Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: Suicide-related ideations, communications, and behaviors

Clergy referral of suicidal individuals: a qualitative study

In a national study, 25% of help-seekers contacted clergy; suicidal behavior was one of the significant predictors for making contact. Clergy have been found to refer 10% of help-seekers to mental health providers. This qualitative study explored the referral practices of 15 northeastern Mainline and Evangelical Protestant clergy when contacted by suicidal individuals; all referred to mental health providers. Participants reported low confidence with risk identification and provided moving examples of pastoral care.

The relation between sexual orientation and suicide attempts in Austria

Previous studies indicate that homosexual or bisexual individuals are at a higher risk of attempting suicide compared to heterosexuals. To overcome biases in these studies, more rigorous definitions of "suicide attempts" and the assessment of multiple dimensions of sexual orientation are needed. In addition, studies from the German speaking region are sparse, especially those not recruiting participants from the gay or lesbian communities. We solicited self-reported suicide attempts among 1,382 Austrian adults recruited through structured snowball sampling from students' social networks. Suicide attempts were more frequently reported by those participants with homosexual or bisexual fantasies, partner preference, behavior, and self-identification, compared to their heterosexually classified counterparts. This was true for any dimension of sexual orientation and for suicide attempts with intent to die or suicide attempts that required medical treatment. Our Austrian study confirmed existing evidence that homosexual and bisexual individuals are at an increased risk for attempting suicide. This should be considered in suicide preventive efforts.

An exploratory study of the relationship between diverse life events and specific personality disorders in a sample of suicide attempters

Personality disorder (PD) increases risk for suicidal behavior. Certain life events (LE) can precipitate suicidal behaviors in patients with PD. A fundamental question is whether specific combinations of LE and PD increase suicidal risk. Four hundred forty-six suicide attempters (SA) were recruited from emergency rooms. We used a healthy control group (n = 515) to identify the best cut-off point for the instrument used to diagnose PD. We used the DSM-IV version of the International Personality Disorder Questionnaire-Screening Questionnaire, the Mini International Neuropsychiatric Interview, and the Social Adjustment Scale to assess PD, Axis I disorders, and LE, respectively. After controlling for Axis I disorders, we found that "Death of spouse" preceded suicidal acts in those with antisocial PD (FET p = 0.024) and patients with narcissistic PD attempted suicide after being Fired at work (FET p = 0.002), among others. Our data suggest the presence of particular LE-PD associations in suicide attempters. Some LE-PD relationships appear independent of Axis I disorders in suicide attempters. This may offer a basis for specific targeted therapies or prevention programs aimed at decreasing suicidal risk.

Pediatric suicide-related presentations: a systematic review of mental health care in the emergency department

STUDY OBJECTIVE

We evaluate the effectiveness of interventions for pediatric patients with suicide-related emergency department (ED) visits.

METHODS

We searched of MEDLINE, EMBASE, the Cochrane Library, other electronic databases, references, and key journals/conference proceedings. We included experimental or quasiexperimental studies that evaluated psychosocial interventions for pediatric suicide-related ED visits. Inclusion screening, study selection, and methodological quality were assessed by 2 independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy. Consensus was reached by conference; disagreements were adjudicated by a third reviewer. We calculated odds ratios, relative risks (RRs), or mean differences for each study's primary outcome, with 95% confidence intervals (CIs). Meta-analysis was deferred because of clinical heterogeneity in intervention, patient population, and outcome.

RESULTS

We included 7 randomized controlled trials and 3 quasiexperimental studies, grouping and reviewing them according to intervention delivery: ED-based delivery (n=1), postdischarge delivery (n=6), and ED transition interventions (n=3). An ED-based discharge planning intervention increased the number of attended post-ED treatment sessions (mean difference=2.6 sessions; 95% CI 0.05 to 5.15 sessions). Of the 6 studies of postdischarge delivery interventions, 1 found increased adherence with service referral in patients who received community nurse home visits compared with simple placement referral at discharge (RR=1.28; 95% CI 1.06 to 1.56). The 3 ED transition intervention studies reported (1) reduced risk of subsequent suicide after brief ED intervention and postdischarge contact (RR=0.10; 95% CI 0.03 to 0.41); (2) reduced suicide-related hospitalizations when ED visits were followed up with interim, psychiatric care (RR=0.41; 95% CI 0.28 to 0.60); and (3) increased likelihood of treatment completion when psychiatric evaluation in the ED was followed by attendance of outpatient sessions with a parent (odds ratio=2.78; 95% CI 1.20 to 6.67).

CONCLUSION

Transition interventions appear most promising for reducing suicide-related outcomes and improving post-ED treatment adherence. Use of similar interventions and outcome measures in future studies would enhance the ability to derive strong recommendations from the clinical evidence in this area.

The effect of participating in suicide research: does participating in a research protocol on suicide and psychiatric symptoms increase suicide ideation and attempts?

The effect of engaging in an intensive research protocol that inquired extensively about psychiatric and suicide symptoms and exposed participants to a number of images, including suicide-related content was explored. Individuals experiencing a major depressive episode were called at 1 and 3 months after the initial protocol. Participants were asked about changes in suicide ideation and the occurrence of self-harm or suicide attempts following participation. Participants reported experiencing reductions in suicide ideation at the first follow-up and no changes at the second follow-up. No participant reported having engaged in self-harm or having attempted suicide at either follow-up. Results suggest that basic science/nontreatment research can be conducted safely with suicidal participants and in a manner that does not increase suicide symptoms or suicide risk.

Are Suicidal Phenomena in Children Different to Suicidal Phenomena in Adolescents? A Six-Year Review

BACKGROUND

  There has been little published about the nature and frequency of suicidal phenomena in children compared to that of adolescents.

METHOD

  Standardised information on all presentations with suicidal phenomena to the Children's University Hospital, Dublin from 2002 to 2008 were retrospectively analysed from a centralised database.

