Abstract Introduction Insomnia contributes to the development and course of suicidal thought and behavior and is a component in some suicide prevention programming. One such multicomponent intervention is Brief Cognitive Behavioral Therapy for Suicide Prevention (BCBT). BCBT is a 10-12 session suicide prevention intervention that incorporates a sleep module consisting of stimulus control and sleep hygiene into the behavioral elements of its protocol. Our team recently undertook a study to identify BCBT’s most potent components and whether the sequencing of behavioral or cognitive facets of treatment impacted treatment outcomes. Methods Veterans with recent suicidal ideation (SI) or behavior (N = 49) were enrolled in a pilot study that utilized a randomized counterbalance design. All participants received BCBT and were randomized (balanced on sex and history of suicide attempts) to receive one of two sequences: Behavioral before Cognitive (Beh+Cog) or Cognitive before Behavioral (Cog+Beh). To maintain participant safety, in all instances of treatment, the first module consisted of suicide risk assessment, crisis response planning, and means safety counseling. Participants completed weekly assessments prior to each intervention session, collecting data on suicidal thought and behavior, insomnia severity, and depression. Results A piecewise regression was used to examine changes in insomnia, suicidal ideation, suicide cognitions, and depressive symptomatology across groups. The introduction of behavioral components first was associated with more rapid decreases in insomnia severity (Est=-9.93, SE=6.09, p=.027) and SI (Est=11.55, SE=4.93, p=.018) compared to the Cog+Beh group. Severity of depression and suicide cognitions were observed to significantly decrease for both groups in sessions 1-5, but between group differences were not observed. Conclusion Preliminary findings from this ongoing trial suggest that participants that who receive behavioral treatment components first (including stimulus control) report more rapid reductions in both insomnia severity and SI. Findings support a growing literature highlighting the importance of addressing insomnia as part of a broader suicide prevention strategy. Support (if any) This work was supported, in part, by the Innovations Hub, Center of Excellence for Suicide Prevention, VHA Office of Suicide Prevention. Authors’ views do not necessarily represent those of the Department of Veterans Affairs or the United States Government.

OBJECTIVE:Suicidal thoughts and behaviors (STBs) are common among medical students, but larger, diverse studies are needed, especially in low- and middle-income countries. This study aims to assess the prevalence and factors associated with STBs among Brazilian medical students. METHODS:A survey of 1,026 Brazilian medical students gathered data on sociodemographics, STBs, depressive (PHQ-9) and anxiety symptoms (GAD-7), university stressors, learning environment, religiosity, and hazing. Prevalence and regression analyses identified associated factors, and latent class analysis (LCA) identified distinct risk groups. RESULTS:Lifetime prevalence rates were 62.7% for passive thoughts of death, 39.6% for suicidal ideation, and 12.7% for lifetime suicide attempts, with 4.4% reporting at least one attempt in the past year. Anxiety symptoms were associated with all suicidal outcomes. Depressive symptoms, university stressors, and poorer learning environment were associated with higher suicidal ideation scores, while male sex and higher intrinsic religiosity were inversely associated with depressive symptoms. In the LCA, all religiosity dimensions differed significantly across classes, with the highest levels in the Low-Risk group. Hazing victimization and non-cisgender identity were associated with suicidal behaviors. LCA identified three groups: Low-Risk (42.4%) with minimal suicidal thoughts, distress, and higher religiosity; Moderate-Risk (41.1%) with intermediate levels; High-Risk (16.5%) with severe suicidal thoughts, depression, anxiety, university stress, poor environment, and hazing. CONCLUSIONS:Based on our findings, interventions designed to address suicidality in this population may benefit from focusing on modifiable institutional factors (learning environment, university stressors, hazing) alongside individual mental health support, particularly for minority students.

