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On February 23, 2018, PubMed Central Canada (PMC Canada) will be taken offline permanently. No author manuscripts will be deleted, and the approximately 2,900 manuscripts authored by Canadian Institutes of Health Research (CIHR)-funded researchers currently in the archive will be copied to the National Research Council’s (NRC) Digital Repository over the coming months. These manuscripts along with all other content will also remain publicly searchable on PubMed Central (US) and Europe PubMed Central, meaning such manuscripts will continue to be compliant with the Tri-Agency Open Access Policy on Publications.

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1.  Nonsuicidal Self-Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders 
Nonsuicidal self-injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood-disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood-disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16−3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.
PMCID: PMC5724372  PMID: 28211201
2.  The Coping with Long Term Active Suicide Program (CLASP): Description and Pilot Data 
This paper presents a description and pilot data for a new adjunctive intervention designed to reduce suicidal behavior among high-risk individuals. The Coping Long Term with Active Suicide Program (CLASP) has three major components: 1) three individual, in-person meetings, 2) one significant other/family meeting and 3) 11 brief (15-30 min) phone contacts with the patient and his/her significant other. Open trial and pilot randomized trial data provide preliminary evidence that CLASP is a feasible, acceptable and efficacious intervention to reduce suicidal behavior.
PMCID: PMC5047846  PMID: 27038050
3.  Is Cumulative Exposure to Suicide Attempts and Deaths A Risk Factor for Suicidal Behavior among Firefighters? A Preliminary Study 
The present study examined the association between cumulative exposure to suicide attempts and deaths and suicidal behavior in a sample of 61 professional firefighters. On average, firefighters reported 13.1 (SD=16.6) exposures over the course of their lifetime. Cumulative exposure to suicide attempts and deaths was positively correlated with suicidal behavior (r = 0.38, p = 0.004). Moreover, firefighters with 12+ exposures were more likely to screen positive for risk of suicidal behavior (OR = 7.885, p = 0.02). Additional research on the potential impact of cumulative exposure to suicide attempts and deaths on firefighters’ health and safety is needed.
PMCID: PMC5145737  PMID: 27371810
Suicide Contagion; Suicidal Behavior; Trauma
4.  Factors Associated with Suicide Ideation in Severely Obese Bariatric Surgery-Seeking Individuals 
There are high rates of suicide ideation and/or behavior in severely obese individuals. The potential contributors to suicide ideation in a sample of 334 severely obese bariatric surgery candidates was explored. Lack of college education, a history of suicide ideation and/or behavior, psychological distress, hopelessness, loneliness, history of physical and/or sexual abuse, and lifetime major depression were associated with current suicide ideation. Some of the correlates of suicide ideation in severely obese bariatric surgery-seeking samples are similar to those found in the general community and this knowledge may serve to improve the psychological assessment and care for this group.
PMCID: PMC5670739  PMID: 22957662
5.  Anorexia Nervosa, Major Depression, and Suicide Attempts: Shared Genetic Factors 
We evaluated the extent to which genetic and environmental factors influenced anorexia nervosa (AN), major depressive disorder (MDD), and suicide attempts (SA). Participants were 6,899 women from the Swedish Twin study of Adults Genes and Environment. A Cholesky decomposition assessed independent and overlapping genetic and environmental contributions to AN, MDD, and SA. Genetic factors accounted for a substantial amount of liability to all three traits; unique environmental factors accounted for most of the remaining liability. Shared genetic factors may underlie the co-expression of these traits. Results underscore the importance of assessing for signs of suicide among individuals with AN.
PMCID: PMC4996767  PMID: 26916469
anorexia nervosa; major depressive disorder; suicide; twins; comorbidity
6.  The Incremental Utility of Emotion Regulation but Not Emotion Reactivity in Non-Suicidal Self-Injury 
This study assessed the incremental utility of emotion reactivity and emotion regulation in relation to non-suicidal self-injury (NSSI). Participants included 379 college students aged 18-22 who completed self-report measures of emotion regulation, emotion reactivity, and NSSI. Emotion regulation was significantly related to NSSI both ignoring and controlling for reactivity, but the reverse was not true. Participants' use of NSSI for affect regulation appeared to moderate this relation. Findings support emotion regulation deficits as a target for intervention over-and-above heightened emotion reactivity, especially in those who use NSSI to regulate negative affect.
