The affiliation between despair and suicidal ideas and behavior is properly established (e.g. Chesney et al., 2014; De Beurs et al., 2019). Suicide ideation can also be one of many signs of despair in line with the DSM standards, and sometimes an merchandise in despair scales which are used as major outcomes in trials (Kroenke et al., 2001). Due to this fact, it appears logical to imagine that efficient therapies of despair even have a big impact on suicidality. Nevertheless, modern theories of suicidal behaviour, such because the Built-in Motivational Volitional mannequin state that suicidal behaviour is not only a symptom of despair, however reasonably the outcomes of a course of by itself (O’Connor & Kirtley, 2018).
Current years, subsequently, noticed the introduction of therapies such because the collaborative evaluation and administration of suicidality (CAMS) (Jobes et al., 2016), that straight goal suicidality. However, in every day medical observe, depressed sufferers, who typically additionally report suicidal ideation, are more than likely to obtain a psychological intervention similar to cognitive behavioural remedy that particularly focuses on despair and never straight on suicidality. Importantly, suicidality is usually an exclusion criterion for psychological intervention trials.
Thus, the empirical query stays: how massive the impact of psychological interventions aimed toward despair is on suicidal ideation and behaviours given the present obtainable RCTs? A current meta-analysis titled “Evaluation of Suicide Threat in Psychological Interventions for Melancholy” by Miguel and colleagues (2024) aimed to reply this query by systematically investigating any reported results on suicidality inside trials of psychological interventions for despair.
Do present obtainable randomised managed trials on psychological interventions for despair assess suicide threat?
Strategies
The examine utilised the Metapsy database, a “residing analytic database” which incorporates randomised managed trials of psychological therapies for despair. The evaluation included trials with an inactive management group that reported suicide-related outcomes both as an opposed occasion or as a part of the security monitoring. The authors chosen randomised managed trials that aimed to check the consequences of psychological interventions for despair. They included a variety of suicide-related elements, together with suicide ideation (ideas, intents and/or plans), suicidal threat (probability of (non)deadly suicide makes an attempt) and behaviours (makes an attempt and extreme self-harm). The authors solely included research that used established devices.
Outcomes
- 469 RCTs have been recognized wherein a psychological intervention for despair was in comparison with an inactive management.
- Within the majority of research (54%), individuals have been excluded due to a threat for suicide.
- For the meta-analysis on the effectiveness of a psychological intervention of despair on suicidal ideation, solely 12 trials have been chosen.
- These have been fairly completely different trials, one in pregnant folks, one in incarnated, three amongst individuals with a basic medical situation.
- The therapies have been CBT, mindfulness and behavioural activation.
- Total, there was a small impact on suicidal ideation of psychological interventions for despair.
- When excluding trials the place suicide outcomes solely relied on a single merchandise, no important variations have been discovered.
- Moreover, no important longitudinal results have been discovered.
- Additionally, a rise in ranges of suicidality was present in 25 trials.
- Heterogeneity was excessive in all research.
Greater than half (54%) of RCTs on psychological interventions for folks with despair exclude people who find themselves liable to suicide.
Conclusions
- Suicidal ideas and behaviours are not often reported in trials learning the impact of psychological interventions on despair.
- Maybe much more importantly, in additional than half of the research (54%), suicidal sufferers have been excluded.
- The meta-analysis of 12 trials confirmed a small impact of the interventions on suicide ideation, however the authors state these are primarily pushed by 2 research focussing on suicide. When these have been omitted, no important outcomes have been discovered.
- No long-term results have been discovered.
- In 25 research, a rise in suicidality was discovered in the course of the examine.
“Suicidal ideas and behaviours are not often reported in trials learning the impact of psychological interventions on despair.”
Strengths and limitations
The energy of this examine is that it gives an up to date view on the reporting of suicide threat elements inside medical trials, and an outline of the speed of exclusion of suicidal sufferers inside research of despair. The group is a superb knowledgeable group on meta-analyses, so the standard of the search and the evaluation is past doubt.
So far as I can inform, the principle limitation is that as a result of restricted variety of the research and their heterogeneity, the info doesn’t per se inform us a lot in regards to the effectiveness of psychological interventions for despair on suicide ideation. The knowledge is simply not there.
