Suicidal thoughts and behaviors in adults with hoarding disorder

Abstract

Background:

Hoarding disorder (HD) is characterized by difficulty discarding possessions and clutter that impairs daily functioning. Previous research has demonstrated a high correlation between hoarding behaviors and suicidal thoughts and behaviors; however, there is limited research on suicidal thoughts and behaviors in individuals meeting Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for HD. Our aim in this study was to report our findings about suicidal thoughts and behaviors in a HD sample.

Methods:

We used existing data from participants meeting DSM-5 criteria for HD (n = 99). Data about suicidal thoughts and behaviors was collected using a structured instrument, the Columbia-Suicide Severity Rating Scale (C-SSRS).

Results:

Among the 99 participants, 49.5 % and 26.3 % had passive and active suicidal ideation (SI), respectively. Of those with active ideation, 11 participants endorsed thinking about overdose during their most severe SI. 13 participants reported attempting suicide at least once in their lifetime.

Conclusions:

To our knowledge, this is the first study examining suicidal thoughts and behaviors in HD using the structured assessment C-SSRS. In this HD data set, participants reported suicidal thoughts and behaviors at higher rates than the general U.S. population. Our study highlights the importance of screening for suicidal thoughts and behaviors in individuals with HD.

1. Introduction

The World Health Organization highlights suicide as a global public health priority [1]; indeed, the death of a loved one has devastating consequences on family members and communities [2]. Suicidal behaviors are associated with many mental health disorders, including hoarding disorder [HD], which became a new diagnostic entity in 2013 in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [3]. Given that data show a link between HD and suicide attempts [4,5], there is an urgent need to further characterize suicidal thoughts and behaviors in a DSM-5 HD sample using an empirically-validated, suicide-specific scale. Interpreting resulting data in the context of existing data on suicidal thoughts and behaviors in related conditions may help elucidate whether HD is related to suicidality apart from the most common comorbidities, including major depression.

HD is characterized by persistent difficulty parting with possessions, associated distress, cluttered living spaces, and impairment in important areas of functioning [6,7]. Clutter hinders the effective utilization of living spaces for their intended purpose and increases risk of falls and other injuries [3]. Hoarding is a common disorder, with an estimated overall pooled prevalence of 2.5 % of the general population [8]. Individuals with HD have a high rate of co-occurring mental disorders, and, in approximately 50 % of cases, they also meet criteria for major depression [4,9,10]. Other comorbid conditions include anxiety disorders (generalized anxiety disorder, agoraphobia, social phobia, panic disorder), bipolar, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD), among others [4,9,10]. HD is associated with heightened social isolation, medical comorbidity, and significantly lower quality of life [11–14].

Suicidal thoughts and behaviors are common among individuals in the United States. According to data from the Centers for Disease Control and Prevention (CDC), approximately 134 people in the US died by suicide each day in 2022, making suicide the 11th leading cause of death in the country [15]. Furthermore, during 2015–2019, the lifetime prevalence of active and/or passive suicidal ideation (SI) in adults in the US was about 16 % [16,17]. To provide context, we describe SI and suicide risk in several psychiatric populations. In help-seeking individuals in their first episode of psychosis, one study reported 40.8 % SI (assessed by Brief Psychiatric Rating Scale [BPRS; [18]] item 4 cutoff score of ≥3) [19]. In individuals with bipolar disorder, SI varies from 14 % to 59 %, depending on a number of factors including phase of illness, with highest risk during depressive episodes [20]. In a systematic review and meta-analysis on major depressive disorder (MDD), the odds ratio for lifetime SI was 2.88 compared to a control group [21].

Previous meta-analyses and systematic reviews have shown that individuals with OCD and other obsessive-compulsive and related disorders (OCRDs) are at increased risk of suicidal behavior [5,22–29]. In one recent meta-analysis in individuals with OCD, the pooled prevalence of current SI was 27.3 %, the pooled prevalence of lifetime SI was 47.3 %, and lifetime suicide attempts was 13.5 % [22]. In another meta-analysis in individuals with OCRDs, the pooled prevalence of current SI in individuals with grooming disorders was 40.4 %, with HD was 18.4 %, and with BDD was 37.2 %; the pooled rate of lifetime suicide attempts in individuals with grooming disorders was 13.3 %, with HD was 24.1 %, and with BDD was 35.2 % [5]. Taken together, the discrepancy in rates between individuals with OCRDs, and between ideation and attempts within disorders, highlights the importance of exploring more in depth the individual OCRDs, and in this study, we have focused on HD.