OBJECTIVES:This study investigated whether honor ideology, or a belief that one's reputation must be defended at all costs, is related to firearms ownership in soldiers. METHODS:N=301 active-duty soldiers completed online self-report measures in this cross-sectional study. RESULTS:Honor ideology was higher in soldiers who privately own a firearm compared with those who do not currently own and do not plan to after military separation. Higher honor ideology was correlated with a disbelief that private firearms ownership is related to soldier suicide risk. Levels of honor ideology were equal in soldiers who own a private firearm for protection versus other reasons (eg, hunting, maintaining a collection). CONCLUSIONS:Honor ideology may be related to suicide risk through increased likelihood of owning a private firearm and disbelief in private firearm ownership being related to one's own suicide risk in soldiers. Honor ideology could be relevant to consider when means safety initiatives are developed for active-duty military personnel.

BACKGROUND:Suicidal crises can occur when a clinician is not available to intervene. Safety planning-type interventions, such as the Crisis Response Plan (CRP) and the self-guided Safety Plan (SP), were developed to provide patients with skills to manage their suicide risk in daily life. These plans are similar in makeup, but differ in terms of how they are created. This study examined whether plan type moderated associations between frequency of plan use and suicide ideation and affect. METHOD:Participants were 115 military personnel in a randomized clinical trial comparing the effectiveness of CRP versus a self-guided SP who completed an ecological momentary assessment battery. Generalized linear mixed-effects models examined whether plan type moderated the association between daily plan use frequency and clinical outcomes. RESULTS:Treatment group moderated the relationship between plan use frequency and the odds of suicidal ideation. When participants used plans more frequently than their average, they reported lower suicidal ideation and higher positive affect for CRP versus self-guided SP. CONCLUSIONS:More frequent CRP use was linked with lower risk of suicidal ideation and greater positive affect. This may reflect better plan use due to clinician guidance. Results have critical implications for the implementation of safety planning-type interventions.

Background Childhood trauma exposure is a risk factor for suicide. However, not all trauma exposed individuals experience suicidal urges and core factors moderate this risk pathway. Individual differences in volitional emotion regulation capacity may be one key factor that shapes the association between childhood trauma and suicide; however, few studies have comprehensively investigated these associations using both subjective and objective indicators of emotion regulation. We therefore utilized a multimodal design with 80 adults reporting active suicidal urges. Methods Participants completed self-report forms capturing suicidogenic cognitions and severity of suicidal ideation. Volitional cognitive reappraisal was measured using self-report and prefrontal cortex activation (PFC; i.e., ventrolateral and dorsolateral) during instructed reappraisal with functional magnetic resonance imaging. Results Hierarchal linear regression analyses revealed evidence of childhood trauma by PFC activation interactions on suicide risk. At low levels of vlPFC activation, but not high levels, greater childhood trauma was associated with greater suicidal ideation severity and suicide cognitions. Similarly, at low levels of dlPFC activation, but not high levels, greater childhood trauma was associated with suicide cognitions. Conclusion Hypoactivation of regulatory PFC regions during volitional emotion regulation may contribute to increased suicide risk amongst individuals with a history of childhood trauma.

