Correlates of suicide and violence risk in an inpatient population: coping styles and social support

Impulsivity, aggression, and suicidality relationship in adults: A systematic review and meta-analysis

BACKGROUND

The aim of the study was to crystallize the nature of relationships between impulsivity, aggression, and suicidality. We reviewed studies of adults with published, psychometric measures of impulsivity and aggression, and measures of suicidality.

METHODS

Our primary data source was Web of Science (from inception to 31st December 2021). Quality of articles was assessed using a Joanna Briggs Appraisal Tool and publication bias using Trim and Fill. We synthesised results using random effects meta-analyses and explored moderation by measure of impulsivity, aggression, and suicidality, and population.

FINDINGS

77 studies were included in our analysis. We found weak positive relationships between impulsivity (r = 0·19 [95% CI: 0·15-0·22]), aggression (0·23 ([0·17, 0·29]), and impulsive aggression (0·16 [0·1, 0·22]) with suicidality. Heterogeneity was significant and only partially explained by moderators. Limitations included the lack of studies which assess impulsivity or aggression proximal to suicidality.

INTERPRETATION

Given small effect sizes and significant heterogeneity, the study suggests that additional studies are needed in the field to analyze the relation between impulsivity and aggression with suicidality.

FUNDING

None.

Early Trauma Is Associated With Suicidal Ideation in Patients With Panic Disorder

ABSTRACT

There are several predictors of suicidality in patients with panic disorder (PD). Being a woman, younger age, low education level, unmarried status, and symptom severity have been suggested. This study aimed to examine whether early trauma is associated with suicidal ideation in patients with PD. Our study included 267 patients with PD and 105 controls. Data on sociodemographic variables and data from the Early Trauma Inventory Self Report-Short Form, Beck Depression Inventory, Panic Disorder Severity Scale, Anxiety Sensitivity Inventory-Revised, Coping Scales, and Scale for Suicide Ideation were collected, and correlation and regression analyses were performed. This study suggests that clinicians should consider early trauma when assessing suicidal ideation in patients with PD. Clinicians could consider alternative treatments, such as trauma-focused cognitive-behavioral therapy, eye movement desensitization, reprocessing approaches, and classical pharmacological and psychological treatments for patients with PD who have a history of early trauma and are expected to be at high risk for suicide.

Central Amygdala Projections to Lateral Hypothalamus Mediate Avoidance Behavior in Rats

Persistent avoidance of stress-related stimuli following acute stress exposure predicts negative outcomes such as substance abuse and traumatic stress disorders. Previous work using a rat model showed that the central amygdala (CeA) plays an important role in avoidance of a predator odor stress-paired context. Here, we show that CeA projections to the lateral hypothalamus (LH) are preferentially activated in male rats that show avoidance of a predator odor-paired context (termed Avoider rats), that chemogenetic inhibition of CeA-LH projections attenuates avoidance in male Avoider rats, that chemogenetic stimulation of the CeA-LH circuit produces conditioned place avoidance (CPA) in otherwise naive male rats, and that avoidance behavior is associated with intrinsic properties of LH-projecting CeA cells. Collectively, these data show that CeA-LH projections are important for persistent avoidance of stress-related stimuli following acute stress exposure.SIGNIFICANCE STATEMENT This study in rats shows that a specific circuit in the brain [i.e., neurons that project from the central amygdala (CeA) to the lateral hypothalamus (LH)] mediates avoidance of stress-associated stimuli. In addition, this study shows that intrinsic physiological properties of cells in this brain circuit are associated with avoidance of stress-associated stimuli. Further characterization of the CeA-LH circuit may improve our understanding of the neural mechanisms underlying specific aspects of stress-related disorders in humans.

Emotion-Oriented Coping Style Predicts Self-Harm in Response to Acute Psychiatric Hospitalization

Psychiatric hospitalization can cause significant distress for patients. Research has shown that to cope with the stress, patients sometimes resort to self-harm. Given the paucity of research on self-harm among psychiatric inpatients, a better understanding of transdiagnostic processes as predictors of self-harm during psychiatric hospitalization is needed. The current study examined whether coping styles predicted self-harm after controlling for commonly associated factors, such as age, gender, and borderline personality disorder. Participants were 72 patients (mean age = 39.32 years, SD = 12.29, 64% male) admitted for inpatient treatment at a public psychiatric hospital in Sydney, Australia. Participants completed self-report measures of coping styles and ward-specific coping behaviors, including self-harm, in relation to coping with the stress of acute hospitalization. Results showed that younger age, diagnosis of borderline personality disorder, and higher emotion-oriented coping were associated with self-harm. After controlling for age and borderline personality disorder, higher levels of emotion-oriented coping were found to be a significant predictor of self-harm. Findings were partially consistent with hypotheses; emotion-oriented but not avoidance-oriented coping significantly predicted self-harm. This finding may help to identify and provide psychiatric inpatients who are at risk of self-harm with appropriate therapeutic interventions.

