46

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

APPENDIX A. SEARCH STRATEGIES

OVID MEDLINE searched from 2005 – November 18, 2011

Suicide “Suicide”[Mesh] OR “Suicide, Attempted”[Mesh] OR suicid*

Risk “Risk”[Mesh] OR “Risk Assessment”[Mesh] OR “Risk Factors”[Mesh] 

OR risk[Title/Abstract]

Screening “mass screening”[Mesh] OR “Validation studies”[Publication Type] 

OR Screening[title] OR screen[title] OR assessment[title] OR 

assessments[title] OR questionnaire[title] OR questionnaires[title] OR 

instrument[title] OR instruments[title] OR tool[title] OR tools[title] OR 

scale[title] OR scales[title] OR measure[title] OR measures[title]

Prevention Prevent* OR depression OR health education OR health promotion 

OR public opinion OR mass screening OR family physicians OR 

medical Education OR primary healthcare OR antidepressive agents OR 

psychotherapy OR schools OR adolescents OR methods OR firearms OR 

overdose OR poisoning OR gas poisoning OR mass media

Suicide 

Prevention

(“Suicide/prevention and control”[Mesh] OR Suicide, Attempted/

prevention and contril”[Mesh]) NOT (case report* OR editorial* OR 

letter)

Suicide Prevention OR (Suicide AND (Risk OR Screening OR Prevention)

PsycINFO, Cochrane and HAPI Search November 18, 2011

Limited from 2005 – November 18, 2011

Search Strategy:

--------------------------------------------------------------------------------

1 exp Attempted Suicide/ or exp Suicide Prevention/ 

2 (prevent* or depression or health education or health promotion or public opinion or mass 

screening or family physicians or medical education or primary health care or antidepressive 

agents or psychotherapy or schools or adolescents or methods or firearms or overdose or 

poisoning or gas poisoning or mass media).mp. [mp=title, abstract, heading word, table of 

contents, key concepts, original title, tests & measures] 

3 suicide.mp. [mp=title, abstract, heading word, table of contents, key concepts, original title, 

tests & measures] 

4 2 and 3

5 1 or 4 

6 exp Case Report/

7 editorial.mp. 
47

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

8 letter.mp. 

9 6 or 7 or 8 

10 5 not 9 

11 exp Attempted Suicide/ or exp Suicide/ or suicide.mp. 

12 (suicide or suicidal or suicides or sucidality).mp. [mp=title, abstract, heading word, table of 

contents, key concepts, original title, tests & measures]

13 11 or 12 

14 exp Risk Assessment/ or risk.mp. or exp Risk Factors/ 

15 exp Screening/ 

16 exp test validity/ 

17 screening.m_titl. 

18 screen.m_titl. 

19 assessment.m_titl. 

20 assessments.m_titl. 

21 questionnaire.m_titl. 

22 questionnaires.m_titl. 

23 instrument.m_titl. 

24 instruments.m_titl. 

25 tool.m_titl. 

26 tools.m_titl. 

27 scales.m_titl. 

28 measure.m_titl. 

29 measures.m_titl. 

30 risk.mp. 

31 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 

30 

32 13 and 31 

33 10 or 32 
48

Suicide Risk Factors and Risk Assessment Tools:

A Systematic Review Evidence-based Synthesis Program

APPENDIX B. STUDY SELECTION FORM 

VA ESP Suicide Prevention Study Selection Process: Coding

Step 1: Importing citations

• Enter database name, search date, and other details into Custom 1.

Step 2: Title/Abstract level coding

• The objective of the title/abstract review phase is to eliminate obviously irrelevant publications. Abstracts that 

lack an explicit reference to suicidal self-directed violence (e.g., suicidality, behaviors, attempts, and suicides) 

will be excluded at this phase. Reviewers will provide decision and characteristic codes and these will be recorded in Custom 3 of the EndNote library. 

� Decision codes:

 R=Retrieve

 E=Exclude

 B=Retrieve for Background

� Characteristic codes: Our first priority is retrieval of systematic reviews, especially those focusing on Veteran or military populations. Our second priority is retrieval of primary studies in Veteran or military populations. For ease of identifying these subsets of publications in the ENL, reviewers should add either or both of 

the following codes when applicable:

 SR=systematic review

 V=Veteran or military population

Step 3: Full-text level coding

• Record final decision to include study in review, and any other study characteristics of interest

� Characteristics of interest (recorded in Custom Fields):

 Population: Veteran and/or military, or non-Veteran or non-military

 Risk Article Type: Risk factors, or risk assessment

 Study Design: Systematic Review, clinical trial (randomized or nonrandomized), observational study, or

other

� Full-text exclusion codes to be entered into Custom 4:

 1=Non-English language 

 2=Ineligible country (only including US, UK, Canada, New Zealand, Australia)

 3=Ineligible outcome 

 4=Study does not evaluate risk factors or assessments

 5=Ineligible publication type (e.g., letter, editorial, publication available only as abstract, non-systematic 

review, etc.)

 6=Ineligible systematic review due to limitations in quality

 7=Nonsystematic regulatory agency analysis

 8=Risk factor articles that did not account for major potential confounders

 9=Primary articles about risk, not a Veteran or military population

• Full-text coding to be completed in the format of a label affixed to each publication in the format shown below. 

Reviewer 1 will circle relevant characteristics and inclusion decision and list an exclusion code when applicable. 

Reviewer 2 will verify Reviewer 1’s decisions and circle Agree or Disagree. All disagreements will be resolved 

using a consensus process and consensus decisions recorded. 

• Label:

Pop: Vet-Mil / Non-Vet-Mil

Risk: Risk / Assess / NA

Design: SR / CT / Obs / Other

Rev1: Include / Exclude – Code: ____

Rev2: Agree / Disagree Consensus: _____
49

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ERIA USED IN QUALITY ASSESSMENT OF SYSTEMATIC REVIEWS

Criteria Operationalization of Criteria a

rted?

nd evidence (original research) on the 

ases used, date of most recent searches, and 

The purpose of this index is to evaluate the scientific quality (i.e., adherence to scientific principles) of research overviews (review articles) published in the medical literature. It is not intended to measure literary quality, importance, relevance, originality, or other attributes of overviews.The index is for assessing overviews of primary (“original”) research on pragmatic questions regarding causation, diagnosis, prognosis, therapy, or prevention. A research overview is a survey of research. The same principles that apply to epidemiological surveys apply to overviews: a question must be clearly specified, a target population identified and accessed; appropriate information obtained from that population in an unbiased fashion; and conclusions derived, sometimes with the help of formal statistical analysis, as is done in “meta-analyses”. The fundamental difference between overviews and epidemiological studies is the unit of analysis, not the scientific issues that the questions in this index address.Since most published overviews do not include a methods section, it is difficult to answer some of the questions in the index. Base your answers, as much as possible, on information provided in the overview. If the methods that were used are reported incompletely relative to a specific question, score it as “can’t tell,” unless there is information in the overview to suggest either the criterion was or was not met.

?

ably comprehensive?

t 2 databases and looks at other sources 

hes, and queries experts).

orted?

 which studies to include in the overview 

 avoided?

any studies were identified by searches, 

opriate reasons for excluding them (usually 

xclusion criteria).

rted?

g the validity of the included studies 

iately?

eferred to in the text assessed using 

cting studies for inclusion or in analyzing the 

 assessment and did some type of analysis 

results according to quality ratings, excluded 
50

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Criteria Operationalization of Criteria a

bine studies reported?

the findings of the relevant studies (to reach 

ve analysis if there is some mention that 

ble and reasons that it could not be done, or 

ading of evidence scheme used.

For Question 8, if no attempt has been made to combine findings, and no statement is made regarding the inappropriateness of combining findings, check “No” if a summary (general) estimate is given anywhere in the abstract, the discussion, or the summary section of the paper; and if it is not reported how that estimate was derived, mark “No” even if there is a statement regarding the limitations of combining the findings of the studies reviewed. If in doubt, mark “Can’t tell”.For an overview to be scored as “Yes” in Question 9, data (not just citations) must be reported that support the main conclusions regarding the primary question(s) that the overview addresses.The score for Question 10, the overall scientific quality, should be based on your answers to the first nine questions. The following guidelines can be used to assist with deriving a summary score: If the “Can’t tell” option is used one or more times on the preceding questions, a review is likely to have minor flaws at best and it is difficult to rule out major flaws (i.e., a score of 4 or lower). If the “No” option is used on Question 2, 4, 6 or 8, the review is likely to have major flaws (i.e., a score of 3 or less, depending on the number and degree of the flaws).

ppropriately?

udies combined appropriately relative to the 

resses?

 for heterogeneity before pooling, does 

opriate sensitivity analysis, or other such 

d by the reported data?

author(s) supported by the data and/or 

c quality of the overview?

quality of this overview?

Each Question is scored as Yes, Partially/Unclear or No

Major Flaws Minor Flaws Minimal Flaws

3 4 5 6 7 

rom Oxman & Guyatt, J Clin Epidemiol. 1991;44(11):1271-8 and Furlan, Clarke, et al., Spine. 2001 Apr 1;26(7):E155-62.
51

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ERIA USED IN QUALITY ASSESSMENT OF PRIMARY STUDIES RELATED 

SK OF ENGAGING IN SUICIDAL SELF-DIRECTED VIOLENCEa

Description

f population Study describes inclusion criteria for selecting patients, demographics (at least age), and 

setting (primary care vs. hospital vs. other).

Study either reports enrolling (or attempting to enroll) a consecutive series of patients meeting inclusion criteria, or a random sample.

missing data? Was there important differential loss to follow-up or overall high loss to follow-up? 

Numbers should be given for each group.

f risk factor assessment 

cribed or referenced.

Standardized, reproducible methods of assessment and scoring must be reported or referenced.

sessment by independent 

Study describes unbiased risk factor assessment by independent assessors.

surement? Study clearly describes standardized and reproducible methods to identify/define the events 

- suicide attempt or behavior - in the entire population of eligible participants regardless of initial risk assessment.

surement by independent 

Study clearly describes unbiased methods to identify/define the events - suicide attempt or behavior - by independent assessors.

or potential confounders? Potential confounders are accounted for by a comparable control group or statistical methods 

of adjustment.

 2006 and Harris et al. 2001.9, 10
52

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ERIA USED IN QUALITY ASSESSMENT OF PRIMARY STUDIES RELATED 

SK FACTORS TO PREDICT SUICIDAL SELF-DIRECTED VIOLENCEa

Description

population Study describes inclusion criteria for selecting patients, demographics (at least age), and setting 

(primary care vs. hospital vs. other).Study either reports enrolling (or attempting to enroll) a consecutive series of patients meeting inclusion criteria, or a random sample (was any group of patients systematically excluded?)

ssing data 

Was there low overall missing data and no differences between comparison groups in missing data? Was there an adequate description of the handling of missing data? Numbers should be given for each group.

actor measurement?

Study describes reproducible and appropriate methods for measuring prognostic factors. Note the inadequate factors as applicable (e.g., depression without description of measurement method or use of inferior method such as self-report).

me measurement?

Study clearly describes reproducible and appropriate methods to identify/define the events - suicide attempt or behavior. Were methods objective or self-report?

uate (including 

ome events)?

Study has adequate participant numbers to assess differences in suicide rates based on risk factors. Studies of higher risk populations (psychiatric disorders, prior suicide attempts) may need fewer people to have adequate sample size.

tment Study performs statistical adjustment or controls for one or more potential confounders using 

acceptable statistical methods (must include 1 of the following: suicidal ideation, any mental health diagnosis, prior suicide attempt, substance abuse).

ounders adjusted for 

Count of the confounders reported in #7 (total possible = 4).

Is the population relevant to the population of interest? Describe.

 2006 and Harris et al. 2001.9, 10
53

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

LITY RATING OF SYSTEMATIC REVIEWS USING OXMAN AND GUYATT8

Comprehensive search

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall 

scientific 

quality 

(range 1-7; 

higher score 

is better)

Yes Yes Unclear - study 

design not addressed; study comparing rates among ethnic groups

Yes - used 5 criteria from their own previously published work; dual review

Yes Unclear - no 

exclusions made on the basis of quality

No - only two studies included in meta-analysis

Yes 5

Yes Yes Yes No No NA NA - no pooling Yes 3Yes No No No No Unclear Unclear No quantitative 

conclusions

2

Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes No - numbers of 

studies identified, screened, and excluded not reported

No No NA - no pooling NA - no pooling Yes 3

Yes Yes Excluded reviews, 

case series, and irrelevant studies

Yes McGrath and 

Saha method, Delphi method

Unclear if any studies were excluded because of poor quality but all included studies scored ≥6

Only 2 studies included in meta-analysis with suicide as outcome

Yes 6

Yes Yes No report of total 

number identified

Yes Yes Unclear if 

any excluded because of quality

Yes Yes 5

No No No No No Yes Yes Unclear 1Partially - no hand searching or reference lists

Yes Yes Yes Yes Yes Yes Yes 6

Yes Yes Yes Yes Unclear Unclear - not 

used in analyses

Unclear - no meta-analysis

Unclear 4

Yes Yes Yes No No NA NA - no pooling Yes 3Yes Yes 2 independent 

reviewers for abstracts but no report of decisions

No Unclear Yes Unclear Yes 5
54

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Comprehensive search

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall 

scientific 

quality 

(range 1-7; 

higher score 

is better)

Yes Yes Yes Yes - but design 

only

No Yes Yes Yes 6

Partially - no hand searching

Yes Yes Yes Yes Yes No - did not do 

meta-analysis

Unclear 5

Partially - no hand searching

Yes - but vague

Unclear No No No - narrative 

summary

Unclear Unclear 1

Yes Yes Yes Yes Partially - reports 

details of validity assessment, but no analysis based on findings

NA NA - no pooling Yes 6

No - databases only

Yes No - only reports 

number of articles reviewed at full-text level

No NA NA NA - no pooling Yes 3

Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes No - only reports 

number of articles reviewed at full-text level

No No Yes Yes Yes 4

Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes No No Yes Yes Yes 3Yes Yes Yes No - “Formal 

quality assessment rules were not applied, given the lack of consensus and evaluation tools to assess observational studies.”

No NA NA - no pooling Yes 3

Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes Yes Yes Yes 7Yes Yes Yes Yes Yes No - no mention NA - no pooling Yes 6Yes Yes Yes No (same as 

Mironova 2011)93

No NA NA - no pooling Yes 3

Yes Yes Yes Yes No - design only No No No 2
55

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Comprehensive search

Inclusion criteria reported

Selection bias avoided

Validity criteria reported

Validity assessed appropriately

Methods used to combine studies reported

Findings combined appropriately

Conclusions supported by data

Overall 

scientific 

quality 

(range 1-7; 

higher score 

is better)

Yes No Unclear Yes Yes - but weak 

criteria

NA NA Unclear 3

Yes Yes Yes No No No No Yes 3Yes Yes Yes Yes Yes No - no mention Yes Yes 6Yes Yes Yes Yes Yes Yes Yes Yes 7No - databases only

Yes Yes Yes Yes Yes Yes Yes 5

Yes Yes Yes Yes Yes Yes Yes Yes 7
56

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION FOR PRIMARY STUDIES OBTAINED FROM GOOD 

ATIC REVIEWSa

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

acy and 

cidal 

tempt 

 for 

tric MDD, 

D anxiety 

PubMed (1988 to July 2006), Relevant US and British regulatory agency reports, Published abstracts of important scientific meetings (1998-2006), Clinical trial registries

− Berard 2006− Emslie 2006− Emslie 2007− March 2007− Rynn 2007

All non-Veteran, nonmilitary populations

Studies before 2005: 

− Birmaher 2003− Emslie 1997− Emslie 2002− Geller 2001− Geller 2004 − Keller 2001− Liebowitz 2002− March 1998− March 2004− POTS Study Team 2004− Riddle 2001− RUPP Anxiety Study Group 2001− Rynn 2001− Simeon 1990− Wagner 2003− Wagner 2004− Wagner 2004 (Paroxetine) 

Does not report suicide separately from other outcomes:

− von Knorring 2006− Wagner 2006

Ineligible countries:− Berard 2006 (Belgium, Italy, Spain, 

Netherlands, South Africa, United Arab Emirates, Argentina, Mexico)

Placebo-controlled trials of antidepressants in children and adolescents (age <19 years) with MDD, OCD, and non-OCD anxiety disorders
57

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

bis

January 1990 to January 2008 No eligible studies Studies before 2005: − Beautrais 1999

− Fergusson 2002− Kung 2003− Wilcox 2004

Not about suicide:

− Aldington 2008− Andreasson 1990 (Sweden)− Bedard 2007− Blows 2005− Chacko 2006− Drummer 2004− Efird 2004− Hashibe 2006− Laumon 2005 (France)− Llewellyn 2004− Rosenblatt 2004− Sasco 2002− Sidney 1997 − Zhang 1999

Studies with a focus on mortality associated with cannabis use or dependence. General population studies between January 1990 and January 2008 were of most interest.

ence for 

ween 

lifetime 

iatric 

MEDLINE, EMBASE, CINAHL, Current Contents, PsycINFO, ACP Journal Club, CCTR, CDSR, and DARE between January 1980 and December 2008

− Brezo 2008− Fergusson 2008− Pearce 2008

All studies reviewed and excluded according to specific inclusion/exclusion criteria for risk report

Studies before 2005:

− Brown 1999− De Bellis 1994− Dinwiddle 2000− Ernst 1993− Fergusson 2000− Florentine 1999− Garnefski 1992− Harvey 1994− Plunkett 2001− Rimsza 1988

Ineligible country:

− Chowdry 2008 (India)

Longitudinal observational studies that compared individuals who had a history of sexual abuse with a control group
58

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

 risk 

and 

ehavior in 

ar disorder

MEDLINE (1966 to December 2003), EMBASE (1980 to December 2003), Biological Abstracts (1985 to December 2003)

No eligible studies Studies before 2005:

− Angst 2002, Angst and Preisig 

1995, Angst 1986

− Black 1988, Black 1987− Brown 2000− Cassano 1992, Perugi 1988 (Italy)− Coryell 2003, Coryell 2001, Coryell 

1992

− Coryell 2003, Coryell 2001, Coryell 

1992, Coryell 1989, Coryell 1987, Endicott 1985

− Dalton 2003− Dunner 1976− Feinman and Dunner 1996− Goldring and Fieve 1984− Grunebaum 2001, Oquendo 2000− Hantouche 2003 (France)− Hoyer 2002 (Denmark)− King 2001− Lenzi 1999 (Italy)− Leverich 2003, Leverich 2002a, 

Leverich 2002b, Dittmann 2002, Suppes 2001, McElroy 2001 (various including the Netherlands and Germany)

− Linkowski 1985 (Belgium)− Lopez 2001 (Spain)− MacKinnon 2003 − Maj 1994 (Italy)− Nordstrom 1995 (Sweden)− Osby 2001 (Sweden)− Perugi 1997, Perugi 2000 (Italy)− Potash 2000 − Serretti 2002a, Serretti 2002b 

(Italy)

− Stallone 1980− Steblaj 1999 (Slovenia)− Tasi 1999 (Taiwan)− Tasuang 1978− Tondo 1999 (Italy)− Tsai 2002 (Taiwan)− Ucok 1998 (Turkey)− Vieta 1997, Vieta 2001, Vieta 2000, 

Vieta 1999 (Spain)

− Wu 1993 − Young 1993

Investigations of patients with bipolar disorder in which suicide (13 studies) or attempted suicide (23 studies) was reported as an outcome
59

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

stion: 

me of 

c inpatient 

dmitted 

ared 

d 

Medline (up to March 2006), German PSYNDEXplus (1977 to December 2006)

No eligible studies Studies before 2005:

− Gale 1980− Read 1993− Roy 1995 

Studies that a) assessed outcomes of involuntary admission and subsequent treatment and outcomes of voluntary admission and subsequent treatment; b) made a statistical comparison between both groups or reported each group’s results separately so that a statistical comparison could be computed; c) conducted on general psychiatric wards; d) used either admissions or patients as unit of assessment; e) published in 1980 or later; f) in English or German language; g) reported data on included outcomes

er 

bisexual 

er risk of 

ubstance 

uicidal 

erate self

exual 

ntify this 

Medline, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Knowledge, Applied Social Sciences Index and Abstracts, International Bibliography of the Social Sciences, Sociological Abstracts, the Campbell Collaboration and grey literature databases (January 1966 to April 2005)

No eligible studies Studies before 2005:

− Bagley 1997− Cochran 2000− Faulkner 1988− Fergusson 1999− Gilman 2001− Mathy 2002− Matthews 2002− Remafedi 1988− Robin 2002− Russell 2001− Skegg 2003

Papers that provided valid definition of sexual orientation and mental health outcomes
60

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

ength of 

tween 

ric in

graphic, 

matic, 

atment 

Medline, PsycINFO, Embase, SINAHL

− Hunt 2007 Non-Veteran, non-military population

Studies before 2005:− Beisser 1961− Gaertner 2002− Gale 1980− Havaki-Kontaxaki 1994 (Greece)− King 2001− Klinkisch 2003 (Germany)− Krupinski 1998 (Germany)− Modestin 1988 (Switzerland)− Modestin 1989 (Switzerland)− Modestin 1992 (Switzerland)− Modestin 1998 (Switzerland)− Powel 2000− Read 1993− Roy 1995− Schlosser 1982− Schlosser 1998− Shah 1997− Sharma 1998− Spiegl 2002 (Germany)− Steblaj 1999 (Slovenia)− Taiminen 1993 (Finland)− Walkfersdorf 2003 (Germany)− Wolfersdorf 2003 (Germany)Ineligible countries:− Dong 2005 (Hong Kong, China)− Li 2008 (China)− Neuner 2008 (Germany)− Neuner 2010 (Germany)

1) Reported characteristics of a sample of psychiatric in-patients who had died by suicide either as an inpatient or while on approved or unapproved leave from a mental health facility; 2) Reported characteristics of a control group of psychiatric in-patients who did not commit suicide and who were in-patients in the same or similar mental health facilities at close to the same time as the suicide cases; and 3) Casecontrol, nested case-control or cohort control design

st 

 evidence 

 sexual 

gy of 

uicidal 

AMED, Cochrane Reviews, EBSCO, ERIC, MEDLINE, PsycINFO, ScienceDirect (January 1966 to December 2008)

No eligible studies Studies before 2005:

− Neumann 1996 (review)− Paolucci 2001 (review)− Rind 1998 (review)Not about suicide:− Klonsky 2008 (non-suicidal selfinjury, review)

1) Appeared in peer-reviewed journals; 2) published in full; 3) were critical reviews of the literature; 4) were not dissertation papers, editorials, letters, conference proceedings, books, and book chapters; 5) reviewed studies sampling human subjects; 6) investigated medical, neurobiological, psychological, behavioral, sexual, or other health problems following childhood sexual abuse; 7) had primary and sufficient data derived from longitudinal, cross-sectional, case-control, or cohort studies. Only reviews that examined suicidal and non-suicidal forms of self-injury following sexual abuse were included.
61

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

ematic 

enefits 

ening 

epression 

etting, 

ression 

rms of 

ent with 

dications

MEDLINE, CCRCT, CDSR, DARE, PsycINFO (1998 to 2007)

− Martinez 2005− Simon 2006All non-Veteran, nonmilitary populations

Studies before 2005:− Fergusson 2005− Jick 1995− Khan 2003− Storosum 2001Regulatory reviews/analyses of selected drug company data:− Briefing document 2006− Committee on Safety of Medicines 

2009

− Gunnell 2005− Hammad 2006− Levenson 2006− Saperia 2006− Stone 2006

For harms, focused on already-synthesized evidence, supplemented by large observational studies

dity of 

ents to 

suicide avior in 

11 databases between January 1980 and June 2001 and between January 1980 and November 2004

No eligible studies Studies before 2005:

− Arbola-Florez 1988− Arbola-Florez 1989− Daigle 1999− Earthrowl 2002− Wichmann 2000Not about suicide:− Perry 2005 (did not assess suicide 

as an outcome)

Papers that included an assessment of risk for suicide or self-harm behavior using a screening tool

 

ccess 

ide has 

thin 

MEDLINE (1950 to May 2008), EMBASE (1980 to May 2008), AMED (1982 to May 2008), BNI (1985 to May 2008), CINAHL (1982 to May 2008), PsycINFO (1806 to May 2008), SCOPUS (to May 2008), Web of Science (1945 to May 2008) and IBSS (1951 to May 2008)

− Jones-Fairnie 2008− Mellanby 2005− Stark 2006All studies reviewed and excluded according to specific inclusion/exclusion criteria for risk report

Studies before 2005:− Blair 1980− Blair 1982− Botts 1996− Charlton 1993− Charlton 1995− Fasal 1966− Jeyaretnam 2000− Kelly 1998− Kinlen 1983− Lange 1992− Mammerickx 1985− Milham 2001− Miller 1995− Schnurrenberger 1997Ineligible countries− Agerbo 2007 (Denmark)− Hem 2005 (Norway)

Included information on suicide, mental illness, stress and other related issues, in relation to veterinary surgeons or studies of veterinary medicine
62

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ematic 

Time period and databases searched in systematic review

Potentially eligible studies for the current risk report

Excluded studies for the current risk report

Eligibility criteria in systematic review

sk 

 

ness of 

ments and 

reventing 

ehavior 

on

MEDLINE, EMBASE, AMED, PsycINFO (January 1997 to February 2009)

− Barbui 2009− Bridge 2007− Brown 2005− Carter 2005 − Carter 2007− Cooper 2005− Donald 2006− Evans 2005− Fergusson 2005− Hawton 2005− Mann 2005− McMain 2007− McMillan 2007− Nock 2006Bridge 2007 and Hawton 2005 (both systematic reviews) are included in current risk report. All other studies were reviewed and excluded according to specific inclusion/exclusion criteria for risk report.

