On that day: Warnings of acute risk in narratives (WARN) of suicide attempts in adults.

objectivesTo identify acute risk factors or 'warning signs' (WSs) for suicide attempts in adults using a new framework, warnings of acute risk in narratives (WARN), which posits that a broad range of acute symptoms and experiences labeled 'drivers' precipitate a narrower range of highly potent 'WS with direct suicide content' that confer marked near-term risk.

methodsWe asked adult patients [N = 45; ages 18-plus; 49% women] admitted following a suicide attempt to two U.S. academic medical centers to tell the story of the attempt, focusing on the day it occurred. We coded the transcripts with a 43-item manual developed using directive qualitative content analysis. We assessed frequencies of WSs based on WARN and existing formulations including acute suicidal affective disturbance (ASAD), suicide crisis syndrome (SCS), and an influential list from an expert panel.

resultsPatient narratives frequently contained WSs with direct suicide content (n = 36, 80%), most commonly resolving to attempt suicide in the near future (n = 25, 56%) and making preparations to attempt suicide (n = 19, 42%). When WSs with direct suicide content were present, they were nearly always accompanied by emotional drivers such as dramatic change in mood. Cognitive drivers (e.g., hopelessness) and social drivers (e.g., loneliness) were also frequent. Several WSs in the ASAD, SCS, and expert panel's list were commonly identified, underscoring they contain important ideas.

conclusionsConsistent with WARN, diverse drivers were accompanied by a narrower set of WSs with direct suicide content which provide specific targets for prioritization in risk assessments in acute care settings.