Development and pilot study of a suicide prevention intervention delivered by peer support specialists

Suicide rates in the United States have been increasing in recent years, and the period after an inpatient psychiatric hospitalization is one of especially high risk for death by suicide. Peer support specialists may play an important role in addressing recommendations that suicide prevention activities focus on protective factors by improving hope and connectedness. The present study developed a peer specialist intervention titled Peers for Valued Living (PREVAIL) to reduce suicide risk, incorporating components of motivational interviewing and psychotherapies targeting suicide risk into recovery-based peer support. A randomized controlled pilot study was conducted to assess the acceptability, feasibility, and fidelity of the intervention. A total of 70 adult psychiatric inpatients at high risk for suicide were enrolled into the study. Participants were randomized to usual care (n = 36) or to the 12-week PREVAIL peer support intervention (n = 34). Those in the PREVAIL arm completed an average of 6.1 (SD = 5.0) peer sessions over the course of 12 weeks. Fidelity was rated for 20 peer support sessions, and 85% of the peer specialist sessions demonstrated adequate fidelity to administering a conversation tool regarding hope, belongingness, or safety, and 72.5% of general support skills (e.g., validation) were performed with adequate fidelity. Participants' qualitative responses (n = 23) were highly positive regarding peer specialists' ability to relate, listen, and advise and to provide support specifically during discussions about suicide. Findings demonstrate that a peer support specialist suicide prevention intervention is feasible and acceptable for patients at high risk for suicide. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Do criminal associates impact psychiatric inpatients' social support and interpersonal needs?

Suicide risk is elevated among psychiatric inpatients; however, research has not examined moderators of the associations between perceived social support and thwarted belongingness (TB) and perceived burdensomeness (PB), such as involvement with criminal associates. Adult psychiatric inpatients (N = 142) completed assessments. Perceived social support was negatively associated with TB and PB; however, associates' criminal involvement did not moderate these associations. A significant interaction indicated a stronger negative association between perceived social support and TB when participants spent more time with associates. Therefore, time spent with associates, regardless of criminal involvement, may be a relevant interpersonal suicide risk factor.

Psychosocial Correlates of Suicide Ideation: A Comparison of Chinese and U.S. Rural Women

China is the only country in the world where the suicide rate for women is higher than that for men. In particular there is current concern about a high suicide rate for women living in rural areas. In this study, two samples of young women ages 20 to 35, one from rural China ( n=52) and one from rural United States ( n=52) were interviewed as to suicide ideation and suicide risk, as related to psychosocial variables of self-esteem, coping, social support, and attitudes toward suicide. Significant mean differences were obtained between samples on all eleven variables. The pattern of intercorrelations between variables showed both similarities and differences in the two samples. A stepwise multiple-regression analysis indicated that the same four variables, albeit in different order, were predictive of suicide: these variables were self-esteem, instrumental support, the attitude that suicide is morally bad, and an overall rating of coping.

African Americans, Depression, and Suicide Risk

The aim of the current study was to determine which variable would be a better predictor of suicide risk: perceived social support or serum cholesterol level. There was a significant negative correlation between suicide risk and perceived social support but no significant correlation between suicide risk and serum cholesterol. Perceived social support was a better predictor of suicide risk than was serum cholesterol level and accounted for 17% of the variance. Depressed patients with a history of suicide attempt had a significantly lower serum cholesterol level, scored significantly higher on the Suicide Risk Scale, and scored significantly lower on the Perceived Social Support Scale than did depressed patients with no history of suicide attempt. Findings suggest that perceived social support is a better predictor of suicide risk for depressed African Americans.

Depression, Social Support, and Coping Styles among Pregnant Women after the Lushan Earthquake in Ya'an, China

Aim

The aim of this study is to assess the depression of pregnant women in the aftermath of an earthquake, and to identify the social support that they obtained, their coping styles and socio-demographic factors associated with depression.

