 23%). Participants (40/59, 68%) indicated that use of this personalized web search data for prevention purposes was acceptable with noninvasive potential interventions such as connection to a real person (eg, friend, family member, or counselor); however, concerns were raised about detection accuracy, privacy, and the potential for overly invasive intervention.ConclusionsChanges in online search behavior may be a useful and acceptable means of detecting suicide risk. Personalized analysis of online information-seeking behavior showed notable changes in search behavior and search terms that are tied to early warning signs of suicide and are evident 2 months to 7 days before a suicide attempt.

Suicide is a major and preventable public health issue and research has identified several distal risk factors for determining individuals at risk for a suicide attempt. However, understanding imminent processes could enhance individualized safety plan formulations and interventions. Motivation for suicide attempt (MfSA) reflects why an individual engages in a specific attempt. Research indicates such motives can be organized into major factors, but consensus on the number, and their correlates, has not been reached. The sample consisted of 190 patients who attempted suicide within 24 hours of hospitalization and completed the MfSA within the Suicide Attempt-Self Injury Interview. Exploratory factor and correlational analyses were conducted to identify the factors that underlie MfSA. Regression analyses were conducted to examine the relations of MfSA factors to distal suicide risk factors and suicide-related attempt characteristics. Two underlying MfSA factors were identified. Interpersonal MfSA was associated with lower age and higher problematic alcohol use. Intrapersonal MfSA was related to having previous suicide attempts, more past year negative life events, and higher depressive symptoms. The modified MfSA is easy to administer, and its factors show unique associations with important suicide-related constructs. The results could inform safety planning procedures to prevent future death by suicide.

Research on associations of suicidal behavior, including suicide and suicide attempt, with alcohol use disorder (AUD) and acute use of alcohol (AUA) are discussed, with an emphasis on data from meta-analyses. Based on psychological autopsy investigations, results indicate that AUD is prevalent among individuals who die by suicide. Results also indicate that AUD is a potent risk factor for suicidal behavior. Risk estimates are higher for individuals with AUD in treatment settings, when compared to individuals in the community who have AUD. Also, although rates of suicide and prevalence of AUD remain higher in men, they have increased more among women in recent decades. Based on postmortem blood alcohol concentrations, AUA was commonly present among those who died by suicide. AUA is a potent proximal risk factor for suicidal behavior, and the risk increases with the amount of alcohol consumed, consistent with a dose-response relationship. Research indicates that AUA increases risk for suicidal behavior by lowering inhibition and promoting suicidal thoughts. There is support for policies that serve to reduce alcohol availability in populations with high rates of AUD and suicide, that promote AUD treatment, and that defer suicide risk assessments in intoxicated patients to allow the blood alcohol concentration to decrease.

Drinking to cope is associated with suicide ideation and attempts. Event-based research shows drinking, particularly when alcohol is consumed in large quantities, increases the intensity of suicidal thoughts and immediate risk for attempt. Such findings suggest those who typically drink to cope may be especially likely to drink heavily in the hours preceding a suicide attempt. In the first examination of the association between regular use of alcohol as a coping strategy and acute alcohol consumption prior to a suicide attempt, participants included 130 patients hospitalized for a recent attempt. The number of drinks consumed in the acute period preceding the attempt, as well as past-year heavy drinking frequency, typical drinking motives, and depressive symptoms were assessed. The unique impacts of coping motives on odds of consuming any alcohol, and of using specific amounts of alcohol in the acute period, were determined through binary and multinomial logistic regressions. Results demonstrated that commonly drinking for coping motives increased the odds of heavy drinking - but not of using alcohol at low levels - during the acute period. Results held after adjusting for relevant covariates. Clinicians should assess drinking motives and prioritize prevention of drinking to cope to reduce risk of alcohol-related suicide attempts.

