Examining the role of sex in self-injurious thoughts and behaviors

Core psychopathology underlying disordered eating behaviors and nonsuicidal self-injury in university students: a network analysis

OBJECTIVE

Disordered eating behaviors (DEBs) and nonsuicidal self-injury (NSSI) frequently co-occur in university students, yet what underlies this co-occurrence remains unknown. Network analysis was used to identify psychosocial correlates that may link DEBs and NSSI in university students and test whether networks were similar across gender.

PARTICIPANTS

Four hundred and seventy college women and 473 college men (aged 18-25 years).

METHODS

Participants completed online questionnaires. Networks were estimated for men, women, and a combined sample.

RESULTS

The networks for men and women were invariant. The most central nodes in the combined network were difficulties in emotion regulation and body dissatisfaction. Interoception and difficulties in emotion regulation were directly associated with past-month NSSI and strongly associated with body dissatisfaction, linking DEBs and NSSI in the network.

CONCLUSIONS

Difficulties in emotion regulation, interoception, and body dissatisfaction may play critical roles in the comorbidity of DEBs and NSSI in university students.

Assessing the contributions of gender, clinical symptoms, and psychometric traits to non-suicidal self-injury behaviors in Chinese adolescents: a nomogram approach

BACKGROUND

Non-suicidal self-injury (NSSI) behaviors among adolescents with mood disorders represent a significant global public health concern. This study aimed to assess the prevalence and identify key predictors of NSSI behaviors in Chinese adolescents diagnosed with depressive or bipolar disorders, addressing a critical gap in the literature.

METHOD

Data from 2343 participants in the Chinese Adolescent Depression Cohort (CADC) were analyzed. The study employed a comprehensive approach, utilizing medical records, clinical assessments, and validated psychometric instruments. Statistical analyses included chi-square tests, logistic regression, and ROC curve analyses, culminating in the development of a predictive nomogram.

RESULTS

The prevalence of NSSI behaviors was strikingly high at 73.32%. Significant predictors included female gender (AOR = 2.14, 95% CI [1.70, 2.68]), presence of hallucinations (AOR = 1.52, 95% CI [1.18, 1.97]), borderline personality features (AOR = 1.03, 95% CI [1.01, 1.08]), and childhood trauma (AOR = 1.02, 95% CI [1.01, 1.03]). The study's key contribution is a predictive nomogram with an AUC of 0.74, demonstrating good efficacy in predicting NSSI behaviors.

CONCLUSION

This research reveals an alarmingly high prevalence of NSSI behaviors in Chinese adolescents with mood disorders and identifies critical predictors spanning demographic, clinical, and psychometric domains. The developed nomogram offers a novel approach for risk assessment, highlighting the importance of comprehensive evaluations in adolescent mental healthcare. These findings have significant implications for developing targeted interventions and improving risk assessment strategies in clinical practice.

Prospective analysis of sex differences and factors associated with suicidal thoughts and behaviours in young people from the MILESTONE Italian sample

Suicide is a significant leading cause of death among young people, particularly those struggling with mental disorders. The present study utilised data from 230 young people (aged 16-18 years) undergoing a transitional care process from Child and Adolescent Mental Health Services to Adult Mental Health Services within the MILESTONE European project (2014-2019), a longitudinal cluster randomised controlled trial. The objectives of this study were to monitor temporal patterns of general health and social functioning over two years, to detect sex differences, and to identify factors associated with Suicidal Thoughts and Behaviours (STB) at the first and last time points. The results demonstrate a decrease in STB over the two-year follow-up period among all participants. Females exhibited a higher prevalence of STB across all time points, whereas males only exhibited STB at the nine-month follow-up. The most influential factors associated with STB were previous suicide attempts and mood disorders at baseline, and mood disorders and relational problems at the end of follow-up. These findings emphasise the importance of monitoring STB and informing young people undergoing a transitional care period about its key risk factors. Moreover, sex differences in STB suggest the need for different preventive strategies for males and females.