PMCID: PMC5012951  PMID: 26945972
Emotional regulation; self-injurious behavior; emotion reactivity; NSSI
7.  The Association of Multiple Identities with Self-directed Violence and Depression among Transgender Individuals 
Transgender individuals have a high prevalence of self-directed violence; however, there is scant literature focusing on their unique experiences. This study examined the differences in self-harm, suicidal ideation, suicide attempt, and depression based on racial/ethnic identity and sexual orientation among transgender individuals. Data were gathered from the Fall 2008 and Spring 2009 National College Health Assessment. Across racial/ethnic identities, greater proportions of transgender students endorse self-directed violence than their cisgender peers. Among transgender individuals, sexual minorities were more likely to report suicidal ideation than their heterosexual peers, and racial/ethnic minorities had higher odds of attempting suicide than non-Hispanic white individuals.
PMCID: PMC5087282  PMID: 26916366
8.  Effect of Problem-Solving Therapy on Depressed Low-Income Homebound Older Adults’ Death/Suicidal Ideation and Hopelessness 
Previous study findings of psychotherapy’s effect on suicide prevention have been inconsistent. The present study reports the results of secondary analyses of outcome data from a short-term depression treatment on reducing death/suicidal ideation among 158 low-income homebound adults aged 50+. The treatment, in-person or telehealth problem-solving therapy (PST), compared to telephone support call, has been found effective in reducing depressive symptoms and disability among participants. Compared to support call participants, tele-PST participants, but not in-person PST participants, exhibited lower ideation ratings across the follow-up period. Effect sizes at 36 weeks were 0.31 for tele-PST and 0.17 for in-person PST. Hopelessness mediated the effect of tele-PST but not in-person PST; however, in-person PST also alleviated hopelessness, which led to lower ideation. Clinical implications of the findings are discussed.
PMCID: PMC4829492  PMID: 26456016
Homebound older adults; tele-delivered problem-solving therapy; hopelessness
9.  Family-Based Preventive Interventions: Can the Onset of Suicide Ideation and Behavior Be Prevented? 
Suicide & life-threatening behavior  2016;46(Suppl 1):S3-S7.
Suicide is the 2nd leading cause of death for youth aged 10 to 24. Research informed prevention efforts have the opportunity to decrease risk for suicidal ideation and behavior before it is manifested. Indeed, there is a small body of research findings demonstrating both proximal and distal effects of preventive interventions delivered in childhood and adolescence on suicidal ideation and/or behavior. These efforts build off of other secondary analyses of prevention research that has demonstrated benefits for multiple types of youth outcomes. This supplement provides ‘proof of concept’ that family-based preventive interventions aimed at reducing a number of risk factors for suicide (e.g., substance use, externalizing and internalizing behavior) can prevent suicidal ideation and behaviors.
PMCID: PMC4839188  PMID: 27094108
10.  Long-term effects of the Family Check-Up in Early Adolescence on Risk of Suicide in Early Adulthood 
Suicide & life-threatening behavior  2016;46(Suppl 1):S15-S22.
This study examines the impact of the Family Check-Up, a school-based prevention program, as delivered in public secondary schools on suicide risk across adolescence. Students were randomly assigned to a family-centered intervention (N = 998) in sixth grade, and offered a multilevel intervention that included (a) a universal classroom-based intervention, (b) the Family Check-Up (selected; Dishion, Stormshak, & Kavanagh, 2011), and (c) family management treatment (indicated). Engagement with the FCU predicted significant reductions in suicide risk across adolescence and early adulthood.
PMCID: PMC4889021  PMID: 27094106
Family intervention; compliance; prevention; suicide risk; early adolescence
11.  Effects of a Military Parenting Program on Parental Distress and Suicidal Ideation: After Deployment Adaptive Parenting Tools 
Suicide & life-threatening behavior  2016;46(Suppl 1):S23-S31.
Few studies have examined whether parenting prevention programs might mitigate risk for suicidality in parents, yet parent suicidality is a strong risk factor for offspring suicidality. We report results from a randomized controlled trial of a parenting program for deployed National Guard and Reserve (NG/R) families with a school-aged child. Intent-to-treat analyses showed that random assignment to the parenting program (ADAPT) was associated with improved parenting locus of control (LOC). Improved parenting LOC was concurrently associated with strengthened emotion regulation which predicted reductions in psychological distress and suicidal ideation at 12 months post baseline. Results are discussed in the context of ongoing efforts to reduce suicide rates in military populations.