Additionally, the research that did report suicide ideation typically relied on single objects from current despair scales. We all know from completely different research that single objects are inclined to current a biased perception within the degree of suicidality (Millner et al., 2015). Relatedly, we all know from ecological momentary evaluation research that suicidality fluctuates closely even inside intervals of an hour (Kleiman & Nock, 2018). Given this basic small impact, one wonders if a person affected person knowledge meta-analysis (IPDMA) wouldn’t have resulted in a extra fine-grained perception into the connection between psychological interventions for despair and suicidality.
Additionally, a head-to-head comparability of interventions that not directly goal suicidality (similar to psychological intervention for despair) and interventions that straight goal suicidality, similar to CAMS, could be fascinating.
Importantly, but additionally frustratingly, as even in interventions that straight goal suicidality, the impact dimension stays small. One wonders if we’ll ever be capable of get a definitive scientific reply to the query: the way to finest deal with suicidality from RCTs or meta-analysis (Fox et al., 2020).
Single merchandise statements from despair questionnaires don’t present an correct illustration of suicide threat.
Implications for observe
It stays staggering that the sufferers that may want psychological remedy essentially the most, i.e. sufferers with excessive threat for suicidality stay excluded from many of the trials. This limits the insights into the effectiveness of commonest supplied interventions in every day medical observe on suicidality. It is a matter typically addressed, however should be put increased on the agenda of researchers and moral committees.
The perception that the oblique results of the interventions are small is in keeping with many different interventions aimed on the discount of suicidality (Fox et al., 2020). Clinicians may have expertise that when treating despair, in lots of sufferers the suicidality additionally decreases, nevertheless it’s good to not take the impact of psychological interventions on despair on suicidality with no consideration.
Clinicians must be conscious that though it’s seemingly that suicidal threat decreased when the despair remedy is efficient, it could be that for some sufferers, suicidal threat stays current. Due to this fact, clinicians ought to regularly monitor suicidal ideation, and on the finish of remedy explicitly talk about any residual threat for suicidality. Threat elements particular for suicidality, similar to emotions of entrapment or perceived burdensomeness may also assist clinicians to higher assess the danger for suicidality (De Beurs et al., 2018; De Beurs et al., 2020).
Additionally, as soon as somebody has been suicidal, the differential activation speculation states that sufferers usually tend to once more develop into suicidal after one other expertise of stress or entrapment (Lau et al., 2004). Due to this fact, providing a type of psychoeducation or security planning about the way to recognise a novel disaster would possibly higher defend folks from relapse (Nuij et al., 2021).
For researchers, it must be pretty easy to report on the scores on suicide ideation or threat outcomes in papers, making an replace of this examine in 10 yr’s time simpler and extra informative. Ideally, inside research, threat for suicidality must be assessed with devoted scales such because the Suicidal Ideation attributes scale (SIDAS) (van Spijker et al., 2014).
If something, suicidal behaviour is advanced and the results of many interacting variables, and a related query is whether or not any examine or meta-analysis will ever be capable of present particular solutions to what works finest for whom (De Beurs et al., 2020). Different designs, similar to IPDMA, or qualitative interviews would possibly supply the required clinically helpful insights. Totally different views, such because the community perspective, or a complexity perspective may also assist us additional entangle the complexity on the particular person degree (De Beurs et al., 2020). Till then, clinicians ought to at all times pay attention to threat for suicidality inside depressed sufferers, and actively take note of it throughout any type of psychological or pharmacological remedy.
The effectiveness of psychological interventions on suicide threat requires additional analysis consideration to handle the wants of suicidal people.
Assertion of pursuits
Derek de Beurs is member of the Dutch guideline for suicidal behaviour. He is aware of three of the authors (PC, EK and WB).