Suicide is a leading cause of death in the US. Suicide-specific cognitive behavior therapy (CBT) is effective for reducing suicide attempts but is difficult to implement. To evaluate the efficacy of a smartphone-based digital therapeutic intervention designed to deliver suicide-focused CBT in reducing suicidal behavior among patients hospitalized for a suicide attempt or suicidal ideation. This multisite, double-blind, randomized clinical trial was conducted in 6 psychiatric inpatient units across the US. Adult patients admitted with elevated suicide risk from April 2022 to April 2024 were included. Participants completed a baseline assessment and were randomly assigned to either the digital therapeutic group or control application group. The trial was stopped early by the Data Management Safety Board because it surpassed the prespecified futility boundary for the primary end point. Statistical analysis followed the intention-to-treat principle. The digital therapeutic intervention includes 12 sessions of smartphone-based educational modules (lasting 10-15 minutes each) drawn from CBT for suicide prevention. The active control is a 12-session smartphone-based application that delivers safety planning and psychoeducation about suicide. For both interventions, the first session was completed prior to hospital discharge and the remaining self-paced sessions could be completed after discharge. All participants also received treatment as usual, which included suicide risk assessment, supportive listening, crisis resources, clinician assessment, safety planning, and referral to outpatient treatment. The primary end point was time (days) to first actual suicide attempt during follow-up. The secondary end points were change in suicidal ideation from baseline to week 24 (quantified as a change in the Scale for Suicide Ideation total score) and clinician-rated clinical improvement at week 24. The nonprespecified sensitivity analysis end point for suicide attempts was the rate of suicide attempts (actual, aborted, and interrupted). Prespecified subgroup analyses were also conducted to examine treatment effects among patients with vs without prior suicide attempts. A total of 339 participants (mean [SD] age, 27.9 [10.7] years; 224 females [66.1%]) were included. Follow-up data were available from 266 participants (78.5%). Time to first actual suicide attempt, the primary end point, was not significantly different across treatment groups (log-rank χ21 = 3.6; P = .06). Among the 170 participants with prior suicide attempts, nonprespecified sensitivity analyses indicated that the adjusted rate of follow-up suicide attempts was 58.3% lower in the digital therapeutic group than the control application group (0.70 vs 1.68 attempts per person-year; rate ratio [RR], 0.42 [95% CI, 0.18-0.95]; P = .04), and the odds of clinical improvement were higher in the digital therapeutic group than the control application group (97.9% vs 87.5%; odds ratio, 7.59; 95% CI, 1.14-153.62; P = .04). Trajectories of suicidal ideation significantly differed between the digital therapeutic and control application groups (F3,206 = 2.9, P = .04), with decreased suicidal ideation through week 24 in the digital therapeutic group, but in the control application group, suicidal ideation decreased through week 12 and then increased at week 24. Nonprespecified dose-response analyses indicated the suicide attempt rate among patients with a prior suicide attempt decreased by 14.0% for every digital therapeutic module completed (adjusted RR, 0.86; 95% CI, 0.76-0.98; P = .02). In this randomized clinical trial, the digital therapeutic intervention did not change the time to first actual suicide attempt but helped to sustain reductions in suicidal ideation among inpatients with elevated suicide risk. However, among patients with prior suicide attempts, the digital therapeutic intervention helped reduce recurrent suicide attempts and increased the percentage of inpatients with clinician-rated clinical improvement. ClinicalTrials.gov Identifier: NCT05144685.