Neuroimaging studies in major depressive disorder with suicidal ideation or behaviour among Chinese patients: implications for neural mechanisms and imaging signatures

Major depressive disorder (MDD) with suicidal ideation or behaviour (MDSI) is associated with an increased risk of future suicide. The timely identification of suicide risk in patients with MDD and the subsequent implementation of interventions are crucially important to reduce their suffering and save lives. However, the early diagnosis of MDSI remains challenging across the world, as no objective diagnostic method is currently available. In China, the challenge is greater due to the social stigma associated with mental health problems, leading many patients to avoid reporting their suicidal ideation. Additionally, the neural mechanisms underlying MDSI are still unclear, which may hamper the development of effective interventions. We thus conducted this narrative review to summarise the existing neuroimaging studies of MDSI in Chinese patients, including those involving structural magnetic resonance imaging (MRI), functional MRI, neuronal electrophysiological source imaging of the brain dynamics with electroencephalography and magnetoencephalography. By synthesising the current research efforts in neuroimaging studies of Chinese patients with MDSI, we identified potential objective neuroimaging biomarkers, which may aid in the early identification of patients with MDSI who are at high suicide-related risk. Our findings also offer insights into the complex neural mechanisms underlying MDSI and suggest promising therapeutic targets. Furthermore, we propose future directions to discover novel imaging signatures, improve patient care, as well as help psychiatrists and clinical investigators plan their future research.

Gender differences in risk and resilience for suicidal thoughts and behaviors: A national longitudinal survey study of United States veterans with a recent suicide attempt

BACKGROUND

This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention.

METHODS

We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up.

RESULTS

Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = -0.19; 95 % CI = -0.31, -0.07; d = -0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09).

LIMITATIONS

Results may not generalize beyond a VHA-utilizing veteran population.

CONCLUSIONS

Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas.

Suicide risk and mental health in university students according to place of accommodation

Recently, the suicides of university students staying in state dormitories have been covered in the press and social media in Turkey. This coverage has led to the perception that staying in state dormitories increases the risk of suicide. This study aims to examine the effect of university students' accommodation on suicide risk and mental health. In this study, data were collected from 528 students studying in the 2022-2023 academic year. Suicide probability scale and Brief symptom inventory were used as data collection tools. Parametric analyses (t-test and Anova) were used in data analysis. There is no significant effect of accommodation on suicide risk (p = 0.152), but there is a significant effect of accommodation on mental health (p = 0.010). This effect is observed between the home and family. Among university students, there was no significant difference in the effect of place of accommodation on suicide risk. However, it is seen that the place of accommodation is effective on mental health. It can be stated that this situation is of economic origin.

Self-harm behaviors and their intentions: a cross-cultural analysis

BACKGROUND

Self-harm behaviors (performed with either lethal and non-lethal intentions) are common, especially among individuals suffering from mood disorders, and the reasons individuals self-harm vary both by person and by the type of behavior. Understanding these variations may help clinicians determine levels of risk more accurately.

AIMS

To understand whether culture and gender are associated with the likelihood of engaging in specific self-harm behaviors and whether the intention (lethal, ambivalent, non-lethal) of these behaviors vary with culture and gender.

METHODS

2826 individuals took part in an international multilingual online depression/suicidality screening study and reported at least one instance of self-harm in the past year. Participants were grouped into six broad cultural categories (Latin America, South Asia, Russian, Western English, Chinese, Arab).

RESULTS

3-way (culture x gender x intent) interactions were observed for several self-harm behaviors (overdosing, self-burning, asphyxiating, poisoning, and jumping from heights), suggesting that individuals engage in each of these behaviors with different intentions depending on gender and culture. Cultures and genders likewise differed in the likelihood of engaging in several self-harm behaviors.

CONCLUSIONS

Clinicians should consider culture and gender when assessing for suicide risk, as similar self-harming behaviors may reflect different intentions depending on an individual's culture and gender.

Global burden of self-harm and interpersonal violence and influencing factors study 1990-2019: analysis of the global burden of disease study

INTRODUCTION

Widespread concern exists in today's world regarding self-harm and interpersonal violence. This study to analyze the changes in temporal trends and spatial patterns of risk factors and burdens of self-harm and interpersonal violence using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

Temporal trends in self-harm and interpersonal violence were initially summarized using the estimated annual percentage change (EAPC). Data were compiled and visualized to delineate changes in disease burden and factors influencing self-harm and interpersonal violence from 1990 to 2019, stratified by gender, age and GBD region.