Background Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death. Methods Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables. Results Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse. Conclusions The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

Negative life events are elevated in suicidal populations. Diathesis-stress and kindling effects models suggest different mechanisms by which negative life events increase suicide risk. Different forms of negative life events – risk-taking behaviors and stressors – may have different effects on non-fatal suicide attempts and suicide. We assessed the effects of risk-taking behaviors and stressors on suicide, history of non-fatal suicide attempts, and active preparation for suicide in a sample of adults who died by suicide or other causes (N = 377). Psychological autopsy procedures using family member interviews and collateral record review were used to complete a risk-taking behaviors composite measure from the Structured Interview for DSM-IV Personality Disorders, the Modified Life Experiences Scale, and the planning subscale of the Suicide Intent Scale. Stressors were significantly associated with death by suicide, even when accounting for demographic and diagnostic characteristics. Risk-taking behaviors were significantly associated with non-fatal suicide attempts, even when accounting for demographic and diagnostic characteristics. Suicide decedents who did not actively prepare for suicide showed significantly higher risk-taking scores than suicide decedents who actively planned for suicide. Our results suggest that risk-taking behaviors and stressors impact suicide risk through separate mechanisms. Risk-taking behaviors may represent a longstanding vulnerability to act impulsively on suicidal thoughts. Stressors may impact risk for fatal suicidal behaviors in mood disordered populations.

BACKGROUND Research has identified several correlates of suicidal behaviors including depressive symptoms, alcohol use and coping drinking motives. However, their associations and their role as possible causal mechanisms in the prediction of suicide attempt are not well understood. This study examined, both cross-sectionally and longitudinally, the potential pathways from alcohol use, drinking coping motives, and depression to suicide attempts. METHODS Participants (N = 4617) were young Swiss men (mean age = 19.95) participating in the Cohort Study on Substance Use Risk Factors. Measures of depressive symptoms, alcohol use (total drinks per week, heavy episode drinking) and coping drinking motives were used from the baseline and/or 15-month follow-up assessments to predict follow-up suicide attempt. RESULTS Main findings showed indirect associations through depressive symptoms, such that coping drinking motives were positively associated with depressive symptoms, which were in turn positively related to suicide attempts over time (for total drinks per week models, cross-sectional model: B = 0.130, SE = 0.035, 95% CI = 0.072, 0.207; longitudinal model: B = 0.039, SE = 0.013, 95% CI = 0.019, 0.069). Alcohol use was not significantly related to suicide attempt. LIMITATIONS Main limitation includes a low prevalence rate for suicide attempt potentially reducing power effects in the analyses and our focus on distal-yet not proximal, role of alcohol use on suicide attempt. CONCLUSIONS Findings of this study suggest that young men with depressive symptoms and/or those who use alcohol to cope with negative affect may benefit from programs targeting suicidal behaviors.

Research on associations between substances of abuse and suicidal behaviors is a large, complex area. Herein, alcohol, the most commonly abused intoxicant worldwide, is examined with a focus on two topics: (1) acute use of alcohol (AUA) shortly prior to suicidal behavior; and (2) more chronic alcohol use disorder (AUD) and suicidal behavior. First, a brief summary of what is known about AUA, AUD, and suicidal behavior is provided. Next, we draw on preliminary evidence, practical considerations, and our own experience to offer recommendations for intervention research that may lower risk associated with AUA and AUD. The literature on AUD and suicidal behavior is more developed, thus we discuss separately research designed to: (1) prevent individuals with AUD with suicidal ideation from engaging in suicidal behavior; and (2) prevent individuals with AUD who have made a suicide attempt from reattempting. Our focus is on clinical intervention strategies for individuals at risk for suicidal behavior that use alcohol or have developed AUD. We also focus on applied research that may directly lead to practical prevention efforts. Although clinical interventions are important components of a comprehensive suicide prevention strategy, they should be complemented with primary prevention efforts.

OBJECTIVE: Major depressive episodes may be substance induced or occur independent of substance use. Studies of the roles of substance-induced depression (SID) and independent depression (IND) in suicidal behavior are limited to retrospective reports. The purpose of this study was to examine proximal (i.e., acute) risk for suicide attempts associated with SID and IND. METHOD: Individuals who had attempted suicide (n = 100) and nonsuicidal controls (n = 100) matched for site were recruited from residential substance use treatment programs. Participants were ages 18 and older and screened positive for potential alcohol use disorder. Validated semistructured interviews were used to assess SID, IND, and suicide attempts. Analyses of individual-level risk for attempts were based on multivariate logistic regression that adjusted for risk factors. Population-level attributable risk (PAR) fractions for suicide attempts were also calculated to provide estimates of the percentage of attempts in the study population attributable to SID and IND, respectively. RESULTS: SID was identified in 60% of attempters and 35% of controls and IND in 13% of attempters and 3% of controls. Both variables conferred risk for suicide attempt (SID: odds ratio [OR] = 3.73, 95% CI [1.84, 7.58]; IND: OR = 10.38, 95% CI [2.48, 43.49]. PAR for suicide attempts associated with SID and IND was 0.44 and 0.12, respectively. CONCLUSIONS: Both SID and IND confer proximal risk for suicide attempts after adjusting for other risk factors. SID also contributes substantial risk in this population overall. Future research should test the hypothesis that IND confers greater risk than SID at the individual level.