Hyperlinks
Major paper
Miguel, C., Cecconi, J., Harrer, M., Van Ballegooijen, W., Bhattacharya, S., Karyotaki, E., Cuijpers, P., Gentili, C., & Cristea, I. A. (2024). Evaluation of suicidality in trials of psychological interventions for despair: A meta-analysis. The Lancet Psychiatry, 11(4), 252–261. https://doi.org/10.1016/S2215-0366(24)00027-0
Different references
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Dangers of all-cause and suicide mortality in psychological problems: A meta-review. World Psychiatry, 13(2), 153–160. https://doi.org/10.1002/wps.20128
De Beurs, D., Cleare, S., Wetherall, Okay., Eschle-Byrne, S., Ferguson, E., B O’Connor, D., & C O’Connor, R. (2020). Entrapment and suicide threat: The event of the 4-item Entrapment Scale Quick-Kind (E-SF). Psychiatry Analysis, 284. https://doi.org/10.1016/j.psychres.2020.112765
de Beurs, D., Fried, E., Wetheral, Okay., Cleare, S., O’ Connor, D., Ferguson, E., O’ Carroll, R., & O’ Connor, R. (2018). Exploring the psychology of suicidal ideation: A idea pushed community evaluation. Preprint. https://doi.org/10.1016/j.brat.2019.103419
De Beurs, D. P., De Beurs, D., Bockting, C., Kerkhof, A., Scheepers, F., O’Connor, R., Penninx, B., & Van De Leemput, I. (2020). A community perspective on suicidal conduct: Understanding suicidality as a posh system. Suicide and Life-Threatening Habits. https://doi.org/10.1111/sltb.12676
De Beurs, D., Ten Have, M., Cuijpers, P., & De Graaf, R. (2019). The longitudinal affiliation between lifetime psychological problems and first onset or recurrent suicide ideation. BMC Psychiatry. https://doi.org/10.1186/s12888-019-2328-8
Fox, Okay. R., Huang, X., Guzmán, E. M., Funsch, Okay. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized managed trials throughout practically 50 years of analysis. Psychological Bulletin. https://doi.org/10.1037/bul0000305
Jobes, D. A., Comtois, Okay. A., Brenner, L. A., Gutierrez, P. M., & O’Connor, S. S. (2016). Classes Discovered from Scientific Trials of the Collaborative Evaluation and Administration of Suicidality ( CAMS ). In R. C. O’Connor & J. Pirkis (Eds.), The Worldwide Handbook of Suicide Prevention (1st ed., pp. 431–449). Wiley. https://doi.org/10.1002/9781118903223.ch24
Kleiman, E. M., & Nock, M. Okay. (2018). Actual-time evaluation of suicidal ideas and behaviors. Present Opinion in Psychology. https://doi.org/10.1016/j.copsyc.2017.07.026
Kroenke, Okay., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: Validity of a short despair severity measure. Journal of Common Inside Drugs, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Lau, M. A., Segal, Z. V., & Williams, J. M. G. (2004). Teasdale’s differential activation speculation: Implications for mechanisms of depressive relapse and suicidal behaviour. Behaviour Analysis and Remedy, 42(9), 1001–1017. https://doi.org/10.1016/j.brat.2004.03.003
Millner, A. J., Lee, M. D., & Nock, M. Okay. (2015). Single-Merchandise Measurement of Suicidal Behaviors: Validity and Penalties of Misclassification. PLOS ONE, 10(10), e0141606. https://doi.org/10.1371/journal.pone.0141606
Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Security planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219(2), 419–426. https://doi.org/10.1192/bjp.2021.50
O’Connor, R. C., & Kirtley, O. J. (2018). The built-in motivational–volitional mannequin of suicidal behaviour. Philosophical Transactions of the Royal Society B: Organic Sciences. https://doi.org/10.1098/rstb.2017.0268
van Spijker, B. A. J., Batterham, P. J., Calear, A. L., Farrer, L., Christensen, H., Reynolds, J., & Kerkhof, A. J. F. M. (2014). The Suicidal Ideation Attributes Scale ( SIDAS ): Neighborhood‐Based mostly Validation Examine of a New Scale for the Measurement of Suicidal Ideation. Suicide and Life-Threatening Habits, 44(4), 408–419. https://doi.org/10.1111/sltb.12084
The affiliation between despair and suicidal ideas and behavior is properly established (e.g. Chesney et al., 2014; De Beurs et al., 2019). Suicide ideation can also be one of many signs of despair in line with the DSM standards, and sometimes an merchandise in despair scales which are used as major outcomes in trials (Kroenke et al., 2001). Due to this fact, it appears logical to imagine that efficient therapies of despair even have a big impact on suicidality. Nevertheless, modern theories of suicidal behaviour, such because the Built-in Motivational Volitional mannequin state that suicidal behaviour is not only a symptom of despair, however reasonably the outcomes of a course of by itself (O’Connor & Kirtley, 2018).