Examining the relationship between suicidal thoughts and behaviors and hoarding behaviors has been the focus of previous research. Comparisons across studies are challenging because of heterogeneous samples (e.g., OCD, HD), diagnostic criteria (e.g., hoarding rating scale, DSM-5), hoarding symptom assessments (e.g., Yale-Brown Obsessive-Compulsive Scale [30,31], Saving Inventory-Revised [32]), and variety in suicide assessment approaches (e.g., MINI items [33], Anxiety Disorder Interview Schedule for DSM-IV: Lifetime version [ADIS-IV-L; [34]], Suicide Probability Scale[SPS; [35]]). In two studies using OCD samples, both reported that individuals with OCD and hoarding behaviors have significantly higher rates of suicidal thoughts and behaviors than individuals with OCD without hoarding behaviors [36,37]. In another large study, which included a DSM-5 HD sample (n = 313), 10 % of the sample were considered to be at moderate or high risk for suicide at the time of assessment and 19 % reported at least one prior suicide attempt in their lifetime, assessed using questions from the MINI (coded from 0 to 2; with 0 being no past suicide attempts or current suicidal ideation and 2 being a past suicide attempt and current moderate to high suicide risk) [4]. Notably, no prior study has examined suicidal thoughts and behaviors using a comprehensive suicide-specific measure like the Columbia-Suicide Severity Rating Scale (C-SSRS), which is currently recognized by the FDA as the gold standard assessment for evaluating SI and suicidal behavior on clinical trials [38]. The C-SSRS provides a comprehensive assessment of suicidal thoughts and behaviors, including their intensity and severity. Finally, given the high comorbidity with major depression, it is important for studies to assess the contribution of suicidality from hoarding vs depression. We sought to address these challenges by examining a DSM-5 HD sample using the C-SSRS suicide-specific measure.

2. Methods

2.1. Data set

A sample of convenience was used from an existing database of individuals who completed an assessment battery as part of eligibility screening for studies being conducted on HD, OCD, and related disorders between 2016 and 2018 in the laboratory of co-senior author C. I. Rodriguez. Data were analyzed from adults with HD (n = 99), diagnosed using a structured interview (Structured Clinical Interview for DSM-5; SCID) [39]. Individuals were asked for information on SI severity, SI intensity, and suicidal behaviors using the C-SSRS. Information on comorbid conditions, concomitant medications, total scores of the HDRS-17, and demographics was also collected. All participants provided written, informed consent in accordance with Institutional Review Board procedures.

2.2. Measures

2.2.1. Columbia-suicide severity rating scale (C-SSRS)

The C-SSRS is a brief and reliable measure of suicidal thoughts and behaviors [38]. It is comprised of a series of questions, administered as a structured clinical interview [40]. Definitions of the constructs assessed by the C-SSRS are shown below in Table 1. The scale measures four domains. The first is the severity of suicidal ideation (hereafter referred to as the “SI severity subscale”), which is rated on a 5-point ordinal scale in which 1 = wish to be dead, 2 = nonspecific active suicidal thoughts, 3 = suicidal thoughts with methods, 4 = suicidal intent, and 5 = suicidal intent with plan. The second is the intensity of suicidal ideation subscale (hereafter referred to as the “SI intensity subscale”), which comprises five items, each rated on a 5-point ordinal scale: frequency, duration, controllability, deterrents, and reason for ideation. The third is the suicidal behavior subscale, which is rated on a nominal scale that includes actual, aborted, and interrupted suicide attempts; preparatory behaviors; and nonsuicidal self-injurious behavior. Finally, the fourth is the lethality subscale, which assesses the actual lethality or medical damage of any reported suicide attempts; actual lethality is rated on a 6-point ordinal scale, in which 0 is no physical damage or very minor damage and 5 is death. If actual lethality of the suicide attempt is 0, potential lethality of attempts is rated on a 3-point ordinal scale, in which 0 is behavior not likely to result in injury and 2 is behavior likely to result in death despite available medical care [38]. The internal consistency of the SI intensity subscale in our sample was good, with Cronbach’s alpha of 0.82.

Table 1.

C-SSRS definitions [40].