RESULTS

In 2019, the DALY rates of self-harm were 424.7(95% UI 383.25, 466.93). Over the period from 1999 to 2019, self-harm exhibited an overall decreasing trend, with the EAPC of -1.5351 (95% CI -1.6194, -1.4507), -2.0205 (95% CI -2.166, -1.8740) and -2.0605 (95% CI -2.2089, -1.9119), respectively. In contrast, the incidence rate of interpersonal violence was significantly higher than self-harm, with a rate of 413.44 (95% UI 329.88, 502.37) per 100,000 population. Mortality and DALYs of interpersonal violence were lower than those of self-harm, at 5.22 (95% UI 4.87, 5.63) and 342.43 (95% UI 316.61, 371.55). Disease burden of self-harm and interpersonal violence varied by gender, age groups and region. Specific risk factors showed that alcohol use, high temperature and drug use were the main risk factors for self-harm, while alcohol use, intimate partner violence and high temperature were associated with interpersonal violence. Low temperature was a common protective factor for both self-harm and interpersonal violence. The burden of self-harm and interpersonal violence was attributed to different factors influences in different SDI regions.

CONCLUSIONS

The study explored temporal trends and spatial distribution of the global disease burden of self-harm and interpersonal violence, emphasizing the significant impact of factors such as alcohol use, temperature, and drug use on disease burden. Further research and policy actions are needed to interpret recent changes of disease burden of self-harm and interpersonal violence, and dedicated efforts should be implemented to devise evidence-based interventions and policies to curtail risk factors and protect high-risk groups.

Thoughts of self-harm in adolescents: Relationship with violence in the Dominican Republic

Violence against adolescents is a pressing health problem with long-term implications for future physical and mental well-being, such as thoughts of self-harm, which have been associated with suicidal ideation and completion. However, much of the research has been conducted only in high-income countries. This study aimed to examine the correlation between violence against adolescents and self-harm thoughts in La Romana, Dominican Republic (DR). Cross-sectional survey data was collected at a community-based clinic from participants aged 13-20. Participants were recruited through the clinic's adolescent program and peer referral, and verbal consent was obtained. A survey solicited information about each participant's demographics, experiences with violence, and thoughts of harm to self or others. The survey was completed by 49 adolescents. The mean age was 16.78 (SD 2.34); 65% were female. We performed t-tests and Fisher's exact to investigate the relationship between demographics, reported violence experiences and having self-harm thoughts. About half (45%) had experienced physical violence, 76% had experienced emotional violence, and 12% had experienced sexual violence. The most common perpetrators of physical and emotional violence were classmates (12% and 24%), and the most common perpetrator of sexual violence was an ex-partner (4.1%). Ten participants (20.4%) had thought about harming themselves. Self-harm thoughts were significantly associated with being female (p = 0.025), employed (p = 0.05), and to a higher number of experiences of physical (0.029) and sexual violence (p = 0.023). The results of this study suggest a high prevalence of both violence and self-harm thoughts in adolescents in the DR. Interventions that address physical and sexual violence against adolescents may be particularly important. Particular attention should also be paid to screening for self-harm thoughts in female-identifying adolescents. Further research is needed to better understand the relationship between violence and self-harm thoughts in adolescents in the DR.

Nonsuicidal self-injury methods among U.S. Veterans: Latent class analysis and associations with psychosocial outcomes

Nonsuicidal self-injury (NSSI) is a debilitating concern among U.S. veterans, with wall/object-punching commonly endorsed as an NSSI method. We examined how this behavior relates to other NSSI methods and psychosocial outcomes. We conducted a latent class analysis (LCA) of NSSI methods among 1,138 Gulf War Era veterans, (77.9% male), 21.7% of whom endorsed lifetime NSSI. We categorized classes based on their associations with age, sex, combat and military sexual assault exposure, then examined the association of class membership with psychosocial indicators. LCA results supported four classes: 1) High punching/banging NSSI (2.5%); 2) Multimethod NSSI methods (6.3%); 3) High-risk, multimethod NSSI (3.1%); and 4) Low-risk NSSI (88.1%). Psychosocial indicators (suicide attempt, ideation, possible depressive or posttraumatic stress disorders, poor psychosocial functioning) were worse for members of the NSSI classes versus those in the low-risk group. A subset of U.S. veterans may engage in NSSI primarily via punching/banging methods. All patterns of NSSI engagement were associated with negative psychosocial outcomes relative to those in the low-risk class of the behavior.