Importance:Suicide is a leading cause of death in the US. Suicide-specific cognitive behavior therapy (CBT) is effective for reducing suicide attempts but is difficult to implement. Objective:To evaluate the efficacy of a smartphone-based digital therapeutic intervention designed to deliver suicide-focused CBT in reducing suicidal behavior among patients hospitalized for a suicide attempt or suicidal ideation. Design, Setting, and Participants:This multisite, double-blind, randomized clinical trial was conducted in 6 psychiatric inpatient units across the US. Adult patients admitted with elevated suicide risk from April 2022 to April 2024 were included. Participants completed a baseline assessment and were randomly assigned to either the digital therapeutic group or control application group. The trial was stopped early by the Data Management Safety Board because it surpassed the prespecified futility boundary for the primary end point. Statistical analysis followed the intention-to-treat principle. Interventions:The digital therapeutic intervention includes 12 sessions of smartphone-based educational modules (lasting 10-15 minutes each) drawn from CBT for suicide prevention. The active control is a 12-session smartphone-based application that delivers safety planning and psychoeducation about suicide. For both interventions, the first session was completed prior to hospital discharge and the remaining self-paced sessions could be completed after discharge. All participants also received treatment as usual, which included suicide risk assessment, supportive listening, crisis resources, clinician assessment, safety planning, and referral to outpatient treatment. Main Outcomes and Measures:The primary end point was time (days) to first actual suicide attempt during follow-up. The secondary end points were change in suicidal ideation from baseline to week 24 (quantified as a change in the Scale for Suicide Ideation total score) and clinician-rated clinical improvement at week 24. The nonprespecified sensitivity analysis end point for suicide attempts was the rate of suicide attempts (actual, aborted, and interrupted). Prespecified subgroup analyses were also conducted to examine treatment effects among patients with vs without prior suicide attempts. Results:A total of 339 participants (mean [SD] age, 27.9 [10.7] years; 224 females [66.1%]) were included. Follow-up data were available from 266 participants (78.5%). Time to first actual suicide attempt, the primary end point, was not significantly different across treatment groups (log-rank χ21 = 3.6; P = .06). Among the 170 participants with prior suicide attempts, nonprespecified sensitivity analyses indicated that the adjusted rate of follow-up suicide attempts was 58.3% lower in the digital therapeutic group than the control application group (0.70 vs 1.68 attempts per person-year; rate ratio [RR], 0.42 [95% CI, 0.18-0.95]; P = .04), and the odds of clinical improvement were higher in the digital therapeutic group than the control application group (97.9% vs 87.5%; odds ratio, 7.59; 95% CI, 1.14-153.62; P = .04). Trajectories of suicidal ideation significantly differed between the digital therapeutic and control application groups (F3,206 = 2.9, P = .04), with decreased suicidal ideation through week 24 in the digital therapeutic group, but in the control application group, suicidal ideation decreased through week 12 and then increased at week 24. Nonprespecified dose-response analyses indicated the suicide attempt rate among patients with a prior suicide attempt decreased by 14.0% for every digital therapeutic module completed (adjusted RR, 0.86; 95% CI, 0.76-0.98; P = .02). Conclusions and Relevance:In this randomized clinical trial, the digital therapeutic intervention did not change the time to first actual suicide attempt but helped to sustain reductions in suicidal ideation among inpatients with elevated suicide risk. However, among patients with prior suicide attempts, the digital therapeutic intervention helped reduce recurrent suicide attempts and increased the percentage of inpatients with clinician-rated clinical improvement. Trial Registration:ClinicalTrials.gov Identifier: NCT05144685.

Although suicide is complex and heterogeneous, most suicide theories assume that suicidal urges occur primarily in the context of extreme emotional distress. Newer models of suicide based on complex systems theory propose greater heterogeneity in suicidal experiences across individuals and groups, such that some, but not all, suicidal thoughts, urges, and behaviors are associated with extreme negative affect. The present study investigated individual differences in affective states experienced during suicidal urges among 138 adults recruited from the community; 81 (59.1 %) owned handguns and 57 (41.6 %) did not. Participants self-reported their current affect and urge to kill themselves 6 times per day for 28 consecutive days via ecological momentary assessment. Positive and negative affect ratings varied significantly during suicidal urges. The association of positive and negative affect with suicidal urges significantly varied within and between handgun owners and non-owners. Results suggest suicidal urges are characterized by high affective heterogeneity.

U.S. Armed Forces members experience specific demands and stressors that lead to several risk factors of self-harm or harm against others. Military spouses face unique challenges as partners of service members and are often placed in a position to intervene in potentially harmful situations. This study aimed to use qualitative methods to explore military spouses' exposure to their active-duty partner's risk of violence perpetration, firearm suicide, and associated circumstances such as alcohol use and access to personally owned firearms. Participants were adult spouses/partners of active-duty service members, Reserve or Guard members, or recent Veterans (referred to as "military spouses"). Participants completed a 30- to 60-min in-depth interview. An inductive-deductive approach and pattern coding were used to identify trends and key themes. A total of 34 military spouses participated in interviews. Most participants were female (97.06%), White (76.47%), and non-Hispanic (88.24%). Nearly two thirds (61.76%) of participants reported that they and/or their spouse had access to at least one personally owned firearm within their home. Military spouses shared experiences with real-time crisis management related to harmful or hazardous alcohol use and threats of intimate partner violence and firearm suicide. Participants also noted several perceived barriers to prevention and intervention resources and strategies. Due to military spouses' significant exposure to their partner's suicidal behaviors and threat of violence perpetration, as well as the increased access to lethal means (i.e., firearms) and potential for harmful or hazardous alcohol use, existing prevention and intervention strategies may be insufficient. There are multiple intervention opportunities for health care providers to fill this gap. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