Studies before 2005:− Agerbo 2002− Arsenault-Lapierre 2004− Beck 1999− Cedereke 2002− Evans 2004− Guthrie 2001− Harris 1997− Hawton 2000− Horowitz 2001− Huey 2004− Marshall 2001− Motto 2001− Nimeus 2000− Prinstein 2001− Rotheram-Borus 2000− van der Sande 1997− van der Sande 1997Ineligible countries:− Qin 2005 (Denmark)− Tidemalm 2008 (Sweden)− Vaiva 2006 (France)Regulatory reviews:− Gunnell 2005

English language, human, suicide-related outcome, sample size >6, no duplication, emergency department or other acute care setting

cy, 

afety 

atment 

e bipolar 

Medline (1950 to January 2008), Embase (1980 to 2008), PsycINFO (1967 to January 2008), CINAHL (1982 to January 2008), CCRCT and CDSR (to 2008)

− Calabrese 2005Non-Veteran, non-military population

Studies before 2005:− Calabrese 1999− Tohen 2003Not about suicide:− Davis 2005− Ghaemi 2007 (suicidal ideation 

only)

− Thase 2006

Randomized controlled trials of mood stabilizer therapy

th effects 

care 

D among 

scents 

s

DARE, CDSR, Medline, PsycINFO (1998 to May 2006)

− Olfson 2006Non-Veteran, non-military population

Studies before 2005:− Martin 2004− Valuck 2004Ineligible countries:− Sondergard 2006 (Denmark)Regulatory review:− Hammad 2006− Kaizar 2006

Systematic reviews, meta-analyses, and evidence-based guidelines on depression screening, treatment, or associated harms in children and adolescents. For harms, used evidence from randomized controlled trials preferentially, then well-designed nonrandomized controlled trials and high-quality observational studies with sample sizes of at least 1,000.

ws were defined as scoring 6 or higher (on a 7-point scale) according to the Oxman and Guyatt 1991 criteria.8
63

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

MARY OF SYSTEMATIC REVIEW RESULTS RELATED TO ASSESSING RISK 

 GAYNES ET AL., MANN ET AL., AND NICE REVIEWS4-6

aynes 20045 Mann 20054 NICE 20116

66-October 2002 1966-June 2005 Up to January 2011

pulation of interest was primary care patients with 

eviously unidentified suicide risk.

luded randomized controlled trials were conducted in h-risk groups as identified by a deliberate self-harm sode, diagnosis of borderline personality disorder, or 

mission to a psychiatric unit.

Not specified Adults, children, and young people with previous self-harm 

behavior

empted suicide and death by suicide Attempted suicide and death by suicide Primary outcome was repetition of self-harm; also included 

suicide outcomes.

r screening, primary care settings

 exclusions based on country

Included settings not specified. No exclusions based on country

No exclusions by country

r screening, required comparison with a gold standard.cluded clinical trials targeting patients with chronic 

ychotic illnesses.

For risk assessment, prospective cohort studies

ent tools

 studies address the overarching question of whether 

reening for suicide risk in primary care patients 

proves outcomes.

Screening for depression in localized geographic areas results in more treatment of depression and lower suicide rates.Further consideration needs to be given to determining the cost-effectiveness of screening general populations vs identified at-risk populations for reducing suicide rates, the predictive validity and reliability of specific screening instruments, and the appropriateness of standard suicide screening instruments across different cultures.

Tools to predict suicide:6 studies (all cohort designs) looked at predicting a fatal outcome such as suicide in people who have self-harmed.Limitations are high false positive rates in scales with the highest sensitivity, use of small samples of mainly people with suicidal ideation, and long follow-up periods to increase prevalence.Because of these limitations, the use of scales to predict the risk of suicide cannot be recommended in clinical practice.Tools to predict repetition of self-harm:The strongest evidence was from prospective cohort studies, conducted mostly in participants who presented to an emergency department following self-harm. All the scales had relatively low positive predictive values ranging from 12% to 60%. This means that many individuals were wrongly identified as people who would repeat self-harm, thus limiting the clinical utility of these scales and possibly resulting in unnecessary intervention in some individuals. 
64

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

 ABSTRACTION FOR PRIMARY STUDIES RELATED TO ASSESSING RISK 

SUICIDAL SELF-DIRECTED VIOLENCE AMONG MILITARY AND VETERAN 

Study Design Outcome

Risk Factors/Covariates Included in Assessment Calculation Results

Validation of Assessment Tool

Appropriate for Primary Care Settings

o 

at 

 

Prospective cohort

Suicide and suicidal behavior

Mental health diagnoses, age, gender, level of education, age at TBI, race/ethnicity, years since TBI, TBI severity, history of substance abuse, Negative Impression scale

Hierarchical multiple regression results: SPI and Suicidal Ideation Scale subscales from the PAI incrementally contributed to prediction of post-PAI suicidal behavior beyond pre-PAI suicidal behavior alone; only SPI remained a significant predictor when other risk factors were included in the model. SPI cutoff score of ≥15, sensitivity was 0.909 and specificity was 0.951, with a false positive rate of 5%. 

PAI validity information cited No; PAI is over 100 items and 

requires a computer program to score. Recommended use is by psychologists as part of an assessment.

d 

 

.  

am 

d 

Prospective cohort

Suicide attempt

Suicide attempt in the past four months and ever, BDI score, substance use, demographics, combat history

The single best predictor of a suicide attempt after discharge was having attempted suicide in the 4 months prior to intake (χ2[df1,296]=15.03, 

p<0.001). Among those who had not attempted suicide shortly before intake, the next optimal predictor was patients’ BDI scores (BDI ≥46 vs <46): χ2 (df 1252)=10.54, p<0.001. 

Sensitivity for this model calculated at 0.63, with a specificity of 0.80. In a replication sample, the model resulted in sensitivity of 0.11 and specificity of 0.84.

BDI validity information cited. Replication sample results reported in this paper

Yes; BDI is frequently used in primary care contexts, is brief, and easy to administer and score.

s.

Prospective cohort

Suicide and suicidal behavior

Depression and disability/functioning

The ASQ increased odds of prediction of future suicidal behavior by 2.4 in a logistic regression model adjusting for sex, substance abuse, and severity of depression. Using a cutoff of ≥3, the ASQ resulted in sensitivity of 0.60 and specificity of 0.74.

Article cites pilot testing of the measure in a sample of 254, and reports reliability of 0.77 and a single factor structure for the current sample

Yes; 7-item questionnaire.
65

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Study Design Outcome

Risk Factors/Covariates Included in Assessment Calculation Results

Validation of Assessment Tool

Appropriate for Primary Care Settings

y 

.

Retrospective cohort

Suicide Gender, race, marital 

status

IPS total score associated with 1.27 increased odds of suicide when comparing groups after adjustment for age, gender, race, and marital status.

Measure responses were self-report (comparison group) vs estimated by assessors (sample who died by suicide), therefore validity and comparability of surveys is questionable given the sample. IPS included as appendix; other surveys were cited and reliability information reported.

IPS is 34 items; Acquired Capability to Suicide Scale is 20 items; Interpersonal Needs Questionnaire is 25 items. All too long for brief screening in a primary care setting and more appropriately used as part of an in-depth psychological assessment.

nt 

Crosssectional Suicide attempt Age, education, gender, race, marital status, 

employment status, psychiatric diagnoses, suicide history

Decision tree provided comparing rates of suicide attempts for patients grouped according to suicide attempt/ideation history, recent alcohol abuse, recent cocaine abuse, violent behavior, hallucinations, and employment status, as these variables were the significant predictors of suicide attempt in the population studied.

ASI validity information cited. ASI is a structured, clinical 

interview designed to be conducted as part of an intake for a substance abuse treatment program. The clinical interview is lengthy, must be completed by a provider trained in substance abuse treatment, and is not appropriate for brief screening or primary care settings.
66

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

 OF BIAS RATINGS FOR PRIMARY STUDIES RELATED TO ASSESSING 

G IN SUICIDAL SELF-DIRECTED VIOLENCE AMONG MILITARY AND 

ATIONSa

sed 

3. Low loss to followup/ missing data?

4a. Standardized method of risk factor assessment and scoring clearly described or referenced

4b. Unbiased risk factor assessment by independent assessors?

5a. Adequate outcome measurement?

5b. Unbiased outcome measurement by independent assessors?

6. Adequate accounting for potential confounders? 

Overall assessment of potential for bias(Low/Unclear/High)

oes 

 

e 

d 

ne ents 

on 

Unclear - included only patients with sufficient information in the medical record to confirm TBI and assess injury severity

Unclear - all risk factors were assessed via chart review, though the PAI scoring and reporting is likely standardized even in patients’ charts

Unclear – no description of assessor independence or blinding

No - chart review was used as the reference standard for post-PAI suicidal behavior

Unclear - no description of assessor independence or blinding

Yes - though study design was retrospective chart review, all PAI assessments occurred prospectively in relation to suicide-related events, and therefore all potential participants were prospectively assessed as part of one cohort

High

e 

s

Unclear - missing data not reported, but used information typically collected at the outset of most treatment programs

Unclear - questionnaires at intake, but the questionnaires themselves were not described or cited. Did not report how patients’ war zone trauma exposure was collected. Treatment-related variables are likely to be most accurate for readmissions to this program, less so for admissions from other programs.

Unclear - no description of assessor independence or blinding

Unclear - suicide attempts assessed by the Northeast Program Evaluation Center survey, which is adequately cited, though suicide attempt items are reportedly added to the survey and not standard items

Unclear - no description of assessor independence or blinding

Yes - prospective assessment of a single cohort

High

o 

 of 

e 

Yes - 240/283 patients completed both assessments

Yes - standardized procedures and assessment tools described

Yes - states that research assistant assessors were independent

Yes - standardized procedures and assessment tools described. All patients were assessed at followup regardless of assessed risk.

Unclear - no description of assessor independence or blinding for outcome assessment

Yes - prospective study design of a single population

Unclear
67

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

sed 

3. Low loss to followup/ missing data?

4a. Standardized method of risk factor assessment and scoring clearly described or referenced

4b. Unbiased risk factor assessment by independent assessors?

5a. Adequate outcome measurement?

5b. Unbiased outcome measurement by independent assessors?

6. Adequate accounting for potential confounders? 

Overall assessment of potential for bias(Low/Unclear/High)

ates 

udy 

m 

 

 for 

n 

Yes - 5% missing data from suicide cases (3/60) and 3% from controls (4/122)

Unclear - psychological autopsy format used to assess mental state and situation based on review of records containing primarily thirdperson reports. However, used a standardized coding template (Suicide Death Investigation Template) developed by the authors and administered by trained coders that had high inter-rater reliability. Self-report measures used for living comparison sample.

Unclear - no description of assessor independence or blinding

Yes - included deaths by suicide from closed files (no longer under investigation)

Unclear - no description of assessor independence or blinding

No - groups differed with respect to race, marital status, and gender but appropriate statistical adjustments were performed. However, groups likely differed on multiple other un-assessed criteria due to the retrospective design of the study.

High

t  not 

Yes - only 2% missing data (95/5671) from Figure 1

Yes - addiction and suicidal ideation: assessed by face-to-face interview with a validated questionnaire (ASI). Psychiatric diagnoses: accessed nationwide VA database to obtain diagnoses made by experienced clinicians during usual care.

Unclear - no description of assessor independence or blinding

Yes - assessed during face-toface interview with validated questionnaire (ASI)

Unclear - no description of assessor independence or blinding

Yes - all data collected at a single time point from a single population

Unclear

m Hayden et al. 2006 and Harris et al. 2001.9, 10
68

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

A ABSTRACTION FOR PRIMARY STUDIES OF FACTORS TO PREDICT 

RECTED VIOLENCE IN MILITARY AND VETERAN POPULATIONS

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

8441 Canadian 

Community Health Survey Cycle 1.2 - CanadianForces Supplement (CCHS-CFS)

Canadian military personnel, active military within past 6 months, ages 16-54: 5155 regular force members and 3286 reserve force members

Suicide cases vs non-suicide cases

Exposures to 28 traumatic events during their lifetime, socio-demographics (age, marital status, income, education, rank, type of service), and mental disorders

Traumatic events - 28 items from the PTSD section of the Composite International Diagnostic Interview (CIDI).Sociodemographic variables.Mental disorders - survey based on responses to questions from the CIDI.Alcohol use from the CIDI short form.Lifetime suicide attempts: ever attempted suicide or tried to take own life.

Not applicable (N/A)

All analyses stratified by sex. 3 models: 1) unadjusted; 2) adjusted for sociodemographic factors; and 3) adjusted for sociodemographic factors, the presence of any lifetime mental diagnosis, and a comorbidity variable (3 or more mental disorders). Used p<0.01 in order to account for multiple comparisons.

7 categories: 5 groups of trauma (deployment related, accident or other unexpected, sexual trauma, other interpersonal, civilian in war zone or refugee) and “event happened to other,” “other trauma” - 28 individual variables.Males (OR, 95% CI) for suicide attempt):Having purposely injured or killed: 2.69 (1.09-6.61)Toxic chemical exposure: 1.86 (1.09-3.18)Life-threatening illness: 2.25 (1.04-4.89)Civilian in religious terror: 2.38 (1.00-5.72)Females (OR, 95% CI) for suicide attempt::Man-made disaster: 2.16 (1.02-4.55)Child abuse: 2.34 (1.15-4.75)Abused by other person: 3.08 (1.04-9.14)Witness to domestic violence: 1.73 (1.00-3.01)Stalked: 1.86 (1.09-3.19)

36,984 total; 8441 military who completed the CCHSCFS

CCHS-CFS Nationally 

representative Canadian sample, age 15 or older, surveyed between 2001-2002

Compared military to civilian; results presented for military personnel separately

Demographics (education, marital status, income), military rank, regular/reserve service, environment, number of deployments, combat exposure

Survey N/A Logistic regression Adjusted OR (95% CI) for suicide attempt 

in past year: Depressive episode: 80.73 (24.78-262.96)Panic attack: Not significant (NS)Social phobia: 11.11 (3.65, 33.80)Alcohol use: NSAlcohol dependence: 12.51 94.13-37.90)Generalized anxiety disorder: 44.80 (16.12-124.49)PTSD: 26.76 (9.37-76.48)Unadjusted OR (95% CI) for suicide attempt in past year: More senior rank protective (vs junior rank): 0.71 (0.24-3.15) for officer, 0.93 (0.28-2.08) for seniorReserve (vs regular): 0.28 (0.08-0.97) More deployments (vs 0): 0.10 (0.01-2.16) for one, 0.61 (0.11-3.41) for two, 0.69 (0.06-8.53) for 3 or moreHigher odds of suicide attempts for communications/air/sea vs land: 1.23 (0.49-3.13)Combat exposure: 1.83 (0.45-7.53)
69

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

 

1873 suicides and 5619 controls

Total Army Injury and Health Outcomes Database, included army casualty (death) files, inpatient hospital data from the Army Individual Patient Data system and personnel records from the Defense Manpower Data Center

Suicides between 1/1/1990 and 12/31/2003

Suicides compared to controls (controls selected on a 3:1 ratio to cases using the incident suicide date to identify eligible controls based on active-duty status at the time of the suicide)

Demographics, hospitalization experiences (ICD), mental health related hospitalizations, alcohol related diagnoses and non-alcohol related mental health disorders. Service grade, officer status (warrant, commissions)

ICD-9 codes N/A Logistic 

regression: 1) all hypothesized risk factors included; 2) interaction terms for injury, alcohol and mental disorder hospitalizations with each of the other background variables in the model

Adjusted analyses (adjusted OR, 95% CI) for suicide:Protective factors include: time in service (0.97, 0.95-0.99); black vs white (0.64, 0.56-0.74); college education vs none (0.69, 0.55-0.87); warrant office status (0.48, 0.25-0.94); and commissioned officer status (0.66, 0.47-0.93).Risk factors include: male gender (2.73, 2.12-3.55); prior injury hospitalization (2.04, 1.64-2.54); prior alcohol hospitalization (3.41, 2.32-4.99); and mental disorder hospitalization (6.62, 4.77-9.20).Significant interactions for: alcohol and mental disorder and injury hospitalization (0.16, 0.15-0.53); mental disorder and injury (65.55, 15.27-281.45); mental disorder, alcohol and injury (5.99, 1.45-24.80); and injury and mental disorder (16.07, 3.75-68.77).

Case control study with 81 cases and 160 matched controls (92 cases had only 1 control)

Cases of suicide death/suicide attempt were identified between October 2004 and February 2006

Patients who received care from the VAMC and had an EMR note documenting a suicide attempt.Archival data from a large western VAMC. Where possible, two possible patients per case were randomly selected from 3,239 potential patients (chart review to confirm absence of suicide attempt or death).

Controls matched for age and gender, chart review confirmed no suicide in the control group. In two cases only 1 control could be identified vs 2.

PTSD, TBI, neurologic disease

Key word search of the chart

N/A Conditional 

logistic regression, controlling for age and gender 

Univariate analyses: TBI and neurologic conditions were not significantly associated with suicide attempt/death (OR 1.03; 95% CI, 0.57-1.86 for TBI and OR 0.38; 95% CI, 0.08-1.80 for neurologic diseases). PTSD was associated with suicide attempt (OR 2.79; 95% CI, 1.53-5.07).In the model that included both PTSD and TBI, TBI was NS (OR 0.87; 95% CI, 0.47-1.61) but PTSD remained significant (OR 2.85; 95% CI, 1.55-5.22).

49,626 with TBI plus a 5% random sample of patients without TBI (n=389,053)

Individuals who received care within the VHA between 2001-2006

All patients with TBI (n=49,626) plus a 5% random sample of patients without TBI (n=389,053). Of those with TBI, 105 died by suicide.

Those with TBI compared to those without TBI

Substance abuse, bipolar disorder I/II, MDD, other depression, other anxiety, PTSD, schizophrenia/ schizoaffective disorder, age, gender

TBI identified by ICD-9 codes, according to most severe diagnosis. Discharge diagnoses that included epilepsy were excluded.

N/A Models adjusted 

for demographic and psychiatric covariates

Veterans with TBI were 1.55 (95% CI, 1.24-1.92) times more likely to die by suicide than those without a history of TBI, after controlling for psychiatric comorbidities.Any TBI adjusted HR: 1.55 (95% CI, 1.24-1.92)Concussion/fracture HR: 1.98 (95% CI, 1.39-2.82)Cerebral contusion/traumatic intracranial hemorrhage: HR 1.34 (95% CI, 1.09-1.64)
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

656 (465 admitted for suicidal thoughts and 191 for suicidal behaviors)

Random sample of EMRs from patients admitted to large US Army hospital for suicide-related thoughts or behaviors from 2001-2006

Demographics not reported separately for the suicidal behaviors group. Overall 36% women, 61% white, 37% married. Men were more likely to have high school or equivalent as highest educational level, have military rank of E4-6, and have a diagnosis of adjustment disorder. Women were more likely to have unknown educational attainment, be black, and have no military rank (retired or dependent).

Men vs women

Childhood trauma (including sexual abuse, physical abuse, neglect, domestic violence, unspecified trauma), adult trauma (including sexual assault, physical assault, emotional and psychological abuse, military combat, pregnancy loss, unspecified trauma), and number of types of trauma

Chart review N/A Regression 

analyses. 2 sets: Set 1) adjusted for age, race, education, income, military rank, marital status, MDD, dysthymic disorder, bipolar disorder, PTSD, substance or alcohol abuse/use disorder, adjustment disorder and ≥3 lifetimes psychiatric disorders; Set 2) all the above plus other trauma types

For those admitted with suicide-related behaviors, there were no differences between men and women after adjustment for all types of trauma (Set 2). 