PMCID: PMC5113712  PMID: 27094107
12.  Predicting Persistence of Non-suicidal Self-Injury in Suicidal Adolescents 
This study examined prospective predictors of persistent non-suicidal self-injury (NSSI) in adolescents admitted to an inpatient psychiatric unit for suicidal behaviors and followed naturalistically for six months. Seventy-one (77%) participants reported NSSI at baseline and 40 (56%) persisted at the six month follow-up. Those who endorsed automatic positive reinforcement (APR) as the predominant reason for NSSI, were more likely to persist in NSSI. Depression over follow-up, but not at baseline, also predicted persistence. These results suggest that helping high risk adolescents to identify alternative ways of generating emotion(s) to counter the effects of APR that may accompany NSSI, should be a high priority treatment target.
PMCID: PMC4619186  PMID: 25907682
13.  Emphasis on Autonomy and Propensity for Suicidal Behavior in Younger and Older Adults 
A cognitive style marked by emphasis on autonomy has been linked to negative outcomes throughout the life span. Two preliminary studies are presented that examined factors on a measure of autonomy (Personal Style Inventory-Revised) in relation to propensity for suicidal behavior (Suicidal Behaviors Questionnaire-14; SBQ-14). Perfectionism, B = .15, SE = 0.03, p < .01, and Defensive Separation, B = .04, SE = 0.01, p £ .01, predicted SBQ-14 in younger adults. Need for Control, B = .234, SE = 0.10, p < .05, predicted SBQ-14 in older adults. Findings suggest that aspects of autonomy may be relevant to understanding suicidal behavior; however, more research is needed examining the association between autonomy and suicidal behavior in the context of depression. Nonetheless, these studies suggest a promising avenue for future research.
PMCID: PMC5134248  PMID: 22583099
14.  Positive-Themed Suicide Prevention Messages Delivered by Adolescent Peer Leaders: Proximal Impact on Classmates’ Coping Attitudes and Perceptions of Adult Support 
Developing science-based communication guidance and positive-themed messages for suicide prevention are important priorities. Drawing on social learning and elaboration likelihood models, we designed and tested two positive-focused presentations by high school peer leaders delivered in the context of a suicide prevention program (Sources of Strength). Thirty six classrooms in four schools (N=706 students) were randomized to: (a) peer leader modeling of healthy coping, (b) peer leader modeling plus audience involvement to identify trusted adults, or (c) control condition. Students’ attitudes and norms were assessed by immediate post-only assessments. Exposure to either presentation enhanced positive coping attitudes and perceptions of adult support. Students who reported suicide ideation in the past 12 months benefited more than non-suicidal students. Beyond modeling alone, audience involvement modestly enhanced expectations of adult support, congruent with the elaboration likelihood model. Positive peer modeling is a promising alternative to communications focused on negative consequences and directives and may enhance social-interpersonal factors linked to reduced suicidal behaviors.
PMCID: PMC4540682  PMID: 25692382
15.  Suicide Ideations, Suicide Attempts, and Completed Suicide in Persons with Pathological Gambling and their First-Degree Relatives 
We examined the relationship between suicidal ideations and attempts in 95 probands with pathological gambling (PG), 91 controls, and 1075 first-degree relatives. The results were analyzed using logistic regression with GEE. Thirty-four PG probands (35.8%) and 4 controls (4.4%) had attempted suicide (OR = 12.12, P < .001); in 13 the attempt occurred before PG onset. Lifetime suicidal ideations occurred in 60 PG probands (63.2%) and 12 controls (13.2%) (OR = 11.29, P < .001). Suicidality in PG probands is a marker of PG severity and is associated with greater psychiatric comorbidity. Offspring of PG probands had significantly higher rates of suicide attempts than control offspring.