ABSTRACT Introduction Veterans and active duty service members are significantly more likely to die by suicide using firearms compared to the general population. Not-secure firearm storage (e.g., keeping guns loaded/in an unlocked location) is associated with greater risk for suicide and a third of veteran firearm owners store at least 1 personal firearm unsecured. Veterans and active duty service members are also significantly more likely to be diagnosed with posttraumatic stress disorder (PTSD) than the general population. Symptoms of PTSD are divided into 4 criteria: reexperiencing, avoidance, negative affect, and hyperarousal. Research has suggested that endorsement of hyperarousal symptoms is positively associated with unsecure firearm storage and that avoidance symptoms might be negatively associated with unsecure storage practices. The present study examined the relationship between self-reported firearm ownership and storage practices among each item from the Primary Care PTSD Screening for DSM-IV-TR (PC-PTSD-IV) to explore associations between PTSD features and firearm ownership and storage. Materials and Methods Participants were recruited from primary care clinics across 5 military installations in the United States as part of a larger study (Mage = 45.4, SD = 16.9). Among participants (n = 2,685), most of our sample identified as male (51.3%) and white (67.3%) with 61.6% currently serving in the military, 16.8% retirees, and 21.6% family members. PTSD symptoms were assessed using the PC-PTSD-IV and a quarter met the clinical threshold for PTSD. Binomial and multinomial logistic regression analyses were used. Results Among completed responses, 989 (38.1%) people reported owning guns; among gun owners, 386 (39.0%) reported that they were loaded, and 352 (35.6%) reported they were loaded and unlocked. Endorsement of specific items on the PC-PTSD-IV, including those specific to hyperarousal and avoidance, was not significantly associated with storing firearms loaded and/or in nonsecure locations when controlling for military service. Non-responses to items around firearm storage practices were significantly associated with those individuals meeting the clinical threshold for PTSD according to the PC-PTSD-IV and participants currently serving had higher odds of storing at least 1 personal firearm loaded and both loaded and unlocked. Conclusions Results from our study highlight similarities and departures from the previous literature on the connection between PTSD and non-secure firearm storage practices. Further research may examine (1) the relation between PTSD symptoms and firearm storage between active duty service members, retirees, and family members and (2) whether non-response to items regarding firearm ownership is systematic.

Importance:Suicide is a public health crisis, and despite renewed efforts to confront this problem, suicide rates continue to rise in the US. While suicide prevention encompasses a broad array of strategies, treatment development is lagging. Within this realm, clinical trials are the criterion standard for evaluating safety and efficacy of new treatments. Observations:Most clinical trials conducted among patients with mental illness have excluded patients at risk of suicide. Historical reasons for this include regulatory challenges, liability concerns, ethical questions, discomfort working directly with high-risk patients, and the belief that research is too risky for individuals at elevated risk for suicide. Conclusions and Relevance:Several considerations are provided for investigators in the design of trials targeting at-risk populations, including thoughtful selection of study outcome, use of time-to-event design and analysis (which may simultaneously satisfy ethical concerns and scientific aims), enrolling an enriched sample (eg, among patients recently discharged from the hospital), and provision of usual care in the comparator group. Caution should be exercised to avoid excessive or unreasonable safety requirements, which may lead participants to minimize self-report of suicidal ideation or to drop out of trials. Where possible, regulatory bodies (institutional review boards [IRBs] and data and safety monitoring boards) should consult with or include as members those with direct clinical experience with this high-risk population. An important ethical principle for IRB members and other regulators to consider is that suicide-related events are expected in this clinical population.