121,933 individuals; 481 suicides within 1 year of discharge

All patients discharged with a diagnosis of major affective disorder, bipolar disorder, PTSD, or schizophrenia from psychiatric inpatient units in the VA system between 1/1/1994 to 12/31/1998

94% male, 68% white, 44% previously married, 52% not service connected. 25% with alcoholism, 11% with substance abuse, 40% with schizophrenia, 19% with bipolar disorder, 27% with depression, 29% with PTSD.

Suicides vs non-suicides among all discharges from VA inpatient psychiatric unit.

Administrative data available from the patient treatment file: age, race, marital status, service-connected disability status, year of inpatient discharge, type of discharge (community or institution), distance from home to nearest VAMC, and psychiatric diagnosis.Six variables about care delivery: length of stay, readmission, total number of inpatient days in the 6 months after discharge, whether patient had an outpatient visit in 6 months after discharge, and number of 2-month periods in the 6 months following discharge in which the patient had 2 outpatient visits for primary discharge diagnosis. Facility-level variables and social environment variables (community level).

Individual risk factors: from the patient treatment fileDelivery-of -care variables: from the patient treatment file and the outpatient care file (database of all VA outpatient care) Facility-level variables: source not reported.Social environment variables: statewide adjusted suicide rates from the Centers for Disease Control and Prevention mortality reports; minority population from Census Bureau.

12 months following discharge

Calculated suicide rate for each facility. Expected mortality rates were calculated using multivariate logistic regression adjusting for age, gender, race, disability, distance to the VAMC, year of discharge, diagnosis and discharge to the community.Individual variables assessed using Poisson regression.

Quality of care measures associated with suicide mortality among patients discharged from VA inpatient psychiatric programs.(Rate Ratio, p-value):Length of stay:<7 days: 1.41, p<0.04≥7-14 days: 1.33, p<0.03; ≥14-30 days: 1.11, p=0.048Time to readmission:14 days: 0.81 , p=0.2630 days: 0.79, =0.13180 days: 0.55, p=0.0001Inpatient days in 6 months: 1.01, p=0.0001Outpatient visit within 30 days: 1.04, p=0.75Outpatient visits in 6 months: 1.00, p=0.37Continuity of care (reference 3):0: 1.06, p=0.841: 1.59, p<0.032: 1.01, p=0.97
71

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

 

620 in total sample; 409 in the development cohort and 221 in the validation cohort

Intake surveys and clinical diagnostic interviews

630 male Veterans with a primary PTSD diagnosis who consecutively entered the residential treatment program for PTSD at the Palo Alto VA between July 1994 and December 2000. Patients referred to the program by medical and mental health staff in the Pacific Northwest.Mean age 50 (SD 4.55, range 256-76). 60% Caucasian, 13% Hispanic, 90% Vietnam era Veterans, 86% had served in combat. 72% had a history of incarceration.

Validation cohort was 2/3 of the overall sample (n=221)

Suicide attempt in past 4 months and ever, BDI score, substance use, demographics, combat history

Variables obtained from intake questionnaires: age, ethnicity, education, marital status, history of incarceration. Suicide attempts assessed with survey: 1) in lifetime, and 2) in last 4 months.Structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSMIV), including alcohol, cannabis, and hard drugs (cocaine, amphetamine, opioid dependence)

4 months Sensitivity 

and specificity calculated in the replication sample. Used receiver operating characteristic curves to classify people as high/low risk.

“The single best predictor of a suicide attempt after discharge was having attempted suicide in the 4 months prior to intake (χ2[df1,296]=15.03, p<0.001). Among 

those who had not attempted suicide shortly before intake, the next optimal predictor was patients’ BDI scores (BDI ≥46 vs <46): χ2(df1252)=10.54, p<0.001. Sensitivity 

for this model calculated at 0.63, with a specificity of 0.80.”

 

8807 Cohort of 13,870 

patients who received the ASI within 2 weeks of treatment entry into 1 of 149 non-methadone psychosocial facilities in the US; of these 64% provided follow-up data on the ASI an average of 13 months later and are included in the analysis. Additional follow-up data were derived from interviews and self-report assessments.

Mean age: 47 years (SD 9.6).Mean years of education: 13 (SD 2)96% male59% Caucasian; 32% African American; 5% Hispanic/Latino; 4% other race/ethnicity.21% married38% reported fulltime employment

Suicides vs non-suicides in this cohort

Individual items on the ASI as candidate risk factors.

Baseline: ASIFollow-up: ASI plus interview Treatment factors included: 1) number of days of contact with a substance use disorder treatment provider, and 2) number of days of contact with a psychiatric provider

1 year MacArthur 

Model – a series of mixed-model logistic regression analyses including main effects of each pair of candidate risk factors and their interaction

314 of 8807 patients (3.6%) reported a suicide attempt within the 30 days prior to their follow-up assessment.33 items from baseline and 1 treatment factor identified as significant in univariate analyses.OUTCOME: suicide attempt approximately 1 year after entering substance use disorder treatment (assessed as attempt within 30 days prior to assessment). Risk factors:Elevated suicidal/psychiatric symptoms (value=0.73, t-value=10.62, p=0.001); alcohol problems (value=0.02, t-value=3.70, p=0.001); cocaine-adjusted life years (value=0.02, t-value=4.14, p=0.001) Protective factors: Criminal justice system involvement (value=-0.60, t-value=3.60, p=0.001); substance use disorder treatment participation (number of days): (value=-0.08, t-value=5.36, p=0.001)
72

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

887,859 VA patients treated for depression (diagnosis of depression and treatment with antidepressant, or diagnosis of depression during two separate visits) between April 1, 1999 and September 30, 2004.1892 suicides (ICD-9 and NDI).Of 887,859 patients, 589,825 randomly selected for primary/development sample and 298,034 selected for the replication sample.

VA’s National Registry for Depression (NARDEP) linked to the NDI, April 1, 1999 to September 30, 2004. NDI queries were submitted for all those with date of death in the study period according to VA Beneficiary Identification and Records Locator System; also initiated NDI searches for patients who did not use VA services in the year following the study period even if there was no date of death for these patients in VA data system. 

Primary cohort (n=589,825):Age: 58.62 years (SD 14.38) 91.9% maleRace/ethnicity: 76.4% White; 12.4% Black; 2.2% Other; 9.0% Unknown; 4.7% Hispanic.Substance use: 22.1%PTSD: 22.1%Inpatient psychiatric stay in past 12 months: 3.6%Service connection: 31.6%No significant difference between primary and secondary cohorts

Suicide vs non-suicde

Derived from patient records:age, race, sex, substance use disorder diagnosis, diagnosis of PTSD, prior VA hospitalization for any psychiatric diagnosis in the year prior to cohort entry, service connection, and baseline medical comorbidity (sum of all conditions in the past year included in the Charlson Comorbidity Index)

Derived from patient records, not further described

Study period was April 1, 1999 through September 30, 2004. Assessment of risk factors could have been done at any time. Suicide deaths were assessed during the study period and in the year following the study period.

Bayesian Dirichlet Equivalent methods for identification of the strongest predictor - data mining process to examine possible higher-order relationships between predictors

Overall suicide 89.55/100,000 person-years (PYs) in the primary sample of depressed Veterans.Among depressed VA patients with substance use disorder African Americans were significantly less likely to die by suicide than individuals of any other race. In African Americans with substance use disorder, no other variables reliably distinguished those who did vs those who did not die by suicide. In non-African Americans, having been admitted to inpatient psychiatric treatment at least once in the prior 12 months conferred an additional risk for suicide vs those with no psychiatric admission (247.21/100,000 PYs vs 143.05/100,000 PYs).Among depressed VA patients without substance use disorder sex was the strongest indicator of suicide risk: 82.08/100,000 PYs for men vs 26.22/100,000 PYs for women. In women, no other available risk factors reliably identified individuals at differing levels of risk. In men, race was related to suicide risk: African American men 33.30/100,000 PYs vs non-African American men 86.78/100,000. The replication sample confirmed that the groups defined by the development cohort significantly discriminated suicides from non-suices. OR from the primary cohort (95% CI):Any substance use disorder: 2.0 (1.8-2.2)Non- African Americans with substance use disorder: 5.6 (3.7-8.6)Non- African Americans with substance use disorder and any inpatient psychiatric treatment in past 12 months: 2.0 (1.6-2.5)Men without substance use disorder: 2.9 (2.0-4.2)Non- African American men without substance use disorder: 2.6 (1.8-3.8)
73

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

All Veterans who used VA services during FY 1999 (n=3,291,891) who were alive at the start of FY 2000

CDC’s NDI data and VA National Patient Care Database

90% maleAge: 18-29: 4.1%30-39: 8%40-49: 17.1%50-59: 21.5%60-69: 19.8%70-79: 23%≥80: 6.5%Any psychiatric diagnosis: 25.6%Any substance abuse or dependence: 10%Alcohol abuse or dependence: 8.5%Drug abuse or dependence: 5.7%Bipolar disorder: 2.9%Depression: 14.5%

Other anxiety: 7.3%

PTSD: 6.3%Schizophrenia: 4.1%

Those with suicide during follow-up period vs those without suicide

Any psychiatric diagnosis, substance abuse or dependence, alcohol abuse or dependence, drug abuse or dependence, bipolar disorder, depression, other anxiety, PTSD, and schizophrenia

All psychiatric diagnoses were based on ICD-9 codes given during a visit in FY 1998 or FY 1999. Categories were not mutually exclusive (patients could have multiple diagnoses).

Observation period began the first day of FY 2000 and ended the last day of FY 2006 or the date of suicide

Data censored on date of death for those who died from causes other than suicide during the observation period.

Conducted a series of proportional hazards regression models for each variable of interest, then used covariance sandwich estimators to adjust for clustered data (nested within VHA facilities); then proportional HR models examined the HR of suicides for each diagnosis individually, adjusted for age group and stratified by sex. 

Suicide mortality was 11.6/100,000 PYs for women and 40.9/100,000 PY for men. 70% had any psychiatric diagnosis at baseline.Age-adjusted HR (95% CI) for Suicide During FY 1999 to FY 2006 in all VHA patients treated in FY 1999 who were alive at the start of FY 2000:Male:Any psychiatric diagnosis: 2.50 (2.38-2.64)Any substance abuse or dependence: 2.27 (2.11-2.45)Alcohol abuse or dependence: 2.28 (2.12-2.45)Drug abuse or dependence: 2.09 (1.90-2.31)Bipolar disorder: 2.98 (2.73-3.25)Depression: 2.61 (2.47-2.75)

Other anxiety: 2.10 (1.94-2.28)PTSD: 1.84 (1.70-1.98)Schizophrenia: 2.10 (1.93-2.28)Female:Any psychiatric diagnosis: 5.18 (4.08-6.58)Any substance abuse or dependence: 6.62 (4.72-9.29)Alcohol abuse or dependence: 6.04 (4.14-8.82)Drug abuse or dependence: 5.33 (3.58-7.94)Bipolar disorder: 6.33 (4.69-8.54)Depression: 5.20 (4.01-6.75)Other anxiety: 3.48 (2.52-4.81)PTSD: 3.50 (2.51-4.86)Schizophrenia: 6.08 (4.35-8.48) 
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

260,254 total cohort - identified 903 as having died by suicide

FY 1999 LHSV, VA medical records, and suicide deaths identified by the NDI during FY 1999-FY 2006.Patients had to have usable data from the LHSV, be alive at the start of FY 2000 and be included in at least one of the following data sources: National Psychosis Registry, NARDEP; or a random sample of all patients who used VA services in FY 1999 who were not part of other registries. 31,716 were in the National Psychosis Registry and 104,516 were in the NARDEP; of these, 16,074 were in both – these duplicates were eliminated. Data on 120,158 individuals merged with 140,096 from the random sample.

94.68% maleAge: <50 years: 19%50-64: 33%≥65: 48% Race: 75% White; 13% Black; 12% Other.Married/cohabitating: 56%Education: Not a high school graduate: 26%High school through some college: 32%College graduate: 42%.Smoker: 32.5%Mean MCS-12 score: 37.8 (SD 13.7)Mean Physical Component Summary-12 score: 33.2 (SD 11.2)For psychiatric and medical comorbidities, see Table 2 of the article.

Suicides vs non-suicides

Risk Factors: Pain: measured with a single question on the LHSV – “how much bodily pain have you had during the past 4 weeks?” (from the SF-36).Other factors: demographics (age, gender, race), diagnosed psychiatric comorbidities, educational status, smoking, marital status, medical diagnosis by ICD-9.Outcome: death by suicide, defined by the presence of any of the following ICD-10 codes as NDI cause of death from 2000-2006: X60- X84, Y87.0 (McCarthy, 2009).47

ICD-9 codes for psychiatric diagnosis and medical diagnosis

Deaths evaluated from FY 2000 (October 1, 1999) to FY 2006 (September 30, 2006) – total of 7 years

Cox proportional hazards regression

Multivariate results for suicide, HR (95% CI):Demographics:Age ≥65 vs <50: NSAge 50-64 vs <50: NSMale gender: 2.14 (1.46-3.14)Black race vs white: 0.33 (0.25-0.44)Other race vs white: 0.75 (0.61-0.92)Not a high school graduate: NSHigh school graduate/some college: NSSmoker: 1.71 (1.48-1.97)Psychiatric Comorbidity:Schizophrenia: 1.52 (1.24-1.86)Bipolar disorder I or II: 1.53 (1.22-1.92)Depression: 1.27 (1.10-1.46)Other anxiety: 1.28 (1.07-1.54)Drug use disorder: NSMedical Comorbidity:Diabetes: 0.66 (0.53-0.82)Complicated diabetes: NSCerebrovascular disease: 0.66 (0.47-0.91)Cancer: NSOther:MCS-12: 0.98 (0.97-0.99)Physical Component Summary-12: NSSevere pain vs moderate or less pain: 1.33 (1.15-1.54)
75

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

Total n= 5082854 Suicides and 4229 patients who did not die by suicide during the study period selected randomly. 

VA medical records and the NDI. Included VA patients with substance use disorders who were alive at the beginning of FY 2002 and died by suicide during FYs 2002-2006 (n=854) and a random sample of 4228 substance use disorder patients who did not die by suicide during this period. 

97% male28% Black; 58% White; 14% Unknown/other.Age: 18-44 years: 22%45-64 years: 66%≥65 years: 11.5%Region: 22.4% Northeast; 30% South; 26% Central; 21.5% West

Random sample of substance use disorder patients who did not die by suicide was the comparison group for both violent suicide and non-violent suicide

Gender, age, race, region, mental conditions (major depression, other anxiety disorder, bipolar disorder, PTSD, schizophrenia, personality disorder, to or more psychiatric disorders), and substance use disorders (alcohol, cocaine, cannabis, opiate, amphetamine, barbiturate, multiple/other)

ICD-9 codes for substance use disorders and mental diagnoses. Demographic information from the databases.Diagnosis of substance use disorder was defined as patients who received two or more diagnoses of the same substance use disorder from FYs 1997-2001.

4 years Logistic regression 

controlling for gender, race, age, and region.

OR (95% CI) for violent suicides (VS) and non-violent suicides (NVS), compared to those who did not commit suicide:Mental conditions: Major depression: VS 2.09 (1.75-2.50); NVS 4.94 (2.99-5.19)Other anxiety disorder: VS 1.87 (1.55-2.25); NVS 3.26 (2.51-4.25)Bipolar disorder: VS 1.62 (1.32-2.00); NVS3.18 (2.42-4.18)PTSD: VS 1.33 (1.10-1.62); NVS 2.23 (1.70-2.92)Schizophrenia: VS 1.49 (1.20-1.84); NVS 2.57 (1.94-3.40)Personality disorder: VS 1.56 (1.27-1.92); NVS 2.63 (2.00-3.45)Two or more psychiatric disorders: VS 1.93 (1.60-2.34); NVS 3.83 (2.72-5.37)Substance use disorders: Alcohol: VS (NS); NVS 0.71 (0.53-0.94)Cocaine: VS 0.62 (0.46-0.83); NVS (NS)Cannabis: NS for bothOpiate: VS (NS); NVS 1.67 (1.08-2.60)Amphetamine: NS for both Barbiturate: NS for bothMultiple/other: VS 0.80 (0.67-0.98); NVS 1.48 (1.13-1.93)

104,026 Veterans; 216,864 nonVeterans

Data from the 1986-94 National Health Interview Survey. People from the 50 states and Washington DC who were not institutionalized. Suicide data from the Multiple Cause of Death file (1986-97) through the NDI.

Veterans vs NonVeteransAge: 18-44: 25% vs 70%45-64: 45% vs 20%≥65: 30% vs 9%Male: 95% vs 38%White: 85% vs 74%Not white: 14% vs 23%At least one psychiatric condition: 1.5% vs 2.0%

Non-Veterans from the same survey

Age, marital status, living arrangement (alone or with others), race, education, employment status, region of residence, place of residence, BMI, number of chronic non-psychiatric medical conditions, number of psychiatric conditions, self-rated health, and activity limitations

Self-report 12 years Cox proportional 

hazards model adjusting for demographic characteristics, socioeconomic factors and health

Risk factors for suicide, Adjusted HR (95% CI):Age (years): NSRace – white vs non-white: 3.23 (1.75-5.88)Marital status: NSLiving alone (vs with others): NSEducation ≥12 years vs <12 years: 2.67 (1.38-5.17)Employment status: NSRegion of residence: NSPlace of residence – urban/rural: NSPoor self-rated health: NS BMI – overweight vs normal: 0.45 (0.22-0.92)BMI – underweight or obese vs normal: NSNumber of chronic non-psychiatric conditions: NSNumber of psychiatric conditions: NSActivity limitations vs not limited: 4.44 (1.33-14.80)
76

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

 

63 suicides and 63 age and gender matched controls drawn from a cohort of 732 deaths among regular-duty Army, Navy, Air Corps, and special forces personnel. Regression done only on 33 firearms deaths and matched controls.

732 deaths of regularduty military personnel in the Irish Defense Forces between 1970 and 2002

63 suicides; regression done only on 33 firearm suicides that all used military firearms

Suicides were compared with a randomly age-gender matched nonsuicide death (excluded deaths that were “open” i.e., accidental deaths, drownings)

Demographics, details of the suicide

Cause of death (suicide outcome) was determined by examination of the proceedings of Courts of Inquiry and medical records. Variables regarding details of the suicide were obtained from military files which include inquest/autopsy reports, toxicology/forensic reports, and eyewitness/family/ colleague reports.

N/A – retrospective analysis of factors knowing the actual outcome (suicide)

Logistic regression controlling for variables suggested in bivariate analyses and factors that were clinically or occupationally associated with suicide (all listed, but those included are not specifically reported)

3 variables accounted for 84.2% of the variation in the data and 83.3% of the firearm suicides (χ2(df2)=1.0, p<0.001): 

Psychiatric illness or history of deliberate self-harm (OR 0.00; 95% CI, 0.00-8.3x1033), 

performing morning duty (OR 12.6; 95% CI, 2.78-57.3), and a recent medical downgrading (OR =27,766.31; 95% CI, 0.00-1.17x1058).

298 patients with suicidality

Two outpatient clinics, a 20-bed inpatient facility and an emergency room, all affiliated with US Army Medical Center

Mean age: 22.22 years82.2% male62.8% Caucasian

Those with prior selfreported suicide attempt compared to those without

Negative life events using Life Experiences Survey, Modified Scale for Suicidal Ideation, current and past psychiatric diagnoses by the Diagnostic Interview Schedule, incorporating DSM-III-R criteria, and past suicide attempt

Clinical interview N/A Logistic regression 

– one for each of the mental health variables: very early onset bipolar disorder, very early onset MDD, and very early onset anxiety; controlled for age in all; life events as interaction term

OR (95% CI), in the model with age, negative life events and very early onset bipolar disorder, and the interaction term for very early onset bipolar disorder x negative life events:Age: NSNegative life events: NSVery early onset bipolar disorder: NSNegative life events x Very early onset bipolar disorder: 0.88 (0.78-0.99)Very early onset bipolar disorder moderates the association between negative life events and suicide attempts – lower levels of negative life events among attempters with no history of very early onset bipolar disorder.Excluding patients with very early onset bipolar disorder, negative life events was marginally significant for predicting suicide attempts: OR 1.30 (95% CI, 1.02-1.65)Neither very early onset bipolar disorder nor very early onset anxiety moderated the association between life stress and suicide attempt. 
77

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

887,889 patients with depression; 1892 suicide deaths

A national database of US Veterans in depression treatment (NARDEP) linked to NDI; April 1, 1999 to September 30, 2004

Age: 18-44 years: 16.1% 45-64 years: 50.1% ≥65 years: 33.8% 

91.9% male76.5% white22.1% with substance abuse disorder

None Any anxiety disorder

PTSDAnxiety disorder NOSPanic disorderGeneralized anxiety disorderSocial phobiaOCDAny other anxiety disorderEver prescribed anxiety medicationEver prescribed high dose anxiety medication

Treatment and administrative records, pharmacy database records

5.5 years Logistic regression 

analysis; adjusted for gender, age, race, ethnicity, marital status, and presence of a substance use disorder

Predictors of suicide among depressed Veterans, Adjusted OR (95% CI):Any anxiety disorder: 1.07 (0.98-1.18)PTSD: 0.87 (0.77-0.97)Anxiety disorder (not otherwise specified): 1.25 (1.12-1.38)Panic disorder: 1.26 (1.04-1.53)Generalized anxiety disorder: 1.27 (1.09-1.47)Social phobia: 0.59 (0.29-1.18)OCD: 1.10 (0.73-1.67)Any other anxiety disorder: 1.05 (0.85-1.29)Ever prescribed anti-anxiety medication: 1.71 (1.55-1.88)Ever prescribed high dose anti-anxiety medication: 2.26 (1.98-2.57)

821 Telephone 

interview, U.K.

