suicide, any acute changes in substance use behavior should be examined in connection to potential increases in suicide risk. Nonsuicidal self injury Although by definition non-suicidal self-injury (NSSI) is engaged in without suicidal intent, a host of recent research demonstrates that NSSI is associated with risk for future suicidal behavior (Cipriano, Cella, & Cotrufo, 2017; Selby et al., 2019), and is as strong a predictor of future suicide attempts as are previous Proximal factors Economic factors Economic uncertainty has been linked to an immediate increase in suicide risk for those affected (Vandoros, Avendano, & Kawachi, 2019), although economic factors alone are unlikely to be the sole cause of suicidal behavior. Findings include acute adverse financial market conditions as a risk for proximal increases in suicidal behavior (Agrrawal, Waggle, & Sandweiss, 2017). Individuals reporting chronic income and full-time employment problems have also been found to have higher risk (Griffith, 2017). Rates across various socioeconomic statuses tend to fluctuate over time, but suicide rates are generally higher in more economically deprived communities (Iemmi, Bantjes, Coast, Channer, Leone, et al., 2016). Health disparities and illness Health disparities are preventable differences in the incidence, prevalence, mortality and disease burden that are closely linked with social, economic, and environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their race or ethnicity; religion; socioeconomic status; sexual orientation; gender, gender expression, or gender identity; age; mental health; cognitive, sensory or physical disability; geographic location; or other characteristics historically linked to discrimination or exclusion (Barnett, Gonzalez, Miranda, Chavira, & Lau, 2018; Oberg, Colianni, & King- Schult, 2016). Young women with a history of an abortion are also indicated to be at higher risk for suicide (Miranda-Mendizzbal et al., 2019), which may be connected to poor access to healthcare and broader support networks. Family dysfunction A history of dysfunction in the family of origin is another distal potentiating factor. Family histories of violence, abuse (physical and sexual), neglect, and parental separations are associated with increased suicide risk, as well as a variety of self-harming Suicidal ideation is an important risk factor in the detection of potential suicidal behavior and involves increased thoughts about and potential desires for death, active thoughts about harming oneself or taking one’s life, consideration of potential suicide methods and/or plans, and contemplation about planning for one’s death (Klonsky, May, & Saffer, 2016). The more intense and frequent suicidal ideation becomes on a daily basis, the greater the need for clinical concern. However, although suicidal ideation is present in the majority of cases of suicidal behavior, suicidal ideation is a non-specific risk factor for suicide, and it is not predictive of imminent suicide risk. Indeed, to date, no studies have found that asking someone about current suicidal ideation is predictive of a suicide attempt in the very near future (Franklin et al., 2016). Accordingly, presence of suicidal ideation should also indicate the need for further suicide risk assessment, however, suicidal ideation in the absence of other risk factors is unlikely to indicate imminent suicide risk. Nonetheless, safety precautions in the presence of suicidal Potentiating factors Suicidal ideation
suicide attempts themselves (Kiekens et al., 2018). In most cases, NSSI functions as a behavioral coping mechanism through which highly emotional vulnerable individuals use the pain and vividness of the NSSI behavior to distract themselves from these distressing emotions (Selby et al., 2019). However, NSSI behavior should be addressed in clinical settings as an essential way to reduce future risk of suicidal behavior. behaviors (Clements-Nolle, Lensch, Yang, Martin, Peek, & Yang, 2020). Additionally, it appears that suicide tends to run in families, and it has been estimated that social environment and genetic factors play about an equal role in determining who engages in suicidal behaviors (Lin & Tsai, 2016). Other family dysfunction factors linked to suicidal behavior include parental separation or divorce, presence of psychiatric diagnoses in other family members, domestic violence, and displacement (e.g., temporary living situations vs. stable ones; Clements-Nolle et al., 2020; Marshall, Semovski, & Stewart, 2020; Miranda-Mendizzbal et al., 2019). Romantic relationships and divorce Difficulties in romantic relationships can be a contributing or even a potentiating factor for suicidal behavior. Dating violence in young women, for example, has been connected to suicide risk (Miranda-Mendizzbal et al., 2019). Non-married and especially divorced status are predictive of suicide among men and, to a lesser degree, women (Kyung-Sook, SangSoo, Sangjin, & Young-Jeon, 2018). As will be seen in subsequent discussion of theoretical models of suicide, romantic relationships represent one of the most important interpersonal relationships an individual can have, and problems in this area can substantially weaken interpersonal connections that buffer against suicide risk. Domestic violence Women experiencing turbulent relationships are also at increased risk for suicide, especially when the relationship is characterized by domestic violence and in cases where the partner is exhibiting addiction, coercion, physical assault, jealousy, infidelity, or threatening divorce (Rahmani, Salmasi, Rahmani, Bird, Asghari, et al., 2019). Patients indicating the presence of domestic violence in their home should be carefully screened for suicide risk in addition to addressing personal safety concerns. is known to be one of the strongest risk factors for suicidal behavior (Marie et al., 2020) and should be taken very seriously, as will be discussed in the upcoming section on suicide risk assessment. Access to lethal means Access to means to enable a suicide attempt is a particularly troubling risk factor for suicide, especially among men (Miranda- Mendizzbal et al., 2019). In the United States, more than 50% of deaths by suicide involve utilizing a firearm (Khazem & Anestis, 2016). Indeed, the presence of a gun in the home is one of the strongest predictors differentiating those who died by suicide from other suicidal individuals who attempt but survive suicide (Knopov, Sherman, Raifman, Larson, & Siegel, 2019; Santaella- Tenorio, Cerdá, Villaveces, & Galea, 2016). Firearms simply are a very lethal suicide attempt method. This lethality is aided by the quickness and extent of physical trauma that firearms can deliver. All suicide assessments should include questions about the availability of firearms (Khazem & Anestis, 2016). Contrary to interviewers’ concerns, patients are likely to adhere to advice about gun removal, and legislation that reduces access to guns is related to lower suicide rates (Houtsma et al., 2018; Anestis et al., 2015). If the patient does have firearms at home, the assessing clinician should advise him or her to remove the ability to access the guns.
ideation should always be taken. Suicide plans and preparations
Common behaviors under the umbrella of suicide plans include giving away possessions, writing notes, acquiring weapons or other items that will facilitate a suicidal act. A patient acknowledging the presence of suicidal planning and preparing
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