Fear of dying in panic attacks predicts suicide attempt in comorbid depressive illness: prospective evidence from the National Epidemiological Survey on Alcohol and Related Conditions

Factor Structure and Validation of the Revised Suicide Crisis Inventory in a Korean Population

OBJECTIVE

Because of the exceptionally high suicide rates in South Korea, new assessment methods are needed to improve suicide prevention. The current study aims to validate the revised Suicide Crisis Inventory-2 (SCI-2), a self-report measure that assesses a cognitiveaffective pre-suicidal state in a Korean sample.

METHODS

With data from 1,061 community adults in South Korea, confirmatory factor analyses were first conducted to test the proposed one-factor and five-factor structures of the SCI-2. Also, an exploratory factor analysis (EFA) was performed to examine possible alternative factor structure of the inventory.

RESULTS

The one-factor model of the SCI-2 resulted in good model fit and similarly, the five-factor model also exhibited strong fit. Comparing the two models, the five-factor was evaluated as the superior model fit. An alternative 4-factor model derived from EFA exhibited a comparable model fit. The Korean version of the SCI-2 had high internal consistency and strong concurrent validity in relation to symptoms of suicidal ideation, depression, and anxiety.

CONCLUSION

The SCI-2 is an appropriate and a valid tool for measuring one's proximity to imminent suicide risk. However, the exact factor structure of the SCI-2 may be culture-sensitive and warrants further study.

A comprehensive model of predictors of suicide attempt in individuals with panic disorder: Results from a national 3-year prospective study

OBJECTIVE

People with panic disorder are at increased risk of suicide. Multiple factors influence their risk suggesting a need to combine them into an integrative model to develop more effective suicide prevention strategies for this population. In this report, we sought to build a comprehensive model of the 3-year risk of suicide attempt in individuals with panic disorder using a longitudinal nationally representative study, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; wave 1, 2001-2002; wave 2, 2004-2005).

METHOD

We used structural equation modeling to simultaneously examine effects of six broad groups of clinical factors previously identified as potential predictors of suicide attempt in adults with panic disorder: 1) severity of panic disorder, 2) severity of comorbidity, 3) prior history of suicide attempt, 4) family history of psychiatric disorders, 5) sociodemographic characteristics and 6) treatment-seeking behavior.

RESULTS

The 3-year prevalence rate of suicide attempt was 4.6%. A general psychopathology factor, lower physical health-related quality of life, prior suicide attempt and a greater number of stressful life events at baseline significantly and independently predicted suicide attempt between the two waves (p < .05). R-square of the models ranged from 0.47 to 0.50.

CONCLUSION

This model may help inform future research and identify high-risk individuals among adults with panic disorder.

Alcohol use and risk of suicide: a systematic review and Meta-analysis

Objectives: Alcohol use has several consequences and is one of the variables that increase risk of suicide. This meta-analysis was performed using cohort studies to clarify the association of alcohol use and suicide.Method: Scientific sources were reviewed regarding the keywords. After screening, thirty cohort studies were identified for the meta-analysis. The analysis was performed based on the random effects and subsequent analysis of the subgroups, based on various variables.Result: Analysis of the results showed that there is a relationship between alcohol use and suicide. Risk Ratio (RR) between alcohol use and suicide was 1.65. In men, pooled RR was 1.56 with 95% CI = 1.20-2.03, and in women, the pooled RR was equal to 1.40 with 95% CI = 1.11-1.77.Conclusion: Overall, the findings indicate that alcohol use is a risk factor for suicide. Therefore, it seems that prevention and control of alcohol use can be effective in promoting mental health.

Suicide risk around the world: a meta-analysis of longitudinal studies

PURPOSE

Suicidal thoughts and behaviors (STBs) have been a persistent problem worldwide. Identifying risk factors for STBs across distinct areas of the world may help predict who or where requires the greatest attention. However, risk factors for STBs are infrequently explored cross-nationally. The present study examined whether psychopathology prospectively predicts STBs across different areas of the world, and whether certain country-level factors moderate the degree of risk conferred.

METHODS

We conducted a meta-analysis of 71 longitudinal studies from 30 different countries that featured psychopathology-related variables predicting STB outcomes. Meta-regression was used to evaluate whether the following country-level factors modified risk: geographic region, income level, and degree of mental health structural stigma.

RESULTS

Over 90% of studies had been conducted in North America and Europe. When assessed by country income level, it was found that only one longitudinal study on psychopathology and STB was conducted outside of a high-income country. Moreover, less than 10% of studies were conducted in high structural stigma contexts. Meta-regression findings revealed that the variation in risk effect sizes across studies was not explained by models including country-level factors.