Personnel who had previously participated in the King’s Centre for Military Health Research military health study (4.7% reported prior suicide attempt) – initial recruitment via mailing, stratified by serving status (regular/reserve) and deployment status (first phase Iraq or not), oversampled for those reporting psychological distress

Self-reported intentional self-harm vs. none

PHQ, Primary Care PostTraumatic Disorder Screen, 2000 Adult Psychiatric Morbidity Survey questions about suicide

Self-report N/A Adjusted OR 

using STATA with weighted percentages: adjusted for age, gender, marital status, educational status, engagement type, rank at interview, service, length of service, serving status at interview, experience of deployment to Iraq, and number of childhood adversity factors

Adjusted OR (95% CI) for intentional selfharm (adjusted for age, serving status and childhood adversity):PTSD or PHQ diagnosis: 4.65 (1.91-11.33)Any PHQ diagnosis: 4.14 (1.75-9.81)Any depressive syndrome: 3.08 (1.08-8.78)Any anxiety syndrome: NSAlcohol abuse: NSSomatization disorder: 3.65 (1.20-11.03)PTSD: 8.48 (2.73-26.33)Adjusted OR (95% CI) for intentional selfharm (adjusted for age, educational status, engagement type, rank, service, serving status, and childhood adversity):Serving status at interview – left service vs serving: 2.82 (1.08-7.34) Age at interview: 0.94 (0.87-1.00) (p=0.042)Childhood adversity (vs 6-16 factors): 0.11 (0.04-0.33) for 0-1 factors; 0.19 (0.07-0.52) for 2-3 factors; and NS for 4-5 factorsNS: Experience of deployment to Iraq, rank at interview, service (Navy, Army, Royal Air Force), length of service, educational status, and engagement type
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

20 cases who attempted suicide; and 20 controls who did not attempt suicide (matched on age and Childhood Trauma Questionnaire score)

100 consecutive abstinent substance-dependent patients who completed the ConnorDavidson Resilience Scale, who were seen in the Substance Abuse Treatment Program at the Department of VA New Jersey Health Care System, East Orange Campus. Identified 20 substance abuse patients who had attempted suicide 

Met DSM-IV criteria for substance dependence and were abstinent when studied. Excluded those with lifetime history of schizophrenia, other psychosis, or mental retardation.

20 substance abuse patients who had not attempted suicide, matched on age and Childhood Trauma Questionnaire score

Resilience measured by the Connor-Davidson Resilience Scale score

Psychiatric interview conducted by a psychiatrist about sociodemographic variables, substance dependence history, and lifetime history of suicide attempt. Supplemented by collateral information from program staff, medical records, program internist and physicians assistant, and treating mental health professional.

N/A Matched on age 

and Childhood Trauma Questionnaire score; t-tests and chi-square

20 patients who had never attempted suicide had significantly higher ConnorDavidson Resilience Scale scores than the 20 age and Childhood Trauma Questionnaire matched patients who had attempted suicide: mean Connor-Davidson Resilience Scale score 63.61 (SD 20.44) vs 47.55 (SD 18.14), p<0.0123.

294,952 VA National 

Care Patient Database, NDI, and outpatient VA pharmacy records, from FY 2001- 2005, in VA healthcare settings

Patients aged ≥60 years old who had been diagnosed with dementia in VA healthcare settings between FY 2001 and FY 2005

N/A Demographics (gender, 

marital status, race, and age), psychiatric disorders (PTSD, any anxiety disorder, depression, any personality disorder, any substance use disorder [except nicotine dependence], schizophrenia, and bipolar disorder), medical comorbidity, healthcare utilization, psychiatric prescription medication use.

ICD-9 codes and ICD-10 codes, Charlson Comorbidity Index

N/A Bivariate analyses 

– chi-square tests of independence, multivariate logistic regression models

Adjusted analyses predicting suicide (adjusted OR, 95% CI):Risk factors:White 1.49 (1.14-1.95)Depression 2.04 (1.45-2.85)Anti-anxiety medication 1.98 (1.48-2.65)Antidepressant medication 2.11 (1.57- 2.84)Protective factors: inpatient psychiatric hospital stay 2.31 (1.54-3.46)inpatient nursing home stay 0.33 (0.14-0.75)
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

2116 August 2006- 

August 2007;Survey of active duty military personnel serving at US Marine Corps installations in Southern California and Arizona

Mean age: 24.1 years (SD 5.3) 92% maleEthnicity/race not reported58% had been combat deployed

None Combat deployment, 

prior engagement in risky behavior, mental health issues

Self-report, anonymous survey

Crosssectional Logistic regression; 

demographic variables, prior high-risk behavior, combat deployment

Results of logistic regression analyses predicting current suicide attempt, Adjusted OR (p-value NS unless specified):Male: 0.58 Older age: 0.97Higher rank: 0.76Higher education: 1.23Navy (vs Marines): 0.79Single: 0.78Divorced/Separated/Widowed: 3.90 (p<0.01)Prior behavior: 8.58 (p<0.001)Combat deployment: 0.86Prior behavior x deployment: 1.68

 

34,245 VA database 

July 1997 to September 1997, 150 VA facilities across the US

Patients seeking treatment for substance use disorders, other psychiatric disorders, or both

Those with suicide attempt in past 30 days vs those without.

Demographics (age, education, race, marital status), psychiatric diagnoses (psychotic disorder, depressive disorder, PTSD, anxiety disorder, alcohol abuse/dependence, drug abuse/dependence, personality disorder), suicide attempts over the past 30 days and during lifetime, sexual abuse in the past 30 days and during lifetime, and physical abuse in the past 30 days and during lifetime

ASI administered by trained interviewers

N/A Bivariate 

analyses, multivariate logistic regression analyses; adjusted for sexual and physical abuse (lifetime and past 30 days), psychiatric disorders, alcohol/drug abuse, age, marital status

Multivariate logistic regression analysis of suicide attempts in the past 30 days among men seeking treatment for substance use disorders, psychiatric disorders or both (adjusted OR; 95% CI): sexual abuse in past 30 days (2.08; 1.26-3.43), physical abuse in past 30 days (2.38; 1.83-3.10), lifetime sexual abuse before past 30 days (1.33; 1.10-1.61), lifetime physical abuse before past 30 days (NS), psychotic disorder (1.48; 1.28-1.73), depressive disorder (2.38; 2.07-2.74), PTSD (1.37; 1.19-1.57), anxiety disorder (1.45; 1.26-1.67), alcohol abuse/dependence (NS), drug abuse/dependence (NS), personality disorder (1.74; 1.50-2.01), older age (0.97; 0.96-0.98), married (NS)
80

ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

887,859 VA patients 

receiving antidepressant treatment between April 1,1999 and September 30, 2004

Mean age: 58.6 years (SD 14.4) 91.9% male

76.5% white; 12.4% black; 2.1% other (Asian, American, Native, Pacific Islander, multiracial); 9.0% unknown race; 4.7% Hispanic

None Time period (in five 

sequential 12-week periods following treatment events), age, gender, race, ethnicity, marital status, diagnosis of a substance abuse disorder, PTSD, and service connection

Data from VA’s NARDEP. Not specified how data were collected.

60 weeks following their last treatment event of interest, date of death, or end of study (September 30, 2004), whichever came first

Poisson regression model used to fit piecewise exponential models, with generalized estimating equations to allow for correlation within patients when multiple episodes of treatment events were included in the analyses.RRs calculated after adjusting for age, gender, race, ethnicity, marital status, diagnosis of a substance use disorder, PTSD, and service connection.

Time period was significantly associated with suicide following all treatment events (P<0.001).RR (95% CI) for first compared to second 12-week periods:Following psychiatric hospitalizations: 1.9 (1.5-2.4)Following new antidepressant starts: 1.8 (1.5-2.1)Following other antidepressant starts: 1.8 (1.4-2.3)Following dose changes: 1.4 (1.1-1.8)Following “any antidepressant regimen change”: 1.8 (1.5-2.1)Following “any treatment event”: 1.8 (1.6-2.1)
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

405 Computerized 

Patient Record System, January 1, 1994 to December 31, 2002, VA Greater Los Angeles Healthcare System

Patients with pharmacy records of lithium, divalproex, carbamazepine, gabapentin, topiramate, and lamotrigine dispensed from January 1, 1994 to December 31, 2002; who were given a chart diagnosis of bipolar disorder type I or type II, schizoaffective disorder bipolar type, or bipolar disorder not otherwise specified; who received ≥6 months of care for bipolar disorder by an attending psychiatric physician with a chart documentation of inquiry about suicidal behavior by the psychiatrist

N/A Demographics (gender, 

age), diagnoses (bipolar I disorder, bipolar II disorder, schizoaffective disorder, bipolar disorder not otherwise specified), pharmacotherapy (mood stabilizer monotherapy, antidepressant monotherapy, mood stabilizer combined with an antidepressant), outcomes (suicide, suicide attempts, hospitalization for suicidal intent)

Assumed DSM-IV diagnostic criteria, “suicidal behavior life chart” to track medications received and occurrence of suicidal behavior events

Followed for a mean of 3 years

Generalized linear regression model, with (log) number of events as dependent measures, medication status as independent variable, and (log) total time observed as an offset variable specifying Poisson error. This method models the rates (events/[time at risk]) as an exponential function of medication status.

Comparison of suicidal behavior during mood stabilizer therapy vs mood stabilizer combined with antidepressant: χ2=8.71, 

df=1; p=0.003Suicidal behavior during mood stabilizer monotherapy compared with antidepressant monotherapy: On Lithium: χ2=19.14, df=1; p<0.0001

On Divalproex: χ2=14.4, df=1; p=0.0001

On mood stabilizer monotherapy: χ2=29.87, 

df=1; p<0.0001Suicidal behavior event rates during antidepressant and/or mood stabilizer therapy in bipolar patients who received all three treatments, Rate (all events/100 PY):On mood stabilizer monotherapy: 13.41On mood stabilizer + antidepressant: 23.72On antidepressant alone: 38.18

Note: 1 suicide in the mood stabilizer + antidepressant group; none in the others. 5 attempted suicides among the mood stabilizer + antidepressant group; 7 attempted suicides in the antidepressant monotherapy group and none in the mood stabilizer monotherapy group. 
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Sample size Data source, 

sample time frame, location

Population characteristics

Comparison group (if any)

Risk factor(s) measured Method of 

measurement of risk factor(s)

Length of follow-up/ observation time

Statistical analysis methods/ Control for confounding

Results

405 Computerized 

Patient Record System,January 1, 1994 to December 31, 2002, VA Greater Los Angeles Healthcare System)

Patients identified with pharmacy records of lithium, divalproex, carbamazepine, gabapentin, topiramate, and lamotrigine dispensed from January 1, 1994 to December 31, 2002; who were given a chart diagnosis of bipolar disorder type I or type II, schizoaffective disorder bipolar type, or bipolar disorder not otherwise specified; who received ≥6 months of care for bipolar disorder by an attending psychiatric physician with a chart documentation of inquiry about suicidal behavior by the psychiatrist

N/A Demographics (gender, 

age), diagnoses (bipolar I disorder, bipolar II disorder, schizoaffective disorder, bipolar disorder not otherwise specified), pharmacotherapy (mood stabilizer monotherapy, antipsychotic monotherapy, mood stabilizer combined with an antipsychotic), outcomes (suicide, suicide attempts, hospitalization for suicidal intent)

Assumed DSM-IV diagnostic criteria, “suicidal behavior life chart” to track medications received and occurrence of suicidal behavior events

Followed for a mean of 3 years

Rates of events calculated by medication status over total time observed. Rates were then compared using a generalized linear regression model, with (log) number of events as dependent measures, medication status as independent variable, and (log) total time observed as an offset variable specifying Poisson error. This method models the rates (events/[time at risk]) as an exponential function of medication status. 

Non-lethal suicide event rates were 9.4 times greater (χ2=28.29; p<0.0001) 

during antipsychotic monotherapy and 3.5 times greater during mood stabilizer + antipsychotic therapy (χ2=15.13; p=0.0001) 

than during mood stabilizer monotherapy.

 

807,694 VA’s NARDEP 

linked to VA Medicare Data Merge Initiative and the NDI, April 1, 1999 to September 30, 2004

Patients with a diagnosis of a depressive disorder and who had been prescribed an antidepressant, or patients with two medical visits that resulted in the diagnosis of depressive disorders during the study period

N/A Demographics (gender, 

race, ethnicity [Hispanic or not], age, region of treatment location), diagnoses (depression, PTSD, substance abuse), inpatient psychiatric hospitalization, Charlson Comorbidity Index (for physical comorbidities), and service connection 

Unclear N/A Unadjusted 

suicide rates; adjusted suicide rates (by age, gender, race, ethnicity, and psychiatric and substance abuse comorbidity status); estimated suicide rate using crude mortality and estimated HRs using Cox proportional hazards regression models; estimated adjusted HRs and 95% CI

Adjusted analyses (adjusted OR, 95% CI):Protective factors include: woman vs man 

(0.35, 0.26-0.47), black vs white (0.24, 0.19-0.30), Hispanic vs not (0.47, 0.35-0.63), age ≥ 65 vs age 18-44 (0.85, 0.73-0.99), age 45-64 vs age 18-44 (0.74, 0.64-0.84), PTSD diagnosis vs not (0.77, 0.68-0.87), service connection vs not (0.86, 0.77-0.96), Northeast region vs South (0.76, 0.66-0.87), Central region vs South (0.80, 0.71-0.91. Non-significant factors include Charlson score ≥1 vs 0 (0.95, 0.86-1.01), West region vs South region (0.92, 0.81-1.01). 

Risk factors include: any substance use 

(1.74, 1.55-1.96), previous inpatient stay for psychiatric disorder in last 12 months (1.92, 1.61-2.28). When adding interaction terms for PTSD x age ≥65 and PTSD x age 45-64, PTSD is no longer a significant protective variable for suicide. Only other changes with this model: age ≥ 65 no longer significant.
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

 OF BIAS RATINGS FOR PRIMARY STUDIES OF FACTORS TO PREDICT 

RECTED VIOLENCEIN MILITARY AND VETERAN POPULATIONSa

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

HS-CFS data Unsure - no 

information on missing data

Unsure - face-toface interview Unsure - self-report Yes - N=8441 Yes - lifetime mental disorder 

diagnosis

1 of 4 Unclear Canadian armed 

forces personnel

HS-CFS is a 

tative sample 

Canadian 

rces personnel; 

2 is a nationally 

tative sample of 

s age ≥15 years

Unsure - no information on missing data

Partially - clinical interview for mental health diagnosis; self-report for alcohol use

Unsure - selfreport: asked the following question on survey: have you “attempted suicide or tried to take [your] own life in the past 12 months?”

Yes - N=36,984 civilians, 8441 armed forces personnel

Yes - mental disorders, alcohol dependence

2 of 4 Unclear Canadian armed 

forces personnel

ntified suicides 

 sources: Total 

ry and Health 

s Database, all 

s and inpatient 

data from the Army 

 Patient Data 

and personnel rom Defense 

er Data Center

Unsure - missing data not reported

Unsure - ICD-9 codes from hospital and Army personnel records

Yes - death records for suicide

Yes - N=1873 cases, 5619 controls

Yes - mental disorder and alcohol disorder

2 of 4 Unclear US Army soldiers 

who committed suicide within 120 days of postmilitary discharge

cases included 

om selection for 

with replacement 

cessary

Unsure - unknown number of suicides were missed because they were not identified by the VA database

Yes - keyword search of the medical records for identification of risk factors, specifically PTSD, TBI and neurologic disease; described in detail

Yes - similar assessment to risk factors: keyword search plus chart review by licensed clinical psychologist

Yes - N=81 cases, 160 controls

Matched on age and gender, all had mental health diagnosis (PTSD)

1 of 4 (PTSD) Unclear US Veterans 

receiving mental health services

ntified by ICD-9 

 diagnosis of TBI 

elated diagnoses, 

 epilepsy

Unsure - no information on missing data

Unsure - based on ICD-9 codes, but unknown number of missed cases of TBI due to underdiagnosis

Yes - based on ICD9 codes Yes - 105 suicide deaths Cox proportional hazards survival 

models for time to suicide; adjusted for psychiatric comorbidities (among other factors)

1 of 4 (any mental health disorder)

Unclear People who 

received VA inpatient or outpatient healthcare services

dom sample of 

m those admitted 

dal thoughts or 

s

Unclear - missing data not reported 

Unsure - chart review only, but trained coders assessed reliability

Yes - patients were admitted to a psychiatric unit for suicidal thoughts or behaviors

Yes - N=465 with suicidal thoughts, 191 with suicidal behaviors

Yes - MDD, other psychiatric diagnoses, substance or alcohol abuse

2 of 4 Unclear Patients admitted 

to a US army hospital
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

patients 

ed with one of 

noses in a 4-year 

Unclear - missing data not reported

Unsure Yes - NDI and ICD9 codes to identify 

suicide deaths

Yes - N=121,933 Yes 2 of 4 (psychiatric 

diagnosis, including substance abuse)

Unclear Psychiatric 

inpatients from US VA hospitals

secutive 

ns

Unsure - missing data not reported, but used information typically collected at the outset of most treatment programs

Unsure - questionnaires at intake, meant to be generalizable to other programs. However, the questionnaires themselves were not described or cited. Did not report how patients’ war zone trauma exposure was collected. Treatment-related variables are likely to be most accurate for readmissions to this program, less so for admissions from other programs.

Unsure - self-report; violent behavior and suicide attempts assessed with items from the Northeast Program Evaluation Center Survey

Yes - N=630, 8.1% attempted suicide (n=50)

Yes - chi square only, but given that they have already controlled for psychiatric diagnosis by including only patients with PTSD who were entering substance abuse treatment, this is adequate

3 of 4 Unclear Veterans 

diagnosed with PTSD entering residential rehabilitation program for substance abuse

essed all patients 

nto VA substance 

ders program, no 

 criteria used

No - enrolled only those who completed followup (n=8807) from 13,870 total enrolled

Yes - used ASI, standardized measure. Trained all providers on administration and then required all patients to complete at intake.

Unsure - selfreported suicide attempt in past 30 days

Yes - N=8807 Yes - was 

entirely a substance use disorder population; assessed 35 risk factors and included 5 in the final model

4 of 4 (details of substance use, psychiatric diagnoses, suicidal ideation, prior suicide attempts - last 3 felt to be proxies for each other and therefore combined into one variable)

Unclear Veterans enrolled 

in substance use disorder programs

 used data from a 

 time period and 

sion criteria, but 

if all patient data 

ewed for eligibility

Unsure - does not report how many of the final analytic cohorts were missing variables

Unsure - chart review (possible inaccuracies in race; 9% unknown race, for example), assume most risk factors determined by ICD-9 code

Yes - suicide outcome was confirmed by NDI and they were careful to query even those patients without a death date but who did not receive VA services in following year

Yes - N=1275 suicide deaths

Yes - substance abuse and mental health

2 of 4 (assessed depressed population only; additional factors: PTSD, psychiatric admission, substance use disorder. No report of suicidal ideation or prior attempts.)

Unclear US VA patients 

treated for depression
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

abase; all patients 

fied time period

Unsure - no information on missing data

Unsure - all risk factors determined by ICD-9 code; they were careful to design the study such that risk factors were assessed prior to the outcome

Yes - NDI Yes - N=7684 suicide 

deaths

Yes - proportional hazard regression, adjusted for substance abuse and mental health

2 of 4 Unclear Veterans seeking 

services tend to have poorer general physical and mental health functioning than the US population. Rank, socioeconomic status and time since military discharge may be important and were not examined.

SV was mailed to 

l random sample 

n enrollees; RR 

ted

Unsure - no information on missing data

Unsure - medical records review; used ICD-9 diagnostic codes for psychiatric diagnoses and substance use disorders; self-report for pain outcomes and SF-36

Yes - NDI data Yes - overall sample size 

N=260,254

Yes - substance abuse and mental health

2 of 4 (all had substance use disorder)

Unclear US Veterans

SV was mailed to 

l random sample 

n enrollees; RR 

ted

Unsure - no information on missing data

Unsure - chart review only; ICD-9 for psychiatric and substance use disorder diagnoses

Yes - NDI data Yes - N=854 Yes - substance 

abuse and mental health

2 of 4 Unclear US Veterans with 

substance use disorder

d all data from a 

n-based health 

Unsure - missing data not reported; unclear if missing outcome, demographic, or risk factor data on some of the population

Yes - number of psychiatric conditions ascertained based on ICD-9 codes

Yes - objective measures used (NDI, ICD-9 codes)

Yes - N=320,000; 104,026 Veterans; 197 suicide deaths in Veterans

Yes - had at least one psychiatric condition (and other factors)

1 of 4 (number of psychiatric conditions)

Unclear Veterans, males 

only (too few women to include in analysis); various service areas

ewed all causes 

for all personnel 

ring the study 

Partly - excluded open-verdict deaths (drowning, train accidents, and single-vehicle road traffic accidents; 5.2% of deaths were drowning and 18.7% were road traffic accidents)

Unsure - assume data (e.g. psychiatric diagnosis) collected from military files but not described

Unsure - military files and proceedings of Courts of Inquiry were reviewed by the investigators to determine cause of death

Yes - N=63 suicide deaths (overall sample 732 deaths)

Yes - bivariate analysis; confounders included psychiatric diagnosis, history of deliberate self-harm, and recent psychiatric assessment

2 of 4 (psychiatric diagnosis, past history of deliberate selfharm)

Unclear Irish Defense 

Forces
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

 no data on 

ve recruitment

Unsure - design of study ensured that all data were complete

Unclear - licensed professionals did assessments using standard measures. No information on whether they were blinded to past suicide attempts.

Unsure - self-report suicide attempts

Yes - 41.8% reported a non-fatal suicide attempt prior to entry in the program

Yes - all patients had suicidality. They evaluated specific mental health diagnoses in the setting of suicidality.

2 of 4 (suicidality and mental health diagnosis)

Unclear Moderate - these 

were patients at a US Army Medical Center, so could include spouses and dependents of military personnel

Unsure - no information on missing data is reported

Unsure - comorbid anxiety disorders and substance use disorders obtained from clinical and administrative records, but unclear about content or blinding of raters

Yes - suicide mortality determined from cause of death contained in NDI

Yes - N=1892 suicide deaths

Yes 2 of 4 (anxiety 

disorders and substance use disorders)

Unclear US Veterans with 

depression

Unsure - 24% (262/1083) were not surveyed due to declining to participate (10%), could not be traced (15%) or unavailable for interview (2%). Noted no evidence of response bias in response to health, but did not provide details of how this was determined. 

Unsure - self-report via questionnaire and clinical interview

Unclear - selfreported self-harm Yes - 80/821 had a history of a suicide 

attempt

No - univariable analysis of factors including mental health diagnosis and substance abuse, but, did not simultaneously adjust for required confounders.