Nationwide, the opioid epidemic continues to have a significant and widespread adverse impact on morbidity and mortality. The number of individuals dying by suicide and unintentional overdose has continued to increase over the past decade, with opioids being involved in a significant proportion of each category of mortality in 2017. Currently, most strategies for decreasing opioid-overdose deaths do not include systematic screening for suicide risk, nor do they address the necessity to customize interventions for those who misuse opioids to decrease near-term suicide risk (defined here as less than 72 h) factors. Improved screening of near-term and chronic suicide risk along with rapid access to treatment is of critical importance to prevent opioid-related deaths by suicide.

OBJECTIVE: The present study examined whether reasons for living (RFL) would partially account for the associations between traditional risk factors (depressive symptoms, hopelessness) and suicidal ideation and attempts. METHOD: Data were collected from 1,075 undergraduate college students who completed a battery of online assessments. RESULTS: Results from a series of simultaneous mediational models indicated that the relations between risk factors and current suicidal ideation were partially mediated by total RFL (and Coping Beliefs and Self-Evaluation subscales). Further, total RFL (and the Coping Beliefs subscale) fully mediated the relation between hopelessness and past-year suicide attempt, and partially mediated the depressive symptoms-suicide attempt relation. CONCLUSIONS: This study demonstrates the importance of assessing for the presence of these suicide risk and protective factors. Implications for the improved identification and treatment of young adults at risk for suicide are discussed. Language: en

Impulsivity is a risk factor for suicidal outcomes (e.g., suicidal ideation, suicide attempts, and death by suicide; for a review, see Brezo, Paris, & Turecki, 2006). However, impulsivity is a heterogeneous construct, believed to reflect divergent processes. Given the multifacted nature of impulsivity, and the multiple approaches used to assess this construct and its subcomponents, it is essential to test the overlap among various methods that are purportedly tapping the same psychological processes. This focus can facilitate more refined scientific communication, aid attempts to develop more precise measures of impulsivity facets, and ultimately improve the theoretical and clinical utility of research linking impulsivity with suicidal behaviors. More specifically, impulsivity is a broad construct that has been assessed using multiple methods (e.g., self-report questionnaires, behavioral tasks) when studying maladaptive outcomes such as suicidal behaviors (e.g., Dougherty et al., 2004; Swann et al., 2005). Although “impulsivity” is a common term, there is no general consensus regarding strict definitions of this construct or its possible components. There are a multitude of definitions of impulsivity (e.g., Moeller, Barratt, Dougherty, Schmitz, & Swann, 2001), which leads to inconsistent use of the term across and within research domains and disciplines. As noted by several researchers (e.g., Cyders & Coskunpinar, 2011; Smith et al., 2007), this indistinctness hampers scientific progress on several fronts, including impeding translational approaches, obscuring theory, and hindering the development of clinical interventions. Given the disagreements in how to best define the construct of impulsivity and its facets, it is unsurprising that researchers have developed a plethora of different assessment methods and approaches. For example, numerous studies have focused their attention on developing self-reported assessments of impulsivity. Consolidating various self-report measures through the use of exploratory and confirmatory factor analysis, Whiteside and Lynam (2001) suggested a four-factor solution for impulsivity: sensation seeking, lack of planning, lack of persistence, and urgency (acting rashly when distressed). However, a separate area of research has focused on the development of behavioral assessments of impulsivity. Numerous behavioral tasks have been developed, including tasks thought to measure inhibitory control (e.g., the Go Stop Task; Dougherty, Mathias, Marsh, & Jagar, 2005), persistence (e.g., the Mirror Tracing Persistence Task; Strong et al., 2003) risk taking (e.g., the Balloon Analogue Risk Task; Lejuez et al., 2002), and delayed discounting (e.g., the Single Key Impulsivity Paradigm; Dougherty, Mathias, Marsh, & Jagar, 2005; see Cyders & Coskupinar, 2011; Strauss & Smith, 2009 for a detailed discussion of construct validity for questionnaire and behavioral assessments). There have been increasing efforts to organize various facets of impulsivity as measured by both questionnaire and behavioral approaches. In order to facilitate increased consilience among research groups that tend to utilize either questionnaire or behavioral measures of impulsivity, some researchers have suggested conceptual overlap among some impulsivity facets assessed by self-report measures (e.g., the UPPS facets) and behavioral indicators of impulsivity. Specifically, as noted by Dick et al. (2010) and Bechara and Van der Linden (2005), urgency may relate to measures of prepotent response inhibition (e.g., go/no go tasks). Indeed, some initial evidence suggested that performance on go/no-go tasks correlated with measures of urgency (Gay, Rochat, Billieux, d’Acremont, & Van der Linden, 2008). However, more recent evidence suggests that consilience may be difficult between questionnaire measures and behavioral tasks thought to assess similar impulsivity facets. In a recent meta-analysis, Cyders and Coskunpinar (2011) found significant but small (significant rs ranged from .10-.13) overlap between laboratory tasks and questionnaire-based measures of impulsivity. Based on these findings, Cyders and Coskunpinar concluded that the various measures of “impulsivity” should not be referred to as measuring the same construct and researchers should carefully specify the constructs they are aiming to operationalize when using both behavioral and questionnaire-based measures of impulsivity. The goal of the current paper is to examine the relations among various questionnaire and behavioral assessments of impulsivity in a sample of recent suicide attempters. Specifically, this multitrait, multimethod approach does not have any bearing on the “impulsivity” of the recent suicide attempt but rather illuminates the extent to which multiple measures (e.g., self-report urgency and behavioral prepotent response measures) thought to assess the same construct (e.g., inhibitory control) overlap in a high-risk sample of interest to both researchers and clinicians (i.e., suicide attempters). This information can be used to improve future research and clinical efforts involving suicidal behaviors by allowing for more informed decisions when assessing traits related to impulsivity. Further, these results can help guide attempts to design measures of impulsivity in specific clinical samples by showing strengths and shortcomings of existing approaches for assessing impulsivity.