Methods

A total of 128 pregnant women from three hospitals in the epicenter area were recruited immediately after the Ya’an earthquake. Their depression was investigated using the Edinburgh Postnatal Depression Scale (EPDS) with a cutoff score of 14; the social support that they obtained was measured using the Social Support Questionnaire; and their coping styles were assessed using the Coping Styles Questionnaire.

Results

Immediately after the earthquake, the incidence rate of depression in pregnant women was 35.2%, higher than that of the general pregnant population (7%-14%). The EPDS scores were significantly correlated with gestation age at the time of the earthquake, objective support, subjective support, use of support, negative coping style, and positive coping style. The regression analysis indicated that risk factors of prenatal depression include the number of children, relatives wounded, subjective support, and coping styles. A further analysis of the interaction between social support and two types of coping styles with depression showed that there was interaction effect between subjective social support and positive coping styles in relation to EPDS scores. There was an inverse relationship between low EPDS scores and positive coping styles and high social support, and vice versa.

Conclusion

The timing of the occurrence of the earthquake may not necessarily affect the progress of the illness and recovery from depression, and psychological intervention could be conducted in the immediate aftermath after the earthquake. The impact of coping styles on prenatal depression appeared to be linked with social support. Helping pregnant women to adopt positive coping styles with good social support after a recent major earthquake, which is a stressor, may reduce their chances of developing prenatal depression.

The co-occurrence of aggression and self-harm: systematic literature review

BACKGROUND

Epidemiological research supports an association between aggression and self-harm through data on the frequency with which individuals exhibit both behaviours. Unbiased evidence, however, is needed to draw conclusions about the nature and extent of co-occurrence.

METHOD

Systematic review of published studies was undertaken to evaluate whether or not the frequency with which aggression and self-harm co-occur is beyond that which would be expected by chance. Outcome measures included: (a) between-group differences on a standardised aggression/self-harm measure - the groups defined by scores on a measure of the other behaviour; (b) correlations between the two behaviours; (c) co-occurrence rates in populations defined by the presence of either behaviour; (d) co-occurrence rates in populations not defined by either behaviour. Odds ratios were calculated for studies presenting complete frequency data.

RESULTS

123 studies, some yielding more than one type of result, met the inclusion criteria. Most case-control studies found elevated levels of aggression in self-harming populations (or self-harm in aggressive populations) compared to controls. The majority of correlational, co-occurrence rate, and odds ratio data found aggression and self-harm to be associated.

LIMITATIONS

Results were subject to descriptive synthesis only and thus, unable to report an overall effect size.

CONCLUSIONS

Evidence suggests that aggression and self-harm frequently co-occur. Such evidence necessitates more theoretical discussion and associated research on the source and nature of co-occurrence. Nonetheless, individuals who present with one behaviour may be considered an 'at-risk' group in terms of exhibiting the other. Such evidence holds implications for practice (e.g. risk assessment).

A proposed model of the development of suicidal ideations

BACKGROUND

Suicidal ideations may precede suicide attempts. They are of particular concern in psychiatric populations because psychopathology is a major risk factor for suicide. The factors affecting the development of suicide ideations may differ among psychiatric patients with and without a previous suicide attempt and individuals without a psychiatric diagnosis.

OBJECTIVES

The aim of this study is to develop a model of suicide ideation in psychiatric patients and the general population.

METHOD

The study included 196 participants: 92 psychiatric patients with a previous suicide attempt ("attempters"); 47 psychiatric patients who had never attempted suicide ("non-attempters"); and 57 healthy control subjects. Data were collected on socio-demographic parameters, clinical history, and details of the suicide attempts. Participants completed a battery of psychological instruments assessing aggression-impulsivity, mental pain (including depression and hopelessness) and communication difficulties, in addition to negative life events. Findings were correlated with suicidal ideation by group.

RESULTS

The correlations of the different variables with suicidal ideation differed between suicide attempters and non-attempters; therefore, the model was analyzed separately for each group. The study yielded three major findings: negative life events had a significant effect on both anger-in and impulsivity in non-attempters but not in attempters; hopelessness moderately contributed to suicidal ideations in attempters but not in non-attempters; loneliness contributed significantly to depression in non-attempters but was less distressing in attempters.

