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Importance: Suicide prevention requires risk identification, intervention, and follow-up. Traditional risk identification relies on patient self-reporting, support network reporting, or face-to-face screening. Statistical risk models have been studied and some have been deployed to augment clinical judgment. Few have been tested in clinical practice via clinical decision support (CDS). Barriers to effective CDS include potential alert burden for a stigmatized clinical problem and lack of data on how best to integrate scalable risk models into clinical workflows., Objective: To evaluate the effectiveness of risk model-driven CDS on suicide risk assessment., Design, Setting, and Participants: This comparative effectiveness randomized clinical trial was performed from August 17, 2022, to February 16, 2023, in the Department of Neurology across the divisions of Neuro-Movement Disorders, Neuromuscular Disorders, and Behavioral and Cognitive Neurology at Vanderbilt University Medical Center, an academic medical center in the US Mid-South. Patients scheduled for routine care in those settings were randomized at visit check-in. Follow-up was completed March 16, 2023, and data were analyzed from April 11 to July 24, 2023. Analyses were based on intention to treat., Interventions: Interruptive vs noninterruptive CDS to prompt further suicide risk assessment using a real-time, validated statistical suicide attempt risk model. In the interruptive CDS, an alert window via on-screen pop-up and a patient panel icon were visible simultaneously. Dismissing the alert hid it with no effect on the patient panel icon. The noninterruptive CDS showed the patient panel icon without the pop-up alert. When present, the noninterruptive CDS displayed "elevated suicide risk score" in the patient summarization panel. Hovering over this icon resulted in a pop-up identical to the interruptive CDS., Main Outcomes and Measures: The main outcome was the decision to assess risk in person. Secondary outcomes included rates of suicidal ideation and attempts in both treatment arms and baseline rates of documented screening during the prior year. Manual medical record review of every trial encounter was used to determine whether suicide risk assessment was subsequently documented., Results: A total of 561 patients with 596 encounters were randomized to interruptive or noninterruptive CDS in a 1:1 ratio (mean [SD] age, 59.3 [16.5] years; 292 [52%] women). Adjusting for clinician cluster effects, interruptive CDS led to significantly higher numbers of decisions to screen (121 of 289 encounters [42%]) compared with noninterruptive CDS (12 of 307 encounters [4%]) (odds ratio, 17.70; 95% CI, 6.42-48.79; P < .001) and compared with the baseline rate the prior year (64 of 832 encounters [8%]). No documented episodes of suicidal ideation or attempts occurred in either arm., Conclusions and Relevance: In this randomized clinical trial of interruptive and noninterruptive CDS to prompt face-to-face suicide risk assessment, interruptive CDS led to higher numbers of decisions to screen with documented suicide risk assessments. Well-powered large-scale trials randomizing this type of CDS compared with standard of care are indicated to measure effectiveness in reducing suicidal self-harm., Trial Registration: ClinicalTrials.gov Identifier: NCT05312437.

Suicide a leading cause of death among adolescents and is nearly always preceded by suicidal ideation (SI). Concerningly, SI during adolescence is not uncommon, as it is reported by as much as 20% of American youth. As such, SI in adolescence has been the subject of substantial research. Literature points to anger in adolescence as a relatively strong correlate of SI. However, work is limited, focusing on cross-sectional associations between anger in adolescence and SI and conceptualizing anger as a broad construct, failing to investigate the many narrow facets that comprise it. We address these gaps by investigating anger in adolescence as a (1) cross-sectional and (2) prospective correlate of SI and (3) investigating broad versus narrow conceptualizations of anger in adolescence as they relate to SI. Among two samples (Study 1, nationally representative community-based youth, n  = 1,729; Study 2, high-risk juvenile justice involved youth, n  = 1,406), anger in adolescence was cross-sectionally related to SI. However, when controlling for SI at baseline, anger in adolescence was not a prospective risk factor for SI at follow-up, nine years later. Finally, narrow facets of anger (e.g., argumentative, defiant, irritable, resentful, spiteful) were not more closely related than broad conceptualizations of anger to SI. These findings indicate that while anger in adolescence is cross-sectionally associated with SI, it should not necessarily be viewed as a valid risk factor for development of SI over the course of nearly a decade. Further, findings did not elucidate any narrow facets of anger that are particularly linked with SI.

Suicide prevention requires risk identification, appropriate intervention, and follow-up. Traditional risk identification relies on patient self-reporting, support network reporting, or face-to-face screening with validated instruments or history and physical exam. In the last decade, statistical risk models have been studied and more recently deployed to augment clinical judgment. Models have generally been found to be low precision or problematic at scale due to low incidence. Few have been tested in clinical practice, and none have been tested in clinical trials to our knowledge., Methods: We report the results of a pragmatic randomized controlled trial (RCT) in three outpatient adult Neurology clinic settings. This two-arm trial compared the effectiveness of Interruptive and Non-Interruptive Clinical Decision Support (CDS) to prompt further screening of suicidal ideation for those predicted to be high risk using a real-time, validated statistical risk model of suicide attempt risk, with the decision to screen as the primary end point. Secondary outcomes included rates of suicidal ideation and attempts in both arms. Manual chart review of every trial encounter was used to determine if suicide risk assessment was subsequently documented., Results: From August 16, 2022, through February 16, 2023, our study randomized 596 patient encounters across 561 patients for providers to receive either Interruptive or Non-Interruptive CDS in a 1:1 ratio. Adjusting for provider cluster effects, Interruptive CDS led to significantly higher numbers of decisions to screen (42%=121/289 encounters) compared to Non-Interruptive CDS (4%=12/307) (odds ratio=17.7, p-value <0.001). Secondarily, no documented episodes of suicidal ideation or attempts occurred in either arm. While the proportion of documented assessments among those noting the decision to screen was higher for providers in the Non-Interruptive arm (92%=11/12) than in the Interruptive arm (52%=63/121), the interruptive CDS was associated with more frequent documentation of suicide risk assessment (63/289 encounters compared to 11/307, p-value<0.001)., Conclusions: In this pragmatic RCT of real-time predictive CDS to guide suicide risk assessment, Interruptive CDS led to higher numbers of decisions to screen and documented suicide risk assessments. Well-powered large-scale trials randomizing this type of CDS compared to standard of care are indicated to measure effectiveness in reducing suicidal self-harm. ClinicalTrials.gov Identifier: NCT05312437.

We discuss computational language analysis as it pertains to suicide prevention research, with an emphasis on providing non-technologists with an understanding of key issues and, equally important, considering its relation to the broader enterprise of suicide prevention. Our emphasis here is on naturally occurring language in social media, motivated by its non-intrusive ability to yield high-value information that in the past has been largely unavailable to clinicians., (© 2020 The American Association of Suicidology.)