Premenstrual disorders and gender differences in adolescent mental health

BACKGROUND

Gender differences in mental health emerge in adolescence. The timing coincides with the development of premenstrual disorders (PMDs). Here, we examine the association between PMDs and adolescent mental health in the context of gender differences.

METHODS

A cross-sectional analysis comprising 21,239[10,563 (49.7 %) girls] individuals aged 10-19 years from the Santai Youth Mental Health Promotion Cohort in China. Possible PMDs, major depression disorder (MDD), general anxiety disorder (GAD), history of self-injury, and high suicide-risk status were surveyed using standard questionnaires. We used logistic regression to contrast the prevalence of outcomes between girls with and without PMDs, and boys.

RESULTS

The prevalence rates of possible MDD and GAD were comparable between girls without PMDs and boys [OR1.03 (0.96-1.11) and 0.99 (0.92-1.07)], whereas a higher burden was observed in girls with PMDs [OR4.76(4.31-5.26) and 3.86(3.50-4.27), respectively]. Moreover, MDD/GAD prevalence among premenarchal girls was comparable to their peer boys. Greater gender differences in self-injury and high suicide-risk status were also found for girls with PMDs [OR 4.70 (4.22-5.24) and 7.49 (6.6-8.5)] than that for girls without PMDs [OR1.45(1.33-1.59) and 1.81 (1.62-2.03)].

LIMITATION

Girls with PMDs may have overreported depressive and/or anxiety symptoms due to the overlap of symptomology.

CONCLUSIONS

The greater gender differences in adolescent mental ill-health among girls with PMDs lend support to the hypothesis that PMDs play an important role in the gender disparities in adolescent mental health, particularly in depression and anxiety.

Prevalence and associated factors of internet addiction among Chinese adolescents: association with childhood trauma

Introduction

Internet addiction (IA) is common among adolescents and may have severe consequences. This study aimed to investigate the prevalence and factors associated with IA among middle school students of Hunan Province, China. Relevance between IA and childhood trauma was also explored.

Methods

One thousand six hundred ten students were enrolled in this cross-sectional study. Data collected included demographics; internet addiction (revised-Chen internet addiction scale); childhood trauma (CTQ-SF); depression, anxiety, and stress symptoms (DASS-21); suicidal behaviors, as well as non-suicidal self-injury (NSSI). Cramer's V analysis, univariable logistic regression and multivariable logistic regression were used for associations and identifying independent relevance of IA, respectively.

Results

The prevalence of IA was 12.8%. Cramer's V analysis showed that IA was associated with emotional abuse, emotional and physical neglect, NSSI, suicidal behaviors, stress, anxiety and depressive symptoms, physical disorder history. Regression analysis showed that IA was independently associated with emotional neglect (OR = 3.062, 95% CI: 2.083, 4.501, p < 0.001); physical neglect (OR = 2.328; 95% CI: 1.590, 3.409, p < 0.001); depressive symptoms (OR = 2.218, 95% CI: 1.467, 3.353, p < 0.001) nationality (OR = 1.888, 95% CI: 1.034, 3.447, p = 0.006) and age (OR = 1.253, 95% CI: 1.066, 1.471, p = 0.006).

Discussion

IA is common among middle school students. Attention should be paid to students with childhood trauma since they have a higher risk for IA, which may increase the risk for suicidal behaviors.