CONCLUSION

The mechanism underlying suicidal ideation appears to differ between psychiatric patients who have previously attempted suicide and those who have not, supporting a dual model of suicidal ideation. Although this is only a preliminary study, these findings are important for furthering our understanding of the process of transition of suicidal thoughts to completion of suicide. These results need further replication with a larger cohort of subjects.

An examination of the relationship between anger and suicide risk through the lens of the interpersonal theory of suicide

Research has implicated a relationship between anger and suicidality, though underlying mechanisms remain unclear. The current study examined this relationship through the lens of the interpersonal theory of suicide (ITS). According to the ITS, individuals who experience thwarted belongingness, perceived burdensomeness, and elevated acquired capability for suicide are at increased risk for death by suicide. The relationships between anger and these variables were examined and these variables were examined as potential mediators between anger and suicidal ideation and behavior. Additionally, exposure to painful and provocative events was examined as a potential mediator between anger and acquired capability. As part of intake at a community mental health clinic, 215 outpatients completed questionnaires assessing depression, suicidal ideation, anger, perceived burdensomeness, thwarted belongingness, and acquired capability. Regression analyses revealed unique relationships between anger and both thwarted belongingness and perceived burdensomeness, covarying for depression. The association between anger and acquired capability trended toward significance. The links between anger and suicidal ideation and behavior were fully mediated by thwarted belongingness and perceived burdensomeness, but this effect was driven by perceived burdensomeness. Additionally, the link between anger and acquired capability was fully mediated by experience with painful and provocative events. In conclusion, results suggest that anger is uniquely associated with perceived burdensomeness and thwarted belongingness. Anger is associated with suicidal ideation and behavior via perceived burdensomeness and with greater acquired capability for suicide via experiences with painful and provocative events. Treatment for problematic anger may be beneficial to decrease risk for suicide.

Aggression-impulsivity, mental pain, and communication difficulties in medically serious and medically non-serious suicide attempters

BACKGROUND

Unbearable mental pain, depression, and hopelessness have been associated with suicidal behavior in general, while difficulties with social communication and loneliness have been associated with highly lethal suicide attempts in particular. The literature also links aggression and impulsivity with suicidal behavior but raises questions about their influence on the lethality and outcome of the suicide attempt.

OBJECTIVES

To evaluate the relative effects of aggression and impulsivity on the lethality of suicide attempts we hypothesized that impulsivity and aggression differentiate between suicide attempters and non-attempters and between medically serious and medically non-serious suicide attempters.

METHOD

The study group included 196 participants divided into four groups: 43 medically serious suicide attempters; 49 medically non-serious suicide attempters, 47 psychiatric patients who had never attempted suicide; and 57 healthy control subjects. Data on sociodemographic parameters, clinical history, and details of the suicide attempts were collected. Participants completed a battery of instruments for assessment of aggression-impulsivity, mental pain, and communication difficulties.

RESULTS

The medically serious and medically non-serious suicide attempters scored significantly higher than both control groups on mental pain, depression, and hopelessness (p<.001 for all) and on anger-in, anger-out, violence, and impulsivity (p<.05 for all), with no significant difference between the two suicide attempter groups. Medically serious suicide attempters had significantly lower self-disclosure (p<.05) and more schizoid tendencies (p<.001) than the other three groups and significantly more feelings of loneliness than the medically non-serious suicide attempters and nonsuicidal psychiatric patients (p<.05). Analysis of aggression-impulsivity, mental pain, and communication variables with suicide lethality yielded significant correlations for self-disclosure, schizoid tendency, and loneliness. The interaction between mental pain and schizoid traits explained some of the variance in suicide lethality, over and above the contribution of each component alone.

CONCLUSIONS

Aggression-impulsivity and mental pain are risk factors for suicide attempts. However, only difficulties in communication differentiate medically serious from medically non-serious suicide attempters. The combination of unbearable mental pain and difficulties in communication has a magnifying effect on the risk of lethal suicidal behavior.