1 of 4 (psychological distress – childhood adversity)

High UK armed forces 

personnel, 70% of whom reported psychological distress as defined by a score of 4 or more on the 12-item general health questionnaire

 53 who had never 

d the Childhood 

Questionnaire 

tematically 

rom those that 

Yes - only included those who completed the Childhood Trauma Questionnaire

Unsure - self-report supplemented by collateral information from clinicians and medical records

Unsure - selfreported history of suicide attempt via psychiatric interview by study psychiatrist; supplemented by collateral information from clinicians and medical records

No - although 41 patients had attempted suicide, only possible to match 20 cases with 20 controls for analysis

Unsure - assessed resilience in population of abstinent substance abuse patients matched for childhood trauma; but did not adjust further

1 of 4 (all had substance abuse)

High Abstinent 

substance abuse patients who were seen in the Substance Abuse Treatment Program at the Department of VA in New Jersey and had attempted suicide
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

patients diagnosed 

entia between FY 

dentified in the 

nal Care Patient 

e; dementia 

 identified by 

Unsure - not reported. 294,952 patients; 241 suicide deaths. No description of how many people were excluded from the overall eligible sample.

Yes - medical records for demographics, ICD-9 codes for diagnosis of dementia, psychiatric and medical comorbidities

Yes - suicide deaths identified by NDI and ICD-10 codes

Yes - 241 suicide deaths in cohort of 294,952 patients with dementia

Yes - controlled for psychiatric comorbidities, age, sex, race, marital status, medical comorbidities, healthcare utilization and medication use

1 of 4 (psychiatric illness)

Unclear Veterans with 

dementia who are ≥60 years old

ndance at survey 

 sessions was 

 commander 

nd availability 

ning schedule

Unsure - included only those who provided data on their deployment and answered at least 7 or 8 questions on risky behavior. Missing data from 19%; did not report whether missing data differed between groups.

Partly - risky behavior was selfreported via an anonymous written survey. Combat deployment status was determined by record of combat pay (objective).

Unsure - outcome was risky behavior, including attempted suicide; determined by self-report on an anonymous survey

Yes - 7% of sample reported a suicide attempt (148/2116)

Yes 2 of 4 (prior selfharm or suicide 

attempt, any mental health diagnosis)

Unclear US military 

personnel; active duty, mean age 24 years, 92% male

Yes - regression analysis included data from 97% of males (32,271/33,236)

Partly - Sexual and physical abuse: Unclear due to use of face-toface interview, but with a validated questionnaire (ASI). Psychiatric diagnoses: Yes, accessed nationwide VA database to obtain diagnoses made by experienced clinicians during usual care.

Unsure - selfreported suicide attempt in the past 30 days

Yes - overall 33,236 men; 1120 attempted suicide in past 30 days

Yes 2 of 4 (mental 

health diagnosis, substance abuse)

Unclear US Veterans 

seeking treatment for psychiatric disorders; 99% had substance use disorder; mean age 47 years; main findings based on data from males (too few females to include in analysis)

patients in the 

 receiving an 

ssant during the 

eframe

Unsure - no information on missing data

Yes - ICD-9 codes for depression and substance abuse disorder from the registry

Yes - used NDI data and did a sensitivity analysis in which deaths of undetermined intent were considered suicides

Yes - overall sample size over 887,000; 1346 suicides

Yes 2 of 4 (all had 

depression; adjusted for substance abuse disorder and PTSD)

Unclear US Veterans 

receiving treatment for depression; mean age 59 years, 92% male
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

-biased selection 

 group that was 

s the population 

t

Unclear - completeness of data not described

No - all diagnoses based on chart review; medications from pharmacy data. Patients were not randomly assigned to medications and there was no accounting for severity of illness, provider preference, etc. in the analysis. 

No - chart review of psychiatrist documentation about suicidal behavior

Unsure - N=405 No - see notes 

under #4

1 of 4 (since all patients were bipolar the study essentially accounted for the mental health diagnosis and could assess other risk factors within this population)

High US Veterans with 

bipolar disorder in Southern California

-biased selection 

 group that was 

s the population 

t

Unclear - completeness of data not described

No - all diagnoses based on chart review; medications from pharmacy data. Patients were not randomly assigned to medications and there was no accounting for severity of illness, provider preference, etc. in the analysis. 

No - chart review of psychiatrist documentation about suicidal behavior

Unsure - N=405 No - see notes 

under #4

1 of 4 (since all patients were bipolar the study essentially accounted for the mental health diagnosis and could assess other risk factors within this population)

High US Veterans with 

bipolar disorder in Southern California
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

ased

3. Low loss to follow-up/ missing data adequately described?

4. Adequate/ unbiasedrisk factormeasurement?

5. Adequate/ unbiased outcomemeasurement?

6. Was the sample size adequate (including adequate number of outcome events)?

7. Adequate statisticaladjustment

8. Number of required confounders adjusted for in analysis (X of 4)

Overall assessment of potential for biasLow/Unclear/High

External validity

patients with a 

 of depression 

ntidepressant 

on, or had 

cal visits with 

 of depressive 

 during the study 

Unsure - reported that patients with missing data for key covariates were excluded from all analyses, but details only provided for 9% excluded due to missing race data. 1,500,000 starting; with 807,694 satisfying inclusion/exclusion criteria.

Unsure - information on substance abuse diagnosis, diagnosis of PTSD, and prior VA psychiatric hospitalization obtained from the VA’s NARDEP database, but details of coding process and blinding of raters was not described. Race data is excluded from analyses because it was unreliably documented.

Yes - suicides identified from NDI database based on ICD-10 codes, compiled from death certificates

Yes - N=807,694 Yes - present 

adjusted HR with PTSD x age interaction

3 of 4 (substance abuse, history of PTSD, inpatient psychiatric stay)

Unclear Individuals 

receiving treatment for depression in the US VA health system

m Hayden et al. 2006 and Harris et al. 2001.9, 10
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

R REVIEW COMMENTS AND AUTHOR RESPONSES

Response

, scope, and methods for this review clearly described?

essed in answers 2 and 3 could, 

 addressed with a more complete 

tives, scope, and methods. 

We have revised and expanded the description of scope and methods section to provide a more detailed explanation of the EBPWG requests.

does not describe how issues 

 of the studies reported was 

Statistical power for studies of predictive tools and variables is included in the quality (risk of bias) assessment. In this report, we use the following question in our quality (risk of bias) assessment for each study: “Was the sample size adequate (including adequate number of outcome events)?” was part of our quality (risk of bias) assessment for each study – see Appendix K. We have also added additional detail in the Methods section to make this clearer.

 the potential problems and pitfalls 

n of suicide attempts as outcomes.

We briefly addressed the limitations of suicide attempts as outcomes in that section of results, but have added identification of suicide attempts to the Limitations section of the report as well, to further emphasize that issue.

t is stated that key questions 3 

red but not addressed because of 

me of evidence identified for the 

 however, based on the outcomes 

dations) I am not sure I concur.

We established the scope of this report with the EBPWG. Because non-VA literature is less directly applicable to the VA and DOD populations than literature that reports on data from Veteran and military populations, those studies constitute a weaker body of evidence, given the focus of this review. Along with the EBPWG, we agreed that a detailed look at the strongest body of evidence would be most helpful and that a summary of prior systematic reviews for non-VA populations would suffice. Therefore, we have removed reference to questions 3 and 4 (non-Veteran and non-military populations) from the report since it was confusing to readers.

hese are described well. I was 

ble of contents listing 4 key 

 2 of them appearing in the 

y. I think you need to explain in 

mary why you did not address KQs 

want to explicate further what you 

sufficient volume of evidence to not 

See above.

ation of bias in our synthesis of the evidence? 

ed in the draft document for not 

ns 3 and 4 do not make sense. 

stions appears to reflect some 

See above.
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

some questions were not addressed See above.

lished or unpublished studies that we may have overlooked?

012 issue on suicide- a study by 

ters might be useful.

We agree that this issue provides potentially valuable information on suicide among Veteran and military populations; however the publication date puts it out of the scope of this systematic review. While not identified systematically nor quality rated, it cannot be included in this report. However, we reviewed the Bossarte et al. study informally: They assessed age, gender, race, mental health status and social/emotional support as risk factors for selfreported suicide attempts on the BFSS. A report of depression, anxiety or PTSD carried an adjusted OR of 21.7 (CI 5.6-84.3); no other factors were significant. Even if included, this study would not add significantly to or change the conclusions of our current report.

arting the literature review in 2005 

ed. Basing it on the Mann review 

e because that review does not 

 instruments or risk factors. Basing 

view does not make sense because 

viewed relevant literature only until 

The Mann review does review assessment tools. We have clarified the scope and this decision as being based on EBPWG request for the strongest and most directly applicable recent literature on Veterans and members of the military (given the existing literature on civilian populations through such reports as Mann, Gaynes, NICE 2011, Brown, and Goldston). Additionally, we have further summarized the information obtained from other, similar systematic reviews throughout the report to present a more comprehensive review of the literature.

include information from merged 

ilizing VHA services and the NDA, 

 on suicide attempts.

Per follow-up discussions with our stakeholder group, we will not include these unpublished data in this report, but the CPG may choose to make use of such raw data as appropriate.

ider adding: information and 

g warning signs (Risk factors are 

ms of understanding behaviors at a 

evel. The field is moving towards 

vidualized thoughts/behaviors] that 

We have added a discussion of warning signs in the Future Directions section.

ding non-Veteran/military data. We have clarified the scope and this decision was based on EBPWG request for recent 

literature on Veterans and members of the military (given the existing literature on civilian populations through such reports as Mann, Gaynes, NICE 2011, Brown, and Goldston). Additionally, we have further summarized the information obtained from other, similar systematic reviews throughout the report to present a more comprehensive review of the literature.

n might exist in the work of the 

r for Patient Safety, which is not 

ort (for obvious reasons). It might 

his out and refer readers to NCPS

Per follow-up discussions with our stakeholder group, we will not include such data in this report, but the CPG may choose to make use of such raw data as appropriate.
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

ised that you did not find 

g Patient Health Questionnaire 

and suicide behavior or ideation. 

pecifically asks about suicidal 

udies have been done using the 

ars--you may want to consider do 

ry focused search for manuscripts 

HQ and possible suicide-related 

We did not find any articles evaluating the PHQ-9 that met our inclusion criteria. We have added a discussion of the PHQ-9 and recent literature on the PHQ-9 with regard to suicidality to the Recommendations for Future Research section of this report.

arting the literature review in 2005 

e.

We have clarified the scope and this decision was based on EBPWG request for recent literature on Veterans and members of the military (given the existing literature on civilian populations through such reports as Mann, Gaynes, NICE 2011, Brown, and Goldston). Additionally, we have further summarized the information obtained from other, similar systematic reviews throughout the report to present a more comprehensive review of the literature.

published VA reports that could 

.

Per follow-up discussions with our stakeholder group, we will not include these unpublished data in this report, and the CPG may choose to make use of such raw data as appropriate.

ional suggestions or comments below. If applicable, please indicate the page and line numbers from the draft report.

al health diagnosis as a potential 

 be helpful to differentiate 

 MH diagnosis versus those from 

xisting data- as getting a diagnosis 

ndicate treatment engagement

We have added this point to the limitations section.

tudies involving national VA 

 VA users, who may not all be 

 non-Veterans received care at 

ould be important to note this 

While this may be true in some studies, we anticipate that there are low numbers of non-Veterans included in the VA databases and it may not be possible to identify them individually. Additionally, these people are still members of the Veteran community, which is a population of interest in these studies.

nd include citations:

ent would change “Completed 

unds like a positive event to “Death 

We have now cited both Crosby and Brenner articles on the topic, and clarified terminology throughout, including removal of the term “completed” throughout the entire report. However, we use terms (e.g., suicide attempt) as they were reported in the primary studies in order to provide accurate information from these studies. 
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

Page 1, some of citations at bottom 

on military/VA sources) this is not 

the text.

We acknowledge that the introduction to this report cites some studies that are not from military or Veteran populations. This section is meant to explain that there are factors derived from military experience that have reasonable likelihood of contributing to increased suicide risk. We have added a citation for TBI that includes Veteran population (Brenner, 2011). 

nown risk factors don’t always lead 

comes (at least directly) – this is 

ing signs may be helpful

We have added wording to the Future Research section to acknowledge that warning signs may signify a more immediate state of risk than traditional risk factors which reflect a state of overall heightened risk. 

s – page 12 – it may be helpful to 

y using chart data (PAI scores) that 

e patient before the attempt would 

In this section, we specifically describe the risk of bias due to lack of assessor blinding as related to chart review methods for assessment of suicide attempts. This outcome is potentially influenced by lack of assessor blinding because of it is not as objective or clearly defined as a test score that is included in a patient’s chart. We agree that chart review along for determination of a previously collected assessment tool score would carry a low risk of bias for that outcome.

ussion – Page 24 – it is not clear 

of the Hendin study are sufficiently 

on 10)

We have added a statement describing the risk of bias for this study.

ussion – Page 24 – is the ASI still 

nted? – it was my understanding 

We have corrected this information throughout the report.

ussion – Page 24 – would be 

y that the PAI study was only with 

TBIs.

We have added this information.

ussion – Page 25 – would be 

tions in attempt and suicide 

We have added citations to the Summary and Discussion section.

to add. I think the synthesis is 

many clinicians and administrators 

for an instrument or set of variables 

n an individual patient. We know 

 that some interventions are 

e population but still struggle with 

dual cases.

Noted.

mary has a few typos: p3, line 28 

specificity is missing; p4. line 9 the 

ment being discussed is missing; 

We have made these corrections.
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

ewhere in the article) the term 

is very confusing – what does it 

The term “religious terror” comes directly from the article that assessed this risk factor (Belik 2009). It is the variable name associated with the question: “Have you ever lived as a civilian in a place where there was ongoing terror of civilians for political, ethnic, religious, or other reasons?” We have clarified this in the text and table.

 confirm your nomenclature 

nal VA standards on nomenclature 

ehaviors. This nomenclature 

edged early and clearly—a table 

ument currently does not use the 

istently.

We have now cited both Crosby and Brenner articles on the topic, and clarified terminology throughout, including removal of the term “completed” throughout the entire report. However, we use terms (e.g., suicide attempt) as they were reported in the primary studies in order to provide accurate information from these studies.

t is unclear to me if suicidal 

red an outcome you looked at—

re and weren’t included?

See above; we have clarified terminology related to outcomes and state that suicidal selfdirected violence, but not suicidal ideation, outcomes were included in this report.

nclude studies that were included 

eview, it would be important and 

iefly) what the findings were from 

mpare and contrast them—did we 

 and what did we learn?

We have added a more comprehensive summary from this Mann report as well as from the Gaynes and NICE 2011 Self-Harm reports.

define reclassification analysis. We have done this in the Summary and Discussion under KQ#1.

in the text of individual studies, I 

 just a bit more about the design/

dy, in particular overall design 

ohort) and how long patients 

he same time, in the Executive 

ou have more detail on the specific 

ed.

Thank you. We have taken this comment into account in our edits of the main report and also the Executive Summary

mmary, I would include the names 

es, not just the abbreviations in the 

ng studies that used those measures.

We have made this change.

ain document, you say that 

suggests that only 4% of people 

sk in primary care are truly at 

ce the Gaynes study. To my 

% figure is the result of an estimate 

enario—you may want to review 

We have provided additional information on the estimates from the Gaynes article; included these because they demonstrate the difficulties with developing assessment tools for rare outcomes. 
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

c models are overly detailed (e.g. 

c types of pharmacotherapy or 

r me these detract a bit from the 

 flow and don’t add much

We have condensed these into one overall model, and have kept the amount of detail to be consistent with the Suicide Prevention Interventions report.

 that 2 studies were of limited 

 two?—you report that 3 of the 

ological flaws with high risk of 

4 of the 26 studies identified for KQ2 had high risk of bias and were cited and not reviewed further. 

dations (and perhaps other places 

ggest you address need for briefer 

nt on how long/brief the screens are 

r further testing.

We have made this recommendation throughout the report.

ical performance measures, programs, quality improvement measures, patient care services, or conferences that will be 

t? If so, please provide detail.

of a review of instruments that 

he basis of studies in the civilian 

ort has limited utility. It should 

e clinical performance measures, 

mprovement measures, patient care 

ences.

We have updated the report to include a more in depth summary of existing assessment literature on civilian populations from the Mann, Gaynes, NICE 2011, Brown, and Goldston reports.

ould impact current practices. Noted.

 is quite prominent across many 

d DoD.

Noted.

continue to educate stakeholders 

to support the use of specific risk 

ents.

Noted.

al Health—Suicide Prevention

er of Excellence

Noted.

y recommendations on how this report can be revised to more directly address or assist implementation needs.

 for the field to know what are the 

rithms of suicide risk, and perhaps 

el for clinicians to use to identify 

nel at highest risk ) (e.g. through 

SS). 

We agree that this is an important goal. 
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ssessment Tools: A Systematic Review Evidence-based Synthesis Program

Response

 has rolled out the PHQ-9 which 

 on suicidal ideation- some 

 on its utility in predicting suicide 

We have updated the assessment section to include information on the PHQ-9, though we did not find any studies on this assessment tool that met inclusion criteria. We included PHQ-9 in the Discussion.We have updated the report to include a more in depth summary of existing assessment literature on civilian populations from the Mann, Gaynes, NICE 2011, Brown, and Goldston reports.

re: if and how findings should be 

rent practices (e.g., intake)

Recommendations are beyond the scope of this report and will be addressed by the EBPWG.

re to implement. Noted.

er routinely used in VA substance 

report also seems to discuss the 

n primary care for some but not all 

That would be useful to address as 

We have made this correction re: the ASI. We also provide an expanded discussion of screening and assessment tools that could most easily be applied in primary care settings.We have updated the report to include a more in depth summary of existing assessment literature on civilian populations from the Mann, Gaynes, NICE 2011, Brown, and Goldston reports.

with contact details of any additional individuals/stakeholders who should be made aware of this report.

 Zeiss- OMHS

Schohn- OMHO

 and Rick Stark- Primary Care/

Noted. We will disseminate the report accordingly.Noted. We will disseminate the report accordingly.

and Development – to help press 

esearch

Noted. We will disseminate the report accordingly.Noted. We will disseminate the report accordingly.

, Robert Bossarte Noted. We will disseminate the report accordingly.
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Suicide Risk Factors and Risk Assessment Tools:

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APPENDIX N. ABBREVIATIONS

Abbreviation Term

ASI Addiction Severity Index

ASQ Affective States Questionnaire

BDI Beck Depression Inventory

CCHS-CFS Canadian Community Health Survey Cycle 1.2 - Canadian Forces 

Supplement

CI Confidence interval

CIDI Composite International Diagnostic Interview

DoD Department of Defense

DSM Diagnostic and Statistical Manual of Mental Disorders

EBPWG Evidence Based Practice Working Group

EMR Electronic medical record

FY Fiscal year

HR Hazard ratio

ICD International Classification of Diseases

IPS Interpersonal Psychological Survey

LHSV Large Health Survey of Veterans

MCS Mental Component Summary

MDD Major Depressive Disorder

N/A Not applicable

NARDEP National Registry for Depression

NDI National Death Index

NICE National Institute for Health and Clinical Excellence

NS Not significant

OCD Obsessive-compulsive disorder

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

OR Odds ratio

PAI Personality Assessment Inventory

PHQ Patient Health Questionnaire

PTSD Post-traumatic stress disorder

PY Person-year

RR Relative risk

SD Standard deviation

SPI Suicide Potential Index

TBI Traumatic brain injury

UK United Kingdom

US United States

VA Veterans Affairs

VAMC Veterans Affairs Medical Center

VHA Veterans Health Administration

vs Versus
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Suicide Risk Factors and Risk Assessment Tools:

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APPENDIX O. EXCLUDED STUDIES

The following full-text publications were considered for inclusion but failed to meet the criteria 

for this report. 

Exclusion codes: 

1 = non-English language

2 = ineligible country

3 = ineligible outcome

4 = did not evaluate risk factors or assessments 

5 = ineligible publication type

6 = ineligible systematic review due to limitations in quality

7 = ineligible nonsystematic regulatory agency analysis

8 = did not account for major potential confounders

9 = primary articles about risk, not a Veteran or military population

Excluded Trials Exclusion 

Code

1 Abe K, Mertz KJ, Powell KE, Hanzlick RL. Characteristics of black and white suicide decedents in 

Fulton County, Georgia, 1988-2002. Am J Public Health. 2006 Oct;96(10):1794-8.

9

2 Acharya N, Rosen AS, Polzer JP, et al. Duloxetine: meta-analyses of suicidal behaviors and 

ideation in clinical trials for major depressive disorder. [erratum appears in J Clin Psychopharmacol 

27 (1): 57]. J Clin Psychopharmacol. 2006 Dec;26(6):587-94.

6

3 Afifi TO, MacMillan H, Cox BJ, Asmundson GJ, Stein MB, Sareen J. Mental health correlates of 

intimate partner violence in marital relationships in a nationally representative sample of males and 

females. Journal of Interpersonal Violence. 2009 Aug;24(8):1398-417.

9

4 Ahmadian M, Fata L, Asgharnezhad A, Malakooti K. A comparison of the early maladaptive 

schemas of suicidal and non-suicidal depressed patients with non-clinical sample. Advances in 

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6 Akdeniz F, Karadag F. Does menstrual cycle affect mood disorders? Turk Psikiyatri Dergisi. 

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7 Aksoy-Poyraz C, Ozdemir A, Ozmen M, Arikan K, Ozkara C. Electroconvulsive therapy for 

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8 Alexander MJ, Haugland G, Ashenden P, Knight E, Brown I. Coping with thoughts of suicide: 

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9 Allen JP, Cross G, Swanner J. Suicide in the Army: a review of current information. Mil Med. 

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36 Ayer L, Althoff R, Ivanova M, et al. Child Behavior Checklist Juvenile Bipolar Disorder (CBCLJBD) and CBCL Posttraumatic Stress Problems (CBCL-PTSP) scales are measures of a single 

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39 Baca-Garcia E, Perez-Rodriguez MM, Diaz Sastre C, Saiz-Ruiz J, de Leon J. Suicidal behavior in 

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42 Baigent MF. Understanding alcohol misuse and comorbid psychiatric disorders. Current Opinion in 

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44 Bakim B, Karamustafalioglu K, Akpinar A. Suicides and attempted suicides in alcohol and other 

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49 Baldassano CF. Illness course, comorbidity, gender, and suicidality in patients with bipolar 

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50 Baldessarini RJ, Pompili M, Tondo L. Suicidal risk in antidepressant drug trials. Arch Gen 

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51 Baldessarini RJ, Tondo L, Davis P, Pompili M, Goodwin FK, Hennen J. Decreased risk of suicides 

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52 Baldwin DS, Reines EH, Guiton C, Weiller E. Escitalopram therapy for major depression and 

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53 Balestrieri M, Rucci P, Sbrana A, et al. Lifetime rhythmicity and mania as correlates of suicidal 

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54 Balis T, Postolache TT. Ethnic differences in adolescent suicide in the United States. International 

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55 Ballard ED, Pao M, Horowitz L, Lee LM, Henderson DK, Rosenstein DL. Aftermath of suicide in 

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56 Balousek S, Plane MB, Fleming M. Prevalence of interpersonal abuse in primary care patients 

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57 Balsis S, Cully JA. Comparing depression diagnostic symptoms across younger and older adults. 