Current years, subsequently, noticed the introduction of therapies such because the collaborative evaluation and administration of suicidality (CAMS) (Jobes et al., 2016), that straight goal suicidality. However, in every day medical observe, depressed sufferers, who typically additionally report suicidal ideation, are more than likely to obtain a psychological intervention similar to cognitive behavioural remedy that particularly focuses on despair and never straight on suicidality. Importantly, suicidality is usually an exclusion criterion for psychological intervention trials.
Thus, the empirical query stays: how massive the impact of psychological interventions aimed toward despair is on suicidal ideation and behaviours given the present obtainable RCTs? A current meta-analysis titled “Evaluation of Suicide Threat in Psychological Interventions for Melancholy” by Miguel and colleagues (2024) aimed to reply this query by systematically investigating any reported results on suicidality inside trials of psychological interventions for despair.
Do present obtainable randomised managed trials on psychological interventions for despair assess suicide threat?
Strategies
The examine utilised the Metapsy database, a “residing analytic database” which incorporates randomised managed trials of psychological therapies for despair. The evaluation included trials with an inactive management group that reported suicide-related outcomes both as an opposed occasion or as a part of the security monitoring. The authors chosen randomised managed trials that aimed to check the consequences of psychological interventions for despair. They included a variety of suicide-related elements, together with suicide ideation (ideas, intents and/or plans), suicidal threat (probability of (non)deadly suicide makes an attempt) and behaviours (makes an attempt and extreme self-harm). The authors solely included research that used established devices.
Outcomes
- 469 RCTs have been recognized wherein a psychological intervention for despair was in comparison with an inactive management.
- Within the majority of research (54%), individuals have been excluded due to a threat for suicide.
- For the meta-analysis on the effectiveness of a psychological intervention of despair on suicidal ideation, solely 12 trials have been chosen.
- These have been fairly completely different trials, one in pregnant folks, one in incarnated, three amongst individuals with a basic medical situation.
- The therapies have been CBT, mindfulness and behavioural activation.
- Total, there was a small impact on suicidal ideation of psychological interventions for despair.
- When excluding trials the place suicide outcomes solely relied on a single merchandise, no important variations have been discovered.
- Moreover, no important longitudinal results have been discovered.
- Additionally, a rise in ranges of suicidality was present in 25 trials.
- Heterogeneity was excessive in all research.
Greater than half (54%) of RCTs on psychological interventions for folks with despair exclude people who find themselves liable to suicide.
Conclusions
- Suicidal ideas and behaviours are not often reported in trials learning the impact of psychological interventions on despair.
- Maybe much more importantly, in additional than half of the research (54%), suicidal sufferers have been excluded.
- The meta-analysis of 12 trials confirmed a small impact of the interventions on suicide ideation, however the authors state these are primarily pushed by 2 research focussing on suicide. When these have been omitted, no important outcomes have been discovered.
- No long-term results have been discovered.
- In 25 research, a rise in suicidality was discovered in the course of the examine.
“Suicidal ideas and behaviours are not often reported in trials learning the impact of psychological interventions on despair.”
Strengths and limitations
The energy of this examine is that it gives an up to date view on the reporting of suicide threat elements inside medical trials, and an outline of the speed of exclusion of suicidal sufferers inside research of despair. The group is a superb knowledgeable group on meta-analyses, so the standard of the search and the evaluation is past doubt.
So far as I can inform, the principle limitation is that as a result of restricted variety of the research and their heterogeneity, the info doesn’t per se inform us a lot in regards to the effectiveness of psychological interventions for despair on suicide ideation. The knowledge is simply not there.