Coping, symptoms, and functioning outcomes of patients with posttraumatic stress disorder

This study examines the association between approach coping and better functioning outcomes and the reciprocal relationships between coping and posttraumatic stress disorder (PTSD) symptoms in patients diagnosed with PTSD. Posttraumatic stress disorder patients receiving services in five VA health care systems were randomly selected and surveyed at baseline and followed 10 months later. Analyses of longitudinal data using structural equation modeling techniques showed that more approach coping predicted better family and social functioning. Cognitive avoidance coping predicted more PTSD symptoms, and more PTSD symptoms predicted more approach coping and more behavioral avoidance coping. Approach coping may enable patients with chronic PTSD to establish and maintain better relationships with family and friends, despite continuing PTSD.

Le soutien social peut-il protéger les hommes de la tentative de suicide ?

Cette étude tente d’examiner si le soutien social peut constituer un facteur de protection de la tentative de suicide chez les hommes et, le cas échéant, à identifier quelles sont les formes et les sources de soutien les plus importantes. Elle compare deux groupes d’hommes qui ont vécu des événements de vie sévères au cours des 12 derniers mois : 40 hommes admis à l’urgence d’un hôpital suite à une tentative de suicide et 40 hommes sans antécédent suicidaire. Les résultats indiquent que les hommes qui ont tenté de se suicider perçoivent moins de soutien disponible dans leur entourage et sont moins satisfaits du soutien reçu suite à l’événement le plus difficile survenu au cours de la dernière année. L’aide tangible et l’assurance de sa valeur sont les formes de soutien les plus importantes. L’étude souligne l’importance du soutien social dans la prévention des comportements suicidaires chez les hommes.

Coping styles of type I and type II alcohol-dependent men undergoing treatment

The purpose of this study was to investigate the ways by which individuals with alcohol dependence, who were subgrouped into type I and type II according to the typology criteria of von Knorring et al, (J. Study Alcohol. 1987;48:523-527), cope with life events. One hundred male alcohol-dependent individuals participating in a therapeutic program composed the study sample. Of the 100, 61 subjects were categorized as type I and 39 subjects as type II. Coping styles were measured using a self-administered questionnaire that includes 8 subscales of coping styles. The type II subgroup scored significantly lower on the suppression subscale and significantly higher on the replacement, mapping, and substitution subscales as compared with the type I subgroup, of which the latter difference was at a tendency level. As regards the remaining 4 coping style subscales, minimization, help seeking, blame, and reversal, no significant differences were found between the 2 patient subgroups. The differences found may be taken into account in the development of therapeutic programs for the 2 subgroups.

Factors associated with suicide attempts in female inmates: the hegemony of hopelessness

In this study factors associated with past suicide attempts in female inmates were examined. Female inmate participants (N = 105) were given structured diagnostic assessments of antisocial and borderline personality disorders and substance dependence, as well as measures of depression, hopelessness, problem-focused coping styles, and reasons for living. There was a high lifetime prevalence of past suicide attempts (38.1%). Suicide attempts were positively associated with personality disorders, hopelessness, depression, childhood physical/emotional abuse, and family history of suicide and mood disorders, and negatively associated with income, reasons for living, and problem-focused coping. Controlling for hopelessness, borderline personality disorder and family history of suicide attempts were the only variables that remained uniquely associated with suicide attempts.

Children's reasons for living, self-esteem, and violence

Attitudes toward violence and reasons for living in young adolescents with high, moderate, and low self-esteem were examined. The authors devised an Attitudes Toward Violence questionnaire; the Rosenberg's Self-esteem Scale (RSE) and the Brief Reasons for Living in Adolescents (BRFL-A) was used to assess adaptive characteristics. The independent variables were gender and self-esteem. The dependent variables were total Reasons for Living score and Attitudes Toward Violence score. Participants included 138 boys and 95 girls, ages 11 to 15 years (M = 13.3) from a city middle school. The results showed that for the dependent variable attitudes toward violence, main effects were found for both gender and self-esteem. For the dependent variable reasons for living, a main effect was found for self-esteem but not for gender. An inverse relationship was found between violence and reasons for living. Being male and low self-esteem emerged as predictors of more accepting attitudes toward violence. Low self-esteem was significantly related to fewer reasons for living.

Defense styles, impulsivity and suicide attempts in major depression

BACKGROUND

The aim of our study was to identify if defense mechanisms are associated with impulsivity and lifetime suicide attempts in depressed patients.

SAMPLING AND METHODS

The Defense Style Questionnaire, the Impulsivity Rating Scale and the Impulse Control Scale were used in 77 depressed inpatients.