Personality and emotion dysregulation profiles predict differential engagement in a wide range of health-risk behaviors

OBJECTIVE

Health-risk behaviors have an unclear etiology and college students have elevated risk for engagement. Emotion dysregulation and several personality dimensions have been implicated in health-risk behaviors, but these constructs have rarely been studied together. Further, it is unknown if different types of health-risk behaviors have distinct etiologies.

PARTICIPANTS

2077 college students completed a cross-sectional survey.

METHODS

Latent profile analysis discerned classes of participants from emotion dysregulation and personality dimensions. Differential engagement in self-injury, suicidality, disordered eating, substance misuse, and unprotected sex was evaluated across classes.

RESULTS

Three classes were identified, which were primarily distinguished by emotion dysregulation, urgency, and neuroticism. Health-risk behaviors generally increased across classes with increasing emotion-related constructs. Self-injury and suicidality demonstrated different patterns than other health-risk behaviors.

CONCLUSIONS

Results elucidate heterogeneity in health-risk behavior engagement. Focusing on emotional difficulties may be more important for reducing self-injury and suicidality than disordered eating, substance misuse, and risky sex.

Self-Harm Events and Suicide Deaths Among Autistic Individuals in Ontario, Canada

IMPORTANCE

Reasons for elevated suicide risks among autistic people are unclear, with insufficient population-based research on sex-specific patterns to inform tailored prevention and intervention.

OBJECTIVES

To examine sex-stratified rates of self-harm events and suicide death among autistic individuals compared with nonautistic individuals, as well as the associated sociodemographic and clinical risk factors.

DESIGN, SETTING, AND PARTICIPANTS

This population-based matched-cohort study using linked health administrative databases in Ontario, Canada included all individuals with physician-recorded autism diagnoses from April 1, 1988, to March 31, 2018, each matched on age and sex to 4 nonautistic individuals from the general population. Self-harm events resulting in emergency health care from April 1, 2005, to December 31, 2020, were examined for one cohort, and death by suicide and other causes from April 1, 1993, to December 31, 2018, were examined for another cohort. Statistical analyses were conducted between October 2021 and June 2023.

EXPOSURE

Physician-recorded autism diagnoses from 1988 to 2018 from health administrative databases.

MAIN OUTCOMES AND MEASURES

Autistic and nonautistic individuals who were sex stratified a priori were compared using Andersen-Gill recurrent event models on self-harm events, and cause-specific competing risk models on death by suicide or other causes. Neighborhood-level income and rurality indices, and individual-level broad diagnostic categories of intellectual disabilities, mood and anxiety disorders, schizophrenia spectrum disorders, substance use disorders, and personality disorders were covariates.

RESULTS

For self-harm events (cohort, 379 630 individuals; median age at maximum follow-up, 20 years [IQR, 15-28 years]; median age of first autism diagnosis claim for autistic individuals, 9 years [IQR, 4-15 years]; 19 800 autistic females, 56 126 autistic males 79 200 nonautistic females, and 224 504 nonautistic males), among both sexes, autism diagnoses had independent associations with self-harm events (females: relative rate, 1.83; 95% CI, 1.61-2.08; males: relative rate, 1.47; 95% CI, 1.28-1.69) after accounting for income, rurality, intellectual disabilities, and psychiatric diagnoses. For suicide death (cohort, 334 690 individuals; median age at maximum follow-up, 19 years [IQR, 14-27 years]; median age of first autism diagnosis claim for autistic individuals, 10 years [IQR, 5-16 years]; 17 982 autistic females, 48 956 autistic males, 71 928 nonautistic females, 195 824 nonautistic males), there was a significantly higher crude hazard ratio among autistic females (1.98; 95% CI, 1.11-3.56) and a nonsignificantly higher crude hazard ratio among autistic males (1.34; 95% CI, 0.99-1.82); the increased risks were associated with psychiatric diagnoses.

CONCLUSIONS AND RELEVANCE

This cohort study suggests that autistic individuals experienced increased risks of self-harm events and suicide death. Psychiatric diagnoses were significantly associated with the increased risks among both sexes, especially for suicide death, and in partially sex-unique ways. Autism-tailored and autism-informed clinical and social support to reduce suicide risks should consider multifactorial mechanisms, with a particular focus on the prevention and timely treatment of psychiatric illnesses.