	Definition
Passive suicidal ideation/thoughts	Thoughts about a wish to be dead or not alive anymore or wish to fall asleep and not wake up.
Active suicidal ideation/thoughts	Thoughts of wanting to end one’s life/die by suicide (e. g., “I’ve thought about killing myself”) with or without thoughts of ways to kill oneself/associated methods, intent, or plan during the assessment period.
suicidal behavior
Preparatory actions	Acts or preparation toward imminently making a suicide attempt.
Nonsuicidal self-injury	Self-injurious act performed without any intent to die.
Aborted suicidal attempt	When person begins to take steps toward making a suicide attempt but stops themselves before they actually have engaged in any self-injurious behavior.
Interrupted suicidal attempt	When the person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have occurred).
Suicidal attempt	A potentially self-injurious act committed with at least some wish to die, as a result of act.
Suicidal behavior	Combined variable that includes preparatory actions, aborted suicide attempt, interrupted suicide attempt, actual suicide attempt (non-fatal), and death by suicide.

2.2.2. Hamilton depression rating scale (HDRS-17)

The HDRS is a widely utilized tool for assessing depression. In our study, we employed the 17-item version of this scale. These 17 items are designed to measure the severity of depressive symptoms, such as evaluating the level of agitation observed during the interview or assessing how an individual’s mood affects their work or leisure activities. Scores ranging from 0 to 7 are considered within the normal range, scores from 8 to 16 suggest mild depression, scores from 17 to 23 indicate moderate depression, and scores exceeding 24 are indicative of severe depression [41]. The maximum score on the 17-point scale is 52 [42,43]. The internal consistency of the HDRS-17 in our sample was good, with Cronbach’s alpha of 0.79.

2.2.3. Structured clinical interview for DSM-5-research version (SCID-5-RV)

The SCID is a widely utilized tool for assessing DSM-5 disorders in research studies. The SCID-5 is structured into diagnostic sections, covering a wide range of mental health conditions. It evaluates mood disorders, psychotic disorders, substance use disorders, anxiety disorders, OCRDs, eating disorders, somatic symptom disorders, certain sleep disorders, externalizing disorders, as well as trauma- and stressor-related disorders [39].

2.2.4. Demographic information

We collected demographic information as part of an initial self-report survey given to all participants interested in being part of our screening protocol. The information collected for our data analyses was gender, race, and ethnicity.

2.2.5. Concomitant medication

We collected the name of medications used by all participants throughout the study through an interview with an MD. Subsequently, the psychotropic medications were categorized by functional class (antidepressant, anxiolytic, psychostimulant, anticonvulsant mood stabilizer, atypical antipsychotic, opioid antagonist, and non-stimulant ADHD medication).

2.3. Statistical analysis

Descriptive statistics were computed for the C-SSRS, HDRS-17, concomitant psychotropic medication, psychiatric comorbidities from SCID-5-RV, and demographic variables (age, gender, ethnicity, race, and educational level). For our inferential statistics, we divided the sample into HD with SI and HD without SI. We used the HDRS-17 to assess current depression and the SCID-5-RV to assess for lifetime mood disorder (MDD, bipolar disorder, and/or persistent depressive disorder). To examine if there were any significant differences between the total HDRS scores in individuals with passive SI and those with active SI, we conducted independent samples t-tests. To find differences between passive SI, active SI, and lifetime diagnosis of MDD or a mood disorder, we conducted Pearson Chi-square tests.

3. Results

3.1. Sociodemographic data

From this sample with 99 HD participants, 51 participants endorsed SI, suicidal behaviors, or both, as assessed by the C-SSRS. Demographic data of those who endorsed SI, suicidal behavior, or both showed that the majority were female (82 %), white (71 %), and non-Hispanic (94 %), with a college education (98 %). For more details on the demographic data, see Table 2.

Table 2.

Sociodemographic information.