RESULTS

Impulsivity was correlated positively with immature and neurotic styles and negatively with mature style. Some but not all defense mechanisms were relevant in this respect. The number of lifetime suicide attempts was positively correlated not only with impulsivity, but also with immature style and to a lesser extent with neurotic style. Several defense mechanisms were involved in these correlations: undoing, projection, passive aggression, acting out, splitting and somatization.

CONCLUSIONS

Like impulsivity, defense styles may be relevant to discriminate recurrent suicide attempters in depression. Prospective assessment of defense styles and suicide attempts in depression is needed.

Impulsiveness as a factor in sexual offending by people with mild intellectual disability

BACKGROUND

It has been suggested that sexual offending by people with intellectual disability (ID) results from a pattern of impulsive behaviour that is consistent with psychosocial disadvantage, rather than sexual deviancy. This study aimed to explore this hypothesis by assessing levels of impulsiveness in sexual offenders, non-sexual offenders and non-offenders with mild ID.

METHOD

Impulsiveness was assessed using a modified version of the Barratt Impulsiveness Scale (11th edition). Total impulsivity scores were compared between sexual offenders, non-sexual offenders and non-offenders, all with mild ID.

RESULTS

There was a significant difference in the levels of impulsiveness between sexual offenders and non-sexual offenders with ID (t=2.83, P<0.01). The sexual offenders were less impulsive than non-sexual offenders.

CONCLUSIONS

This study did not support the hypothesis that sexual offending by people with ID is better explained by impulsive behaviour rather than sexual deviancy. It supports recent findings that among the general population, sexual offenders are less impulsive than controls and violent offenders.

Suicidality, impulsivity and aggression--is there a link to 5HIAA concentration in the cerebrospinal fluid?

In biological suicide research, low cerebrospinal fluid-5-hydroxyindolacetic acid (CSF-5HIAA) concentrations have been associated with suicidality, aggression and impulsivity. However, it frequently appears that the interpretation of existing study results is flawed. The analysis of various published findings suggests that contaminating factors like impulsivity or depressive symptoms in suicide attempters are often not taken into consideration at the time of suicide. The seemingly 'robust' association of low CSF-5HIAA concentration with 'suicidality' and 'aggression' is in fact rather weak. Reported associations of subgroups of suicidal behavior (e.g. violent suicide attempts) with low CSF-5HIAA concentrations are likely to represent somewhat premature translations of findings from studies that have flaws in methodology. Furthermore, the perception of 'suicidal behavior' as autoaggressive behavior or inwardly directed aggression in the view of the authors may not be useful in biological suicide research. The construct of aggressivity is insufficiently defined, resulting in difficulties to interpret empirical data. Some evidence exists, however, that reduced CSF-5HIAA concentrations might be related to certain depressive symptoms and changes in impulsivity. More carefully designed studies are required to overcome the existing methodological shortcomings.

Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder

An emerging literature suggests that posttraumatic stress disorder (PTSD) patients are at an increased risk for suicide. The objective of this study was: a) to reexamine the relationship between PTSD and suicide by comparing suicide risks of persons with PTSD, to persons with anxiety disorder and to matched controls; and b) to examine the relationship between anger, impulsivity, social support and suicidality in PTSD and other anxiety disorders. Forty-six patients suffering from PTSD were compared with 42 non-PTSD anxiety disorder patients and with 50 healthy controls on measures of anger, impulsivity, social support, and suicide risk. Persons with PTSD had the highest scores on the measures of suicide risk, anger, and impulsivity and the lowest scores on social support. Multivariate analysis revealed that in the PTSD group, impulsivity was positively correlated with suicide risk and anger was not. PTSD symptoms of intrusion and avoidance were only mildly correlated with suicide risk at the bivariate level but not at the multivariate level. For the PTSD and anxiety disorder groups, the greater the social support, the lower the risk of suicide. For the controls, social support and impulsivity were not related to suicide risk, whereas anger was. These findings suggest that persons with PTSD are at higher risk for suicide and that in assessing suicide risk among persons with PTSD, careful attention should be paid to levels of impulsivity, which may increase suicide risk, and to social support, which may reduce the risk.

