Concealed suicidality can be a major impediment for clinicians conducting a suicide risk assessment. Client minimization and denial of suicidal thoughts can lead clinicians to undertreat and under-monitor clients experiencing a suicidal crisis. Five recommendations are given to address potential weak areas of suicide assessment with adults including routinized processes and a reliance on assessment instruments that may underestimate risk when individuals have no prior attempts or significant mental illness. Specifically, the authors highlight the importance of continued training and education in suicide assessment, how considering the context of the assessment can heighten one's sensitivity to concealment of suicidal ideation and how different assessment instruments and interview techniques, when chosen with care, can increase the candor of client expression. The authors also recommend attending to clinician anxiety both as a way of maintaining rapport as well as a method of identifying clues that the assessment is not producing accurate information. Finally, application of recommendations is demonstrated through case vignettes.

Issue Suicide continues to present a major public health concern in many societies. Suicide prevention efforts have failed to reduce the rate of suicide in most countries. A change of intervention strategy can help to prevent these deaths from despair. Description of the problem Suicide prevention strategies are examined through an integrative review combined with more than 30 years of experience conducting research on suicide attempters and psychological autopsy research on adults who had died by suicide. Journal articles published since 2005 were reviewed for strategies designed to prevent death by suicide. Results Suicide risk is examined by confronting the means, motives and opportunities for suicidal behavior. Prevention strategies that limit access to lethal means can have a beneficial impact if the method is easily accessible and not easily replaced. Unfortunately, some individuals merely shift to a different method for their suicidal act. Prevention strategies that restrict the opportunity for self-injury provide time to confront underlying disorders and initiate treatment. Unfortunately, many patients do not continue treatment beyond the acute crisis, and there is often a resurgence of suicidal behavior after discharge from the hospital. Prevention strategies that aim to confront the person’s motivation to die may reduce the underlying cause. It is important to provide interventions to help reduce the desperation and isolation that underlie suicidal urges. These intervention strategies hold potential for making lasting changes that could eliminate, instead of temporarily suppressing, the desire to die. Lessons Restricting access to lethal methods and limiting times when a suicidal person is left alone can temporarily block suicidal urges. However, the motive underlying the suicidal urges remains intact. The motivation to die can be addressed through interventions that focuses on helping clients to build a life worth living. Key messages • Suicide prevention strategies can confront the desire for death by helping to build a life that is worth living. • Comprehensive interventions aimed at reducing depression, isolation and addiction hold potential for reducing the rate of suicide.

IntroductionSuicide premeditation is a critical factor to consider when assessing suicide risk. Understanding which individuals are more or less likely to plan their suicidal behavior can shed light on how suicidal thoughts turn into actions.MethodThe present study used psychological autopsy data to identify factors associated with level of premeditation among 131 adults who died by suicide.ResultsLogistic regression analyses indicated that suicide decedents with higher premeditation scores had higher odds of being diagnosed with a depressive disorder and choosing a violent suicide method, specifically a firearm. Individuals with lower premeditation scores had higher odds of being diagnosed with a polysubstance use disorder.ConclusionSuicide decedents exhibiting greater premeditation before their deaths were different in several ways from suicide decedents exhibiting less premeditation. A better understanding of suicide premeditation can ultimately aid in the development of improved risk assessments and targeted safety interventions for those struggling with suicidal thoughts.

ObjectivesInterpersonal factors play an important role in the etiology and treatment of depression. Social support derives from compassionate words and helpful actions provided by family, friends or a significant other. The present study was designed to examine various sources of social support as they relate to the severity of depressive symptoms, hopelessness and suicide risk in adult psychiatric outpatients.MethodParticipants were recruited through mental health clinics at a veteran's affairs medical centre. A total of 96 depressed patients were assessed using a diagnostic interview and self‐report measures of depression severity, hopelessness and social support. Among these depressed adults, 45.8% had attempted suicide at least once. Social support variables were compared between suicide attempters and non‐attempters to better understand the relationship between social support and suicidal behaviour.ResultsDepression severity and hopelessness were both significantly associated with lower levels of social support in multiple areas. Individuals with a history of suicide attempt reported lower levels of available support as compared to those who have never attempted suicide.ConclusionDeficient social relationships increase the risk of suicide in depressed patients, exceeding the impact of depression alone on suicide risk. The lack of social support may play a vital role in feelings of hopelessness and isolation that contribute to a suicidal crisis. Psychosocial treatment should be considered to reduce the risk of suicide and severity of depression by strengthening social support and bolstering interpersonal relationships.

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