Evan M. Kleiman

Risk Factors for Suicidal Thoughts and Behaviors: A Meta-Analysis of 50 Years of Research.

Suicidal thoughts and behaviors (STBs) are major public health problems that have not declined appreciably in several decades. One of the first steps to improving the prevention and treatment of STBs is to establish risk factors (i.e., longitudinal predictors). To provide a summary of current knowledge about risk factors, we conducted a meta-analysis of studies that have attempted to longitudinally predict a specific STB-related outcome. This included 365 studies (3,428 total risk factor effect sizes) from the past 50 years. The present random-effects meta-analysis produced several unexpected findings: across odds ratio, hazard ratio, and diagnostic accuracy analyses, prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction. The homogeneity of existing research means that the present meta-analysis could only speak to STB risk factor associations within very narrow methodological limits—limits that have not allowed for tests that approximate most STB theories. The present meta-analysis accordingly highlights several fundamental changes needed in future studies. In particular, these findings suggest the need for a shift in focus from risk factors to machine learning-based risk algorithms.

Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies

BACKGROUND A history of self-injurious thoughts and behaviors (SITBs) is consistently cited as one of the strongest predictors of future suicidal behavior. However, stark discrepancies in the literature raise questions about the true magnitude of these associations. The objective of this study is to examine the magnitude and clinical utility of the associations between SITBs and subsequent suicide ideation, attempts, and death. METHOD We searched PubMed, PsycInfo, and Google Scholar for papers published through December 2014. Inclusion required that studies include at least one longitudinal analysis predicting suicide ideation, attempts, or death using any SITB variable. We identified 2179 longitudinal studies; 172 met inclusion criteria. RESULTS The most common outcome was suicide attempt (47.80%), followed by death (40.50%) and ideation (11.60%). Median follow-up was 52 months (mean = 82.52, s.d. = 102.29). Overall prediction was weak, with weighted mean odds ratios (ORs) of 2.07 [95% confidence interval (CI) 1.76-2.43] for ideation, 2.14 (95% CI 2.00-2.30) for attempts, and 1.54 (95% CI 1.39-1.71) for death. Adjusting for publication bias further reduced estimates. Diagnostic accuracy analyses indicated acceptable specificity (86-87%) and poor sensitivity (10-26%), with areas under the curve marginally above chance (0.60-0.62). Most risk factors generated OR estimates of <2.0 and no risk factor exceeded 4.5. Effects were consistent regardless of sample severity, sample age groups, or follow-up length. CONCLUSIONS Prior SITBs confer risk for later suicidal thoughts and behaviors. However, they only provide a marginal improvement in diagnostic accuracy above chance. Addressing gaps in study design, assessment, and underlying mechanisms may prove useful in improving prediction and prevention of suicidal thoughts and behaviors.

Social support as a protective factor in suicide: Findings from two nationally representative samples

BACKGROUND Suicide is a problem of worldwide concern and research on possible protective factors is needed. We explored the role of social support as one such factor. Specifically, we hypothesized that increased social support would be associated with decreased likelihood of a lifetime suicide attempt in two nationally representative samples as well as a high-risk subsample. METHODS We analyzed the relationship between social support and lifetime history of a suicide attempt, controlling for a variety of related psychopathology and demographic variables, in the National Comorbidity Study Replication (NCS-R), a United States sample and the Adult Psychiatric Morbidity Study (APMS), an English sample. RESULTS Results indicate that social support is associated with decreased likelihood of a lifetime suicide attempt controlling for a variety of related predictors in both the full US sample (OR=0.68, p<.001) and the full English sample (OR=0.93, p<.01). LIMITATIONS The cross-sectional data do not allow true cause and effect analyses. CONCLUSIONS Our findings suggest social support is associated with decreased likelihood of a lifetime suicide attempt. Social support is a highly modifiable factor that can be used to improve existing suicide prevention programs worldwide.

A meaningful life is worth living: Meaning in life as a suicide resiliency factor

Given the high rate of suicide worldwide, it is imperative to find factors that can confer resiliency to suicide. The goal of the present study was to examine the search for and the presence of meaning in life as possible resilience factors. We hypothesized that the presence of, but not the search for, meaning in life would predict decreased suicidal ideation over an eight-week time period and decreased lifetime odds of a suicide attempt. We also examined a subsidiary hypothesis that the presence of, but not the search for, meaning in life would mediate the relationship between the two variables associated with the interpersonal psychological theory of suicide (i.e., perceived burdensomeness and thwarted belongingness) and suicidal ideation. Our results were generally in support of our hypothesis: presence of meaning in life predicted decreased suicidal ideation over time and lower lifetime odds of a suicide attempt. Surprisingly, search for meaning in life also predicted decreased suicidal ideation over time. Finally, the search for, but not presence of, meaning in life mediated the relationship between the interpersonal psychological theory variables and suicidal ideation. These findings suggest that interventions that target meaning in life may be useful to attenuate suicide risk in individuals.

Meta-analysis of risk factors for nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) is a prevalent and dangerous phenomenon associated with many negative outcomes, including future suicidal behaviors. Research on these behaviors has primarily focused on correlates; however, an emerging body of research has focused on NSSI risk factors. To provide a summary of current knowledge about NSSI risk factors, we conducted a meta-analysis of published, prospective studies longitudinally predicting NSSI. This included 20 published reports across 5078 unique participants. Results from a random-effects model demonstrated significant, albeit weak, overall prediction of NSSI (OR=1.59; 95% CI: 1.50 to 1.69). Among specific NSSI risk factors, prior history of NSSI, cluster b, and hopelessness yielded the strongest effects (ORs>3.0); all remaining risk factor categories produced ORs near or below 2.0. NSSI measurement, sample type, sample age, and prediction case measurement type (i.e., binary versus continuous) moderated these effects. Additionally, results highlighted several limitations of the existing literature, including idiosyncratic NSSI measurement and few studies among samples with NSSI histories. These findings indicate that few strong NSSI risk factors have been identified, and suggest a need for examination of novel risk factors, standardized NSSI measurement, and study samples with a history of NSSI.

