Diagnostic and psychosocial differences in psychiatrically hospitalized military service members with single versus multiple suicide attempts

Characteristics of Single vs. Multiple Suicide Attempters Among Adult Population: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

We aimed to examine the factors that differentiate single and multiple suicide attempters in adult population. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines to conduct this review and meta-analysis. The review protocol was registered in PROSPERO. We carried out a systematic literature search in three databases to identify original studies that explored the differences between single and multiple suicide attempters among adult population.

RECENT FINDINGS

There might be meaningful differences between those individuals that attempt suicide once in their lifespan and those who make multiple attempts in terms of sociodemographic and clinical characteristics. There are no previous meta-analysis addressing this topic in the adult population. A total of 75 studies were included in the review and 69 were included in the meta-analysis. Multiple attempters were more likely to present certain disorders such as mood and psychotic disorders, as well as personality or substance use disorders. Higher suicide ideation and suicide intent scores also characterized this group. Childhood trauma experiences, stressful life events, and higher rates of hopelessness were statistically significant in multiple attempters. Identifying the factors predicting multiple suicide attempts helps to delineate a high-risk suicidal profile that should be taken into account in the clinical and suicide prevention scenario.

Adjustment disorder in the Armed Forces: a systematic review

BACKGROUND

In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population.

AIM

The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes.

METHOD

A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines.

RESULTS

Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness.

CONCLUSION

This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

Factors associated with multiple suicide attempts in a nationally representative study of U.S. military veterans

OBJECTIVE

Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from multiple suicide attempters (MSA) in a nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans.

ANALYSES

(a) estimated the lifetime prevalence of SSA and MSA; and (b) examined factors that differentiated veterans with a SSA from MSA.

RESULTS

The lifetime prevalences of SSA and MSA were 1.9% and 2.0%. The strongest correlates of MSA were history of lifetime depression (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.43-8.35), non-suicidal self-injury (OR, 3.28; 95% CI, 1.27-8.45), drug use disorder (OR, 4.0; 95% CI, 1.67-9.54), and marital status (OR, 0.40, 95% CI, 0.18-0.87), which accounted for 15.5%-41.4% of the total explained variance in MSA.

DISCUSSION

Half of military veterans who have attempted suicide in the United States report more than one attempt, suggesting that suicide attempts are not a one-time occurrence for a substantial proportion of veterans. Veterans who attempt suicide more than once show more deliberate self-harm behavior and have greater psychiatric comorbidities relative to single attempters. Implications for future research examining risk factors for suicide attempts among veterans are discussed.

A systematic review of suicidal behaviour in men: A narrative synthesis of risk factors

RATIONALE

Suicides by men outnumber those by women in every country of the world. To date, there has not been a comprehensive systematic review of risk factors for suicidal behaviour in men to better understand the excess deaths by suicide in men.

OBJECTIVE

The present systematic review seeks to determine the nature and extent of the risk factors to predict suicidal behaviour in men over time.

METHODS

A range of databases (CINAHL, PsycINFO, Web of Science Core Collection, Pubmed, Embase, and Psychology and Behavioural Sciences Collection) were searched from inception to January 2020 for eligible articles. The findings were collated through a narrative synthesis of the evidence.

RESULTS

An initial 601 studies were identified. Following the inclusion and exclusion criteria, there were 105 eligible studies (62 prospective and 43 retrospective) identified. Overall, the risk factors with the strongest evidence predicting suicidal behaviour in men were alcohol and/or drug use/dependence; being unmarried, single, divorced, or widowed; and having a diagnosis of depression. In the prospective studies, the most consistent evidence was for sociodemographic factors (19 risk factors), mental health/psychiatric illness (16 risk factors), physical health/illness (13 risk factors), and negative life events/trauma (11 risk factors). There were a small number of psychological factors (6 factors) and characteristics of suicidal behaviour (3 factors) identified. The findings from the retrospective studies provided further evidence for the risk factors identified in the prospective studies.

CONCLUSIONS

This systematic review has highlighted the wide range of risk factors for suicidal behaviour in men, in this review alone 68 different risk factors were identified. Many factors can interact and change in relevance throughout an individual's life. This review has identified extensive gaps in our knowledge as well as suggestions for future research.

Acute Shame Predicts Urges for Suicide but not for Substance Use in a Veteran Population

OBJECTIVE

There is an urgent need to identify ways to reduce rates of suicide among Veterans with a substance use disorder. Since co-occurring disorders can make diagnosis and treatment complex, it is useful for the mental health field to examine common factors that may underlie both problems. One common factor that underlies both substance use and suicidal behavior is shame. This brief report presents data collected in an experimental study examining shame as an acute risk factor for suicide and substance use in Veterans.

METHOD

Thirty-eight Veterans admitted to an inpatient Veterans Affairs Medical Center unit with suicidal ideation completed measures on depression, hopelessness, addiction, and suicidality. Participants were randomized to either a shame mood induction group or a control group, and completed pre- and postexperiment measures on urges for suicide, urges for substance use, and level of shame.

RESULTS

Results indicate that an acute increase in shame resulted in an increase in an urge for suicide, but was not associated with changes in urges for substance use.

CONCLUSIONS

Acute feelings of shame may be a risk factor for increases in suicidal ideation. Limitations and suggestions for future directions are discussed.