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58 Bangs ME, Tauscher-Wisniewski S, Polzer J, et al. Meta-analysis of suicide-related behavior 

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59 Barak Y, Olmer A, Aizenberg D. Antidepressants reduce the risk of suicide among elderly 

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60 Barak Y. The aging of Holocaust survivors: myth and reality concerning suicide. Isr Med Assoc J. 

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61 Barbe RP, Rubovszky G, Venturini-Andreoli A, Andreoli A. The treatment of borderline 

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62 Basham C, Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA 

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63 Bauer MS, Wisniewski SR, Kogan JN, Marangell LB, Thase ME, Sachs G. Brief report: paroxetine 

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64 Baum AL. Suicide in athletes: a review and commentary. Clin Sports Med. 2005 Oct;24(4):853-69, 

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65 Beasley CM, Jr., Ball SG, Nilsson ME, et al. Fluoxetine and adult suicidality revisited: an updated 

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66 Beautrais AL, Fergusson DM, Horwood LJ. Firearms legislation and reductions in firearm-related 

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67 Beautrais AL, Gibb SJ, Fergusson DM, Horwood LJ, Larkin GL. Removing bridge barriers 

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68 Beghi M, Rosenbaum JF. Risk factors for fatal and nonfatal repetition of suicide attempt: a critical 

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69 Bell GS, Gaitatzis A, Bell CL, Johnson AL, Sander JW. Suicide in people with epilepsy: how great 

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70 Benda BB. Gender Differences in Predictors of Suicidal Thoughts and Attempts Among Homeless 

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71 Benham C. The relationship between creativity and psychiatric vulnerability: A meta-analysis of 

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72 Bennewith O, Nowers M, Gunnell D. Effect of barriers on the Clifton suspension bridge, England, 

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73 Berard R, Fong R, Carpenter DJ, Thomason C, Wilkinson C. An international, multicenter, 

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74 Bergen H, Hawton K, Murphy E, et al. Trends in prescribing and self-poisoning in relation to UK 

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75 Bergman J, Miodownik C, Palatnik A, Lerner V. Efficacy of bupropion XR in treatment-resistant 

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76 Berlin I, Chen H, Covey LS. Depressive mood, suicide ideation and anxiety in smokers who 

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77 Bernert RA, Joiner TE. Sleep disturbances and suicide risk: A review of the literature. 

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78 Bessant M, King EA, Peveler R. Characteristics of suicides in recent contact with NHS Direct. 

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79 Bhui K, McKenzie K, Rasul F. Rates, risk factors & methods of self harm among minority ethnic 

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80 Bishop SC, Basch S, Futterweit W. Polycystic ovary syndrome, depression, and affective disorders. 

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81 Black SA, Gallaway M, Bell MR, Ritchie EC. Prevalence and risk factors associated with suicides 

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82 Bocchetta A, Fadda D, Satta G, Del Zompo M, Gessa GL, Cocco P. Long-term lithium treatment 

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83 Bodner E, Ben-Artzi E, Kaplan Z. Soldiers who kill themselves: the contribution of dispositional 

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84 Bohnert AS, Roeder K, Ilgen MA. Unintentional overdose and suicide among substance users: A 

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85 Boivin JF, Roy E, Haley N, Galbaud du Fort G. The health of street youth: a Canadian perspective. 

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86 Bonnewyn A, Shah A, Demyttenaere K. Suicidality and suicide in older people. Reviews in 

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87 Borges G, Loera CR. Alcohol and drug use in suicidal behaviour. Current Opinion in Psychiatry. 

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88 Borschmann R, Hogg J, Phillips R, Moran P. Measuring self-harm in adults: A systematic review. 

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89 Boscarino JA. Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years 

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90 Boscarino JA. The mortality impact of combat stress 30 years after exposure: Implications for 

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91 Bossarte RM, Claassen CA, Knox KL. Evaluating evidence of risk for suicide among veterans. Mil 

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92 Bouris A, Guilamo-Ramos V, Pickard A, et al. A systematic review of parental influences on the 

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93 Bowers L, Banda T, Nijman H. Suicide inside: a systematic review of inpatient suicides. J Nerv 

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94 Brady J. The association between alcohol misuse and suicidal behaviour. Alcohol and Alcoholism. 

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95 Brand BL, Classen CC, McNary SW, Zaveri P. A review of dissociative disorders treatment studies. 

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96 Bray RM, Pemberton MR, Lane ME, Hourani LL, Mattiko MJ, Babeu LA. Substance use and 

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97 Breggin PR. Recent U.S., Canadian, and British Regulatory Agency Actions Concerning 

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98 Brenner LA, Homaifar BY, Adler LE, Wolfman JH, Kemp J. Suicidality and veterans with a 

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99 Brent D, Emslie G, Clarke G, et al. Switching to another SSRI or to venlafaxine with or without 

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100 Brent DA, Emslie GJ, Clarke GN, et al. Predictors of spontaneous and systematically assessed 

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101 Brent DA, Greenhill LL, Compton S, et al. The Treatment of Adolescent Suicide Attempters study 

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102 Breslau N, Schultz LR, Johnson EO, Peterson EL, Davis GC. Smoking and the Risk of Suicidal 

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103 Brewin C, Garnett R, Andrews B. Trauma, identity and mental health in UK military veterans. 

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104 Brezo J, Barker ED, Paris J, et al. Childhood trajectories of anxiousness and disruptiveness as 

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105 Brezo J, Paris J, Barker ED, et al. Natural history of suicidal behaviors in a population-based 

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106 Brezo J, Paris J, Hebert M, Vitaro F, Tremblay R, Turecki G. Broad and narrow personality traits 

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107 Brezo J, Paris J, Tremblay R, Vitaro F, Hebert M, Turecki G. Identifying correlates of suicide 

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108 Brezo J, Paris J, Turecki G. Personality traits as correlates of suicidal ideation, suicide 

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109 Bridge JA, Barbe RP, Birmaher B, Kolko DJ, Brent DA. Emergent suicidality in a clinical 

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110 Bridge JA, Goldstein TR, Brent DA. Adolescent suicide and suicidal behavior. Journal of Child 

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111 Britton PC, Conner KR. Suicide attempts within 12 months of treatment for substance use 

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112 Brody S, Potterat JJ, Muth SQ, Woodhouse DE. Psychiatric and Characterological Factors 

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113 Brower KJ, McCammon RJ, Wojnar M, Ilgen MA, Wojnar J, Valenstein M. Prescription sleeping 

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114 Brown GR, McBride L, Bauer MS, Williford WO, Cooperative Studies Program 430 Study T. 

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115 Bruce ML. Suicide risk and prevention in veteran populations. Ann N Y Acad Sci. 2010 

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116 Bryan CJ, Cukrowicz KC, West CL, Morrow CE. Combat experience and the acquired capability 

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117 Bryan CJ, Cukrowicz KC. Associations between types of combat violence and the acquired 

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118 Bryan CJ, Johnson LG, David Rudd M, Joiner TE, Jr. Hypomanic symptoms among first-time 

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119 Bryan CJ, Morrow CE, Anestis MD, Joiner TE. A preliminary test of the interpersonalpsychological theory of suicidal behavior in a military sample. Personality and Individual 

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120 Burrows S, Laflamme L. Socioeconomic disparities and attempted suicide: state of knowledge and 

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121 Bursztein Lipsicas C, Henrik Makinen I. Immigration and suicidality in the young. The Canadian 

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122 Bushe CJ, Taylor M, Haukka J. Mortality in schizophrenia: a measurable clinical endpoint. J 

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123 Butler T, Allnutt S, Kariminia A, Cain D. Mental health status of Aboriginal and non-Aboriginal 

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124 Butterfield MI, Stechuchak KM, Connor KM, et al. Neuroactive Steroids and Suicidality in 

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125 Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane 

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126 Calabrese J, Keck P, Macfadden W, et al. A randomized, double-blind, placebo-controlled trial of 

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127 Calati R, Porcelli S, Giegling I, et al. Catechol-o-methyltransferase gene modulation on suicidal 

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128 Capron DW, Cougle JR, Ribeiro JD, Joiner TE, Schmidt NB. An interactive model of anxiety 

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129 Carballo JJ, Currier D, Figueroa AE, et al. Neurobiological underpinnings of suicidal behavior: 

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130 Carpenter DJ, Fong R, Kraus JE, Davies JT, Moore C, Thase ME. Meta-analysis of efficacy and 

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131 Carr A. Depression in young people: description, assessment and evidence-based treatment. Dev 

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132 Carragher N, Mewton L, Slade T, Teesson M. An item response analysis of the DSM-IV criteria for 

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133 Catanese AA, John MS, Di Battista J, Clarke DM. Acute cognitive therapy in reducing suicide risk 

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134 Cauffman E, MacIntosh R. A Rasch Differential Item Functioning Analysis of the Massachusetts 

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135 Chan J, Draper B, Banerjee S. Deliberate self-harm in older adults: A review of the literature from 

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137 Chioqueta AP, Stiles TC. Psychometric properties of the Beck Scale for Suicide Ideation: a 

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139 Church MK, Maurer M, Simons FE, et al. Risk of first-generation H(1)-antihistamines: a GA(2)

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142 Cohen VK. Keeping students alive: mandating on-campus counseling saves suicidal college 

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144 Colucci E, Martin G. Ethnocultural aspects of suicide in young people: a systematic literature 

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145 Combs H, Romm S. Psychiatric inpatient suicide: A literature review. Primary Psychiatry. 2007 

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151 Correa H, Viana MM, Romano-Silva MA, Duval F. Psychoneuroendocrinology and suicidal 

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152 Coryell WH. Clinical Assessment of Suicide Risk in Depressive Disorder. CNS Spectrums. 2006 

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156 Crawford MJ, Sharpe D, Rutter D, Weaver T. Prevention of suicidal behaviour among army 

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160 Dahle K-P, Lohner JC, Konrad N. Suicide Prevention in Penal Institutions: Validation and 

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161 Daigle MS, Daniel AE, Dear GE, et al. Preventing suicide in prisons, part II. International 

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163 Damm N. Risk and protective factors for suicide among combat veterans with posttraumatic 

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164 Daniel AE. Preventing Suicide in Prison: A Collaborative Responsibility of Administrative, 

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165 Darke S, Kaye S, McKetin R, Duflou J. Major physical and psychological harms of 

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169 de Abreu LN, Lafer B, Baca-Garcia E, Oquendo MA. Suicidal ideation and suicide attempts 

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170 De Leo D. The world health organization: Approach to evidence-based suicide prevention. 

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172 Dejong TM, Overholser JC. Assessment of depression and suicidal actions: agreement between 

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175 Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces. 

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182 Dube P, Kurt K, Bair MJ, Theobald D, Williams LS. The p4 screener: evaluation of a brief measure 

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190 Eneman M, Sabbe B. Hopelessness in patients with schizophrenia. Suffering from and with 

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191 Evans E, Hawton K, Rodham K, Deeks J. The prevalence of suicidal phenomena in adolescents: a 

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192 Evans E, Hawton K, Rodham K. Suicidal phenomena and abuse in adolescents: A review of 

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193 Everly GS, Jr., Flynn BW. Principles and practical procedures for acute psychological first 

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194 Fajutrao L, Locklear J, Priaulx J, Heyes A. A systematic review of the evidence of the burden of 

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196 Fear NT, Wessely S. Young people leaving the UK armed forces at increased risk of suicide. Evid 

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202 Flood AM, Boyle SH, Calhoun PS, et al. Prospective study of externalizing and internalizing 

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204 Flouri E. Psychological and Sociological Aspects of Parenting and Their Relation to Suicidal 

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215 Friedman B, Heisel MJ, Delavan RL. Psychometric properties of the 15-item geriatric depression 

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233 Goeb J, Even C, Nicolas G, Gohier B, Dubas F, Garre J. Psychiatric side effects of interferon-beta 

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234 Golden WE, Hermann RC, Jewell M, Brewster C. Development of evidence-based performance 

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235 Goldman-Mellor SJ, Saxton KB, Catalano RC. Economic contraction and mental health: A review 

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246 Graham P. Review of Assessment scales in child and adolescent psychiatry. European Child & 

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251 Gunnell D, Eddleston M, Phillips MR, Konradsen F. The global distribution of fatal pesticide selfpoisoning: systematic review. BMC Public Health. 2007;7:357.2

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254 Gutierrez PM, Osman A. Getting the best return on your screening investment: An analysis of the 

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272 Haw C, Harwood D, Hawton K. Dementia and suicidal behavior: A review of the literature. 

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273 Haw C, Hawton K, Sutton L, Sinclair J, Deeks J. Schizophrenia and Deliberate Self-Harm: A 

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274 Hawgood J, De Leo D. Anxiety disorders and suicidal behaviour: an update. Curr Opin Psychiatry. 

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275 Hawton K, Harriss L, Casey D, et al. Self-harm in UK armed forces personnel: descriptive and 

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276 Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. Schizophrenia and suicide: systematic review of 

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277 Hawton K. Completed suicide after attempted suicide. BMJ. 2010;341:c3064. 5

278 Hays JT, Ebbert JO. Adverse effects and tolerability of medications for the treatment of tobacco 

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279 Hazell P. Depression in children and adolescents. Clin Evid (Online). 2009;2009. 3

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281 Heisel MJ, Duberstein PR. Suicide Prevention in Older Adults. Clinical Psychology: Science and 

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282 Heisel MJ, Links PS, Conn D, van Reekum R, Flett GL. Narcissistic personality and vulnerability 

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283 Heisel MJ. Suicide and Its Prevention Among Older Adults. The Canadian Journal of Psychiatry / 

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284 Hennekens CH, Hennekens AR, Hollar D, Casey DE. Schizophrenia and increased risks of 

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285 Hennen J, Baldessarini RJ. Suicidal risk during treatment with clozapine: A meta-analysis. 

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286 Herman SM. Is the SADPERSONS Scale accurate for the veterans affairs population? 

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287 Hernandez JAR, Navarro-Ruiz JM, Hernandez GT, Gonzalez AR. Construction of an attitudinal 

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288 Herrell R, Henter ID, Mojtabai R, et al. First psychiatric hospitalizations in the US military: the 

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289 Hesdorffer DC, Berg AT, Kanner AM. An update on antiepileptic drugs and suicide: are there 

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290 Hesdorffer DC, Rauch SL, Tamminga CA. Long-term psychiatric outcomes following traumatic 

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291 Hetrick S, Merry S, McKenzie J, Sindahl P, Proctor M. Selective serotonin reuptake inhibitors 

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292 Hirsch JK. A review of the literature on rural suicide: Risk and protective factors, incidence, and 

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293 Hittner JB. How robust is the Werther effect? A re-examination of the suggestion-imitation model 

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294 Holden RR, DeLisle MM. Factor analysis of the Beck Scale for Suicide Ideation with female 

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295 Holden RR, DeLisle MM. Factor Structure of the Reasons for Attempting Suicide Questionnaire 

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296 Holi MM, Pelkonen M, Karlsson L, et al. Psychometric properties and clinical utility of the Scale 

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297 Holtmann M, Bolte S, Poustka F. [Suicidality in depressive children and adolescents during 

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298 Hong J, Reed C, Novick D, Haro JM, Aguado J. Clinical and economic consequences of 

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299 Hopwood CJ, Baker KL, Morey LC. Extratest validity of Selected Personality Assessment 

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300 Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J 

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301 Hough D, Lewis P. A suicide prevention advisory group at an academic medical center. Mil Med. 

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302 Huesmann L, Taylor LD. The role of media violence in violent behavior. Annual Review of Public 

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303 Hughes JR. Smoking and suicide: A brief overview. Drug and Alcohol Dependence. 2008 

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304 Hughes S, Cohen D. A systematic review of long-term studies of drug treated and non-drug treated 

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305 Humeau M, Papet N, Jaafari N, Gotzamanis L, Lafay N, Senon J. Availability of firearms and risk 

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306 Hutchinson JW, Greene JP, Hansen SL. Evaluating active duty risk-taking: military home, 

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307 Huth-Bocks AC, Kerr DC, Ivey AZ, Kramer AC, King CA. Assessment of psychiatrically 

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308 Hwang JP, Lee TW, Tsai SJ, et al. Cortical and subcortical abnormalities in late-onset depression 

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309 Ide N, Wyder M, Kolves K, De Leo D. Separation as an important risk factor for suicide: A 

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310 Ilgen MA, Burnette ML, Conner KR, Czyz E, Murray R, Chermack S. The association between 

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311 Ilgen MA, Tiet Q, Finney JW, Harris AH. Recent suicide attempt and the effectiveness of inpatient 

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312 Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Mental illness, previous suicidality, and access 

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313 Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Pain and suicidal thoughts, plans and attempts 

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314 Ille R, Spona J, Zickl M, et al. “Add-On”-therapy with an individualized preparation consisting 

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315 Innamorati M, Pompili M, Amore M, et al. Suicide prevention in late life: Is there sound evidence 

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316 Inoue K, Tanii H, Abe S, et al. The risk factors of suicide by poisoning among psychiatry 

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317 Iorio A, Marchesini E, Awad T, Gluud LL. Antiviral treatment for chronic hepatitis C in patients 

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318 Irons J. Fluvoxamine in the treatment of anxiety disorders. Neuropsychiatr Dis Treat. 2005 

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319 Jacono J, Jacono B. The use of puppetry for health promotion and suicide prevention among 

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320 Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder 

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321 Jakupcak M, Hoerster KD, Varra A, Vannoy S, Felker B, Hunt S. Hopelessness and suicidal 

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322 Jakupcak M, Vannoy S, Imel Z, et al. Does PTSD moderate the relationship between social support 

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323 Jakupcak M, Varra EM. Treating Iraq and Afghanistan war veterans with PTSD who are at high 

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324 Janet Kuramoto S, Brent DA, Wilcox HC. The impact of parental suicide on child and adolescent 

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325 Jayasekera H, Carter G, Clover K. Comparison of the Composite International Diagnostic 

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326 Jimenez-Trevino L, Blasco-Fontecilla H, Braquehais MD, Ceverino-Dominguez A, Baca-Garcia E. 

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327 Jobe TH, Harrow M. Long-Term Outcome of Patients With Schizophrenia: A Review. The 

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328 Joe S, Bryant H. Evidence-based suicide prevention screening in schools. Children & Schools. 

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329 Joe S, Niedermeier D. Preventing Suicide: A Neglected Social Work Research Agenda. Br J Soc 

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330 Joe S, Niedermeier DM. Social work research on African Americans and suicidal behavior: a 

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331 Johansson K, Ekblad S, Lindencrona F, Shahnavaz S. Promoting mental health and preventing 

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332 Johnson J, Wood AM, Gooding P, Taylor PJ, Tarrier N. Resilience to suicidality: The buffering 

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333 Joiner TE, Jr., Brown JS, Wingate LR. The Psychology and Neurobiology of Suicidal Behavior. 

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334 Jones G, Gavrilovic JJ, McCabe R, Becktas C, Priebe S. Treating suicidal patients in an acute 

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335 Jones-Fairnie H, Ferroni P, Silburn S, D. L. Suicide in Australian veterinarians. Aust Vet J. 

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336 Jorm AF, Kelly CM, Morgan AJ. Participant distress in psychiatric research: a systematic review. 

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337 Judd F, Cooper A-M, Fraser C, Davis J. Rural suicide--people or place effects? Australian and New 

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338 Juurlink DN, Mamdani MM, Kopp A, Redelmeier DA. The risk of suicide with selective serotonin 

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339 Kaczmarek TL, Hagan MP, Kettler RJ. Screening for Suicide Among Juvenile Delinquents: 

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340 Kaizar EE, Greenhouse JB, Seltman H, Kelleher K. Do antidepressants cause suicidality in 

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341 Kang HK, Bullman TA. Risk of suicide among US veterans after returning from the Iraq 

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342 Kanner AM. Depression and epilepsy: A review of multiple facets of their close relation. 

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343 Kao YC, Liu YP. Suicidal Behavior and Insight into Illness Among Patients with Schizophrenia 

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344 Kaplan MS, Huguet N, McFarland BH, Mandle JA. Factors associated with suicide by firearm 

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345 Kaplan MS, McFarland BH, Huguet N. Characteristics of adult male and female firearm 

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346 Kaplan MS, McFarland BH, Huguet N. Firearm suicide among veterans in the general population: 

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347 Kapur N, While D, Blatchley N, Bray I, Harrison K. Suicide after leaving the UK armed forces--a 

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348 Karayal ON, Anway SD, Batzar E, Vanderburg DG. Assessments of suicidality in double-blind, 

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349 Kasckow J, Montross L, Golshan S, et al. Suicidality in middle aged and older patients with 

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350 Kashdan TB, Frueh B, Knapp RG, Hebert R, Magruder KM. Social anxiety disorder in veterans 

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351 Kasper S, Montgomery SA, Moller HJ, et al. Longitudinal analysis of the suicidal behaviour risk 

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352 Katz LY, Elias B, O’Neil J, et al. Aboriginal suicidal behaviour research: from risk factors to 

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353 Kausch O, Rugle L, Rowland DY. Lifetime histories of trauma among pathological gamblers. Am J 

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354 Kelly CM, Jorm AF, Kitchener BA, Langlands RL. Development of mental health first aid 

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355 Kene-Allampalli P, Hovey JD, Meyer GJ, Mihura JL. Evaluation of the reliability and validity of 

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356 Kenedi CA, Goforth HW. A Systematic Review of the Psychiatric Side-Effects of Efavirenz. AIDS 

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357 Kennard BD, Silva SG, Mayes TL, et al. Assessment of safety and long-term outcomes of initial 

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358 Kennedy A, Cloutier P, Glennie JE, Gray C. Establishing best practice in pediatric emergency 

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359 Kennedy CH, Cook JH, Poole DR, Brunson CL, Jones DE. Review of the first year of an overseas 

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360 Kessing LV, Sondergard L, Kvist K, Andersen PK. Suicide risk in patients treated with lithium. 