RESULTS

  During the time period of the study, 401 young people presented for assessment, of whom 21.9% (N = 88) were under 12 years of age. Children differed from adolescents in terms of gender distribution, method of self-harm, and risk factors present.

CONCLUSION

  Children under 12 are capable of displaying suicidal phenomena and differ considerably to adolescents in this regard.

Surrogate endpoints in suicide research

Surrogate endpoints frequently substitute for rare outcomes in research. The ability to learn about completed suicides by investigating more readily available and proximate outcomes, such as suicide attempts, has obvious appeal. However, concerns with surrogates from the statistical science perspective exist, and mounting evidence from psychometric, neurochemical, genetic, and neuroimaging studies suggests that surrogates may be particularly problematic in suicide research. The need for greater phenotypic refinement of suicide-related behaviors, development of and adherence to a shared suicide nomenclature, and conservative interpretation of investigational results that are limited to the precise population and suicide-related behavior under examination are discussed.

Relationships of suicide ideation with cause-specific mortality in a longitudinal study of South Koreans

Using 7-year mortality follow-up data (n = 341) from the 1998 National Health and Nutrition Examination Surveys of South Korean individuals (N = 5,414), the authors found that survey participants with suicide ideation were at increased risk of suicide mortality during the follow-up period compared with those without suicide ideation. The cause-specific analyses showed that, in men, suicide ideation was significantly associated with mortality due to cardiovascular disease, external causes, and other causes. However, there was no significant association between suicide ideation and cause-specific mortality in women. The relationship between suicide ideation and cause-specific mortality in men was not fully explained by baseline health status, socioeconomic status, health behavior, or psychosocial factors.

The acquired capability for suicide: a comparison of suicide attempters, suicide ideators, and non-suicidal controls

BACKGROUND

The Interpersonal Theory of Suicide states that to make a serious or lethal suicide attempt, a person must experience reductions in fear and pain sensitivity sufficient to overcome self preservation reflexes (i.e., the acquired capability for suicide). The purpose of this study was to examine the fearlessness component of the acquired capability for suicide using self-report assessment instruments and an objective measure of aversion (the affectively modulated startle reflex task).

METHODS

Depressed suicide ideators (n=15), depressed suicide attempters (n=15), and a group of control participants (n=14) were compared on their self-report of acquired capability and painful and provocative life events, and completed the affectively modulated startle reflex task. This task compared electromyography recordings of participants' eye-blink response to a startle probe while viewing pictures of varying hedonic valence (neutral, positive, negative, and suicide-related).

RESULTS

Suicide attempters reported the highest levels of fearlessness and pain insensitivity and a greater history of painful and provocative life events. Although no group differences were found on the psychophysiology data, participants reacted to suicide-related images with less aversion compared to neutral images with no differences between suicide-related and positive images.

CONCLUSIONS

Self-reported fearlessness and pain insensitivity can differentiate suicide attempters and suicide ideators. Results suggest that one's self-perception (i.e., cognitions regarding fear and pain tolerance) are more functionally related to suicide attempts than psychophysiological reactivity to suicide-related stimuli.

Patients' own statements of their future risk for violent and self-harm behaviour: a prospective inpatient and post-discharge follow-up study in an acute psychiatric unit

Recently patients' responsibility for and ownership of their own treatment have been emphasised. A literature search on patients'' structured self-reported assessment of future risk of violent, suicidal or self mutilating behaviour failed to disclose any published empirical research. The present prospective naturalistic study comprised all involuntary and voluntary acutely admitted patients (n=489) to a psychiatric hospital during one year. Patients' self-reported risks of violence and self-harm at admission and at discharge were compared with episodes recorded during hospital stay and 3 months post-discharge. Patients' predictions were significant concerning violent, suicidal and self-injurious behaviour, with AUC values of 0.73 (95%CI=0.61-0.85), 0.92 (95%CI=0.88-0.96) and 0.82 (95%CI=0.67-0.98) for hospital stay, and 0.67 (95%CI=0.58-0.76), 0.63 (95%CI=0.55-0.72) and 0.66 (95%CI=0.57-0.76) after 3 months, respectively. Moderate or higher risk predictions remained significant in multivariate analysis, and risk of violence even after gender stratification. Self-harm predictions were significant for women. Moderate or higher risk scores remained significant predictors of violence one year post-discharge. Controlling for readmissions the results remained the same. Low sensitivity limits the clinical value, but relatively high positive predictive values might be clinically important. Still future research is recommended to explore if self prediction is a valid adjuvant method to established risk assessment procedures.

Non-suicidal self-injury, attempted suicide, and suicidal intent among psychiatric inpatients

Although attempted suicide and non-suicidal self-injury (NSSI) differ in several important ways, a significant number of individuals report histories of both behaviors. The current study further examined the relations between NSSI and attempted suicide among psychiatric inpatients. Self-report questionnaires were administered to 117 psychiatric inpatients at a general hospital (M=39.45 years old, S.D.=12.84 years, range=17-73 years). We found that presence and number of NSSI episodes were significantly related to presence and number of suicide attempts. Supporting the importance of NSSI assessment, patients' history of NSSI (presence and frequency) was more strongly associated with history of suicide attempts than were patients' depressive symptoms, hopelessness, and symptoms of borderline personality disorder, and as strongly associated with suicide attempt history as current levels of suicidal ideation. Finally, among patients with a history of suicide attempts, those with an NSSI history reported significantly greater lethal intent for their most severe attempt, and patients' number of prior NSSI episodes was positively correlated with the level of lethal intent associated with their most severe suicide attempt.