CONCLUSIONS

Our findings show critical underrepresentation of low- and middle-income countries, which account for a large proportion of global suicide deaths. This reveals a need to broaden the scope of longitudinal research on STB risk, such that countries across more regions, income levels, and degrees of structural stigma are fully accounted for. Such lines of research will improve generalizability of findings, and more precisely inform prevention efforts worldwide.

Suicide Risk and Emotional Responses to Thoughts of Death: The Response to Morbid Ideations Questionnaire

BACKGROUND

There is need for deeper understanding of the processes by which suicidal thoughts lead to action. Examination of morbid ideation and the emotional sequelae of such ideation that may feed suicide ideation (SI) and attempts (SA) have been limited.

METHOD

Adult psychiatric outpatients (N = 385) were administered the Response to Morbid Ideation Questionnaire (RMI-Q) and measures of SI, suicidal thoughts and behaviors (STB), and other psychiatric symptom severity. We examined (1) incidence and prevalence in mentation of morbid ideations and emotional responses to these ideations, (2) differences in emotional responses between individuals of varying levels of suicide history, and (3) the relationships of different types of morbid ideations and emotional responses with concurrent SI and symptom severity.

RESULTS

Morbid ideation was reported by 87.5% of participants and associated with lifetime and concurrent levels of SI/STB. Calm/relieved emotional responses were associated with lifetime and concurrent levels of SI/STB, while negative-valence responses to morbid ideations were associated with concurrent severity of psychopathology.

CONCLUSIONS

Our results suggest that the role of morbid ideation and its emotional sequelae in the development of suicidal motivation and action deserves further attention and may be a treatment target for suicide risk reduction.

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide-specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self-reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence-based components-entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre-suicidal mental state, regardless of their self-reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.

Suicidal ideation in primary care patients suffering from panic disorder with or without agoraphobia

BACKGROUND

Suicidal ideation is common in patients suffering from panic disorder. The present study investigated rates of suicidal ideation and risk factors for suicidal ideation in a sample of primary care patients suffering from panic disorder with or without agoraphobia.

METHODS

A total of N = 296 patients [n = 215 (72.6%) women; age: M = 43.99, SD = 13.44] were investigated. Anxiety severity, anxiety symptoms, avoidance behavior, comorbid depression diagnosis, severity of depression, age, sex, employment status, living situation and frequency of visits at the general practitioner were considered as risk factors of suicidal ideation.

RESULTS

Suicidal ideation was experienced by 25% of the respondents. In a logistic regression analysis, depression diagnosis and depression severity emerged as significant risk factors for suicidal ideation. Anxiety measures were not associated with suicidal ideation.

CONCLUSION

Suicidal ideation is common in primary care patients suffering from panic disorder with or without agoraphobia. Individuals with greater burden of mental illness in terms of mood disorder comorbidity and depressive symptomatology are especially likely to suffer from suicidal ideation.

Suicidality in Subjects With Anxiety or Obsessive-Compulsive and Related Disorders: Recent Advances

PURPOSE OF REVIEW

Historically, anxiety disorders have not been considered as important determinants of suicide, but in the last years, many works have challenged this assumption. Here, we will review the available evidence on the relationship between suicide and anxiety disorders (e.g., obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, panic disorder, and body dysmorphic disorder), with special emphasis on findings published in the last years.

RECENT FINDINGS

Overall, anxiety disorders increase the risk of suicide. Specifically, 16% of patients with social anxiety disorder reported suicidal ideation in the previous month, and 18% of them had a history of suicide attempts. Similarly, in patients with panic disorder, suicidal ideation prevalence ranged between 17 and 32%, and 33% of them had a history of suicide attempts. Generalized anxiety disorder (GAD) was the most frequent anxiety disorder in completed suicides (present in 3% of people who committed suicide) and also subthreshold GAD was clearly linked to suicide ideation. Post-traumatic stress disorder was positively associated with suicidal ideation, and in patients with obsessive-compulsive disorder, suicide ideation rates ranged from 10 to 53% and suicide attempts from 1 to 46%. Body dysmorphic disorders presented a suicide ideation prevalence of about 80%. Suicide risk is increased in subjects with anxiety disorder. This risk is higher in the presence of comorbidities, but it is not clear whether it is independent from such comorbidities in some disorders.

Entrapment as a mediator of suicide crises

BACKGROUND

Prior research has validated the construct of a suicide crisis syndrome (SCS), a specific psychological state that precedes and may precipitate suicidal behavior. The feeling of entrapment is a central concept of the SCS as well as of several other recent models of suicide. However, its exact relationship with suicidality is not fully understood. In efforts to clarify the exact role of entrapment in the suicidal process, we have examined if entrapment mediates the relationship of other components of the SCS, including ruminative flooding, panic-dissociation, fear of dying and emotional pain, with suicidal ideation (SI) in recently hospitalized psychiatric inpatients.