Both intoxication and chronic heavy alcohol use are associated with suicide. There is extensive population-level evidence linking per capita alcohol consumption with suicide. While alcohol policies can reduce excessive alcohol consumption, the relationship between alcohol policies and suicide warrants a critical review of the literature. This review summarizes the associations between various types of alcohol policies and suicide, both in the United States and internationally, as presented in English-language literature published between 1999 and 2014. Study designs, methodological challenges, and limitations in ascertaining the associations are discussed. Because of the substantial between-states variation in alcohol policies, U.S.-based studies contributed substantially to the literature. Repeated cross-sectional designs at both the ecological level and decedent level were common among U.S.-based studies. Non-U.S. studies often used time series data to evaluate pre-post comparisons of a hybrid set of policy changes. Although inconsistency remained, the published literature in general supported the protective effect of restrictive alcohol policies on reducing suicide as well as the decreased level of alcohol involvement among suicide decedents. Common limitations included measurement and selection bias and a focus on effects of a limited number of alcohol policies without accounting for other alcohol policies. This review summarizes a number of studies that suggest restrictive alcohol policies may contribute to suicide prevention on a general population level and to a reduction of alcohol involvement among suicide deaths.

Presence of, and comorbidity between, psychiatric disorders is a risk factor for suicide attempts. No study to date has used a person-centered approach to determine whether there are subgroups of attempters showing differing patterns of psychiatric disorders. This study aimed to identify psychiatric subgroups amongst recent suicide attempters (i.e., hospitalized within 24 h of their attempt) and to determine whether identified classes could be differentiated in terms of important clinical correlates. Participants included 97 adult patients who were hospitalized due to a recent suicide attempt at a large Trauma 1 hospital. A structured diagnostic interview assessed a range of psychiatric disorders, and a battery of measures assessed acute and distal clinical correlates and characteristics of the current attempt. The person-centered analytic approach of latent class analysis was used to identify psychiatric diagnostic subgroups, or classes, of attempters. Three psychiatric subgroups were identified: Major Depressive Disorder, High Externalizing Disorders, and High Internalizing High Externalizing Disorders. Classes were found to significantly differ on a range of acute and distal clinical correlates, but not by demographics. Identification of psychiatric subgroups of individuals who have recently attempted suicide has important practical implications for increasing subsequent treatment utilization and tailoring treatment interventions for this population.