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361 Khan A, Schwartz K. Suicide risk and symptom reduction in patients assigned to placebo in 

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362 Kilbane EJ, Gokbayrak N, Galynker I, Cohen L, Tross S. A review of panic and suicide in bipolar 

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363 Kim YA, Bogner HR, Brown GK, Gallo JJ. Chronic medical conditions and wishes to die among 

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364 Kim YS, Leventhal B. Bullying and suicide. A review. Int J Adolesc Med Health. 2008 AprJun;20(2):133-54.6

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366 King CA, Kramer A, Preuss L, Kerr DC, Weisse L, Venkataraman S. Youth-Nominated Support 

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367 King CA, Merchant CR. Social and interpersonal factors relating to adolescent suicidality: A 

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368 Kirsch I. Medication and suggestion in the treatment of depression. Contemporary Hypnosis. 

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369 Kleespies PM, AhnAllen CG, Knight JA, et al. A study of self-injurious and suicidal behavior in a 

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370 Klein DF. The flawed basis for FDA post-marketing safety decisions: the example of antidepressants and children. Neuropsychopharmacology. 2006 Apr;31(4):689-99.5

371 Klomek AB, Sourander A, Gould M. The association of suicide and bullying in childhood to young 

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372 Klonsky E, May A. Rethinking impulsivity in suicide. Suicide and Life-Threatening Behavior. 

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373 Kodaka M, Postuvan V, Inagaki M, Yamada M. A systematic review of scales that measure 

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374 Koenig HG. Research on religion, spirituality, and mental health: a review. Can J Psychiatry. 2009 

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375 Koerts J, Leenders K, Koning M, Bouma A, van Beilen M. The assessment of depression in 

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376 Kohli MA, Salyakina D, Pfennig A, et al. Association of genetic variants in the neurotrophic 

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377 Kolla NJ, Eisenberg H, Links PS. Epidemiology, risk factors, and psychopharmacological 

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378 Konrad N, Daigle MS, Daniel AE, et al. Preventing suicide in prisons, part I. Recommendations 

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379 Kooyman I, Dean K, Harvey S, Walsh E. Outcomes of public concern in schizophrenia. Br J 

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380 Kostenuik M, Ratnapalan M. Approach to adolescent suicide prevention. Can Fam Physician. 2010 

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381 Koukopoulos A, Albert MJ, Sani G, Koukopoulos AE, Girardi P. Mixed depressive states: 

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382 Kovacic Z, Henigsberg N, Pivac N, Nedic G, Borovecki A. Platelet serotonin concentration and 

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383 Kratochvil CJ, Vitiello B, Walkup J, et al. Selective serotonin reuptake inhibitors in pediatric 

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384 Krause JS, Reed KS, McArdle JJ. Factor structure and predictive validity of somatic and 

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385 Krishnan K. Psychiatric and Medical Comorbidities of Bipolar Disorder. Psychosomatic Medicine. 

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386 Krishnan P, Hawranik P. Diagnosis and management of geriatric insomnia: a guide for nurse 

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387 Krysinska K, De Leo D. Suicide on railway networks: Epidemiology, risk factors and prevention. 

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388 Krysinska K, Heller TS, De Leo D. Suicide and deliberate self-harm in personality disorders. 

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389 Krysinska K, Lester D. Post-traumatic stress disorder and suicide risk: a systematic review. Arch 

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390 Krysinska K, Martin G. The struggle to prevent and evaluate: Application of population 

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392 Ku YC, Tsai YF, Lin YC, Lin YP. Suicide experiences among institutionalized older veterans in 

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393 Kukla L, Hruba D, Tyrlik M. [Suicidal attempts within the set of young adult parents of children 

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394 Kumar S, Malone D. Panic disorder. Clin Evid (Online). 2008;2008. 3

395 Kuritarne SI. [Features of borderline suicidality. Review of the literature]. Psychiatr Hung. 

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396 Kutcher S, Gardner DM. Use of selective serotonin reuptake inhibitors and youth suicide: Making 

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397 Lake CR. How academic psychiatry can better prepare students for their future patients. Part I: 

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398 Lake CR. How academic psychiatry can better prepare students for their future patients. Part II: a 

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399 Lakeman R, FitzGerald M. How people live with or get over being suicidal: a review of qualitative 

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400 Langhinrichsen-Rohling J, Friend J, Powell A. Adolescent suicide, gender, and culture: A rate and 

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401 Langhinrichsen-Rohling J, Snarr JD, Slep AM, Heyman RE, Foran HM. Risk for suicidal ideation 

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402 Lapierre S, Dube M, Bouffard L, Alain M. Addressing suicidal ideations through the realization of 

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403 Large M, Ryan C, Nielssen O. The validity and utility of risk assessment for inpatient suicide. 

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404 Large M, Smith G, Nielssen O. The epidemiology of homicide followed by suicide: a systematic 

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405 Large MM, Nielssen OB, Lackersteen SM. Did the introduction of ‘dangerousness’ and ‘risk 

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406 Large MM, Nielssen OB. Suicide in Australia: meta-analysis of rates and methods of suicide 

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407 LeGris J, van Reekum R. The Neuropsychological Correlates of Borderline Personality Disorder 

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408 Lemaire CM, Graham DP. Factors associated with suicidal ideation in OEF/OIF veterans. J Affect 

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409 Lemon DD. Killing me softly: A meta-analysis examining risk factors associated with suicide 

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410 Leon AC, Solomon DA, Li C, et al. Antidepressants and risks of suicide and suicide attempts: a 27-

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411 Lester D, McSwain S, Gunn JF, 3rd. A test of the validity of the IS PATH WARM warning signs 

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412 Lester D. Resources and Tactics for Preventing Suicide. Clinical Neuropsychiatry: Journal of 

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413 Lester D. Suicide and Islam. Archives of Suicide Research. 2006;10(1):77-97. 5

414 Levinson DF. The genetics of depression: a review. Biol Psychiatry. 2006 Jul 15;60(2):84-92. 5

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416 Li D, Duan Y, He L. Association study of serotonin 2A receptor (5-HT2A) gene with schizophrenia 

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417 Li D, He L. Meta-analysis supports association between serotonin transporter (5-HTT) and suicidal 

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418 Li Z, Page A, Martin G, Taylor R. Attributable risk of psychiatric and socio-economic factors for 

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419 Licinio J, Wong M-L. Depression, antidepressants and suicidality: a critical appraisal. Nat Rev 

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420 Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. 

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421 Links PS, Eynan R, Heisel MJ, et al. Affective instability and suicidal ideation and behavior in 

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422 Links PS, Hoffman B. Preventing suicidal behaviour in a general hospital psychiatric service: 

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423 Liu X, Buysse DJ. Sleep and youth suicidal behavior: A neglected field. Current Opinion in 

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424 Lizardi D, Dervic K, Grunebaum MF, Burke AK, Mann J, Oquendo MA. The role of moral 

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425 Lizardi D, Gearing R. Religion and suicide: Buddhism, Native American and African religions, 

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426 Lizardi D, Stanley B. Treatment engagement: A neglected aspect in the psychiatric care of suicidal 

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427 Long CG, Fulton B, Dolley O, Hollin CR. Dealing with Feelings: the effectiveness of cognitive 

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428 Lopez-Morinigo JD, Ramos-Rios R, David AS, Dutta R. Insight in schizophrenia and risk of 

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429 Ludwig J, Marcotte DE, Norberg K. Anti-depressants and suicide. J Health Econ. 2009 

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430 Luxton DD, Greenburg D, Ryan J, Niven A, Wheeler G, Mysliwiec V. Prevalence and impact of 

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431 Lynch MA, Howard PB, El-Mallakh P, Matthews JM. Assessment and management of hospitalized 

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432 Lyness JM, Heo M, Datto CJ, et al. Outcomes of minor and subsyndromal depression among 

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433 MacNeil MS. An epidemiologic study of Aboriginal adolescent risk in Canada: The meaning of 

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434 Madhusoodanan S, Ibrahim FA, Malik A. Primary prevention in geriatric psychiatry. Annals of 

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435 Magnusson PK, Rasmussen F, Lawlor DA, Tynelius P, Gunnell D. Association of body mass index 

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436 Maharaj RG, Nunes P, Renwick S. Health risk behaviours among adolescents in the Englishspeaking Caribbean: A review. Child and Adolescent Psychiatry and Mental Health. 2009 

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437 Mak A. A short review on the diagnostic issues of bipolar spectrum disorders in clinically 

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438 Malmberg, Lena, Fenton, Mark, Rathbone, John. Individual psychodynamic psychotherapy 

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439 Mann J, Currier D. A Review of Prospective Studies of Biologic Predictors of Suicidal Behavior in 

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440 Mann J, Currier D. Evidence-based suicide prevention strategies: An overview. Pompili, Maurizio 

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441 Manna M. Effectiveness of formal observation in inpatient psychiatry in preventing adverse 

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442 Manor I, Gutnik I, Ben-Dor DH, et al. Possible association between attention deficit hyperactivity 

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443 Manthorpe J, Iliffe S. Social work with older people--Reducing suicide risk: A critical review of 

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444 Manthorpe J, Iliffe S. Suicide in later life: public health and practitioner perspectives. Int J Geriatr 

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445 Marangell LB, Bauer MS, Dennehy EB, et al. Prospective predictors of suicide and suicide 

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446 March J, Silva S, Vitiello B, Team T. The Treatment for Adolescents with Depression Study 

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447 March JS, Klee BJ, Kremer CM. Treatment benefit and the risk of suicidality in multicenter, 

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448 March JS, Silva S, Petrycki S, et al. The Treatment for Adolescents With Depression 

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449 Marqueling AL, Zane LT. Depression and suicidal behavior in acne patients treated with 

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450 Marqueling AL, Zane LT. Depression and suicidal behavior in acne patients treated with 

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451 Marshall BD, Werb D. Health outcomes associated with methamphetamine use among young 

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452 Martin SL, Macy RJ, Sullivan K, Magee ML. Pregnancy-associated violent deaths: the role of 

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453 Maslov B, Marcinko D, Milicevic R, Babic D, Dordevic V, Jakovljevic M. Metabolic syndrome, 

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454 Maughan B, Iervolino AC, Collishaw S. Time trends in child and adolescent mental disorders. 

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455 McAuliffe N, Perry L. Making it safer: a health centre’s strategy for suicide prevention. Psychiatr 

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456 McCarthy JF, Valenstein M, Kim HM, Ilgen M, Zivin K, Blow FC. Suicide mortality among 

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457 McCartney G, Thomas S, Thomson H, et al. The health and socioeconomic impacts of major 

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458 McElroy SL, Kotwal R, Kaneria R, Keck PE, Jr. Antidepressants and suicidal behavior in bipolar 

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459 McMillan D, Gilbody S, Beresford E, Neilly L. Can we predict suicide and non-fatal self-harm 

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460 Mee S, Bunney BG, Reist C, Potkin SG, Bunney WE. Psychological pain: a review of evidence. J 

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461 Melle I, Johannessen JO, Friis S, et al. Course and predictors of suicidality over the first two 

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462 Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the 

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463 Merrick J, Merrick E, Lunsky Y, Kandel I. Review of suicidality in persons with intellectual 

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464 Michel PO, Lundin T, Larsson G. Suicide rate among former Swedish peacekeeping personnel. Mil 

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465 Miller EJ, Chung H. A literature review of studies of depression and treatment outcomes among 

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466 Miller M, Barber C, Azrael D, Calle EE, Lawler E, Mukamal KJ. Suicide among US veterans: 

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467 Miller PG, Coomber K, Staiger P, Zinkiewicz L, Toumbourou JW. Review of rural and regional 

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468 Mills JF, Green K, Reddon JR. An evaluation of the Psychache Scale on an offender population. 

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469 Mills JF, Kroner DG. Predicting suicidal ideation with the Depression Hopelessness and Suicide 

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470 Mills PD, Neily J, Luan D, Osborne A, Howard K. Actions and implementation strategies to 

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471 Mills PD, Watts BV, Miller S, et al. A checklist to identify inpatient suicide hazards in veterans 

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472 Milner A, De Leo D. Who seeks treatment where? Suicidal behaviors and health care: evidence 

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473 Mironova P, Rhodes AE, Bethell JM, et al. Childhood physical abuse and suicide-related behavior: 

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474 Moller HJ, Baldwin DS, Goodwin G, et al. Do SSRIs or antidepressants in general increase 

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475 Moller HJ. Evidence for beneficial effects of antidepressants on suicidality in depressive patients: a 

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476 Moller HJ. Is there evidence for negative effects of antidepressants on suicidality in depressive 

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477 Montross LP, Zisook S, Kasckow J. Suicide Among Patients with Schizophrenia: A Consideration 

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478 Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras 

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479 Morey LC, Hopwood CJ, Gunderson JG, et al. Comparison of alternative models for personality 

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480 Morrison R, O’Connor RC. A systematic review of the relationship between rumination and 

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481 Mortimer AM, Singh P, Shepherd CJ, Puthiryackal J. Clozapine for treatment-resistant 

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482 Moscicki EK, West JC, Rae DS, Rubio-Stipec M, Wilk JE, Regier DA. Suicidality is associated 

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483 Mosholder AD, Willy M. Suicidal adverse events in pediatric randomized, controlled clinical trials 

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486 Muehlenkamp JJ, Cowles ML, Gutierrez PM. Validity of the Self-Harm Behavior Questionnaire 

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487 Muehlenkamp JJ, Gutierrez PM, Osman A, Barrios FX. Validation of the Positive and Negative 

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488 Mulder RT, Joyce PR, Frampton CM, Luty SE. Antidepressant treatment is associated with a 

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489 Muller B, Georgi K, Schnabel A, Schneider B. Does sport have a protective effect against suicide? 

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493 Nademin ME. An investigation of interpersonal-psychological variables in Air force suicides: A 

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494 Naud H, Daigle MS. Predictive validity of the Suicide Probability Scale in a male inmate 

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495 Navarro-Mancilla AA, Rueda-Jaimes GE. Internet Addiction: A Critical Review of the Literature. 

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498 Nock MK, Borges G, Bromet EJ, Cha CB, Kessler RC, Lee S. Suicide and suicidal behavior. 

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499 Nock MK, Holmberg EB, Photos VI, Michel BD. Self-Injurious Thoughts and Behaviors 

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500 Nock MK, Prinstein MJ, Sterba SK. Revealing the form and function of self-injurious thoughts and 

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501 Nordentoft M, Branner J. Gender differences in suicidal intent and choice of method among 

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506 Oldham J. PTSD and suicide. Journal of Psychiatric Practice. 2008 Jul;14(4):195. 5

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509 Olmsted CL, Kockler DR. Topiramate for alcohol dependence. Ann Pharmacother. 2008 

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510 Olson LM, Wahab S. American Indians and Suicide: A Neglected Area of Research. Trauma, 

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511 Omalu B, Hammers JL, Bailes J, et al. Chronic traumatic encephalopathy in an Iraqi war veteran 

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512 Omar HA. A model program for youth suicide prevention. Int J Adolesc Med Health. 2005 JulSep;17(3):275-8.4

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514 Opler M, Sodhi D, Zaveri D, Madhusoodanan S. Primary psychiatric prevention in children and 

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515 Oquendo M, Currier D, Mann J. Prospective studies of suicidal behavior in major depressive and 

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516 Oquendo MA, Chaudhury SR, Mann J. Pharmacotherapy of Suicidal Behavior in Bipolar Disorder. 

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517 Osman A, Barrios FX, Gutierrez PM, Williams JE, Bailey J. Psychometric properties of the Beck 

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518 Osman A, Gutierrez PM, Schweers R, Fang Q, Holguin-Mills RL, Cashin M. Psychometric 

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520 Owens C, Owen G, Lambert H, et al. Public involvement in suicide prevention: understanding and 

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524 Page SA, King MC. No-suicide agreements: current practices and opinions in a Canadian urban 

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525 Pagura J, Fotti S, Katz LY, Sareen J, Swampy Cree Suicide Prevention T. Help seeking and 

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526 Palmer BA, Pankratz V, Bostwick JM. The Lifetime Risk of Suicide in Schizophrenia: A 

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527 Palmer S. Suicide statistics for the UK and the National Suicide Prevention Strategy. Palmer, 

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531 Pavot W, Diener E. The Satisfaction With Life Scale and the emerging construct of life satisfaction. 

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532 Pedersen AG. Citalopram and suicidality in adult major depression and anxiety disorders. Nord J 

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533 Pedersen AG. Escitalopram and suicidality in adult depression and anxiety. Int Clin 

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534 Pena JB, Caine ED. Screening as an Approach for Adolescent Suicide Prevention. Suicide and Life 

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535 Peterson J, Skeem J, Manchak S. If you want to know, consider asking: How likely is it that 

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536 Pettit JW, Garza MJ, Grover KE, et al. Factor structure and psychometric properties of the 

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537 Phillips KA. Suicidality in body dysmorphic disorder. Primary Psychiatry. 2007 Dec;14(12):58-66. 5

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539 Pisani AR, Cross WF, Gould MS. The Assessment and Management of Suicide Risk: State of 

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540 Platt B, Hawton K, Simkin S, Mellanby RJ. Suicidal behaviour and psychosocial problems in 

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541 Ploderl M, Sauer J, Fartacek R. Suicidality and mental health of homosexual and bisexual men and 

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542 Pompili M, Di Cosimo D, Innamorati M, Lester D, Tatarelli R, Martelletti P. Psychiatric 

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543 Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: A metaanalysis. Nordic Journal of Psychiatry. 2005 Oct;59(5):319-24.5

544 Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in the epilepsies: a meta-analytic 

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545 Pompili M, Girardi P, Tatarelli G, Ruberto A, Tatarelli R. Suicide and attempted suicide in eating 

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546 Pompili M, Girardi P, Tatarelli R. Death from suicide versus mortality from epilepsy in the 

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547 Pompili M, Innamorati M, Girardi P, Tatarelli R, Lester D. Evidence-based interventions 

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548 Pompili M, Innamorati M, Tatarelli R. Suicide and anorexia nervosa. Minerva Psichiatrica. 2007 

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549 Pompili M, Lester D, Innamorati M, et al. Preventing suicide in jails and prisons: Suggestions from 

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3

550 Pompili M, Mancinelli I, Girardi P, Ruberto A, Tatarelli R. Suicide in Anorexia Nervosa: A MetaAnalysis. International Journal of Eating Disorders. 2004;36(1):99-103.5

551 Pompili M, Mancinelli I, Ruberto A, Kotzalidis GD, Girardi P, Tatarelli R. Where Schizophrenic 

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6

552 Pompili M, Serafini G, Forte A, Del Casale A, Innamorati M, Tatarelli R. Suicide risk in cancer 

patients. Medicina Psicosomatica. 2008 Jul-Sep;53(3):105-16.

1

553 Pompili M, Serafini G, Innamorati M, et al. Suicide risk in first episode psychosis: A selective 

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6

554 Poon LH, Kang GA, Lee AJ. Role of tetrabenazine for Huntington’s disease-associated chorea. 

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4

555 Portzky G, van Heeringen K. Deliberate self-harm in adolescents. Current Opinion in Psychiatry. 

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5

556 Posey S. Veterans and suicide: A review of potential increased risk. Smith College Studies in Social 

Work. 2009 Jul;79(3-4):368-74.

5

557 Posner K, Melvin GA, Stanley B. Identification and monitoring of suicide risk in primary care 

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5

558 Posner K, Oquendo MA, Gould M, Stanley B, Davies M. Columbia Classification Algorithm of 

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5

559 Posternak MA, Zimmerman M. Therapeutic effect of follow-up assessments on antidepressant and 

placebo response rates in antidepressant efficacy trials: meta-analysis. British Journal of Psychiatry. 

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6

560 Preston E, Hansen L. A systematic review of suicide rating scales in schizophrenia. Crisis: The 

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6

561 Preti A, Rocchi MB, Sisti D, Camboni MV, Miotto P. A comprehensive meta-analysis of the risk of 

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5

562 Price RK, Chen L-S, Risk NK, et al. Suicide in a natural history study: Lessons and insights 

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563 Probst C, Zelle BA, Sittaro NA, Lohse R, Krettek C, Pape HC. Late death after multiple severe 

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564 Procter NG. Parasuicide, self-harm and suicide in Aboriginal people in rural Australia: A review of 

the literature with implications for mental health nursing practice. International Journal of Nursing 

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5

565 Purselle DC, Heninger M, Hanzlick R, Garlow SJ. Differential association of socioeconomic status 

in ethnic and age-defined suicides. Psychiatry Res. 2009 May 30;167(3):258-65.

9

566 Quarantini LC, Netto LR, Andrade-Nascimento M, et al. Comorbid mood and anxiety disorders 

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3

567 Raja M, Azzoni A, Koukopoulos AE. Psychopharmacological treatment before suicide attempt 

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2

568 Raja M, Azzoni A. Are antidepressants warranted in the treatment of patients who present suicidal 

behavior? Hum Psychopharmacol. 2008 Dec;23(8):661-8.

2

569 Ramey HL, Busseri MA, Khanna N, Hamilton YN, Ottawa YN, Rose-Krasnor L. Youth 

engagement and suicide risk: testing a mediated model in a Canadian community sample. J Youth 

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3

570 Randle AA, Graham CA. A review of the evidence on the effects of intimate partner violence on 

men. Psychology of Men & Masculinity. 2011 Apr;12(2):97-111.

5

571 Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment 

of mental illness in athletes. Sports Med. 2010 Nov 1;40(11):961-80.

5

572 Redden L, Pritchett Y, Robieson W, et al. Suicidality and divalproex sodium: Analysis of controlled 

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7

573 Reeves RR, Ladner ME. Antidepressant-induced suicidality: An update. CNS Neuroscience & 

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5

574 Reeves RR, Ladner ME. Antidepressant-induced suicidality: implications for clinical practice. 

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5

575 Reeves RR, Panguluri RL. Neuropsychiatric complications of traumatic brain injury. J Psychosoc 

Nurs Ment Health Serv. 2011 Mar;49(3):42-50.

5

576 Rehkopf DH, Buka SL. The association between suicide and the socio-economic characteristics of 

geographical areas: a systematic review. Psychol Med. 2006 Feb;36(2):145-57.

6

577 Reinherz HZ, Tanner JL, Berger SR, Beardslee WR, Fitzmaurice GM. Adolescent suicidal ideation 

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3

578 Reutfors J, Bahmanyar S, Jonsson EG, et al. Diagnostic profile and suicide risk in schizophrenia 

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2

579 Reviere SL, Farber EW, Twomey H, et al. Intimate partner violence and suicidality in low-income 

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580 Reynolds SK, Lindenboim N, Comtois KA, Murray A, Linehan MM. Risky assessments: 

participant suicidality and distress associated with research assessments in a treatment study of 

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581 Rhodes AE, Boyle MH, Tonmyr L, et al. Sex differences in childhood sexual abuse and suiciderelated behaviors. Suicide Life Threat Behav. 2011 Jun;41(3):235-54.6

582 Ribeiro JD, Pease JL, Gutierrez PM, et al. Sleep problems outperform depression and hopelessness 

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583 Richa N, Richa S, Salloum S, Baddoura C, Millet B, Mirabel-Sarron C. Familial risk factors 

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584 Richardson T. Correlates of substance use disorder in bipolar disorder: A systematic review and 

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6

585 Ridenour TA. Inhalants: Not to be taken lightly anymore. Current Opinion in Psychiatry. 2005 

May;18(3):243-7.