Coping style of substance-abuse patients: effects of anxiety and mood disorders on coping change

The authors studied the coping style of substance-abuse patients during clinical cognitive-behavioral group therapy, and the effects of mood and anxiety disorders on changes in coping style. Change in coping style was studied prospectively in a cohort of 132 residential-drug-abuse patients. In addition to pretreatment assessments, which included diagnosis of mood and anxiety disorders and addiction severity, repeated measurements of coping style were performed at predetoxification, pretreatment, and after three and six months of treatment. Considerable change in coping style between predetoxification and pretreatment was found, suggesting that coping assessment in a predetoxification phase is confounded by state factors surrounding treatment entry. Coping style of detoxified substance abusers is related to the presence of mood and anxiety disorders. Coping style was not found to be related to the severity of drug abuse. Furthermore, maladaptive coping styles decreased after three months of inpatient-substance-abuse treatment, and more-adaptive coping styles remained stable for another three months of inpatient treatment. Patients with an anxiety disorder improved less on coping style when compared to non-anxiety patients. Presence of a mood disorder had no impact on coping-style improvement. The results indicate that more attention should be focused on anxiety disorders during substance-abuse treatment in order to improve coping style. Furthermore, more studies are needed on the relation between substance abuse, coping style, and psychopathology.

The Schizophrenia Suicide Risk Scale (SSRS): development and initial validation

BACKGROUND

Estimations about the lifetime risk of suicide in schizophrenia vary between 4 and 10%. At present, there does not exist a suicide risk scale developed particularly for schizophrenic patients. The aims of the present study were to: (1) develop a clinically useful semi-structured scale for the estimation of short-term suicide risk among schizophrenic patients, and (2) to carry out an initial validation of the scale.

METHODS

A 25-item Schizophrenia Suicide Risk Scale (SSRS) was constructed on the base of the literature. The SSRS scores of 69 living schizophrenic patients (LS group) were compared with the scores of 69 schizophrenic suicides (SS group) whose data had been collected previously from The Finnish nationwide and representative psychological autopsy study. Internal consistency of the SSRS was evaluated with Cronbach alpha. The most important SSRS items predicting suicide were identified with a logistic regression analysis. Sensitivity, specificity, positive predictive value, and negative predictive value of the SSRS in predicting suicide with various cut-off scores were calculated.

RESULTS

In the final logistic regression model, the following SSRS items significantly predicted suicide: suicide plans communicated to someone during the past 3 months; one or more previous suicide attempts; loss of professional skills demanding job; depression observed during an interview; and suicide plans communicated during an interview. With high cut-off scores the specificity of the SSRS became satisfactory, but the sensitivity dropped below 32%. Internal consistency of the anamnestic history of the SSRS was low, which suggests that anamnestic risk factors for suicide in schizophrenia are multifactorial. Internal consistency of the interview-based items was high, and present state risk factors seemed to consist of two separate factors, depression-anxiety and irritability.

CONCLUSIONS

The SSRS may be clinically useful in identifying schizophrenic patients with a particularly high risk for suicide. However, the SSRS seems not to be a practical screening instrument for suicide risk in schizophrenia, and it is probably impossible to construct a suicide risk scale with both high sensitivity and high specificity in this disorder.

Risk factors for suicide attempts among African American women

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care.

Suicide risk and coping styles in posttraumatic stress disorder patients

BACKGROUND

Suicide and suicidal behavior have been found to be increased among posttraumatic stress disorder (PTSD) patients. The present study examined suicide risk and Plutchik's coping styles in PTSD patients.

METHOD

47 PTSD patients were compared with 42 patients with mixed non-PTSD anxiety disorders and 50 healthy control subjects, matched for age and gender, on a measure of suicide risk.

RESULTS

The PTSD patients scored significantly higher than the two control groups on the suicide risk measure. Furthermore, in the PTSD group, suicide risk was significantly negatively correlated with the coping mechanisms of mapping, minimization and replacement and positively correlated with the coping style of suppression. Furthermore, the coping styles significantly explained the variance of the suicide risk measure for all three groups.

CONCLUSIONS

The cognitive map of PTSD patients highly resembles other populations with high suicide risk. Clinicians treating victims of traumatic events should focus on problem-solving therapies in order to help these patients deal less rigidly with everyday stresses and by this decrease the suicide risk.

Self-efficacy and social support as mediators in the relation between disease severity and quality of life in patients with epilepsy

PURPOSE

This study examined the influence of two psychosocial variables mediating between disease severity and quality of life (QoL) in epilepsy; social support and mastery (measured by locus of control and self-efficacy). A model placing these two variables as mediators between disease severity and QoL was tested with structural equation modeling.