How adolescents who cut themselves differ from those who take overdoses

The aims of this study were to identify in what ways adolescents who cut themselves differ from those who take overdoses, and to investigate the role of contagion in these behaviours. Data from an anonymous self-report questionnaire survey of 6,020 adolescents in 41 schools were analysed. Comparison of 220 adolescents who reported self-cutting in the previous year with 86 who had taken overdoses in the previous year as the sole method of deliberate self-harm (DSH) showed that far more of those who cut themselves had friends who had also engaged in DSH in the same period (OR 2.84, 95% CI 1.5-5.3, P < 0.001), and fewer had sought help from friends before cutting (OR 0.5, 95% CI 0.3-0.9, P < 0.02). Self-cutting usually involved less premeditation. Analyses at both the individual and school level showed that the association between engaging in DSH and exposure to DSH amongst peers was largely confined to girls who cut themselves. There are important differences between adolescents who cut themselves and those who take overdoses. Contagion may be an important factor in DSH by adolescents, especially in girls who cut themselves. These findings are relevant to the design of prevention and treatment programmes.

Patterns of distress, precipitating events, and reflections on suicide attempts by young Latinas

By most epidemiological accounts, young US Latinas attempt suicide more often than other youth. Little is known, however, about the circumstance and internal experiences of the attempts. To understand this phenomenon, we conducted thematic analyses of twenty-seven qualitative interviews with teenage Latinas (aged 11-19) living in New York City who had attempted suicide. Collected between July 2005 and July 2009, the interviews explored the emotional, cognitive and physical experiences of the attempts and the social situations in which they took place. Results show that the girls were divisible nearly equally into a group with a stated intent of death and a group that did not intend death. The pathways to the suicidal event consisted of a pattern of continuous, escalating stress (primarily at home) that created the emotionally combustible conditions for the attempt. A trigger event that either reminded them of past stress or revived feelings of that stress catalyzed the attempt. Guilt and remorse were common responses to the suicide attempts, and on reflection the girls demonstrated some broader perspectives. Results of the analysis clarify the sociocultural context of the suicide attempts, underscoring the cultural discontinuity experienced by adolescent Latinas, who struggle to reconcile traditional Hispanic gender socialization with their own insertion in a modern Western society.

Capable of suicide: a functional model of the acquired capability component of the Interpersonal-Psychological Theory of Suicide

A functional model of the acquired capability for suicide, a component of Joiner's (2005) Interpersonal-Psychological Theory of Suicide, is presented. A component of Joiner's (2005) Interpersonal-Psychological Theory of Suicide a functional model of the acquired capability for suicide is presented. The model integrates the points discussed by Joiner into a unified and specific conceptualization of acquired capability. Several points are elaborated on, such as the interaction between specific diatheses with life events, the role of short-term bolstering of the capability for suicide, and how contextual factors moderate the experience of painful and provocative life events; thereby leading to fearlessness and pain insensitivity to the actions and ideas involved in suicide.

[Nonsuicidal self-injury in adolescence]

Nonsuicidal self-injury (NSSI) usually starts in adolescence. International studies report prevalence rates between 3 and 37% (for Germany between 15 and 26%) in adolescents. From a neurobiological perspective, there is evidence that primarily the serotonergic system is involved in the origin and maintenance of this behaviour. NSSI is often used by adolescents to influence aversive affective states, but sometimes serves other functions as well, such as self-punishment or anti-dissociation. To date there are many assessment instruments, some of which are available in a German translation. Regarding psychotherapeutic interventions there is evidence for a good efficacy of dialectical behavioral therapy for adolescents (DBT-A). There is little evidence for psychopharmacological interventions in childhood and adolescence; thus treatment should focus on psychotherapeutic interventions.

Standardized screening for suicidal adolescents in primary care

OBJECTIVE

To determine if brief standardized screening for suicide risk in pediatric primary care practices will increase detection rates of suicidal youth, maintain increased detection and referral rates, and be replicated in other practices.

PATIENTS AND METHODS

Physicians in 3 primary care practices received brief training in suicide risk, and 2 standardized questions were inserted into their existing electronic medical chart psychosocial interview. The questions automatically populated for all adolescents aged 12.0 to 17.9 years. Deidentified data were extracted during both intervention trials and for the same dates of the previous year. Referral rates were extracted from social work records.

RESULTS

The rates of inquiry about suicide risk increased 219% (clinic A odds ratio [OR]: 2.04 [95% confidence interval (CI): 1.56-2.51]; clinic B OR: 3.20 [95% CI: 2.69-3.71]; clinic C OR: 1.85 [95% CI: 1.38-2.31]). The rate of case detection increased in clinic A (OR: 4.99 [95% CI: 4.20-5.79]), was maintained over 6 months after the intervention began (OR: 4.38 [95% CI: 3.74-5.02]), and was replicated in both clinic B (OR: 5.46 [95% [CI: 3.36-7.56]) and clinic C (OR: 3.42 [95% CI: 2.33-4.52]). The increase in case detection was 392% across all 3 clinics. Referral rates of suicidal youth to outpatient behavioral health care centers increased at a rate equal to that of the detection rates.

CONCLUSIONS

Standardized screening for suicide risk in primary care can detect youth with suicidal ideation and prompt a referral to a behavioral health care center before a fatal or serious suicide attempt is made.

Exploration of factors related to hara-kiri as a method of suicide and suicidal behavior

OBJECTIVE

The objective of this study was to explore factors associated with hara-kiri as a method of suicide and suicidal behavior in contemporary Japan.

METHODS

A retrospective study was conducted on medical records of 421 patients (174 male; 247 female) who were considered suicidal and treated at the Kitasato University Hospital Emergency Medical Center in Japan between January 2006 and March 2008. We compared hara-kiri and all other methods regarding sociodemographics and clinical features of all suicidal patients.

RESULTS

Instances of hara-kiri suicide attempt had the highest proportion of males (63%) among all suicide and suicidal behavior. One-way analysis of variance revealed significant differences between hara-kiri and other suicide attempt methods in the age of the suicidal patients. Result of multiple logistic regression analysis indicated that those who attempted hara-kiri suicide were likely to be male, be diagnosed with schizophrenia, survive, and be married.