OBJECTIVE:Posttraumatic stress disorder (PTSD) symptoms can co-occur with somatic symptoms, associations which may be partly due to threat-responsive changes in the autonomic nervous system. Prior studies support between-person associations of elevated autonomic symptoms with higher PTSD severity. However, there is a need to distinguish between- and within-person variation in symptoms over time. METHOD:This study used a latent growth model with structured residuals to examine the dynamics of PTSD and autonomic symptoms in a U.S. population-based sample. Participants were 475 adults with an exposure to a potentially traumatic stressor (Mage = 47.89 ± 17.46; 62.9% female; 64.0% Caucasian, 14.3% Black or African American, 13.5% Hispanic, 2.3% Asian, 5.9% mixed race or ethnicity). Data were collected over four time points spaced approximately 1.5 months apart between July 2020 and January 2021 during the COVID-19 pandemic. PTSD and autonomic symptoms were measured using the Abbreviated Post-Traumatic Stress Disorder Checklist and the supradiaphragmatic symptoms subscale of the Body Perception Questionnaire-Short Form. RESULTS:Latent PTSD and autonomic symptoms were positively associated (β = .499, SE = .048). At each wave, within-individual elevations in PTSD symptoms co-occurred with elevations in autonomic symptoms (β range: .221-.317). At several time points, elevated PTSD symptoms also predicted future elevations in autonomic symptoms (β range: .215-.304, p < .05). A history of childhood maltreatment was associated with higher PTSD (β = .309, p < .001) and autonomic symptom intercepts (β = .335; p < .001). CONCLUSIONS:Results support the linkage between PTSD and autonomic symptoms over time and suggest that elevations in PTSD symptoms may precede future autonomic symptoms. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

Importance:US military personnel and veterans have higher rates of suicide than the general population. Previous trials support the efficacy of brief cognitive behavioral therapy (BCBT) for reducing suicide attempts among military personnel compared with treatment as usual, and replication of these findings is needed. Objective:To test the efficacy of BCBT for reducing suicide attempts and suicidal ideation among high-risk military personnel and veterans. Design, Setting, and Participants:This was a 2-arm, parallel randomized clinical trial comparing BCBT with present-centered therapy (PCT), conducted from 2020 to 2025. The setting was 3 US-based outpatient psychiatric clinics and included US military personnel and veterans reporting suicidal ideation during the past week and/or suicidal behavior during the past month who were either self-referred or referred by their mental health clinicians. Interventions:Participants were randomly assigned to either BCBT, a psychotherapy that teaches emotion regulation skills, or PCT, a problem-solving psychotherapy, using a computerized algorithm with stratification for sex and number of prior suicide attempts. Main Outcomes and Measures:The primary outcome was suicide attempt, assessed with the Self-Injurious Thoughts and Behaviors Interview-Revised. Results:Of 154 individuals assessed for eligibility, 108 (mean [SD] age, 32.8 [12.8] years; 79 male [73.1%]) were enrolled. Fewer patients receiving BCBT (n = 2, estimated proportion = 5.6%) than PCT (n = 8, estimated proportion = 27.9%) attempted suicide during follow-up. Mean time to first suicide attempt was 638.6 (90% CI, 557.8-719.3) days in the PCT group vs 755.9 (90% CI, 715.1-796.8) days in the BCBT group (log-rank χ21 = 3.6; P = .03). BCBT significantly reduced the risk of any suicide attempt (hazard ratio [HR], 0.25; 90% CI, 0.07-0.90; P = .04) as well as the rate of follow-up suicide attempts (0.06 vs 0.18 attempts per participant-year, risk ratio, 0.24; 90% CI, 0.08-0.70; P = .02). Suicidal ideation significantly decreased in both groups (F8,264 = 7.2, P < .001) with no differences between groups (F8,266 = 0.2; P = .49). Conclusions and Relevance:This randomized clinical trial found that BCBT reduced suicide attempts among US military personnel and veterans reporting recent suicidal ideation and/or suicidal behaviors compared with an active comparator. These results replicate earlier findings. Trial Registration:ClinicalTrials.gov Identifier: NCT03769259.

