crisis (Ferro, Rhodes, Kimber, Duncan, Boyle, et al., 2017; Henson, Brock, Charnock, et al., 2019; Lund, Nadorff, Winer, & Seader, 2016; Racine, 2018). Although biological risk factors likely play a role in the suicidal ideation and behavior of some patients, meta-analytic research has found that many biological links to suicidal behavior are relatively small (Chang et al., 2016), so while it is important to consider biological risk factors, suicide risk assessment and intervention should primarily focus on proximal biological risk factors (e.g., chronic pain or illness) as well as behavioral and psychosocial risk factors. Biological sex (i.e., for cis- gendered men versus women) is another important factor to consider, with men being more likely to die by suicide but with women attempting suicide far more often than men (Siegel & Rothman, 2016). Psychiatric diagnoses As has been previously discussed, aside from past suicide attempts, psychopathology is the most important predictor of suicide and is strongly associated with other forms of suicidal behavior. The vast majority (90 to 95%) of individuals who die by suicide have some diagnosable disorder at the time of death (Choi, Lee, & Han, 2020); it is likely that the fraction who did not were experiencing subclinical levels of psychopathology. Although most mental illnesses increase risk for death by suicide (APA, 2013), there are several disorders that are associated with particularly high risk. These include schizophrenia (approximately 13-fold increase in risk; Cassidy, Yang, Kapczinski, & Passos, 2018), anorexia nervosa (up to a 31-fold increase in risk; Selby & Coniglio, 2020), bipolar disorder (approximately 17- fold increase in risk; Olfson et al., 2016), major depressive disorder (approximately 20-fold increase in risk; Olfson et al., 2016), impulse- control disorders such as opioid use (approximately 14-fold increase in risk; Maruti et al., 2017), and personality disorders, especially borderline personality disorder (up to a 45-fold increase in risk; Soloff & Chiappetta, 2019). Retrospective interviews with informants, commonly referred to as psychological autopsies, have frequently been used to investigate the association between psychopathology and suicide and have consistently shown that roughly 90% of individuals who die by suicide had an identifiable psychiatric disorder before death (Perlis et al., 2016). Prior suicide attempts Approximately half of individuals who die by suicide do so after a single attempt (Franklin et al., 2016), which means that about 50% of individuals will die on their first attempt. A recent study on risk factors for death by suicide concluded that prior attempts and suicidal ideation were the best predictors of completed suicide (Ribeiro et al., 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 Proximal factors Economic factors
2016). However, it should be noted that prior attempts and suicidal ideation were relatively weak predictors, as they only increased risk for later death by suicide two-fold. Some research suggests that people who make multiple attempts (i.e., two or more) are at greater risk for further suicide attempts and completion than people who have made only one attempt (Defayette, Adams, Whitmyre, Williams, & Esposito-Smythers, 2020). Additionally, research suggests that, among attempters, the greatest risk for a subsequent attempt is in the 6 months to 2 years following the attempt (Franklin et al., 2016). Clearly, clinicians should take note of any history of prior attempts, as well as the timing of the behavior, in order to better assess risk status. Substance use The connection between heavy substance use and suicidal behavior has long been a subject of investigation, with questions arising as to whether the substance drives the individual toward suicidal behavior, or whether the substance is used as a way of coping with the suicidal behavior (Chesin, Interian, Kline, Hill, et al., 2019). Recent meta-analytic studies have identified substance use as a major predictor of suicidal behavior, with the odds of suicide increasing seven-fold among substance users relative to those refraining from substance use (Conner, Bridge, Davidson, Pilcher, & Brent, 2019). For example, alcohol use increases the proximal risk for suicidal behavior because of its ability to increase psychological distress and aggressiveness, push suicidal ideation into action through suicide-specific alcohol expectancies, and limit cognition, which in turn impairs the creation and implementation of alternative coping strategies (Borges, Bagge, Cherpitel, Conner, et al., 2017). Because of the clear link between a variety of substance use disorders and 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 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. 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
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Book Code: SWUS1525
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