CONCLUSION

Our findings indicate that hara-kiri as a method of suicide and suicidal behavior remains prevalent in Japan, and the study findings also suggest that both clinical and cultural factors might play a role in hara-kiri as a method of suicide and suicidal behavior.

The interpersonal theory of suicide

Suicidal behavior is a major problem worldwide and, at the same time, has received relatively little empirical attention. This relative lack of empirical attention may be due in part to a relative absence of theory development regarding suicidal behavior. The current article presents the interpersonal theory of suicidal behavior. We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs-thwarted belongingness and perceived burdensomeness (and hopelessness about these states)-and further that the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior. According to the theory, the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences. In the current article, the theory's hypotheses are more precisely delineated than in previous presentations (Joiner, 2005), with the aim of inviting scientific inquiry and potential falsification of the theory's hypotheses.

Suicidal behavior and alcohol abuse

Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

Relational hopes: A study of the lived experience of hope in some patients hospitalized for intentional self-harm

Hopelessness is a well-established predictor of suicide, and inspiring hope is an important goal in mental health care, but there are few studies of hope among persons with suicidal behavior. The aim of this study was to interpret the lived experience of hope in some patients hospitalized for intentional self-harm. Twelve persons that had engaged in suicidal behavior by ingesting an overdose of medication were interviewed shortly after hospitalization and asked to narrate about their hopes. The transcripts were analyzed using a phenomenological hermeneutic method inspired by Ricoeur's theory of interpretation. The naïve reading was one of hope being relational. The structural analysis identified three themes: hopes for life, hopes for death, and the act of hoping. We interpreted the common theme of the interviews as being definite and indefinite relational hopes for life and death. For clinicians, expressions of indefinite hopes may raise concerns about the low likelihood of fulfillment. However, the expression of indefinite hope may serve to avoid experiencing failure, disappointment, and hopelessness.

Suicide attempts within 12 months of treatment for substance use disorders

There are limited prospective data on suicide attempts (SA) during the months following treatment for substance use disorders (SUD), a period of high risk. In an analysis of the Drug Abuse Treatment Outcomes Study, a longitudinal naturalistic multisite study of treated SUDs, variables associated with SA in the 12 months following SUD treatment were examined. Participants included 2,966 patients with one or more SUDs. By 12 months, 77 (2.6%) subjects had attempted suicide. Multivariate logistic regression analyses were used to identify variables associated with SA. Variables collected at baseline that were associated with SA included lifetime histories of SA, suicidal ideation (SI), depression, cocaine as primary substance of use, outpatient methadone treatment, and short-term inpatient treatment. Male sex, older age, and minority race or ethnicity were associated with lower likelihood of SA. After controlling for baseline predictors, variables assessed at 12 months associated with SA included SI during follow-up and daily or more use of cocaine. The data contribute to a small but growing literature of prospective studies of SA among treated SUDs, and suggest that SUDs with cocaine use disorders in particular should be a focus of prevention efforts.

The perspectives of young adults on recovery from repeated suicide-related behavior

BACKGROUND

This qualitative study sought to develop an understanding of how young adults between the ages of 18-25 years, who have a history of two or more suicide attempts, transition away from high-risk suicide-related behaviors.

AIMS

To understand the transition to safer behaviors and to provide clinical suggestions for those who provide care to this population.

METHODS

Sixteen young adults under the age of 25 years, who had completed at least one cycle of intervention for people with repeated suicide attempts, participated in this qualitative, grounded theory study.

RESULTS

The young adults described a pathway that included three major elements: (a) "living to die", (b) ambivalence and tipping/turning points, and (c) a process of recovery that included small steps or phases (pockets of recovery) toward life. The journey was not always experienced as steady movement forward, and the potential for relapse either in the young people's behavior or their wish to engage in their relationship with death could ebb and flow.

CONCLUSIONS

Clinicians need to be aware that the struggle to live is a process involving a fluid pathway moving between three key elements.

Suicidality and suicide in older people

Suicide is accepted as a major health problem worldwide, especially in the young and middle aged. It is, however, a significant health problem in older people as well, and those aged 65 years and over generally have the highest suicide rates compared with all other age groups. In research literature from the last decade, there has been an increased interest in disentangling the phenomenon of suicide in later life. This paper aims to critically review the literature on suicide and suicidality in later life published from 2000 to 2009. Prevalence rates as well as risk and protective factors are mapped and correlates reviewed. The association between suicidality and help-seeking behaviour is considered. Finally, potential prevention strategies are reviewed.

The Problematic Label of Suicide Gesture: Alternatives for Clinical Research and Practice

Historically, certain terms used to describe psychopathology have evolved over time due to changing social and political contexts. This paper explores the importance of a clear and consistent language for characterizing suicide-related behaviors with a particular focus on the commonly used label "suicide gesture." The historical and contemporary uses of the term are explored, and clinical, research, and training implications are discussed. Clinicians and researchers are strongly encouraged to consider discontinuing the use of the term suicide gesture in light of its associated dismissive connotations and inconsistent application in clinical practice and research. In lieu of the term suicide gesture, recommendations are made regarding an increased emphasis by clinicians and researchers on more precise descriptions of suicidal behaviors and the functional assessment of suicide-related behaviors.

Rumination and Lifetime History of Suicide Attempts

The primary goal of the current study was to examine the link between rumination (brooding and reflective rumination) and histories suicide attempts in adult psychiatric inpatients. As predicted, psychiatric inpatients reporting histories of suicide attempts exhibited higher current levels of brooding, but not reflective, rumination than did those with no prior suicide attempts. These results were maintained even after statistically controlling for patients' current depressive symptom levels. These results support the hypothesis that rumination, particularly brooding rumination, may be a risk factor for suicide attempts.