Additionally, the research that did report suicide ideation typically relied on single objects from current despair scales. We all know from completely different research that single objects are inclined to current a biased perception within the degree of suicidality (Millner et al., 2015). Relatedly, we all know from ecological momentary evaluation research that suicidality fluctuates closely even inside intervals of an hour (Kleiman & Nock, 2018). Given this basic small impact, one wonders if a person affected person knowledge meta-analysis (IPDMA) wouldn’t have resulted in a extra fine-grained perception into the connection between psychological interventions for despair and suicidality.
Additionally, a head-to-head comparability of interventions that not directly goal suicidality (similar to psychological intervention for despair) and interventions that straight goal suicidality, similar to CAMS, could be fascinating.
Importantly, but additionally frustratingly, as even in interventions that straight goal suicidality, the impact dimension stays small. One wonders if we’ll ever be capable of get a definitive scientific reply to the query: the way to finest deal with suicidality from RCTs or meta-analysis (Fox et al., 2020).
Single merchandise statements from despair questionnaires don’t present an correct illustration of suicide threat.
Implications for observe
It stays staggering that the sufferers that may want psychological remedy essentially the most, i.e. sufferers with excessive threat for suicidality stay excluded from many of the trials. This limits the insights into the effectiveness of commonest supplied interventions in every day medical observe on suicidality. It is a matter typically addressed, however should be put increased on the agenda of researchers and moral committees.
The perception that the oblique results of the interventions are small is in keeping with many different interventions aimed on the discount of suicidality (Fox et al., 2020). Clinicians may have expertise that when treating despair, in lots of sufferers the suicidality additionally decreases, nevertheless it’s good to not take the impact of psychological interventions on despair on suicidality with no consideration.
Clinicians must be conscious that though it’s seemingly that suicidal threat decreased when the despair remedy is efficient, it could be that for some sufferers, suicidal threat stays current. Due to this fact, clinicians ought to regularly monitor suicidal ideation, and on the finish of remedy explicitly talk about any residual threat for suicidality. Threat elements particular for suicidality, similar to emotions of entrapment or perceived burdensomeness may also assist clinicians to higher assess the danger for suicidality (De Beurs et al., 2018; De Beurs et al., 2020).
Additionally, as soon as somebody has been suicidal, the differential activation speculation states that sufferers usually tend to once more develop into suicidal after one other expertise of stress or entrapment (Lau et al., 2004). Due to this fact, providing a type of psychoeducation or security planning about the way to recognise a novel disaster would possibly higher defend folks from relapse (Nuij et al., 2021).
For researchers, it must be pretty easy to report on the scores on suicide ideation or threat outcomes in papers, making an replace of this examine in 10 yr’s time simpler and extra informative. Ideally, inside research, threat for suicidality must be assessed with devoted scales such because the Suicidal Ideation attributes scale (SIDAS) (van Spijker et al., 2014).
If something, suicidal behaviour is advanced and the results of many interacting variables, and a related query is whether or not any examine or meta-analysis will ever be capable of present particular solutions to what works finest for whom (De Beurs et al., 2020). Different designs, similar to IPDMA, or qualitative interviews would possibly supply the required clinically helpful insights. Totally different views, such because the community perspective, or a complexity perspective may also assist us additional entangle the complexity on the particular person degree (De Beurs et al., 2020). Till then, clinicians ought to at all times pay attention to threat for suicidality inside depressed sufferers, and actively take note of it throughout any type of psychological or pharmacological remedy.
The effectiveness of psychological interventions on suicide threat requires additional analysis consideration to handle the wants of suicidal people.
Assertion of pursuits
Derek de Beurs is member of the Dutch guideline for suicidal behaviour. He is aware of three of the authors (PC, EK and WB).