	Whole sample (N = 99)	Participants with STB (n = 51)	Participants without STB (n = 48)	P value*
Gender a				0.028
Male	28 [28.28 %]	9	19
Female	71 [71.72 %]	42	29
Race				n.s.
Caucasian	72 [72.73 %]	36	36
African	5 [5.05 %]	3	2
American/Black
Native	1 [1.01 %]	1	0
Hawaiian/Pacific Islander
American	2 [2.02 %]	1	1
Indian/Alaskan Native
Asian	13 [13.13 %]	6	7
More Than One	1 [1.01 %]	1	0
Race
Unknown	1 [1.01 %]	1	0
Other	4 [4.04 %]	2	2
Ethnicity				n.s.
Hispanic	5 [5.05 %]	3	2
Non-Hispanic	94 [94.95 %]	48	46
Education completed b
High school	9 [9.09 %]	5	4	n.s.
4-year college	39 [39.39 %]	24	15
Graduate school	16 [16.16 %]	7	9
Masters	7 [7.07 %]	6	1
Professional school	12 [12.12 %]	8	4
Age, years (SD| Range)	57.61 (10.07| 24–75)	55.67 (11.34| 24–70)	59.54 (8.13| 34–75)	n.s.

Abbreviations: STB, suicidal thoughts and behaviors; n.s., not significant.

^*Chi-square.

^aself-reported, no participants identified as non-binary.

^bEducation data for 1 STB and 15 non-STB participants was missing.

3.2. C-SSRS results

Table 3 shows our findings on STB in the sample. Of those who reported active SI in which they thought about a method of suicide (n = 26), 11 participants reported they thought about an overdose during their most severe active SI. Table 4 details the intensity of suicidal ideation.

Table 3.

Lifetime and current, passive and active, SI and suicidal behavior in individuals with DSM-5 HD.

Suicidal thoughts and behaviors	Total (n = 99)
Passive SI—lifetime	49 (49.5 %)
Passive SI—recent (past month)	16 (16.2 %)
Active SI—lifetime	26 (26.3 %)
Active SI—recent (past month)	3 (3.0 %)
Preparatory actions—lifetime	4 (4.0 %)
Preparatory actions—recent (past three months)	0 (0 %)
Nonsuicidal self-injury—lifetime	6 (6.1 %)
Suicide attempt—lifetime	13 (13.1 %)
Suicide attempt—recent (past three months)	0 (0.0 %)

Abbreviations: SI, suicidal ideation; DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition; HD, hoarding disorder.

Table 4.

Intensity of suicidal ideation (n = 51).

	Total lifetime	Total recent
Frequency
Less than once a week	17 (33 %)	8 (16 %)
Once a week	6 (12 %)	2 (4 %)
2–5 times a week	8 (16 %)	2 (4 %)
Daily or almost daily	8 (16 %)	3 (6 %)
Many times each day	7 (14 %)	0
Duration
Fleeting - few seconds or minutes	20 (39 %)	10 (20 %)
Less than 1 h/some of the time	8 (16 %)	3 (6 %)
1–4 h/a lot of time	9 (18 %)	2 (4 %)
More than 8 h/persistent or continuous	9 (18 %)	0
Controllability
Easily able to control thoughts	20 (39 %)	12 (24 %)
Can control thoughts with little difficulty	7 (14 %)	3 (6 %)
Can control thoughts with some difficulty	8 (16 %)	1 (2 %)
Can control thoughts with a lot of difficulty	4 (8 %)	1 (2 %)
Unable to control thoughts	4 (8 %)	0
Deterrents
Deterrents definitely stopped you from attempting suicide	36 (71 %)	16 (31 %)
Deterrents probably stopped you	3 (6 %)	0
Deterrents definitely did not stop you	3 (6 %)	0
Reasons for ideation
Completely to end or stop the pain (you couldn’t go on living with the pain or how you were feeling)	40 (78 %)	13 (25 %)
Equally to get attention, revenge, or a reaction from others and to end/stop the pain	1 (2 %)	0
Mostly to end or stop the pain (you couldn’t go on living with the pain or how you were feeling)	3 (6 %)	1(2 %)

For details on reported protective and risk factors, concomitant medications, and comorbidities, see the supplementary appendix (Tables S1–S3).

3.3. Relationship between suicidal thoughts and behaviors and HDRS-17 total scores

Table 5 includes HDRS-17 scores and severity for participants who reported lifetime history of SI and/or suicidal behavior.

Table 5.

HDRS-17 scores for participants with and without a lifetime history of suicidal ideation or behavior.

Severity of depression	Participants with STB total (n = 48)	Participants without STB total (N = 47)
None	20	39
Mild	26	7
Moderate	1	1
Severe	1	0
Mean (min-max; ±SE)	8.39 (0–24; ± 0.75)	4.12 (0–18; ± 0.64)*

Abbreviations: HDRS, Hamilton Depression Rating Scale; STB, suicidal thoughts and behaviors.