Screening for depression and suicidality in patients with cardiovascular illnesses

The American Heart Association (AHA) and the American Psychiatric Association jointly recommend screening for depression in cardiology clinics. This includes screening for suicidality. It is not known how frequently patients disclose suicidal thinking (ideation) in this setting, and what proportion of those will turn out to have suicidal intent. Patients were screened for depression using a protocol identical to the one endorsed by the AHA in a cardiology community clinic in Elmhurst (Queens, New York). Depression was assessed using the Patient Health Questionnaire. Reports of suicidal ideation were immediately evaluated by a mental health professional. We determined the degree to which suicidal ideation was identified, the proportion of patients with suicidal intent of those reporting suicidal ideation, and the relation between depression and suicidal ideation in this setting. One thousand three patients were screened; 886 had complete Patient Health Questionnaire data. Of those, 12% (109 patients) expressed suicidal ideation. Four of those were hospitalized for suicidal intent (0.45% of all screened patients). Suicidal ideation and depression were correlated (point biserial correlation coefficient 0.478). In conclusion, suicidal ideation can and will be identified using the AHA depression screening recommendations, but only a very small fraction (0.45%) of screened patients will turn out to have suicidal intent. Discovery and stabilization of suicidal patients is an important benefit of the screening, but the fact that >12% of all screened patients will need to be immediately evaluated for suicidal intent has important implications for resource allocation to screening programs.

Adolescent suicide risk screening in the emergency department

OBJECTIVES

Many adolescents who die by suicide have never obtained mental health services. In response to this, the National Strategy for Suicide Prevention recommends screening for elevated suicide risk in emergency departments (EDs). This cross-sectional study was designed to examine 1) the concurrent validity and utility of an adolescent suicide risk screen for use in general medical EDs and 2) the prevalence of positive screens for adolescent males and females using two different sets of screening criteria.

METHODS

Participants were 298 adolescents seeking pediatric or psychiatric emergency services (50% male; 83% white, 16% black or African American, 5.4% Hispanic). The inclusion criterion was age 13 to 17 years. Exclusion criteria were severe cognitive impairment, no parent or legal guardian present to provide consent, or abnormal vital signs. Parent or guardian consent and adolescent assent were obtained for 61% of consecutively eligible adolescents. Elevated risk was defined as 1) Suicidal Ideation Questionnaire-Junior [SIQ-JR] score of > or =31 or suicide attempt in the past 3 months or 2) alcohol abuse plus depression (Alcohol Use Disorders Identification Test-3 [AUDIT-3] score of > or =3, Reynolds Adolescent Depression Scale-2 [RADS-2] score of > or =76). The Beck Hopelessness Scale (BHS) and Problem Oriented Screening Instrument for Teenagers (POSIT) were used to ascertain concurrent validity.

RESULTS

Sixteen percent (n = 48) of adolescents screened positive for elevated suicide risk. Within this group, 98% reported severe suicide ideation or a recent suicide attempt (46% attempt and ideation, 10% attempt only, 42% ideation only) and 27% reported alcohol abuse and depression. Nineteen percent of adolescents who screened positive presented for nonpsychiatric reasons. One-third of adolescents with positive screens were not receiving any mental health or substance use treatment. Demonstrating concurrent validity, the BHS scores of adolescents with positive screens and the POSIT scores of those with positive screens due to alcohol abuse and depression indicated substantial impairment. The addition of alcohol abuse with co-occurring depression as a positive screen criterion did not result in improved case identification. Among the subgroup screening positive due to depression plus alcohol abuse, all but one (>90%) also reported severe suicide ideation and/or a recent suicide attempt. This subgroup (approximately 17% of adolescents who screened positive) also reported significantly more impulsivity than other adolescents who screened positive.

CONCLUSIONS

The suicide risk screen showed evidence of concurrent validity. It also demonstrated utility in identifying 1) adolescents at elevated risk for suicide who presented to the ED with unrelated medical concerns and 2) a subgroup of adolescents who may be at highly elevated risk for suicide due to the combination of depression, alcohol abuse, suicidality, and impulsivity.

No cathartic effect in suicide attempters admitted to the emergency department

The goal of the present study was to test the hypothesis that suicide attempts have a cathartic effect. We retrospectively investigated sociodemographic and clinical characteristics of suicide attempters admitted to the emergency department of a university hospital who were referred for a psychiatric assessment. The participants were 158 consecutive patients admitted to the emergency department because of a suicide attempt between January, 2006, and February, 2007; controls were 360 consecutive psychiatric referrals who did not report suicidal behavior. More than 70% of suicide attempters were coded on the triage classification system as critical/urgent. Loglinear analysis indicated that the risk of suicidal ideation was 9 times higher (p <0.001) and the risk of depressive mood was twice as high (p <0.001) among the attempters as in the control group of nonattempters, while their risk of anxiety (p <0.05) and agitation (p <0.05) was approximately half that of the nonattempters. The attempters also had a 5 times greater risk of being diagnosed with bipolar disorder (p <0.001) than the nonattempters. However, despite the fact that bipolar disorders were overrepresented in the group of attempters, suicidal ideation in the few hours after a suicide attempt was associated only with depressive mood. Based on these findings, it is recommended that psychiatric evaluation of suicide attempters in the emergency department should ideally include the use of psychometric instruments evaluating suicide ideation and suicide risk.

Distinguishing between subgroups of adolescents who self-harm

The differences in factors associated with subgroups of adolescents in the continuum of deliberate self-harm (DSH) phenomena were investigated. In an anonymous self-report survey of 6,020 adolescents aged 15 and 16 years, 3.2% of adolescents (5.3% females, 1.3% males) reported DSH with intent to die, 2.8% (4.3% females; 1.5% males) reported DSH without intent to die, and 15% (22.4% females; 8.5% males) reported thoughts of DSH without acts. Regression analysis indicated considerable overlap in vulnerability factors along the spectrum of DSH thoughts and acts. A uniquely distinct relationship was found between DSH of a friend and DSH without intent to die on one hand and DSH of a family member with DSH with intent to die on the other. Results indicate that familial and nonfamilial social influences on DSH behavior may be important in designing prevention programs and that educational programs for the promotion of psychological well-being may be helpful for adolescents at any point along the spectrum of DSH that was examined.