Hyperlinks
Major paper
Miguel, C., Cecconi, J., Harrer, M., Van Ballegooijen, W., Bhattacharya, S., Karyotaki, E., Cuijpers, P., Gentili, C., & Cristea, I. A. (2024). Evaluation of suicidality in trials of psychological interventions for despair: A meta-analysis. The Lancet Psychiatry, 11(4), 252–261. https://doi.org/10.1016/S2215-0366(24)00027-0
Different references
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Dangers of all-cause and suicide mortality in psychological problems: A meta-review. World Psychiatry, 13(2), 153–160. https://doi.org/10.1002/wps.20128
De Beurs, D., Cleare, S., Wetherall, Okay., Eschle-Byrne, S., Ferguson, E., B O’Connor, D., & C O’Connor, R. (2020). Entrapment and suicide threat: The event of the 4-item Entrapment Scale Quick-Kind (E-SF). Psychiatry Analysis, 284. https://doi.org/10.1016/j.psychres.2020.112765
de Beurs, D., Fried, E., Wetheral, Okay., Cleare, S., O’ Connor, D., Ferguson, E., O’ Carroll, R., & O’ Connor, R. (2018). Exploring the psychology of suicidal ideation: A idea pushed community evaluation. Preprint. https://doi.org/10.1016/j.brat.2019.103419
De Beurs, D. P., De Beurs, D., Bockting, C., Kerkhof, A., Scheepers, F., O’Connor, R., Penninx, B., & Van De Leemput, I. (2020). A community perspective on suicidal conduct: Understanding suicidality as a posh system. Suicide and Life-Threatening Habits. https://doi.org/10.1111/sltb.12676
De Beurs, D., Ten Have, M., Cuijpers, P., & De Graaf, R. (2019). The longitudinal affiliation between lifetime psychological problems and first onset or recurrent suicide ideation. BMC Psychiatry. https://doi.org/10.1186/s12888-019-2328-8
Fox, Okay. R., Huang, X., Guzmán, E. M., Funsch, Okay. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized managed trials throughout practically 50 years of analysis. Psychological Bulletin. https://doi.org/10.1037/bul0000305
Jobes, D. A., Comtois, Okay. A., Brenner, L. A., Gutierrez, P. M., & O’Connor, S. S. (2016). Classes Discovered from Scientific Trials of the Collaborative Evaluation and Administration of Suicidality ( CAMS ). In R. C. O’Connor & J. Pirkis (Eds.), The Worldwide Handbook of Suicide Prevention (1st ed., pp. 431–449). Wiley. https://doi.org/10.1002/9781118903223.ch24
Kleiman, E. M., & Nock, M. Okay. (2018). Actual-time evaluation of suicidal ideas and behaviors. Present Opinion in Psychology. https://doi.org/10.1016/j.copsyc.2017.07.026
Kroenke, Okay., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: Validity of a short despair severity measure. Journal of Common Inside Drugs, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Lau, M. A., Segal, Z. V., & Williams, J. M. G. (2004). Teasdale’s differential activation speculation: Implications for mechanisms of depressive relapse and suicidal behaviour. Behaviour Analysis and Remedy, 42(9), 1001–1017. https://doi.org/10.1016/j.brat.2004.03.003
Millner, A. J., Lee, M. D., & Nock, M. Okay. (2015). Single-Merchandise Measurement of Suicidal Behaviors: Validity and Penalties of Misclassification. PLOS ONE, 10(10), e0141606. https://doi.org/10.1371/journal.pone.0141606
Nuij, C., van Ballegooijen, W., de Beurs, D., Juniar, D., Erlangsen, A., Portzky, G., O’Connor, R. C., Smit, J. H., Kerkhof, A., & Riper, H. (2021). Security planning-type interventions for suicide prevention: Meta-analysis. The British Journal of Psychiatry, 219(2), 419–426. https://doi.org/10.1192/bjp.2021.50
O’Connor, R. C., & Kirtley, O. J. (2018). The built-in motivational–volitional mannequin of suicidal behaviour. Philosophical Transactions of the Royal Society B: Organic Sciences. https://doi.org/10.1098/rstb.2017.0268
van Spijker, B. A. J., Batterham, P. J., Calear, A. L., Farrer, L., Christensen, H., Reynolds, J., & Kerkhof, A. J. F. M. (2014). The Suicidal Ideation Attributes Scale ( SIDAS ): Neighborhood‐Based mostly Validation Examine of a New Scale for the Measurement of Suicidal Ideation. Suicide and Life-Threatening Habits, 44(4), 408–419. https://doi.org/10.1111/sltb.12084