METHODS

The Suicide Crisis Inventory (SCI) and Beck Scale for Suicidal Ideation (BSS) were administered to 200 high-risk adult psychiatric inpatients hospitalized following SI or suicide attempt, assessing SCS and SI levels at admission, respectively. The possible mediation effects of entrapment on the relationship between the other components of the SCS and SI at admission were evaluated.

RESULTS

Entrapment significantly and fully mediated the relationship of ruminative flooding, panic-dissociation, and fear of dying with SI, with no direct relationships between these variables and SI reaching statistical significance. Further, no reverse mediation relationships between these variables and SI were found, indicating that the mediation effects of entrapment were unidirectional. While entrapment did mediate the association between emotional pain and SI, the direct relationship between emotional pain and SI was also significant. Moreover, in reverse mediational analysis, emotional pain was a partial mediator of the relationship between entrapment and SI.

CONCLUSION

Entrapment and emotional pain may have a more direct association with SI than the other components of the SCS, including ruminative flooding, panic-dissociation, and fear of dying, the effects of which are mediated by the former. This suggests entrapment and emotional pain may represent key symptomatic targets for intervention in acutely suicidal individuals. Further research is needed to determine the relationship of these constructs to suicidal behavior.

Understanding Suicide Risk within the Research Domain Criteria (RDoC) Framework: Insights, Challenges, and Future Research Considerations

Suicide is a leading cause of death worldwide. Prior research has focused primarily on sociodemographic and psychiatric risk factors with little improvement in the prediction or prevention of suicidal behavior over time. The Research Domain Criteria (RDoC) may be an especially useful framework for advancing research in this area. This paper provides a brief and broad overview of research on suicidal behavior relating to each of the RDoC domains-highlighting the RDoC construct(s) where research has focused, construct(s) where research is lacking, and suggestions for future research directions. We also discuss major challenges for suicide research within the RDoC framework, including the intersection of RDoC domains, interaction of domains with the environment, incorporation of developmental stage, integration of distal and proximal processes, and inclusion of suicide-specific constructs. We conclude by underscoring important considerations for future research aimed at using the RDoC framework to study suicidal behavior and other forms of psychopathology.

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-analytic review

Suicidal thoughts and behaviors are highly prevalent public health problems with devastating consequences. There is an urgent need to improve our understanding of risk factors for suicide to identify effective intervention targets. The aim of this meta-analysis was to examine the magnitude and clinical utility of anxiety and its disorders as risk factors for suicide ideation, attempts, and deaths. We conducted a literature search through December 2014; of the 65 articles meeting our inclusion criteria, we extracted 180 cases in which an anxiety-specific variable was used to longitudinally predict a suicide-related outcome. Results indicated that anxiety is a statistically significant, yet weak, predictor of suicide ideation (OR=1.49, 95% CI: 1.18, 1.88) and attempts (OR=1.64, 95% CI: 1.47, 1.83), but not deaths (OR=1.01, 95% CI: 0.87, 1.18). The strongest associations were observed for PTSD. Estimates were reduced after accounting for publication bias, and diagnostic accuracy analyses indicated acceptable specificity but poor sensitivity. Overall, the extant literature suggests that anxiety and its disorders, at least when these constructs are measured in isolation and as trait-like constructs, are relatively weak predictors of suicidal thoughts and behaviors over long follow-up periods. Implications for future research priorities are discussed.

Clinical symptoms associated with suicidality in patients with panic disorder

BACKGROUND

Patients with panic disorder have higher rates of suicide than the general population. Among panic disorder subjects, early onset, female gender, alcohol abuse, and mood disorder increase the risk of suicidality. However, less is known about the unique relationships between discrete DSM-IV panic symptoms and higher suicidality. Therefore, in the current study we examined the panic symptom profile that is associated with higher suicidality in a sample of outpatients with panic disorder.

METHODS

This cross-sectional study included 427 patients diagnosed with current panic disorder on the basis of the DSM-IV-TR. In order to assess the contribution of the clinical variables, a univariate logistic regression was carried out examining the relationships between the demographic variables, suicidality from the suicide module of the Korean version of the MINI International Neuropsychiatric Interview Plus, and DSM-IV panic symptoms. Additionally, a multivariate logistic regression was performed to identify specific panic symptoms that were significant risk factors for suicidality among patients with current panic disorder.