Predicting depression, anxiety and self-harm in adolescents: the role of perfectionism and acute life stress

Despite the growing evidence that perfectionism is associated with adolescent psychological distress, few studies have investigated this relationship prospectively with measures designed for use in adolescent populations. In the present study, within a diathesis-stress framework, we investigated the extent to which perfectionism and acute life stress predict depression, anxiety and self-harm among adolescent school children (n = 515) over a 6 month period (Time 1-Time 2). Socially prescribed perfectionism (SPP), self-oriented perfectionism-critical (SOP-critical) and the associated interactions with acute life stress differentially predicted anxiety, depression and self-harm. Acute life stress was an independent predictor of depression, anxiety and self-harm. SPP predicted depression and interacted with acute life stress to predict self-harm. SOP-critical and the SOP-critical by acute life stress interaction predicted anxiety. Self-oriented perfectionism-striving (SOP-striving) did not predict any of the Time 2 measures of distress. The dimensions of perfectionism are differentially associated with psychological distress. Tailored clinical interventions focused on adolescent perfectionism should offer promise in tackling psychological morbidity in adolescence.

Suicide and suicidal ideation in Parkinson's disease

Little is known about the prevalence and correlates of suicidal behavior in Parkinson's disease (PD). In the first part of the study, we followed a cohort of 102 consecutive PD patients for 8 years and found that the suicide-specific mortality was 5.3 (95% CI 2.1-12.7) times higher than expected. In the second part, we tested 128 PD patients for death and suicidal ideation and administered an extensive neurological, neuropsychological and psychiatric battery. Current death and/or suicidal ideation was registered in 22.7%. On univariate logistic regression analysis, psychiatric symptoms (depression, but also anxiety and hopelessness), but not the PD-related variables, were associated with such ideation. On multivariate logistic regression analysis this association held for major depression (odds ratio=4.6; 95% CI 2.2-9.4; p<0.001), psychosis (odds ratio=19.2; 95% CI 1.4-27.3; p=0.026), and increasing score of the Beck Hopelessness Scale (odds ratio=1.2; 95% CI 1.0-1.4; p=0.008). In conclusion, the suicide risk in PD may not be as high as it is expected, but it is certainly not trivial. According to our data almost a quarter of PD patients had death and/or suicidal ideation, that may significantly influence their quality of life.

Personality subtypes of suicidal adults

Research into personality factors related to suicidality suggests substantial variability among suicide attempters. A potentially useful approach that accounts for this complexity is personality subtyping. As part of a large sample looking at personality pathology, this study used Q-factor analysis to identify subtypes of 311 adult suicide attempters using Shedler-Westen Assessment Procedure-II personality profiles. Identified subtypes included internalizing, emotionally dysregulated, dependent, hostile-isolated, psychopathic, and anxious somatizing. Subtypes differed in hypothesized ways on criterion variables that address their construct validity, including adaptive functioning, Axis I and II comorbidity, and etiology-related variables (e.g., history of abuse). Furthermore, dimensional ratings of the subtypes predicted adaptive functioning above DSM-based diagnoses and symptoms.

An international comparison of adolescent non-suicidal self-injury (NSSI) and suicide attempts: Germany and the USA

BACKGROUND

This study examined the prevalence of non-suicidal self-injury (NSSI), suicide attempts, suicide threats and suicidal ideation in a German school sample and compared the rates with a similar sample of adolescents from the midwestern USA by using cross-nationally validated assessment tools.

METHOD

Data were provided from 665 adolescents (mean age 14.8 years, S.D.=0.66, range 14-17 years) in a school setting. Students completed the Self-Harm Behavior Questionnaire (SHBQ), the Ottawa Self-Injury Inventory (OSI) and a German version of the Center for Epidemiological Studies-Depression Scale (CES-D).

RESULTS

A quarter of the participants (25.6%) endorsed at least one act of NSSI in their life, and 9.5% of those students answered that they had hurt themselves repetitively (more than four times). Forty-three (6.5%) of the students reported a history of a suicide attempt. No statistically significant differences were observed between the German and US samples in terms of self-injury or suicidal behaviors.

CONCLUSIONS

By using the same validated assessment tools, no differences were found in the prevalence and characteristics of self-injury and suicidal behaviors between adolescents from Germany and the USA. Thus, it seems that NSSI has to be understood as worldwide phenomenon, at least in Western cultures.

Childhood trauma and risk for past and future suicide attempts among women in prison

PURPOSE

We sought to determine whether childhood trauma is an independent risk factor for past suicide attempts and the future likelihood of attempts among women in prison.

METHODS

A random sample of 247 women incarcerated in a state prison in Las Vegas, Nevada, completed a confidential interview that included the Childhood Trauma Questionnaire, the 18-item Brief Symptom Inventory, standard measures of illicit drug use, and the revised Suicidal Behaviors Questionnaire. Multiple logistic regression models were developed to evaluate the independent influence of cumulative childhood trauma on past suicide attempts with intent to die and the future likelihood of suicide attempts.

RESULTS

Childhood trauma was frequently reported by female prisoners: emotional abuse (58%), physical abuse (54%), sexual abuse (51%), emotional neglect (53%), and physical neglect (41%). Factors independently associated with past suicide attempts included having a higher childhood trauma score (p < .001), a higher psychological distress score (p=.005), and longer duration of current incarceration (> or =5 years; p=.003). Childhood trauma (p=.05), psychological distress (p < .001), and lack of legal employment before incarceration (p=.05) were independent risk factors for future likelihood of attempting suicide.

