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Abstract: Background: Warning signs are near term risk factors for suicidal behavior that distinguish periods of acute risk within persons from periods of lower risk. Warning signs include behaviors (e.g., drinking to intoxication), experiences (e.g., break-up of relationship), thoughts (e.g., hopelessness), and emotions (e.g., agitation). There are little controlled empirical data on warning signs yet they are of key clinical importance including the decision whether to increase the level of care in order to promote a patient’s safety.
Objective: The purpose of this study is to identify warning signs for suicide attempts, operationalized as behaviors, experiences, thoughts or emotions that are present within 24 hours of an attempt (day of attempt) but not present in the preceding 24 hours (day before). The specific aims of this research are to 1) validate a list of warning signs using a rigorous interview-based methodology; 2) validate a list of warning signs obtained through self-report methodology; 3) compare warning signs obtained through self-report to rigorous interview based data; and 4) conduct exploratory analyses of warning signs in subgroups of keen interest including VHA treated Veterans and individuals treated at civilian hospitals.
Methodology: This is a multisite study with the University of Mississippi Medical Center (UMMC, Courtney Bagge, co-PI) serving as the host site and the VA VISN 2 Center of Excellence for Suicide Prevention (CoE, Kenneth Conner, co-PI) providing additional coordination. Data will be collected from hospitalized suicide attempters recruited from a total of 5 sites including 3 VAMCs (at San Diego, CA; Puget Sound, WA; Little Rock, AK) and 2 civilian hospitals (UMMC, University of Rochester Medical Center - URMC). We will recruit approximately 250 participants from the VAMCs and approximately 250 participants from the civilian hospitals. We will use a case-crossover design for which recent suicide attempters serve as their own control. This study utilizes three primary sources of data: 1) a battery of self-report measures; 2) the Timeline Followback for Suicide Attempts (TLFB-SA) detailed research interview to identify behaviors, etc. on an hourly basis prior to suicide attempt; and 3) select information from participants’ electronic medical records. Impact/Significance: The current study compares higher-risk and lower-risk periods within persons (within subjects design) in order to address the question “when” is a vulnerable individual at “acute” risk for suicidal behavior, consistent with the concept of “warning signs.” Obtaining answers to this question will inform the recognition of acute risk (i.e., warning signs) in individuals for whom there is already concern, a question that clinical providers, worried family members, and other stakeholders are keenly interested in.
PI: Dr. Courtney Bagge
Abstract: In the United States alone, more than 32,000 people commit suicide each year and it is estimated that for every death by suicide there are 8-25 nonfatal suicide attempts. Given the clinical and public health significance of suicide, there is considerable interest in identifying proximal factors that increase the risk for suicide attempts and that determine the timing of suicide attempts among individuals who often report persistent suicidal ideation.
Despite consistent findings of an elevated prevalence of alcohol use surrounding suicide attempts, little is known about whether acute alcohol use serves as a trigger to suicide attempts, or whether the effect of acute alcohol use on suicide attempt differs as a function of chronic alcohol use. Disentangling the effects of acute alcohol use and risk of injury according to an individual’s usual consumption pattern is a matter of great public health interest, and there are known differences in psychological characteristics (e.g., mood disorders, previous treatment history) between those who attempt suicide with and without alcohol use disorders (AUD), as well as between individuals who drink alcohol (A+) and who do not drink alcohol (A-) prior to their attempt. However, little is known about differences on such factors between suicide attempters with AUD+ (who do or do not use alcohol immediately prior to their attempt), AUD- individuals who use alcohol before their attempt, and AUD- individuals who do not consume alcohol prior to their attempt.
In the proposed exploratory/ developmental study (R21), we will examine the unique triggering role of acute alcohol use on suicide attempts as a function of an individual’s baseline AUD status, and will also examine distal psychological characteristics of distinct groups of attempters characterized by acute and chronic alcohol use. To this end, we will employ a case-crossover design with a between-subject comparison, recruiting 150 individuals presenting for medical evaluation after a suicide attempt. The one-session assessment will comprise a diagnostic measure of AUD, a battery of questionnaires assessing psychological characteristics, and a standard interview assessing substance use and other time-varying proximal risk factors during the six hours prior to the suicide attempt, as well as during two matched controls periods.
This exploratory/developmental study will provide preliminary data on the magnitude of the unique within-subject relation between acute alcohol use and attempt among individuals with and without AUD, and will aid in identifying distinguishing characteristics of groups of attempters characterized by different patterns of acute and chronic alcohol use. These preliminary data and effect sizes will be used to inform the development of a larger study. Gaining a better understanding of the triggering effects of acute alcohol use on suicide attempts among those with and without AUD, and identifying psychological characteristics of individuals with different acute and chronic alcohol use patterns will facilitate future identification and treatment of alcohol-related suicide attempts.
Abstract: Given the clinical and public health significance of suicide, there is considerable interest in identifying factors that are associated with the diathesis for suicide attempts. There are links between impulsivity and suicide attempts (Brezo et al., 2006 for review), but the nature of these associations remain unclear. One reason for this may be due to the heterogeneous nature of the construct of impulsivity (see Perry & Carroll, 2008), and it is largely unknown which specific facets of impulsivity relate to suicide attempts. The propensity for impulsive behavior has also been consistently linked to biological mechanisms implicated in suicidal behavior. Examining genetic associations with facets of impulsivity may provide a clearer signal in the search for serotonergic genes associated with suicide attempts (Gottesman & Gould, 2003). The present proposal seeks to examine the inter-relations among serotonergic genes, facets of impulsivity, and suicide attempts.
To achieve this research goal, we will employ a case-control design, recruiting 200 psychiatric inpatients (100 suicide attempters and 100 non-suicidal controls). The two-session assessment will comprise 1) a comprehensive assessment (Axis I and II diagnoses, history of suicide attempt and characteristics of attempt, and facets of impulsivity), and 2) a laboratory session where participants will complete five behavioral measures of impulsivity. At the end of the comprehensive assessment, a saliva sample will be collected in order to examine polymorphisms in serotonergic genes (Tryptophan Hydroxylase [TPH2], and 5HTT).
This study will provide preliminary data on the magnitude of the relation between polymorphisms of serotonergic genes and facets of impulsivity on suicide attempt, as well as the effect of polymorphisms of serotonergic genes on facets of impulsivity. These preliminary data and effect sizes will be used to inform the development of a larger study. Of note, an important aspect of this research is that it will establish biological, self-reported, and laboratory-based measures of distinct impulsivity processes relating to suicide attempts, as well as a suicide attempt characteristics (violent attempts). Given the high cost of suicidality to individuals and to the health care system, gaining a fine-grained understanding of impulsivity-suicide attempt associations is a critical step in allowing us to refine our theoretical models, improve our assessment tools, and suggest better treatments for suicide attempts.
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