METHODS

Eighty-nine patients with epilepsy (58% men, age 36+/-12 years) were given the following instruments: Liverpool Seizure Severity Scale, Interpersonal Support Evaluation List, Epileptic Self-Efficacy Scale, Locus of Control scale, and the World Health Organization's Quality of Life Questionnaire, the WHOQOL.

RESULTS

Structural equation modeling showed good fit between the research model and the data (Bentler-Bonett Normalized Index of fit, 0.96; LISREL GFI, 0.95). Ninety percent of the variance of the WHOQOL was explained by a combination of disease severity, self-efficacy in epilepsy, social support, and locus of control. Mastery was found to mediate the correlation between disease severity and QoL, and social support was found to act as a mediator between disease severity and mastery.

CONCLUSIONS

The study findings emphasize the possibility of improving QoL among patients with epilepsy by counseling and treatment aimed at reinforcing their self-efficacy and locus of control, as well as by improving their SoS.

Changing patterns of attempted suicide in Greece: clinicoepidemiological and psychodynamic data

Greece is known to have one of the lowest rates of both completed and attempted suicides. Yet during the last three decades the pattern of suicide attempts has shown some differentiations, which point to possible changes in family structure and social behavior, bringing the pattern closer to that of western countries. While in 1971-72 the ratio of male to female attempters was 1:4.6, in 1994-96 it was 1:2.3 - the mean age rose from early to middle adulthood - more married people attempted suicide than before - more attempters took alcohol before the act etc. There are, nevertheless, many steady features, e.g. the low rates of attempters in old age (above 65 years: 7.9% of the total), the methods used, the type of preceding stressful life events (more financial than emotional in males), no drug abuse etc. Since the low rates of suicide attempts in Greece have been attributed to cultural parameters and the close bonds in the family, psychodynamic studies were also carried out, which showed that adolescent attempters preserve the ability for outward aggression and their self-destructive act is due to other than intrapsychic factors (usually social and relational problems).

Aggressive behaviour in schizophrenia: role of state versus trait factors

The objective of this article was to elucidate the relative importance of state vs. trait factors in determining aggressive behaviour in schizophrenia. Thirty-one aggressive schizophrenia patients in rehabilitation wards were compared with 31 matched non-aggressive patients with respect to their psychopathology, phenomenologies of hallucinations and delusions, neuroleptic motor side effects, history of aggression and personality traits. Significant differences between the two groups were found in relation to psychopathology, affective responses to hallucinations/delusions, history of aggression and personality traits, but there were no significant differences regarding neuroleptic motor side effects. The effects of history of aggression as well as personality traits were independent of and similar to the total level of psychopathology, but were much smaller when compared to those of negative affective responses to hallucinations/delusions.

Measurement of aggression in psychiatric patients

This article analyzes, describes, and characterizes the methods used for measuring aggression in studies on psychiatric patients. The authors reviewed all studies published between 1985 and 1994 in seven major psychiatric journals and found 103 studies on adult aggression and 43 on childhood and adolescent aggression. Almost half (44.7%) of the adult studies and 23.3% of the child and adolescent studies did not use any structured instrument; the remainder used a total of 52 different instruments, indicating that the methodology in this area is not well established. The methods used for measuring aggression were mainly of three types: observational measures; self-report questionnaires; and structured chart reviews. Each of these tools is described herein, with special focus on reliability and validity. Overall the reliability of the various scales is high, but the empirical validity is rather poor. In choosing a suitable method for measuring aggression, researchers should take into account the direction of investigation (e.g. state vs. trait aggression, dynamic or biological aspects of aggression) and the target population. Practical suggestions in this regard are offered.

Coping styles and suicide risk

A total of 30 psychiatric in-patients admitted because of suicidal behaviour were compared with 30 non-suicidal psychiatric in-patients and 32 healthy controls on measures of suicide risk and coping styles. The three groups were similar with regard to demographic variables, but the suicidal group scored higher on the suicide risk scale. Suicidal patients were significantly less likely to use the coping styles of minimization and mapping. They were unable to de-emphasize the importance of a perceived problem or source of stress. They also lacked the ability to obtain new information required to resolve stressful life events. Four coping styles correlated negatively with the suicide risk (minimization, replacement, mapping and reversal), while another three (suppression, blame and substitution) correlated positively. These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in these high-risk patients.