Thomas E. Ellis

Body Investment, Depression, and Alcohol Use as Risk Factors for Suicide Proneness in College Students

BACKGROUND Individuals who are less invested in their bodies, experiencing symptoms of depression, and consuming alcohol are at increased risk for engaging in suicidal behaviors. AIMS This study examined the relationships among three risk factors - body investment, depression, and alcohol use - and suicide proneness as measured by the Life Attitudes Schedule - Short Form (LAS-SF) in college students (N = 318). METHODS Path analysis was used to construct a causal model of suicide proneness. The Body Investment Scale (BIS) subscales were assumed to be causally prior to depression, which was in turn modeled as occurring prior to alcohol use, which was in turn modeled as prior to suicide proneness. RESULTS As expected, suicide proneness was positively predicted by alcohol use, alcohol use was positively predicted by depression, and depression was negatively predicted by the body image component of the BIS. Additionally, the body image-suicide proneness link was significantly mediated by depression and its direct effect on suicide proneness as well as by the two-mediator path of body image on depression on drinking on suicide proneness. CONCLUSIONS Implications are offered for the improved identification and treatment of young adults at risk for suicidal and health-diminishing behaviors.

Patient Suicide in Psychiatry Residency Programs A National Survey of Training and Postvention Practices

Patient suicide, which has been shown to have great emotional impact upon trainees, is experienced by as many as one in three psychiatry residents. The authors report the results of a national survey of psychiatry residency training programs (N=166) that asked about 1) current training practices in the area of suicide and 2) required or recommended procedures in the event of suicide by a resident’s patient. Results show that programs commonly offer training in the assessment and treatment of suicidal patients, but the question remains as to whether the training is adequate to meet the challenges of working with suicidal individuals. Results also reflect considerable variability in “postvention” practices among programs and training settings, especially in terms of what steps should be taken when a trainee’s patient commits suicide. Implications of the survey for residency training programs are discussed.

Anhedonia predicts suicidal ideation in a large psychiatric inpatient sample.

This study examined the relationship among symptoms of anhedonia and suicidal ideation at baseline, at termination, and over time in 1529 adult psychiatric inpatients. Anhedonia was associated with suicidality cross-sectionally at baseline and at termination. In addition, change in anhedonia from baseline to termination predicted change in suicidality from baseline to termination, as well as level of suicidality at termination; moreover, anhedonia remained a robust predictor of suicidal ideation independent of cognitive/affective symptoms of depression. Symptom-level analyses also revealed that, even after accounting for the physical aspect of anhedonia (e.g., loss of energy), loss of interest and loss of pleasure were independently associated with higher levels of suicidal ideation at baseline, over time, and at discharge. Loss of interest was most highly predictive of suicidal ideation, providing support for recent differential conceptualizations of anhedonia. Taken together, these findings indicate that the manner in which anhedonia is conceptualized is important in predicting suicidal ideation, and that anhedonia symptoms warrant particular clinical attention in the treatment of suicidal patients.

Integrating outcomes assessment and research into clinical care in inpatient adult psychiatric treatment.

The authors describe an evolving outcomes project implemented across the adult inpatient programs at The Menninger Clinic. In the inpatient phase of the project, patients complete a computerized battery of standardized scales at admission, at biweekly intervals throughout treatment, and at discharge. In addition to providing aggregate data for outcomes research, these assessments are incorporated into routine clinical care, with results of each individual assessment provided to the treatment team and to the patient. The inpatient phase of the project employs Web-based software in preparation for a forthcoming follow-up phase in which patients will continue after discharge to complete assessments on the same computer platform. This article begins with a brief overview of related research at the Clinic to place the current project in local historical context. Then the authors describe the assessment instruments, the ways in which the assessments are integrated into clinical care, plans for follow-up assessments, the central role of information technology in the development and implementation of the project, the primary research questions, and some of the major challenges in implementing the project. The article concludes with a discussion of the ways in which the project can serve as a platform for a broad future research agenda.

Neuropsychological Performance and Suicidal Behavior in Adult Psychiatric Inpatients

Although various studies have shown that suicidal persons exhibit greater cognitive deficiencies than both normals and other psychiatric patients, researchers as yet have been unable to account for the source(s) of the differences. Some of these differences (e.g., cognitive rigidity and impaired problem solving) hint of possible organic involvement. This study explored the relationship of neuropsychological functioning to suicidal behavior by comparing 20 suicidal and 27 nonsuicidal psychiatric inpatients on several tests of neuropsychological functioning. Although results showed no significant differences between the two groups on most measures, both groups showed evidence of notably high levels of cortical dysfunction relative to test norms. Thirty-five percent of suicidal patients and 44% of nonsuicidal patients scored in the impaired range. Implications of this high frequency of impairment for the treatment of suicidal and nonsuicidal psychiatric patients are discussed.