Data from four participants was missing from the dataset. This was because they did not complete the assessment (the HDRS-17 was not required for the specific protocol these 4 participants later enrolled in).

^*p < .001.

To explore associations between lifetime SI in HD and current depressive symptoms, we conducted independent samples t–tests. To conduct our analyses, we categorized the SI variable on groups of Yes SI and No SI. Our dependent variable was the total HDRS score. For passive SI, the independent samples t-test showed a significant difference between lifetime passive SI and total HDRS score (t(86) = −4.226, p < .001). We obtained significant differences between active SI and total HDRS score as well (t(86) = − 4.573, p < .001), such that participants with HD who also reported lifetime passive and active SI had higher HDRS scores than those without both types of SI.

3.4. Relationship between suicidal thoughts and behaviors and mood disorder diagnosis (SCID-5-RV)

The Pearson Chi-square showed a significant difference when examining passive SI and lifetime diagnosis of MDD (X2 (1, N = 68) =10.813, p = .001), indicating that individuals with HD with a lifetime diagnosis of a mood disorder exhibited higher levels of lifetime passive SI than those without such diagnosis. Similarly, the analysis revealed a significant difference concerning active SI and lifetime diagnosis of MDD (X2 (1, N = 58) = 4.175, p = .041), suggesting that individuals with HD with a lifetime diagnosis of a mood disorder also demonstrated higher levels of lifetime active SI compared to those without such a diagnosis.

Lifetime passive SI was associated with mood disorder diagnosis (X2 (1, N = 68) =10.161, p = .001) such that those with lifetime diagnosis of a mood disorder had higher levels of passive SI than those without a diagnosis. We did not see a significant association between active SI and lifetime diagnosis of a mood disorder (X2 (1, N = 58) =2.534, p = .111). A greater proportion of individuals with lifetime diagnosis of mood disorder reported lifetime active SI than those without; however, this association did not meet the threshold for statistical significance.

4. Discussion

To our knowledge, this is the first study to examine suicidal thoughts and behaviors in participants with a DSM-5 diagnosis of HD using a structured and validated instrument designed specifically for assessment of suicidal thoughts and behaviors. First, we found that 49.5 % of participants with HD reported passive suicidal thinking during their lives, and 26.3 % described active thoughts about suicide. Second, 13.1 % of participants with HD reported previous suicide attempts. Third, 11 of the 26 participants with HD who described active suicidal thoughts indicated that overdose was the method they considered during their most severe suicidal thoughts. Finally, we found comorbid mood disorders and major depressive disorder diagnosis were significantly correlated with suicidality in HD.

Our findings on SI in our DSM-5 HD population showed high prevalence of lifetime SI, with 49.5 % of people reporting passive SI in their lifetime and 26.3 % reporting active SI (2–5 in the C-SSRS). For comparison, a meta-analysis of individuals with hoarding behaviors reported a 38.3 % lifetime SI and 18.4 % current SI [5]. Additionally, a large study of individuals with DSM-5 HD reported that 10 % of participants were considered to be at moderate or high risk for suicide at the time of assessment [4]. In our study, 16 % of participants reported having SI in the past month prior to the assessment. Differences in the assessment of suicidal thoughts and behaviors may account for why the percentage of current SI in our sample is higher than that observed in the prior meta-analysis of individuals with hoarding symptoms. Namely, the C-SSRS captures SI in a more detailed manner, including the collection and differentiation of both passive and active SI. Additionally, there is an overlap in traits seen in both HD and suicidality, such as hopelessness [26,44]. Moreover, differences in sampling may also account for discrepancies, given DSM-5 HD criteria was not applied in all groups in previous studies. This underscores the importance of our study using a suicide-specific assessment tool in a DSM-5 HD population.

Consistent with our findings on SI, participants also showed a high prevalence of suicide attempts, with a 13 % prevalence of lifetime suicide attempts. Comparatively, approximately 0.7 % of the general adult population in the US has attempted suicide in their lifetime (CDC, 2021) [15]. Hence, participants with HD in our sample showed a higher percentage of past suicide attempts than the general population. This study was conducted with a limited sample, so further studies are needed to corroborate this number. Chakraborty and colleagues [36] found a higher rate of suicide attempts among OCD patients with hoarding behaviors (38 %) vs those without (5 %), suggesting that suicidal thoughts and behaviors may be associated with features specific to hoarding behaviors. The authors further posit that severe illness, comorbidities, and poorer functioning may contribute to the elevated rate of suicide attempts in individuals with OCD and hoarding symptoms [36]. Another large study found that in a sample of individuals with DSM-5 HD, 19 % reported at least having one suicide attempt in their lifetime [4]. In a meta-analysis by Pellegrini and colleagues [5], the prevalence of lifetime suicide attempts in individuals with hoarding behaviors was 24.1 %.