CONCLUSIONS

Childhood trauma is an independent risk factor for attempted suicide among women in prison that persists into adulthood and cannot fully be attributed to psychological distress, illicit drug use, or incarceration duration. Addressing the emotional impact of childhood trauma among female prisoners may increase the effectiveness of correctional suicide prevention efforts.

Number of addictive substances used related to increased risk of unnatural death: a combined medico-legal and case-record study

BACKGROUND

Substance use disorders have repeatedly been found to lead to premature death, i.e. drug-related death by disease, fatal intoxications, or trauma (accidents, suicide, undetermined suicide, and homicide). The present study examined the relationship between multi-drug substance use and natural and unnatural death.

METHODS

All consecutive, autopsied patients who had been in contact with the Addiction Centre in Malmö University Hospital from 1993 to 1997 inclusive were investigated. Drug abuse was investigated blindly in the case records and related to the cause of death in 387 subjects.

RESULTS

Every substance apart from alcohol used previously in life added to the risk of unnatural death in a linear way. There were independent increased risks of fatal heroin overdoses or undetermined suicide. Death by suicide and violent death were unrelated to additional abuse.

CONCLUSION

The number of drugs used was related to an increased risk of unnatural death by undetermined suicide (mainly fatal intoxications) and heroin overdose.

Predicting deliberate self-harm in adolescents: a six month prospective study

Few studies have investigated the extent to which psychosocial/psychological factors are associated with the prediction of deliberate self-harm (DSH) among adolescents. In this study, 737 pupils aged 15-16 years completed a lifestyle and coping survey at time one and 500 were followed up six months later. Six point two percent of the respondents (n = 31) reported an act of DSH between Time 1 and Time 2. In multivariate analyses, worries about sexual orientation, history of sexual abuse, family DSH, anxiety, and self-esteem were associated with repeat DSH during the course of the study, but history of sexual abuse was the only factor predictive of first-time DSH. The findings suggest that school-based programs focused on how young people cope with psychosocial stressors may offer promise.

Suicidal and death ideation in Parkinson's disease

Parkinson's disease (PD) is a chronic, disabling illness affecting primarily the elderly and is associated with a high prevalence of depression. Although these are known risk factors for suicidal and death ideation, little is known about the prevalence and correlates of such ideation in PD. A convenience sample of 116 outpatients with idiopathic PD at two movement disorders centers were administered a modified Paykel Scale for suicidal and death ideation, as well as an extensive psychiatric, neuropsychological, and neurological battery. Univariate and multivariate logistic regression models were used to determine the correlates of suicidal or death ideation. Current death ideation (28%) or suicide ideation (11%) were present in 30% of the sample, and 4% had a lifetime suicide attempt. On univariate logistic regression analysis, increasing severity of depression (odds ratio = 2.92, 95% CI 2.01-4.24, P < 0.001), impulse control disorder (ICD) behaviors sometime during PD (odds ratio = 6.08, 95% CI 1.90-19.49, P = 0.002), and psychosis (odds ratio = 2.45, 95% CI 1.05-5.69, P = 0.04) were associated with either ideation. On multivariate logistic regression analysis, only increasing severity of depressive symptoms (odds ratio = 2.76, 95% CI 1.88-4.07, P < 0.001) predicted suicidal or death ideation. In conclusion, active suicidal or death ideation occurs in up to one-third of PD patients. Comorbid psychiatric disorders, more than PD-related disease variables, are associated with this ideation, highlighting the need for a comprehensive approach to the clinical care of PD patients.

Dimensions of psychopathy in relation to suicidal and self-injurious behavior

Externalizing psychopathology is associated with an increased risk for suicidal behavior. Within the externalizing domain, psychopathy may be an important construct for the understanding of which individuals are at particularly high risk. However, prior studies of psychopathy and suicidal behavior have not distinguished between suicide attempts and nonsuicidal self-injurious behavior (NSIB). The present study used data on 810 civil psychiatric patients from the MacArthur Violence Risk Assessment Project to examine the relationships between scores on the four dimensions of the Psychopathy Checklist: Screening Version (PCL: SV) and suicide attempts and nonsuicidal self-injurious behavior (NSIB). Results indicate that only the antisocial dimension of psychopathy is associated with suicide attempts. With regard to NSIB, an interaction was found such that, among African-Americans, NSIB was more prevalent at higher levels of antisociality. Present findings refine previous results from studies using the two-factor PCL:SV model and have important implications for the assessment of suicide risk.

Relation between traumatic events and suicide attempts in Canadian military personnel

OBJECTIVE

To determine whether exposure to particular types of traumatic events was differentially associated with suicide attempts in a representative sample of active military personnel.

METHOD

Data came from the Canadian Community Health Survey: Mental Health and Well-Being Canadian Forces Supplement (CCHS-CFS), a cross-sectional survey that provided a comprehensive examination of mental disorders, health, and the well-being of currently active Canadian military personnel (n = 8441; aged 16 to 54 years; response rate 81.1%). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicide attempts were measured using a question about whether the person ever "attempted suicide or tried to take [his or her] own life."

RESULTS

The prevalence of lifetime suicide attempts for currently active Canadian military men and women was 2.2% and 5.6%, respectively. Sexual and other interpersonal traumas (for example, rape, sexual assault, spousal abuse, child abuse) were significantly associated with suicide attempts in both men (adjusted odds ratios [AORs] ranging from 2.31 to 4.43) and women (AORs ranging from 1.73 to 3.71), even after adjusting for sociodemographics and mental disorders. Additionally, the number of traumatic events experienced was positively associated with increased risk of suicide attempts, indicating a dose-response effect of exposure to trauma.

CONCLUSIONS

The current study is the first to demonstrate that sexual and other interpersonal traumatic events are associated with suicide attempts in a representative sample of active Canadian military men and women.