Objective: US military veterans are at elevated risk for suicide. High levels of suicide-specific cognitions, an indicator of chronic suicide risk, have been found to predict suicidal behaviors. The objective of this study was to examine data from a large, nationally representative sample of US veterans to determine the prevalence and correlates of high chronic suicide risk, with the goal of providing population-level insight into veterans who may be most at risk. Methods: This study utilized data from the 2019-2022 National Health and Resilience in Veterans Study, a nationally representative sample (N = 2,430), to determine the prevalence of veterans who screened positive for high chronic risk for suicide based on the Brief Suicide Cognitions Scale. The relative importance of sociodemographic, military, health, and psychosocial characteristics associated with high chronic risk was also examined. Results: In total, 250 veterans screened positive for high chronic suicide risk. Analyses revealed that veterans at high risk were lower educated and more likely to report suicidal ideation and disability in activities of daily living. They also endorsed a higher number of adverse childhood experiences and scored lower on measures of protective psychosocial characteristics and social connectedness. Relative importance analyses revealed that lower levels of perceived resilience, social support, and purpose in life accounted for the majority of the explained variance in high chronic suicide risk. Conclusions: Results suggest that interventions to bolster these positive psychological traits may help reduce suicide risk and death by suicide in veterans. Prim Care Companion CNS Disord 2025;27(1):24m03821. Author affiliations are listed at the end of this article.

BACKGROUND:Existing suicide risk screening and detection methods are unable to reliably identify who will engage in suicidal behavior (SB), and when. Modeling the "push-pull" among risk and protective processes could be useful for understanding when patients may be at increased risk for transitioning from lower to higher risk states. This study examines if changing temporal dynamics in wish to live (WTL) and wish to die (WTD) ratings, assessed during consecutively scheduled psychiatric outpatient visits, can differentiate patients who will attempt suicide and signal when suicidal behavior is about to occur. METHODS:78 adults with past-month suicidal ideation and/or suicidal behaviors who enrolled in a randomized clinical trial comparing two outpatient psychotherapies provided weekly WTL and WTD ratings assessed with the first two items of the Scale for Suicide Ideation and weekly occurrence of suicide attempts assessed with items from the Self-Injurious Thoughts and Behaviors Interview-Revised. RESULTS:Session-to-session changes in WTL and WTD were examined using multilevel regression modeling supplemented by eigenvalue decomposition analysis. Temporal patterns significantly differed over time between patients who attempted suicide versus patients who did not. Temporal patterns remained consistent over time among patients who did not attempt suicide. Among patients who attempted, temporal patterns changed from pre- to post-attempt, consistent with a state transition. CONCLUSIONS:Suicidal behaviors represent a state transition that is foreshadowed by unique temporal patterns in self-reported WTL and WTD.