The primary purpose of this study was to examine the interactive effect of borderline personality disorder (BPD) and distress tolerance (DT) on suicidal behavior across levels of intent to die (clear vs ambiguous) and medical severity. One hundred seventy-six adult patients in residential substance use disorder treatment were administered a series of structured interviews, behavioral assessments, and self-report questionnaires. A series of analyses of covariance and multiple regression analyses were conducted to test hypotheses using both categorical and dimensional measures of BPD and DT. Analyses supported hypotheses, indicating that patients with BPD who exhibit high DT are at the greatest risk for engaging in chronic and medically serious suicidal behavior. Although high DT is unlikely to be inherently problematic, results suggest that within the context of severe psychopathology (eg, co-occurring BPD–substance use disorder), the ability to withstand aversive internal states in pursuit of a goal (eg, one's own death) may enable individuals to persist in otherwise unsustainable behavior. In this sense, DT may function in a manner consistent with the acquired capability for suicide (a component of the interpersonal-psychological theory of suicidal behavior defined by a diminished fear of death and enhanced tolerance for pain that, in the presence of suicidal desire, enables individuals to enact lethal self-injury).

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is associated with greater risk for suicidal behavior than either disorder alone. Research highlights the relevance of PTSD symptoms in particular to suicide risk within this population. Research has also provided support for an association between distress tolerance (DT) and both PTSD symptoms and suicidal behavior. This study examined the role of DT in the relationship between PTSD symptom severity and suicidal behavior in a sample of 164 SUD inpatients with a history of Criterion A traumatic exposure. Results indicated that DT moderated the relationship between PTSD symptoms (overall, re-experiencing, and hyperarousal) and medically attended suicide attempts, with the magnitude of the relationship increasing at higher levels of DT.

The Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini, Gunderson, Frankenburg, & Chauncey, 1989) measures four major aspects of borderline personality disorder (BPD): Affect, Cognition, Impulse Action Patterns, and Interpersonal Relationships. In the present study, 353 young adults completed the DIB-R at age 18 (Wave 1) and again two years later (Wave 2) at age 20. Concerning the prediction of future BPD features, three models were compared: (a) Wave 1 Affect scores predicting all Wave 2 BPD features (NA model); (b) Wave 1 Impulse Action Patterns scores predicting all Wave 2 BPD features (IMP model); and (c) both Wave 1 Affect and Impulse Action Patterns scores predicting all Wave 2 BPD features (NA-IMP model). Each model controlled for stabilities over time and within-time covariances. Results indicated that the NA model provided the best fit to the data, and improved model fit over a baseline stabilities model and the other models tested. However, even within the NA model there was some evidence that the impulsivity scores were not accounted for by other BPD features. These results suggest that although negative affect is predictive of most BPD symptoms, it does not fully predict future impulsive behavior.

The present article provides a conceptual framework of the relation between alcohol involvement (A) and suicide attempts (S). This framework can be broadly construed to reflect two dimensions: directionality (direction of causality; A--S, S--A, or a spurious relation) and temporality (distinguishing between proximal and distal effects of both behaviors). We review and evaluate the evidence on the association between A and S among adolescents using this conceptual framework as a guide. The extant data suggest that this relation is complex and not fully understood. Further, it seems unlikely that a single approach will be found to determine direction of causality, and the specification and validation of hypothesized mechanisms will involve a variety of different types of evidence. Suggestions for additional research using informative designs are discussed.

