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, 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, Potentiating factors Suicidal ideation
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. 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. 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
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.
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Book Code: SWUS1524B
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