Prospective prediction of suicide in a nationally representative sample: religious service attendance as a protective factor

BACKGROUND Previous research into religious service attendance as a protective factor against suicide has been conducted only retrospectively, with psychological autopsy studies using proxy informants of completed suicide, rather than prospectively, with completed suicide as a dependent variable. AIMS To determine whether individuals who frequently attended religious services were less likely to die by suicide than those who did not attend so frequently. METHOD We analysed data from a nationally representative sample (n = 20 014), collected in the USA between 1988 and 1994, and follow-up mortality data from baseline to the end of 2006. RESULTS Cox proportional hazard regression analysis indicated that those who frequently attended religious services were less likely to die by suicide than those who did not attend, after accounting for the effects of other relevant risk factors. CONCLUSIONS Frequent religious service attendance is a long-term protective factor against suicide.

A brief mobile app reduces nonsuicidal and suicidal self-injury: evidence from three randomized controlled trials

OBJECTIVE Self-injurious thoughts and behaviors (SITBs) are a major public health problem that traditional interventions have been unable to address on a large scale. The goal of this series of studies was to take initial steps toward developing an effective SITB treatment that can be easily delivered on a very large scale. METHOD We created a brief (1-2 min), game-like app called Therapeutic Evaluative Conditioning (TEC), designed to increase aversion to SITBs and decrease aversion to the self. In 3 separate studies, we recruited participants with recent and severe histories of SITBs from web forums focused on self-injury and psychopathology (Ns = 114, 131, and 163) and randomly assigned them to receive access to the mobile treatment TEC app or a control app for 1 month. We tested the effect of TEC on the frequency of self-cutting, nonsuicidal self-injury more generally, suicide ideation, suicide plans, and suicidal behaviors. RESULTS Analyses showed that, compared with the control app, TEC produced moderate reductions for all SITBs except suicide ideation. Across studies, the largest and most consistent reductions were for self-cutting episodes (32%-40%), suicide plans (21%-59%), and suicidal behaviors (33%-77%). Two of the 3 studies showed that TEC impacted its intended treatment targets and that greater change in these targets was associated with greater SITB reductions. TEC effects were not maintained at the 1-month posttreatment follow-up. CONCLUSIONS Future versions of brief, mobile interventions like that tested here may have the potential to reduce SITBs and related behaviors on a large scale. (PsycINFO Database Record

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.

An experiential avoidance conceptualization of depressive rumination: three tests of the model.

This study examined an experiential avoidance conceptualization of depressive rumination in 3 ways: 1) associations among questionnaire measures of rumination, experiential avoidance, and fear of emotions; 2) performance on a dichotic listening task that highlights preferences for non-depressive material; and 3) psychophysiological reactivity in an avoidance paradigm modeled after the one used by Borkovec, Lyonfields, Wiser, and Deihl (1993) in their examination of worry. One hundred and thirty-eight undergraduates completed questionnaire measures and participated in a clinical interview to diagnose current and past episodes of depression. Of those, 100 were randomly assigned to a rumination or relaxation induction condition and participated in a dichotic listening task, rumination/relaxation induction, and depression induction. Questionnaire measures confirmed a relationship between rumination status and avoidance; however, no significant effects were found in the dichotic listening task. Psychophysiological measures indicated no difference in physiological response to a depression induction among high ruminators (HR). However, low ruminators (LR) in the relaxation condition exhibited a larger IBI response than LR in the rumination condition. Overall, these results provide partial support for an avoidance conceptualization of depressive rumination. Implications of these findings are discussed.

A Contextual Approach to Experiential Avoidance and Social Anxiety: Evidence From an Experimental Interaction and Daily Interactions of People With Social Anxiety Disorder

Experiential avoidance (EA), the tendency to avoid internal, unwanted thoughts and feelings, is hypothesized to be a risk factor for social anxiety. Existing studies of experiential avoidance rely on trait measures with minimal contextual consideration. In two studies, we examined the association between experiential avoidance and anxiety within real-world social interactions. In the first study, we examined the effect of experiential avoidance on social anxiety in everyday life. For 2 weeks, 37 participants with Social Anxiety Disorder (SAD) and 38 healthy controls provided reports of experiential avoidance and social anxiety symptoms during face-to-face social interactions. Results showed that momentary experiential avoidance was positively related to anxiety symptoms during social interactions and this effect was stronger among people with SAD. People low in EA showed greater sensitivity to the level of situational threat than high EA people. In the second study, we facilitated an initial encounter between strangers. Unlike Study 1, we experimentally created a social situation where there was either an opportunity for intimacy (self-disclosure conversation) or no such opportunity (small-talk conversation). Results showed that greater experiential avoidance during the self-disclosure conversation temporally preceded increases in social anxiety for the remainder of the interaction; no such effect was found in the small-talk conversation. Our findings provide insight into the association between experiential avoidance on social anxiety in laboratory and naturalistic settings, and demonstrate that the effect of EA depends upon level of social threat and opportunity.