5

586 Rihmer Z, Akiskal H. Do antidepressants t(h)reat(en) depressives? Toward a clinically judicious 

formulation of the antidepressant-suicidality FDA advisory in light of declining national suicide 

statistics from many countries. Journal of Affective Disorders. 2006 Aug;94(1-3):3-13.

5

587 Rihmer Z, Gonda X. The Effect of Pharmacotherapy on Suicide Rates in Bipolar Patients. CNS 

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5

588 Rihmer Z. Suicide risk in mood disorders. Current Opinion in Psychiatry. 2007 Jan;20(1):17-22. 5

589 Roaldset JO, Bjorkly S. Patients’ own statements of their future risk for violent and self-harm 

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2

590 Roberts SE, Jaremin B, Chalasani P, Rodgers SE. Suicides among seafarers in UK merchant 

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591 Roberts SJ. Health care recommendations for lesbian women. J Obstet Gynecol Neonatal Nurs. 

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5

592 Robertson HT, Allison DB. Drugs associated with more suicidal ideations are also associated with 

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9

593 Robertson K, Parsons TD, Van Der Horst C, Hall C. Thoughts of death and suicidal ideation in 

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9

594 Robinson J, Harris MG, Harrigan SM, et al. Suicide attempt in first-episode psychosis: a 7.4 year 

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9

595 Robson A, Scrutton F, Wilkinson L, MacLeod F. The risk of suicide in cancer patients: a review of 

the literature. Psychooncology. 2010 Dec;19(12):1250-8.

6

596 Rodriguez JR, Quinones-Maldonado R, Alvarado-Pomales A. Military suicide: factors that 

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5

597 Rossow I, Romelsjo A. The extent of the ‘prevention paradox’ in alcohol problems as a function of 

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2

598 Rowell K, Green B, Guidry J, Eddy J. Factors associated with suicide among African American 

adult men: A systematic review of the literature. Journal of Men’s Health. 2008 Dec;5(4):274-81.

6

599 Roy A, Janal MN. Risk factors for suicide attempts among alcohol dependent patients. Arch 

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9

600 Roy A, Roy M, Janal M. Suicide attempts and ideation in African-American type 1 diabetic 

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9

601 Roy A, Sarchiapone M, Carli V. Low resilience in suicide attempters. Arch Suicide Res. 

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602 Roy A, Sarchiopone M, Carli V. Gene-environment interaction and suicidal behavior. J Psychiatr 

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603 Roy A. Characteristics of cocaine dependent patients who attempt suicide. Arch Suicide Res. 

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604 Roy A. Combination of family history of suicidal behavior and childhood trauma may represent 

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605 Rubino A, Roskell N, Tennis P, Mines D, Weich S, Andrews E. Risk of suicide during treatment 

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606 Rucci P, Frank E, Scocco P, et al. Treatment-emergent suicidal ideation during 4 months of 

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2

607 Rudd M, Goulding J, Bryan CJ. Student veterans: A national survey exploring psychological 

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608 Rutledge CM, Rimer D, Scott M. Vulnerable Goth teens: the role of schools in this psychosocial 

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5

609 Ryan C, Huebner D, Diaz RM, Sanchez J. Family rejection as a predictor of negative health 

outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics. 2009 

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9

610 Ryden G, Ryden E, Hetta J. Borderline personality disorder and autism spectrum disorder in 

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2

611 Sadeghi-Nejad H, Watson R. Premature ejaculation: current medical treatment and new directions 

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5

612 Safer DJ, Zito JM. Do antidepressants reduce suicide rates? Public Health. 2007 Apr;121(4):274-7. 5

613 Sahin NH, Batigun AD. [Testing the probability of a model to predict suicide risk in high school 

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1

614 Sajatovic M, Biswas K, Kilbourne AK, Fenn H, Williford W, Bauer MS. Factors associated with 

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8

615 Sakinofsky I. The current evidence base for the clinical care of suicidal patients: strengths and 

weaknesses. Can J Psychiatry. 2007 Jun;52(6 Suppl 1):7S-20S.

6

616 Sakinofsky I. Treating suicidality in depressive illness. Part 1: current controversies. Can J 

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6

617 Sakinofsky I. Treating suicidality in depressive illness. Part 2: does treatment cure or cause 

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6

618 Santa Mina E, Gallop R, Links P, et al. The Self-Injury Questionnaire: Evaluation of the 

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619 Sareen J, Afifi TO, McMillan KA, Asmundson GJ. Relationship between household income 

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620 Sareen J, Cox BJ, Afifi TO, et al. Combat and peacekeeping operations in relation to prevalence of 

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621 Sareen J, Cox BJ, Stein MB, Afifi TO, Fleet C, Asmundson GJ. Physical and mental comorbidity, 

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622 Sareen J, Stein MB, Thoresen S, Belik SL, Zamorski M, Asmundson GJ. Is peacekeeping 

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6

623 Sarkar NN. Childhood sexual abuse and its impact on woman’s health. International Medical 

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624 Saunders KE, Hawton K. Suicidal behaviour and the menstrual cycle. Psychological Medicine: A 

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625 Schafer DW. Causes and rates of death among help-seeking male Vietnam veterans treated for 

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626 Schneeweiss S, Patrick AR, Solomon DH, et al. Comparative safety of antidepressant agents for 

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627 Schneeweiss S, Patrick AR, Solomon DH, et al. Variation in the risk of suicide attempts and 

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9

628 Schneider B, Bartusch B, Schnabel A, Fritze J. [Age and gender: confounders for axis I disorders 

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629 Schneider B, Georgi K, Weber B, Schnabel A, Ackermann H, Wetterling T. [Risk factors for 

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1

630 Schneider R, Burnette ML, Ilgen MA, Timko C. Prevalence and correlates of intimate partner 

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9

631 Scholz BA, Hammonds CL, Boomershine CS. Duloxetine for the management of fibromyalgia 

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632 Schulte PF. Risk of clozapine-associated agranulocytosis and mandatory white blood cell 

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3

633 Schumock GT, Lee TA, Joo MJ, Valuck RJ, Stayner LT, Gibbons RD. Association between 

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634 Scoville SL, Gubata ME, Potter RN, White MJ, Pearse LA. Deaths attributed to suicide among 

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8

635 Seemuller F, Lewitzka U, Muller HJ. In people taking antidepressants, suicidal behaviour is less 

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636 Semiz UB, Basoglu C, Oner O, et al. Effects of diagnostic comorbidity and dimensional symptoms 

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637 Shah A. Psychiatry of old age and ethnic minority older people in the United Kingdom. Reviews in 

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638 Shahid M, Hyder AA. Deliberate self-harm and suicide: a review from Pakistan. Int J Inj Contr Saf 

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2

639 Sharma S, Sharma M. Stress-induced psychological vital signs in military domain: Assessment and 

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5

640 Sher L. Alcoholism and suicidal behavior: A clinical overview. Acta Psychiatrica Scandinavica. 

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641 Sher L. Brain-derived neurotrophic factor and suicidal behavior. QJM. 2011 May;104(5):455-8. 5

642 Shields LB, Hunsaker DM, Hunsaker JC, III. Schizophrenia and suicide: A 10-year review of 

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4

643 Shreeram SS, Malik A. Suicidality in the juvenile justice environment. International Journal of 

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644 Simon GE, Savarino J, Operskalski B, Wang PS. Suicide risk during antidepressant treatment. Am 

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645 Simon NM, Pollack MH, Fischmann D, et al. Complicated grief and its correlates in patients with 

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9

646 Simpson G, Franke B, Gillett L. Suicide prevention training outside the mental health service 

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647 Simpson G, Tate R. Suicidality in people surviving a traumatic brain injury: prevalence, risk 

factors and implications for clinical management. Brain Inj. 2007 Dec;21(13-14):1335-51.

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648 Sinclair JM, Gray A, Hawton K. Systematic review of resource utilization in the hospital 

management of deliberate self-harm. Psychol Med. 2006 Dec;36(12):1681-93.

3

649 Singh T, Williams K. Atypical depression. Psychiatry. 2006 Apr;3(4):33-9. 3

650 Skegg K, Firth H, Gray A, Cox B. Suicide by occupation: does access to means increase the risk? 

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9

651 Skopp NA, Luxton DD, Bush N, Sirotin A. Childhood adversity and suicidal ideation in a clinical 

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8

652 Skruibis P, Gailiene D, Kazlauskas E. Level of hopelessness, attitudes towards suicide and suicide 

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653 Slee N, Garnefski N, van der Leeden R, Arensman E, Spinhoven P. Cognitive-behavioural 

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2

654 Smith EG, Craig TJ, Ganoczy D, Walters HM, Valenstein M. Treatment of Veterans with 

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4

655 Smith EG. Association between antidepressant half-life and the risk of suicidal ideation or behavior 

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656 Smyth CL, MacLachlan M. Confirmatory Factor Analysis of the Trinity Inventory of Precursors 

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3

657 Snarr JD, Heyman RE, Slep AM. Recent suicidal ideation and suicide attempts in a large-scale 

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658 Soyka M, Schmidt P. Outpatient alcoholism treatment--24-month outcome and predictors of 

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9

659 Speckens AE, Hawton K. Social problem solving in adolescents with suicidal behavior: a 

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6

660 Spiegel B, Schoenfeld P, Naliboff B. Systematic review: the prevalence of suicidal behaviour in 

patients with chronic abdominal pain and irritable bowel syndrome. Aliment Pharmacol Ther. 2007 

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6

661 Stanley N, Mallon S, Bell J, Manthorpe J. Suicidal students’ use of and attitudes to primary care 

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3

662 Stapleton J. Do the 10 UK suicides among those taking the smoking cessation drug varenicline 

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5

663 Steele MM, Doey T. Suicidal behaviour in children and adolescents. part 1: etiology and risk 

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664 Stefansson J, Nordstrom P, Jokinen J. Suicide Intent Scale in the prediction of suicide. J Affect 

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665 Stone M, Laughren T, Jones ML, et al. Risk of suicidality in clinical trials of antidepressants 

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666 Strauss JL, Calhoun PS, Marx CE, et al. Comorbid posttraumatic stress disorder is associated with 

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667 Strutt AM, Simpson R, Jankovic J, York MK. Changes in cognitive-emotional and physiological 

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668 Studdert DM, Gurrin LC, Jatkar U, Pirkis J. Relationship between vehicle emissions laws and 

incidence of suicide by motor vehicle exhaust gas in Australia, 2001-06: an ecological analysis. 

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669 Sumner SA, Layde PM, Guse CE. Firearm death rates and association with level of firearm 

purchase background check. Am J Prev Med. 2008 Jul;35(1):1-6.

3

670 Szumilas M, Kutcher S. Teen suicide information on the internet: a systematic analysis of quality. 

Can J Psychiatry. 2009 Sep;54(9):596-604.

5

671 Tang NK, Crane C. Suicidality in chronic pain: a review of the prevalence, risk factors and 

psychological links. Psychol Med. 2006 May;36(5):575-86.

6

672 Taur FM, Chai S, Chen MB, Hou JL, Lin S, Tsai SL. Evaluating the suicide risk-screening scale 

used by general nurses on patients with chronic obstructive pulmonary disease and lung cancer: a 

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2

673 Taylor J, Kemper TS, Loney BR, Kistner JA. Classification of severe male juvenile offenders using 

the MACI clinical and personality scales. J Clin Child Adolesc Psychol. 2006 Feb;35(1):90-102.

9

674 Taylor PJ, Gooding P, Wood AM, Tarrier N. The role of defeat and entrapment in depression, 

anxiety, and suicide. Psychol Bull. 2011 May;137(3):391-420.

3

675 Teasdale T, Engberg A. Suicide after traumatic brain injury: a population study. Journal of 

Neurology, Neurosurgery & Psychiatry. 2001;71(4):436-40.

2

676 Thomas SH, Drici MD, Hall GC, et al. Safety of sertindole versus risperidone in schizophrenia: 

principal results of the sertindole cohort prospective study (SCoP). Acta Psychiatrica Scandinavica. 

2010 Nov;122(5):345-55.

2

677 Thompson R, Kane V, Cook JM, Greenstein R, Walker P, Woody G. Suicidal ideation in veterans 

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3

678 Thorell L. Valid electrodermal hyporeactivity for depressive suicidal propensity offers links to 

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5

679 Thoresen S, Mehlum L, Roysamb E, Tonnessen A. Risk factors for completed suicide in 

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680 Thoresen S, Mehlum L. Suicide in peacekeepers: risk factors for suicide versus accidental death. 

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681 Thoresen S, Mehlum L. Traumatic stress and suicidal ideation in Norwegian male peacekeepers. J 

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2

682 Tondo L, Baldessarini RJ. Long-term lithium treatment in the prevention of suicidal behavior in 

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5

683 Troister T, Links PS, Cutcliffe J. Review of predictors of suicide within 1 year of discharge from a 

psychiatric hospital. Curr Psychiatry Rep. 2008 Feb;10(1):60-5.

6

684 Tsai SJ, Hong CJ, Liou YJ. Recent molecular genetic studies and methodological issues in suicide 

research. Prog Neuropsychopharmacol Biol Psychiatry. 2010 Oct 23.

6

685 Turner O, Windfuhr K, Kapur N. Suicide in deaf populations: a literature review. Ann Gen 

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686 Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression 

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687 Utsey SO, Hook JN, Stanard P. A re-examination of cultural factors that mitigate risk and promote 

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688 Valente SM, Saunders J. Screening for depression and suicide: self-report instruments that work. J 

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689 van den Bosch LM, Verheul R. Patients with addiction and personality disorder: Treatment 

outcomes and clinical implications. Current Opinion in Psychiatry. 2007 Jan;20(1):67-71.

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690 Van Orden KA, Witte TK, Holm-Denoma J, Gordon KH, Joiner TE, Jr. Suicidal behavior on Axis 

VI: Clinical data supporting a sixth axis for DSM-V. Crisis: The Journal of Crisis Intervention and 

Suicide Prevention. 2011;32(2):110-3.

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691 VanCott AC, Cramer JA, Copeland LA, et al. Suicide-related behaviors in older patients with new 

anti-epileptic drug use: data from the VA hospital system. BMC Med. 2010;8:4.

3

692 Vitiello B, Silva SG, Rohde P, et al. Suicidal events in the Treatment for Adolescents With 

Depression Study (TADS). J Clin Psychiatry. 2009 May;70(5):741-7.

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693 Voracek M, Loibl LM. Consistency of immigrant and country-of-birth suicide rates: a metaanalysis. Acta Psychiatr Scand. 2008 Oct;118(4):259-71.6

694 Voracek M, Loibl LM. Genetics of suicide: a systematic review of twin studies. Wien Klin 

Wochenschr. 2007;119(15-16):463-75.

6

695 Wagenaar AC, Toomey TL. Effects of minimum drinking age laws: a review and analyses of the 

literature from 1960 to 2000. Journal of Studies on Alcohol. 2002 (Supplement 14):206-25.

3

696 Wagner KD, Jonas J, Findling RL, Ventura D, Saikali K. A double-blind, randomized, placebocontrolled trial of escitalopram in the treatment of pediatric depression. J Am Acad Child Adolesc 

Psychiatry. 2006 Mar;45(3):280-8.

9

697 Walker J, Hansen CH, Hodges L, et al. Screening for suicidality in cancer patients using Item 9 

of the nine-item patient health questionnaire; does the item score predict who requires further 

assessment? Gen Hosp Psychiatry. 2010 Mar-Apr;32(2):218-20.

3

698 Walker R, Cole JE, Logan T, Corrigan JD. Screening substance abuse treatment clients for 

traumatic brain injury: Prevalence and characteristics. The Journal of Head Trauma Rehabilitation. 

2007 Nov-Dec;22(6):360-7.

9

699 Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple sclerosis: 

Review of a lethal combination. J Rehabil Res Dev. 2006 Jan-Feb;43(1):45-62.

5

700 Walsh S, Clayton R, Liu L, Hodges S. Divergence in contributing factors for suicide among men 

and women in Kentucky: recommendations to raise public awareness. Public Health Rep. 2009 

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9

701 Warner CH, Appenzeller GN, Parker JR, Warner C, Diebold CJ, Grieger T. Suicide prevention in a 

deployed military unit. Psychiatry. 2011 Summer;74(2):127-41.

4

702 Warner CH, Breitbach JE, Appenzeller GN, Yates V, Grieger T, Webster WG. Division mental 

health in the new brigade combat team structure: part II. Redeployment and postdeployment. Mil 

Med. 2007 Sep;172(9):912-7.

4

703 Webb L. Counting girls out: A review of suicide among young substance misusers and gender 

difference implications in the evaluation of risk. Drugs: Education, Prevention & Policy. 2009 

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5

704 Webb RT, Marshall CE, Abel KM. Teenage motherhood and risk of premature death: long-term 

follow-up in the ONS Longitudinal Study. Psychol Med. 2011 Jan 28:1-11.

9

705 Weich S, Patterson J, Shaw R, Stewart-Brown S. Family relationships in childhood and common 

psychiatric disorders in later life: systematic review of prospective studies. Br J Psychiatry. 2009 

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6

706 Weiner J, Richmond TS, Conigliaro J, Wiebe DJ. Military veteran mortality following a survived 

suicide attempt. BMC Public Health. 2011 May 23;11(1):374.

4

707 Welton R. The management of suicidality: Assessment and intervention. Psychiatry. 2007 

May;4(5):24-32.

5

708 Werry JS. Predicting completed suicide. Journal of the American Academy of Child & Adolescent 

Psychiatry. 2007 Sep;46(9):1097.

5

709 White N, Litovitz T, Clancy C. Suicidal antidepressant overdoses: a comparative analysis by 

antidepressant type. J Med Toxicol. 2008 Dec;4(4):238-50.

9

710 Whitlock J, Eckenrode J, Silverman D. Self-injurious behaviors in a college population. Pediatrics. 

2006 Jun;117(6):1939-48.

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711 Wilcox HC, Storr CL, Breslau N. Posttraumatic stress disorder and suicide attempts in a 

community sample of urban American young adults. Arch Gen Psychiatry. 2009 Mar;66(3):305-11.

9

712 Williams JW, Jr., Slubicki MN, Tweedy DS, Bradford DW, Trivedi RB, Baker D. Determining the 

Responsiveness of Depression Questionnaires and Optimal Treatment Duration for Antidepressant 

Medications. 2009 Oct Questionnaires and Optimal Treatment Duration for Antidepressant 

Medications.

3

713 Witte TK, Joiner TE, Jr., Brown GK, et al. Factors of suicide ideation and their relation to clinical 

and other indicators in older adults. Journal of Affective Disorders. 2006 Aug;94(1-3):165-72.

3

714 Wockel L, Goth K, Matic N, Zepf FD, Holtmann M, Poustka F. Psychopharmacotherapy in 

adolescents with borderline personality disorder in inpatient and outpatient psychiatric treatment. 

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1

715 Wohlfarth TD, van Zwieten BJ, Lekkerkerker FJ, et al. Antidepressants use in children and 

adolescents and the risk of suicide. Eur Neuropsychopharmacol. 2006 Feb;16(2):79-83.

7

716 Wojcik BE, Akhtar FZ, Hassell LH. Hospital admissions related to mental disorders in U.S. Army 

soldiers in Iraq and Afghanistan. Mil Med. 2009 Oct;174(10):1010-8.

8

717 Woo J-M, Postolache TT. The impact of work environment on mood disorders and suicide: 

Evidence and implications. International Journal on Disability and Human Development. 2008 

Apr-Jun;7(2):185-200.

6

718 Woodhead C, Rona RJ, Iversen A, et al. Mental health and health service use among post-national 

service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England. Psychol 

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9

719 Wortzel HS, Binswanger IA, Anderson CA, Adler LE. Suicide among incarcerated veterans. J Am 

Acad Psychiatry Law. 2009;37(1):82-91.

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720 Yackel EE, McKennan MS, Fox-Deise A. A nurse-facilitated depression screening program in an 

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3

721 Yamane GK, Butler JL. Suicide burden in the U.S. Air Force: 1990-2004. Mil Med. 2009 

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8

722 Yang AC, Tsai SJ, Huang NE. Decomposing the association of completed suicide with air 

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723 Yoon YH, Chen CM, Yi HY, Moss HB. Effect of comorbid alcohol and drug use disorders on 

premature death among unipolar and bipolar disorder decedents in the United States, 1999 to 2006. 

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9

724 Young KA, Bonkale WL, Holcomb LA, Hicks PB, German DC. Major depression, 5HTTLPR 

genotype, suicide and antidepressant influences on thalamic volume. Br J Psychiatry. 2008 

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3

725 Youssef NA, Rich CL. Does acute treatment with sedatives/hypnotics for anxiety in depressed 

patients affect suicide risk? A literature review. Annals of Clinical Psychiatry. 2008;20(3):157-69.

6

726 Yurgelun-Todd DA, Bueler CE, McGlade EC, Churchwell JC, Brenner LA, Lopez-Larson MP. 

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2011 Jul-Aug;26(4):276-89.

3

727 Zamorski MA. Suicide prevention in military organizations. Int Rev Psychiatry. 2011 

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728 Zhang J, McKeown RE, Hussey JR, Thompson SJ, Woods JR. Gender differences in risk factors 

for attempted suicide among young adults: Findings from the Third National Health and Nutrition 

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9

729 Zisook S, Rush AJ, Lesser I, et al. Preadult onset vs. adult onset of major depressive disorder: a 

replication study. Acta Psychiatr Scand. 2007 Mar;115(3):196-205.

9

730 Zisook S, Trivedi MH, Warden D, et al. Clinical correlates of the worsening or emergence of 

suicidal ideation during SSRI treatment of depression: an examination of citalopram in the 

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731 Zivin K, Eisenberg D, Gollust SE, Golberstein E. Persistence of mental health problems and needs 

in a college student population. J Affect Disord. 2009 Oct;117(3):180-5.

3

732 Zivin K, Pfeiffer PN, McCammon RJ, et al. “No-shows”: who fails to follow up with initial 

behavioral health treatment? Am J Manag Care. 2009 Feb;15(2):105-12.

3