INTRODUCTION:Insomnia and nightmares have both been associated with suicide risk and are both known to be commonly reported in a primary care setting. However, we are unaware of any studies examining the sleep-suicide relationship in the primary care setting. Clarifying these relationships could reveal important clues for improving suicide prevention efforts in primary care and other medical settings. METHOD:Participants included 2,744 primary care patients recruited from six clinics located at five U.S. military installations. Participants completed measures of suicidal ideation, insomnia, and nightmares at baseline and suicidal ideation and suicide attempts were tracked at 6- and 12-month follow-up interviews. RESULTS:Of the 1,792 patients with follow-up data, 57 (3.2%) attempted suicide during the 12-month follow-up. Patients who attempted suicide during follow-up were more likely than patients who did not attempt suicide to have clinical insomnia and nightmares at least weekly. When adjusting for baseline suicidal ideation, clinical insomnia and nightmares at least weekly remained significant predictors of follow-up suicide attempts. CONCLUSIONS:Our findings suggest that insomnia and nightmares are accurate predictors of subsequent suicidal behavior among a primary care population and may offer positive predictive value for suicidal behavior over and above what can be provided by assessing suicidal ideation alone. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Preventing suicide is challenging because there are no ways to reliably determine when someone is about transition from a lower to higher risk state. Dynamic interactions between the wish to live (WTL) and die (WTD) may differentiate higher from lower risk suicide states and signal near-term transitions of increasing risk. In this cohort design, clinical trial participants with posttraumatic stress disorder (PTSD) received prompts to complete a brief survey on their phone 4 times per day for 14 consecutive days at pseudorandom times. Participants were asked to rate their WTL, WTD, suicidal desire, and desire for self-preservation using 4 items from the Scale for Suicide Ideation (SSI). Participants were 116 military personnel and veterans diagnosed with PTSD (69.8 % male, 76.7 % White, M age = 47.2 ± 12.1 years). Multilevel dynamical systems modeling revealed that the WTL and WTD changed in coordinated and opposing directions except when suicidal desire was most severe and was about to worsen at the next time point. Under these conditions, WTL and WTD switched to an oscillatory pattern. Temporal patterns in WTL and WTD differ when people report lower versus higher risk suicidal states. Oscillations in WTL and WTD signal near-term worsening of suicidal desire. Multiple qualitatively distinct suicide risk states exist, suggesting suicide risk is categorical, not continuous.

Objective: US military veterans are at elevated risk for suicide. High levels of suicide-specific cognitions, an indicator of chronic suicide risk, have been found to predict suicidal behaviors. The objective of this study was to examine data from a large, nationally representative sample of US veterans to determine the prevalence and correlates of high chronic suicide risk, with the goal of providing population-level insight into veterans who may be most at risk. Methods: This study utilized data from the 2019-2022 National Health and Resilience in Veterans Study, a nationally representative sample (N = 2,430), to determine the prevalence of veterans who screened positive for high chronic risk for suicide based on the Brief Suicide Cognitions Scale. The relative importance of sociodemographic, military, health, and psychosocial characteristics associated with high chronic risk was also examined. Results: In total, 250 veterans screened positive for high chronic suicide risk. Analyses revealed that veterans at high risk were lower educated and more likely to report suicidal ideation and disability in activities of daily living. They also endorsed a higher number of adverse childhood experiences and scored lower on measures of protective psychosocial characteristics and social connectedness. Relative importance analyses revealed that lower levels of perceived resilience, social support, and purpose in life accounted for the majority of the explained variance in high chronic suicide risk. Conclusions: Results suggest that interventions to bolster these positive psychological traits may help reduce suicide risk and death by suicide in veterans. Prim Care Companion CNS Disord 2025;27(1):24m03821. Author affiliations are listed at the end of this article.

Suicide is a leading cause of death among active-duty military personnel. Although specialty mental health services are readily available, primary care clinics represent the most frequently accessed clinical setting immediately preceding suicide deaths and suicide attempts among service members. Primary care clinics offer a critical and unique opportunity to implement interventions targeting suicide prevention. Effective engagement and response to servicemembers with elevated suicide risk requires scalable alternatives to traditional mental health care. The central focus of this study is to test the efficacy of Aviva, a scalable, digital adaptation of Brief Cognitive Behavioral Therapy for Suicide Prevention in three primary care clinics with active-duty military servicemembers in comparison to treatment as usual. This paper describes the design, methodology, and protocol of an active randomized controlled trial comparing Aviva to treatment as usual. The impact on subsequent suicidal ideation and behaviors during a year-long follow-up period will be evaluated. Clinical Trial Registration: NCT06318962.