We also found that overdosing was a frequently reported method that participants with active SI thought about during their most severe active SI (n = 11). To our knowledge, this is the first study to look at methods people with HD think about during SI. This finding raises the question of whether overdose may be a potential concern in suicidal individuals with HD. There are two main reasons why we believe it might be. First, individuals with HD tend to be isolated, which decreases the likelihood of interruption of suicidal behavior by other people, and research has shown that overdose deaths often occur when individuals are alone at home [45]. Second, people with HD may have increased access to lethal means in their homes among items they may have accumulated. This is particularly concerning with regard to hoarding of medications that could be used for an overdose and may place individuals with HD at heightened risk. Previous studies have shown a consistency between methods contemplated during SI and the actual method of suicide attempt or death by suicide [46]. In a study by Marzano and colleagues in 712 individuals with a history of suicide attempts and 686 individuals with suicidal thoughts (without acting on them) [46], findings showed that study participants contemplated a wider range of means (and more unusual methods) than those used in actual attempts. However, the methods used for the actual attempt were endorsed to be the most accessible at the time, and that the choice was impulsive.

To explore if lifetime SI is associated with depression in our sample, we conducted statistical analyses with the HDRS-17 for depressive symptoms and with the SCID-5RV diagnosis of lifetime MDD or a total of lifetime mood disorders. Our findings on HDRS-17 and both lifetime active and passive SI showed a significant difference in depression symptomatology between individuals with SI and without SI. Our findings show that individuals with lifetime SI had higher scores in the HDRS. Our findings suggest that suicidality in our sample may be indicative of comorbid depression. Furthermore, given that the HDRS-17 measures recent depressive symptoms specifically (in the past two weeks), the higher rates of lifetime active SI in people with higher HDRS-17 scores may also bias to more negative memories of life events [47]. Moreover, in our sample, lifetime passive SI was significantly associated with lifetime comorbid MDD and lifetime comorbid mood disorder. Likewise, lifetime active SI was associated with lifetime comorbid MDD. These findings suggest that suicidality in our sample may be explained by mood disorder or depression comorbidities. Our results highlight the importance to further explore suicidality in HD, to understand if the disorder or comorbidities associated with HD may be a risk factor for SI.

4.1. Limitations

Our study has several limitations. First, our population was limited in size compared to the other studies, and our sample is not necessarily reflective of a representative population. Given that this is a small sample of convenience, findings should be interpreted with caution. Another limitation is the ability to determine whether SI symptoms are a consequence of HD or predated serious HD symptoms. Gathering prospective and systematic data regarding the timing of lifetime SI and suicidal behaviors (e.g., before and after HD onset) will be important for future studies. Lastly, this study does not provide the necessary data to support the magnitude in which SI specifically impacts individuals with HD. Hence, there may be other alternative explanations for our findings on STB and HD, such as comorbidities.

This study also has clinical implications. Primarily, given the substantial prevalence of both suicidal thoughts and behaviors observed within our sample, it may be imperative for clinicians to incorporate a routine screening for suicidality in individuals diagnosed with HD. Identifying individuals with suicidal thoughts and behaviors is crucial, as it enables the implementation of risk reduction strategies. For instance, healthcare professionals may ask about the number of medications stored within their patient’s home, particularly considering the high endorsement of suicidal thoughts related to overdose observed in our findings. In these cases, clinicians may also consider proactively encouraging their patients to locate and dispose expired medication among their clutter. Additionally, during in-person visits, it would be helpful to assess whether the clutter within the individual’s living environment contains any potentially lethal means that may pose a risk to their well-being.

5. Conclusions

Taken together, our findings suggest suicidal thoughts and behaviors are prevalent in individuals with hoarding disorder. Whether in clinical or research settings, our findings may signal that careful clinical assessment is needed to understand suicidal risk, harm reduction, and treatment strategies.