PMCID: PMC4595153  PMID: 25845522
Family study; pathological gambling; suicidal ideations; suicide attempts
16.  Comparison of the Effects of Telephone Suicide Prevention Help by Volunteers and Professional Paid Staff: Results from Studies in the USA and Quebec, Canada 
Research since the 1960s has consistently found that lay volunteers are better at helping suicidal callers than professionals. Yet, professional degrees are increasingly becoming requirements for helpline workers. In our first study, we conducted post hoc comparisons of U.S. helplines with all professional paid staff, all lay volunteers, and a mix of both, using silent monitoring and standardized assessments of 1,431 calls. The volunteer centers more often conducted risk assessments, had more empathy, were more respectful of callers, and had significantly better call outcome ratings. A second study of five Quebec suicide prevention centers used silent monitoring to compare telephone help in 1,206 calls answered by 90 volunteers and 39 paid staff. Results indicate no significant differences between the volunteers and paid employees on outcome variables. However, volunteers and paid staff with over 140 hours of call experience had significantly better outcomes. Unlike the United States, Quebec paid employees were not required to have advanced professional degrees. We conclude from these results and previous research that there is no justification for requiring that suicide prevention helpline workers be mental health professionals. In fact, the evidence to date indicates that professionals may be less effective in providing telephone help to suicidal individuals when compared to trained lay volunteers.
PMCID: PMC5069583  PMID: 26946110
17.  Influences on call outcomes among Veteran callers to the National Veterans Crisis Line 
This evaluation examined the association of caller and call characteristics with proximal outcomes of Veterans Crisis Line calls. From October 1-7, 2010, 665 Veterans with recent suicidal ideation or a history of attempted suicide called the Veterans Crisis Line, 646 had complete data and were included in the analyses. A multivariable multinomial logistic regression was conducted to identify correlates of a favorable outcome, either a resolution or a referral, when compared to an unfavorable outcome, no resolution or referral. A multivariable logistic regression was used to identify correlates of responder-rated caller risk in a subset of calls. Approximately 84% of calls ended with a favorable outcome, 25% with a resolution and 59% with a referral to a local health care provider. Calls from high-risk callers had greater odds of ending with a referral than without a resolution or referral, as did weekday calls (6:00 am to 5:59 pm EST, Monday through Friday). Responders used caller intent to die and the absence of future plans to determine caller risk. Findings suggest that the Veterans Crisis Line is a useful mechanism for generating referrals for high-risk Veteran callers. Responders appeared to use known risk and protective factors to determine caller risk.
PMCID: PMC5064431  PMID: 23611446
18.  Suicide Attempts within 12 Months of Treatment for Substance Use Disorders 
There are limited prospective data on suicide attempts (SA) during the months following treatment for substance use disorders (SUD), a period of high risk. In an analysis of the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal naturalistic multisite study of treated SUDs, variables associated with SA in the 12 months following SUD treatment were examined. Participants included 2,966 patients with one or more SUDs. By 12 months, 77 (2.6%) subjects had attempted suicide. Multivariate logistic regression analyses were used to identify variables associated with SA. Variables collected at baseline that were associated with SA included lifetime histories of SA, suicidal ideation (SI), and depression, cocaine as primary substance of use, outpatient methadone treatment, and short-term inpatient treatment. Male sex, older age, and minority race/ethnicity were associated with lower likelihood of SA. After controlling for baseline predictors, variables assessed at 12 months associated with SA included SI during follow-up and daily or more use of cocaine. The data contribute to a small but growing literature of prospective studies of SA among treated SUDs, and suggest that SUDs with cocaine use disorders in particular should be a focus of prevention efforts.
PMCID: PMC5064437  PMID: 20170258
19.  Suicide and Suicidal Attempts in the United States: Costs and Policy Implications 
The national cost of suicides and suicide attempts in the United States in 2013 was $58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under‐reporting increased the total cost to $93.5 billion or $298 per capita, 2.1–2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit–cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.
PMCID: PMC5061092  PMID: 26511788
20.  A Prospective Examination of the Interpersonal-Psychological Theory of Suicidal Behavior Among Psychiatric Adolescent Inpatients 
The challenge of identifying suicide risk in adolescents, and particularly among high-risk subgroups such as adolescent inpatients, calls for further study of models of suicidal behavior that could meaningfully aid in the prediction of risk. This study examined how well the Interpersonal-Psychological Theory of Suicidal Behavior (IPTS)—with its constructs of thwarted belongingness (TB), perceived burdensomeness (PB), and an acquired capability (AC) for lethal self-injury—predicts suicide attempts among adolescents (N = 376) 3 and 12 months after hospitalization. The three-way interaction between PB, TB, and AC, defined as a history of multiple suicide attempts, was not significant. However, there were significant 2-way interaction effects, which varied by sex: girls with low AC and increasing TB, and boys with high AC and increasing PB, were more likely to attempt suicide at 3 months. Only high AC predicted 12-month attempts. Results suggest gender-specific associations between theory components and attempts. The time-limited effects of these associations point to TB and PB being dynamic and modifiable in high-risk populations, whereas the effects of AC are more lasting. The study also fills an important gap in existing research by examining IPTS prospectively.