RESULTS

We found that 74 (17.33%) panic disorder patients experienced high suicidality. Univariate analyses showed that high suicidality was significantly associated with a younger age (OR = 13.66; 95% CI 2.68-69.70), comorbid depressive disorders (OR = 4.57; 95% CI 2.57-8.11), and the following panic symptoms: palpitations (OR = 2.20; 95% CI 0.90-5.35), trembling (OR = 0.61; 95% CI 0.362-1.18), nausea or abdominal distress (OR = 1.77; 95% CI 0.96-3.27), fear of losing control or going crazy (OR = 2.18; 95% CI 1.12-4.23), and paresthesia (OR = 1.57; 95% CI 0.83-2.98). Multivariate logistic regression analyses demonstrated that specific panic symptoms, such as palpitations (adjusted OR = 2.69; 95% CI 1.08-6.73) and fear of losing control or going crazy (adjusted OR = 2.28; 95% CI 1.21-4.31), were related to suicidality after controlling for confounding factors.

CONCLUSION

Some panic symptoms (e.g. palpitations and fear of losing control or going crazy) are associated with a risk of suicidality among patients with panic disorder. A priori identification of high-risk suicidal subjects could lead to effective treatment strategies for panic disorder.

Predictive validity of the Suicide Trigger Scale (STS-3) for post-discharge suicide attempt in high-risk psychiatric inpatients

Background

The greatly increased risk of suicide after psychiatric hospitalization is a critical problem, yet we are unable to identify individuals who would attempt suicide upon discharge. The Suicide Trigger Scale v.3 (STS-3), was designed to measure the construct of an affective ‘suicide trigger state’ hypothesized to precede a suicide attempt (SA). This study aims to test the predictive validity of the STS-3 for post-discharge SA on a high-risk psychiatric-inpatient sample.

Methods

The STS-3, and a psychological test battery measuring suicidality, mood, impulsivity, trauma history, and attachment style were administered to 161 adult psychiatric patients hospitalized following suicidal ideation (SI) or SA. Receiver Operator Characteristic and logistic regression analyses were used to assess prediction of SA in the 6-month period following discharge from hospitalization.

Results

STS-3 scores for the patients who made post-discharge SA followed a bimodal distribution skewed to high and low scores, thus a distance from median transform was applied to the scores. The transformed score was a significant predictor of post-discharge SA (AUC 0.731), and a subset of six STS-3 scale items was identified that produced improved prediction of post-discharge SA (AUC 0.814). Scores on C-SSRS and BSS were not predictive. Patients with ultra-high (90^th percentile) STS-3 scores differed significantly from ultra-low (10^th percentile) scorers on measures of affective intensity, depression, impulsiveness, abuse history, and attachment security.

Conclusion

STS-3 transformed scores at admission to the psychiatric hospital predict suicide attempts following discharge among the high-risk group of suicidal inpatients. Patients with high transformed scores appear to comprise two clinically distinct groups; an impulsive, affectively intense, fearfully attached group with high raw STS-3 scores and a low-impulsivity, low affect and low trauma-reporting group with low raw STS-3 scores. These groups may correspond to low-plan and planned suicide attempts, respectively, but this remains to be established by future research.

Distinctive emotional responses of clinicians to suicide-attempting patients--a comparative study

BACKGROUND

Clinician responses to patients have been recognized as an important factor in treatment outcome. Clinician responses to suicidal patients have received little attention in the literature however, and no quantitative studies have been published. Further, although patients with high versus low lethality suicidal behaviors have been speculated to represent two distinct populations, clinicians' emotional responses to them have not been examined.

METHODS

Clinicians' responses to their patients when last seeing them prior to patients' suicide attempt or death were assessed retrospectively with the Therapist Response/Countertransference Questionnaire, administered anonymously via an Internet survey service. Scores on individual items and subscale scores were compared between groups, and linear discriminant analysis was applied to determine the combination of items that best discriminated between groups.

RESULTS

Clinicians reported on patients who completed suicide, made high-lethality attempts, low-lethality attempts, or died unexpected non-suicidal deaths in a total of 82 cases. We found that clinicians treating imminently suicidal patients had less positive feelings towards these patients than for non-suicidal patients, but had higher hopes for their treatment, while finding themselves notably more overwhelmed, distressed by, and to some degree avoidant of them. Further, we found that the specific paradoxical combination of hopefulness and distress/avoidance was a significant discriminator between suicidal patients and those who died unexpected non-suicidal deaths with 90% sensitivity and 56% specificity. In addition, we identified one questionnaire item that discriminated significantly between high- and low-lethality suicide patients.

CONCLUSIONS

Clinicians' emotional responses to patients at risk versus not at risk for imminent suicide attempt may be distinct in ways consistent with responses theorized by Maltsberger and Buie in 1974. Prospective replication is needed to confirm these results, however. Our findings demonstrate the feasibility of using quantitative self-report methodologies for investigation of the relationship between clinicians' emotional responses to suicidal patients and suicide risk.