Health-risk behaviors and suicidal ideation: A preliminary study of cognitive and developmental factors

Various theorists have suggested that unhealthy behaviors such as cigarette smoking and problem drinking may be subtle forms of suicidality. Consistent with this view, prior research has shown an association between health risk behaviors and suicidal ideation. In the present study we examined relationships among suicidal ideation, health-related attitudes and behaviors, and adverse childhood events. We hypothesized that unhealthy attitudes, perhaps shaped by adverse childhood events, would help explain the association between suicidal phenomena and unhealthy behaviors. Three-hundred eighteen college students completed surveys covering health risk behaviors, depression, suicidal ideation, and health-related attitudes. Results supported the hypothesized associations among these variables. However, contrary to our hypotheses, the association between suicidal ideation and health-compromising behaviors was limited largely to substance-related behaviors. Moreover, the association between suicidal ideation and health-related attitudes was mediated by depression. Adverse childhood events were associated with health-related attitudes, but this relationship was mediated by depression. These results are less suggestive of the notion of unhealthy behaviors as subtle suicidality than a model in which suicidality associates specifically with psychopathological states such as depression and substance abuse. Implications for treatment and prevention programs are discussed.

Modeling Trajectory of Depressive Symptoms Among Psychiatric Inpatients: A Latent Growth Curve Approach

OBJECTIVE Changes in the parameters of inpatient psychiatric care have inspired a sizable literature exploring correlates of prolonged intervention as well as symptom change over varying lengths of hospitalization. However, existing data offer limited insight regarding the nature of symptom change over time. Objectives of this longitudinal research were to (1) model the trajectory of depressive symptoms within an inpatient psychiatric sample, (2) identify characteristics associated with unique patterns of change, and (3) evaluate the magnitude of expected gains using objective clinical benchmarks. METHOD Participants included 1,084 psychiatric inpatients treated between April 2008 and December 2010. Latent growth curve modeling was used to determine the trajectory of Beck Depression Inventory II depressive symptoms in response to treatment. Age, gender, trauma history, prior hospitalization, and DSM-IV diagnoses were examined as potential moderators of recovery. RESULTS Results indicate a nonlinear model of recovery, with symptom reductions greatest following admission and slowing gradually over time. Female gender, probable trauma exposure, prior psychiatric hospitalization, and primary depressive diagnosis were associated with more severe trajectories. Diagnosis of alcohol/substance use, by contrast, was associated with more moderate trajectories. Objective benchmarks occurred relatively consistently across patient groups, with clinically significant change occurring between 2-4 weeks after admission. CONCLUSIONS The nonlinear trajectory of recovery observed in these data provides insight regarding the dynamics of inpatient recovery. Across all patient groups, symptom reduction was most dramatic in the initial week of hospitalization. However, notable improvement continued for several weeks after admission. Results suggest that timelines for adequate inpatient care are largely contingent on program-specific goals.

Cluster analysis of MCMI scores of suicidal psychiatric patients: Four personality profiles.

Millon Clinical Multiaxial Inventory (MCMI) scores from 299 suicidal psychiatric outpatients were cluster analyzed in hopes of identifying clinical subgroups and deriving specific treatment indications. The analysis revealed four personality profiles: Negativistic/Avoidant/Schizoid, Avoidant/Dependent/ Negativistic, Antisocial, and Histrionic/Narcissistic. This grouping was validated by examining demographics, diagnoses, and scores on several psychometric scales. Results showed few differences in demographics, diagnosis, or intelligence, but significant differences in depression severity, hopelessness, anxiety, problem-solving self-appraisal, and alcohol abuse. Implications for tailoring interventions for subtypes of suicidal patients are discussed.

A Psychometric Study of the Suicide Cognitions Scale With Psychiatric Inpatients.

The cognitive model of suicide makes specific predictions about the role of cognition in suicide risk. This study examined psychometric properties of the Suicide Cognitions Scale (SCS), an instrument designed to measure suicide-specific cognitions, in a sample of 150 patients (age range, 18-75 years, SD = 14.42; 56% female, 94% White) hospitalized for suicide risk associated with multiple, treatment-resistant psychiatric conditions. Findings revealed strong psychometric properties, including internal consistency and test-retest reliability. Incremental validity beyond depression and hopelessness was demonstrated in the prediction of suicidal ideation. Confirmatory factor analysis examining previously reported factor solutions suggested more consistency with a three-factor solution (Unlovability, Unbearability, and Unsolvability) relative to a two-factor solution. Good sensitivity to treatment response over the course of hospitalization also was demonstrated. The hypothesis of residual risk, derived from cognitive theory and predicting that lack of change in suicide schemas would be associated with higher suicide risk at discharge, was supported. Overall, these findings suggest considerable promise for the SCS as a measure of suicide risk that adds predictive utility to measures of depression and hopelessness, with potential usefulness in planning and monitoring treatment for suicidal individuals.

Implementing an evidence-based approach to working with suicidal inpatients

In this article, the authors describe the implementation of a new approach to working with suicidal patients in an inpatient psychiatric facility. The Collaborative Assessment and Management of Suicidality (CAMS) has been under development for almost two decades, but has rarely been implemented or studied in an inpatient setting. Here the authors describe the context for this project, the nature of the CAMS intervention in this setting, the structure for the research aspect of the project, and some of the implementation issues that have arisen as the project has unfolded. The authors conclude that a solid foundation has been laid for an initiative that will both enhance assessment and treatment of at-risk patients and contribute to a body of knowledge that is currently lacking in evidence for interventions with suicidal patients.