Mid-life suicide: an increasing problem in U.S. Whites, 1999-2005

BACKGROUND

The overall suicide rate in the U.S. increased by 6% between 1981 and 1986 and declined by 18% between 1986 and 1999. Detailed descriptions of recent trends in suicide are lacking, especially with regard to the method of suicide. Information is needed on the major changes in rates of suicide in specific population groups in recent years (1999-2005).

METHODS

Mortality data came from the Web-based Injury Statistics Query and Reporting System. Suicide trends during 1981-2005 were analyzed by age, race, gender, and method, with an emphasis on increases between 1999 and 2005. Linear regression was used to examine the significance of trends in suicide mortality. The annual percentage change in rates was employed to measure the linear trend in suicide mortality.

RESULTS

The suicide rate increased after 1999, due primarily to an increase in suicide among whites aged 40-64 years, whose rate of completed suicide between 1999 and 2005 rose by 2.7% annually for men and by 3.9% annually for women,with increases of 6.3% and 2.3% for poisoning, 2.8% and 19.3% for hanging/suffocation, and 1.5% and 1.9% for firearms for men and women, respectively. Rates did not increase for other age or racial groups [corrected].

CONCLUSIONS

The differential increases by age, race, gender, and method underscore a change in the epidemiology of suicide.Whites aged 40-64 years have recently emerged as a new high-risk group for suicide. Although firearms remain the most common method of suicide, the notable increases in suicide by poisoning in men and hanging/suffocation in women deserve prevention attention [corrected].

Clinical predictors of psychiatric and medical morbidities of charcoal-burning suicide attempt in Hong Kong

OBJECTIVE

This naturalistic retrospective cohort study explored the demographic and clinical factors associated with psychiatric and medical morbidities among patients with suicide attempts by burning charcoal.

METHOD

We conducted a follow-up study of 69 cases with charcoal-burning suicide attempts in two general hospitals. The associations between demographic, clinical characteristics and outcomes were analyzed.

RESULTS

The presence of past psychiatric treatment, past history of suicide attempt and physical complications were associated with the occurrence of psychiatric morbidity after the index suicide attempt. Loss of consciousness and abnormal blood acidity were associated with medical morbidity after the index admission.

CONCLUSION

Psychiatric and medical morbidities are common among charcoal-burning suicide attempts and identified clinical factors associated with these problems may be useful in its management.

Suicidal ideation and its recurrence in boys and men from early adolescence to early adulthood: an event history analysis

Occurrence and recurrences of suicidal ideation (SI) were modeled among boys/men assessed annually from ages 12 to 29 years. Multiple-spell discrete-time event-history analyses permitted (a) determination of whether risk for SI escalates with prior experiences of SI (spell effects), while (b) accounting for changes in risk with time (period effects) and (c) controlling for vulnerability factors. Self-reported SI (presence/absence in past week), depressive symptoms, alcohol/substance use, antisocial behavior, and official arrest records were collected annually from 205 boys recruited on the basis of community risk for delinquency. Parents' self-reported psychopathology and SES were collected in childhood. Period effects supported decreasing risk for SI over time. Spell and time-varying 1-year lagged substance use and depressive symptoms independently predicted increased risk for SI. Models involving SI with intent were explored. Consistent with interpersonal psychological theory, risk for young men's SI increases with past experience of SI, even with key propensities controlled. However, risk also decays over time. Targeting conditions that confer risk for SI is essential. Preventing and delaying SI occurrence and recurrence may represent independent mechanisms by which prevention efforts operate.

A review of "suicidal intent" within the existing suicide literature

The results of a systematic literature review that investigated suicide intent are presented. Of the 44 relevant articles identified, 17 investigated the relationships between various suicide risk factors and suicide intent and 25 publications investigated the relationships between suicide intent and various suicide outcomes. Despite recent advancements in the definition and nomological validity of suicide intent, a high degree of variability in the empirical measurement and analysis of suicide intent was found. Such variability limits future research related to measuring suicidal risk and outcomes, reporting suicide intent, or the meaningful comparison of diagnostic approaches or treatments across multiple studies.

The role of attachment styles and interpersonal problems in suicide-related behaviors

The relationships among adult attachment styles, interpersonal problems, and categories of suicide-related behaviors (i.e., self-harm, suicide attempts, and their co-occurrence) were examined in a predominantly psychiatric sample (N = 406). Both anxious and avoidant attachment styles were associated with interpersonal problems. In turn, specific interpersonal problems differentially mediated the relations between attachment style and type of suicide-related behaviors. These findings suggest the importance of distinguishing between these groups of behaviors in terms of etiological pathways, maintenance processes, and treatment interventions.

Actions speak louder than words: An elaborated theoretical model of the social functions of self-injury and other harmful behaviors

The question of why some people do things that are intentionally harmful to themselves continues to puzzle scientists, clinicians, and the public. Prior studies have demonstrated that one fairly extreme, direct form of self-harm, non-suicidal self-injury (NSSI), is maintained by both automatic (i.e., intrapersonal) as well as social (i.e., interpersonal) reinforcement. However, the majority of theoretical and empirical papers on this topic focus almost exclusively on the automatic functions. The purpose of this paper is to provide a more comprehensive analysis of the social functions of NSSI. Evidence is presented supporting the notion that NSSI is maintained by social reinforcement in at least a substantial minority of instances. Moreover, an elaborated theoretical model of the social functions of NSSI is outlined that proposes that this behavior represents a high intensity social signal used when less intense communication strategies fail (e.g., speaking, yelling, crying). The model further proposes that NSSI can serve not only as a signal of distress that is reinforced primarily by the caregiving behavior it elicits from others, but that it also can serve as a signal of strength and fitness that is reinforced by warding off potential threats (e.g., peer victimization), and in some cases can strengthen affiliation with others. Support for this theoretical model is drawn from diverse literatures including psychology, evolutionary biology, and cultural anthropology. The paper concludes with specific recommendations for empirical tests of the proposed model of the social functions of NSSI, as well as other harmful behaviors such as alcohol and drug use.