The current study is based on the hypothesis that alcohol-involved suicide attempts are characterized by lower premeditation and intent, but only when the use of alcohol is not motivated by the desire to facilitate the attempt. Test of this idea was conducted by comparing proximal suicide premeditation and intent of suicide attempts among three groups: individuals who (a) drank to facilitate the attempt (e.g., to "numb fears" about attempting), (b) drank for nonfacilitative motives, and (c) did not use alcohol before the attempt.Participants included 324 (62% female) recent suicide attempters presenting to a Level 1 trauma hospital. The Timeline Followback Interview for Suicide Attempts and a novel Suicide Facilitative Drinking Motives Scale were used to assess facilitative motives for drinking and characteristics of the attempt.One third of participants drank before the attempt, and most (73%) who used alcohol did not do so to facilitate the attempt. As hypothesized, attempts carried out by this group had shorter proximal suicide premeditation and lower suicide intent compared with the other study groups; in contrast, individuals who drank to facilitate the attempt were similar to non-alcohol users on these indices.Alcohol-involved suicide attempts are heterogeneous. Motives for drinking are a key source of heterogeneity insofar as fundamental characteristics of attempts (proximal premeditation, intent) differ as a function of drinking motivation. Clinical implications include that individuals making suicide attempts with facilitative motives for drinking cannot be assumed to be at lowered risk upon a drop in blood alcohol level.

Mechanisms (i.e., thwarted belongingness, perceived burdensomeness, hopelessness) derived from the interpersonal theory of suicide which are hypothesized to account for the relation between sexual orientation self-concept ambiguity and active suicide ideation were examined. Participants included 349 women, among whom 42% currently self-ascribed a non-exclusively heterosexual sexual identity. Among women reporting higher levels of sexual self-concept ambiguity, greater risk for active suicide ideation is found when perceptions of burden and feelings of thwarted belonging co-occur with feelings of hopelessness. Results support relevant theory useful for understanding suicide risk among sexual minority women who acknowledge ambiguity with regard to their sexual orientation.

Research on associations between substances of abuse and suicidal behaviors is a large, complex area. Herein, alcohol, the most commonly abused intoxicant worldwide, is examined with a focus on two topics: (1) acute use of alcohol (AUA) shortly prior to suicidal behavior; and (2) more chronic alcohol use disorder (AUD) and suicidal behavior. First, a brief summary of what is known about AUA, AUD, and suicidal behavior is provided. Next, we draw on preliminary evidence, practical considerations, and our own experience to offer recommendations for intervention research that may lower risk associated with AUA and AUD. The literature on AUD and suicidal behavior is more developed, thus we discuss separately research designed to: (1) prevent individuals with AUD with suicidal ideation from engaging in suicidal behavior; and (2) prevent individuals with AUD who have made a suicide attempt from reattempting. Our focus is on clinical intervention strategies for individuals at risk for suicidal behavior that use alcohol or have developed AUD. We also focus on applied research that may directly lead to practical prevention efforts. Although clinical interventions are important components of a comprehensive suicide prevention strategy, they should be complemented with primary prevention efforts.

The present study evaluated if hopelessness mediated the relations between temperament and recent suicide attempter status in a psychiatric sample. Negative and positive temperament (particularly the positive temperament-positive emotionality subscale) uniquely predicted levels of hopelessness. Although these temperament constructs also demonstrated significant indirect effects on recent suicide attempter status, the effects were partially (for the broad temperament scales) or fully (for the positive emotionality subscale) mediated by levels of hopelessness. These findings indicate that a tendency to experience excessive negative emotions as well as a paucity of positive emotions may lead individuals to experience hopelessness. Although temperament may indirectly influence suicide attempter status, hopelessness mediates these relations.

There is compelling evidence that comorbid borderline personality disorder (BPD) negatively impact the clinical courses and outcomes of substance use disorders (SUD). Conversely, there is little evidence that concurrent SUD exacerbates the clinical characteristics of BPD. Thus, this study sought to examine whether the presence of current substance dependence among BPD patients would be associated with stronger BPD-relevant personality traits and behavioral characteristics. Female BPD patients without (BOR; n = 37) or with current substance dependence (BSUD; n = 19), and female non-BPD/SUD controls (CON; n = 48) were compared with respect to impulsivity, affective lability, affective intensity, externalizing behaviors, and self-harming/suicidal tendencies, taking into consideration their comorbid mood disorders, anxiety disorders, and antisocial personality disorder. Results indicated that both BOR and BSUD groups scored higher than CON in most of the measures, but BOR and BSUD failed to reveal significant group differences especially when the influence of comorbid psychopathology was removed. The overall pattern of findings remained identical even when comparing BPD patients with versus without the diagnosis of lifetime substance dependence. Our results do not support the notion that BPD individuals with SUD display more severe BPD features than individuals with BPD alone.