Who are likely to attempt suicide again? A comparative study between the first and multiple timers

BACKGROUND

Various explanations account for suicide incidents, and some patients continue to attempt afterwards and others never again. The suicide mortality rate increases with the number of serious attempts. The prevention of secondary attempt of suicide should be an important approach to reduce suicide mortality. However, the characteristics of the targeted population of repeated suicide attempters are understudied.

METHODS

This was a cross-sectional data collection from hospital emergency room from patients who had either attempted suicide for the first time (n=721) or for two or more times (n=70). The subjects were between 14 and 53years old and comprised 293 males and 498 females. In-depth interview was conducted for each suicide attempter with a semi-structural protocol. Demographic and social-psychological characteristics were compared between the two groups of suicide attempters. Logistic regression was used to identify independent predictors of multiple attempts.

FINDINGS

The two groups only differed in religion factor among demographic characteristics and multiple suicide attempters group have a higher percentage of subjects who reported to have a religion affiliation than first time suicide attempters. Multiple attempters were more likely to have family suicide history, physical illness, mental disorder, higher scores on Beck Hopelessness Scale (BHS) and Suicide Intent Scale (SIS) and lower scores on Duke Social Support Scale (DSSI). In the final regression model, family history of suicide, mental disorder, hopelessness and social support emerged as significant predictors of multiple suicide attempts.

CONCLUSION

Suicide attempters that have mental disorder, family history of suicide, higher level of hopelessness and lower level of social support are more likely to re-attempt suicide again. Social and clinical interventions may have to also focus on this sub-group of patients with these characteristics to effectively reduce suicide mortality rate.

An Examination of United States Air Force Suicide Decedents Based on Documented Suicide Attempt Histories

In this study, we compared United States military decedents who died by suicide on their first attempt with decedents who had made multiple attempts. Death investigation files for 217 United States Air Force (USAF) personnel who died by suicide between 1996 and 2006 were coded for demographic, psychosocial, and psychiatric characteristics. Among USAF suicide decedents, 77% died by suicide on their first attempt and 23% had a documented history of at least one prior attempt. Decedents with a history of prior attempts were more likely to have an interpersonal stressor within 3 months of death and were twice as likely to have a documented Axis I diagnosis. There were few differences between military suicide decedents based on history of prior attempts. Further research is needed to inform military suicide prevention endeavors.

Motor impulsivity differentiates between psychiatric inpatients with multiple versus single lifetime suicide attempts

A history of multiple suicide attempts conveys greater risk for suicide than a single attempt. Impulsivity may partially explain the association between multiple attempts and increased risk. We examined trait impulsivity, ability to engage in goal-directed behaviors, and impulse control among psychiatrically hospitalized United States military personnel and their dependents. Individuals with a history of multiple versus single attempts had significantly higher motor impulsivity, indicating spur of the moment action. Providers are encouraged to directly assess and treat motor impulsivity among suicidal individuals. Further research should explore whether motor impulsivity is a mechanism of change in psychosocial suicide prevention interventions.

How do repeat suicide attempters differ from first timers? An exploratory record based analysis

Background:

Evidence indicates that repeat suicide attempters, as a group, may differ from 1^st time attempters. The identification of repeat attempters is a powerful but underutilized clinical variable.

Aims:

In this research, we aimed to compare individuals with lifetime histories of multiple attempts with 1^st time attempters to identify factors predictive of repeat attempts.

Setting and Design:

This was a retrospective record based study carried out at a teaching cum Tertiary Care Hospital in South India.

Methods:

Relevant data was extracted from the clinical records of 1^st time attempters (n = 362) and repeat attempters (n = 61) presenting to a single Tertiary Care Center over a 4½ year period. They were compared on various sociodemographic and clinical parameters. The clinical measures included Presumptive Stressful Life Events Scale, Beck Hopelessness Scale, Coping Strategies Inventory – Short Form, and the Global Assessment of Functioning Scale.

Statistical Analysis Used:

First time attempters and repeaters were compared using appropriate inferential statistics. Logistic regression was used to identify independent predictors of repeat attempts.

Results:

The two groups did not significantly differ on sociodemographic characteristics. Repeat attempters were more likely to have given prior hints about their act (χ² = 4.500, P = 0.034). In the final regression model, beck hopelessness score emerged as a significant predictor of repeat suicide attempts (odds ratio = 1.064, P = 0.020).

Conclusion:

Among suicide attempters presenting to the hospital, the presence of hopelessness is a predictor of repeat suicide attempts, independent of clinical depression. This highlights the importance of considering hopelessness in the assessment of suicidality with a view to minimize the risk of future attempts.

Acute vs. chronic stressors, multiple suicide attempts, and persistent suicide ideation in US soldiers

This study examined recent-onset (i.e., acute) and persistent (i.e., chronic) life stressors among 54 acutely suicidal US Army Soldiers and examined their relationship to persistence of suicidal crises over time. Soldiers with a history of multiple suicide attempts reported the most severe suicide ideation (F(2,51) = 4.18, p = 0.021) and the greatest number of chronic stressors (F(2,51) = 5.11, p = 0.009). Chronic but not acute stressors were correlated with severity of suicide ideation (r = 0.24, p = 0.026). Participants reporting low-to-average levels of chronic stress resolved suicide ideation during the 6-month follow-up, but participants reporting high levels of chronic stress did not (Wald χ(1) = 4.57, p = 0.032). Soldiers who are multiple attempters report a greater number of chronic stressors. Chronic, but not acute-onset, stressors are associated with more severe and longer-lasting suicidal crises.