PMCID: PMC5036446  PMID: 25263410
21.  Latina Adolescent Suicide Ideations and Attempts: Associations with Connectedness to Parents, Peers, and Teachers 
Associations between suicidal behavior and social-ecological variables were examined among 1,618 Latina high school students (mean age = 15) from the nationally representative Add Health sample (68% were U.S.-born). Ideations were associated with having a suicidal friend, lower perceived father support, and overall parental caring. Attempts were associated with having a suicidal friend, and lower perceived teacher and parental support. Peer and mother relationship variables were not predictors of ideations or attempts. The protective role of father and teacher support has not previously been emphasized in the literature. Strengthening connections to parents and teachers may reduce suicidal behavior in adolescent Latinas.
PMCID: PMC5035701  PMID: 23062099
22.  The Effect of Participating in Suicide Research: Does Participating in a Research Protocol on Suicide and Psychiatric Symptoms Increase Suicide Ideation and Attempts? 
The current study explored the effect of engaging in an intensive research protocol that inquired extensively about psychiatric and suicide symptoms and exposed participants to a number of images that included suicide-related content. Individuals experiencing a Major Depressive Episode were called at one and three months after the initial protocol. Participants were asked about changes in suicide ideation and the occurrence of self-harm or suicide attempts following participation. Participants reported experiencing reductions in suicide ideation at the first follow-up and no changes at the second follow-up. No participant reported having engaged in self-harm or attempting suicide at either follow-up. Results suggest that basic science/non-treatment research can be conducted safely with suicidal participants and in a manner that does not increase suicide symptoms or suicide risk.
PMCID: PMC5022772  PMID: 21198322
Suicide Research; Suicide Ideation; Suicide Attempts; Self-Harm; Follow-up
23.  Capable of Suicide: A Functional Model of the Acquired Capability Component of the Interpersonal-Psychological Theory of Suicide 
The current review aims to present a functional model of the acquired capability for suicide; a component of Joiner’s (2005) Interpersonal-Psychological Theory of Suicide. This review is aimed at integrating the points discussed by Joiner into a unified and specific conceptualization of acquired capability. Additionally, we offer some points of elaboration; such as the interaction between specific diatheses with life events, the role of short-term bolstering of the capability for suicide, and how contextual factors moderate the experience of painful and provocative life events; thereby leading to fearlessness and pain insensitivity to the actions and ideas involved in suicide.
PMCID: PMC5022773  PMID: 20560748
Interpersonal-Psychological Theory; Suicide; Suicide Attempts; Self-Harm
24.  Suicidal Behavior Outcomes of Childhood Sexual Abuse: Longitudinal Study of Adjudicated Girls 
Childhood sexual abuse (CSA) histories are prevalent among adolescent girls in the juvenile justice system (JJS) and may contribute to their high rates of suicidal behavior. Among 166 JJS girls who participated in an intervention trial, baseline CSA and covariates were examined as predictors of suicide attempt and non-suicidal self-injury (NSSI) reported at long-term follow-up (7–12 years later). Early forced CSA was related to lifetime suicide attempt and NSSI history, and (marginally) to post-baseline attempt; effects were not mediated by anxiety or depressive symptoms. Findings suggest that earlier victimization and younger entry into JJS are linked with girls’ suicide attempt and NSSI.
PMCID: PMC4420727  PMID: 25370436
25.  Suicidal behavior in relatives or associates moderates the strength of common risk factors for suicide 
The prevalence and odds ratios of different suicide risk factors were compared in three pairs of decedents: 80 suicides and 25 injury decedents with blood-relatives with suicidal behavior history (biologically-exposed); 259 suicides and 126 injury decedents with unrelated acquaintances with suicidal behavior history (socially-exposed); and 471 suicides and 523 injury decedents with neither relatives nor acquaintances with suicidal behavior history (unexposed). Negative life events and high psychological stress were more common in socially-exposed suicides than in other suicides. The adjusted odds ratios of most established suicide risk factors were higher in unexposed decedents than in biologically- or socially-exposed decedents, suggesting that the predictive value of established risk factors wanes in individuals who have been exposed to suicidal behavior in family or friends.
PMCID: PMC4452463  PMID: 25443455

Results 1-25 (99)