Mental imagery of suicide and non-suicidal self-injury: A meta-analysis and systematic review

BACKGROUND

The vast majority of research on, and clinical assessment of, cognitions related to suicide and non-suicidal self-injury (NSSI) has focused on verbal thoughts. And yet, mental imagery is more realistic and emotionally arousing than verbal thoughts.

METHODS

We conducted a systematic review and meta-analysis documenting the prevalence of suicidal and NSSI mental imagery and describing the content and characteristics of suicidal and NSSI mental imagery, links between suicidal and NSSI mental imagery and suicidal and NSSI behavior, and how to intervene on suicidal and NSSI mental imagery. Studies published through December 17, 2022 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

Twenty-three articles were included. Prevalence rates of suicidal (73.56%) and NSSI (84.33%) mental imagery were high among clinical samples. Self-harm mental imagery commonly depicts engagement in self-harm behavior and is experienced as vivid, realistic, and preoccupying. When experimentally induced, self-harm mental imagery reduces physiological and affective arousal. Preliminary evidence suggests that suicidal mental imagery is associated with suicidal behavior.

CONCLUSIONS

Suicidal and NSSI mental imagery are highly prevalent and may be associated with heightened risk for self-harm behavior. Assessments and interventions for self-harm should consider incorporating and addressing suicidal and NSSI mental imagery to mitigate risk.

Gender minority stress in transgender people: a major role for social network

BACKGROUND

Gender minority individuals, on average, experience higher rates of mental health problems. Mounting work suggests that gender minority stress (GMS) contributes to mental health outcomes in transgender/gender-nonconforming individuals.

AIM

We assessed whether GMS decreased in transgender people after initiating gender-affirming hormone therapy (GAHT), and we identified social predictors and hormonal associations for GMS at 2 time points.

METHODS

GMS was surveyed through self-report questionnaires tapping into proximal and distal stressors and coping constructs following the minority stress framework. Eighty-five transgender persons wishing to undertake hormonal interventions were assessed prospectively at start of GAHT and after 7.7 ± 3.5 months (mean ± SD). Sixty-five cisgender persons served as a control group.

OUTCOMES

(1) Proximal stressors were surveyed by the Beck Depression Inventory II, State-Trait Anxiety Inventory, Scale for Suicide Ideation, Suicidal Thoughts/Attempts, Stigma Consciousness Questionnaire, and Perceived Stress Scale; (2) distal stressors by the Everyday Discrimination Scale; and (3) coping constructs by the Resilience Scale, social network, social standing, and Marlowe Crowne Social Desirability Scale.

RESULTS

Transgender people experienced higher rates of proximal stressors (Beck Depression Inventory II, State-Trait Anxiety Inventory, Scale for Suicide Ideation, Suicidal Thoughts/Attempts, Perceived Stress Scale) and had lower protective factors (social standing) prior to and during GAHT than cisgender people. Social network and resilience were lower in transgender people relative to cisgender peers only at baseline. Prospectively, decreasing trait anxiety was observed in transgender people. Social factors were adequate predictors of multiple GMS constructs. Specifically, a major role for social network emerged. As for hormonal associations, only serum estradiol levels in transgender women with GAHT were negatively associated with trait anxiety and suicidal thoughts/attempts but positively with resilience and social desirability.

CLINICAL IMPLICATIONS

Stimulating a social environment supportive of diverse identities, particularly by investing in social networks as a resource for resilience, is likely to alleviate GMS.

STRENGTHS AND LIMITATIONS

Longer duration of interventions with sex steroid treatment, with continued resilience-enhancing strategies, is needed to observe further alleviation of GMS in transgender persons. Also, objective and subjective GMS identification with heteronormative attitudes and beliefs should be surveyed for good measure when assessing GMS.

CONCLUSION

Transgender people experienced more GMS throughout study visits than cisgender people did. With a relatively short period of GAHT, some significant changes in and predictors for experienced GMS emerged.

Gender difference in the associations of childhood maltreatment and non-suicidal self-injury among adolescents with mood disorders

Background

Non-suicidal self-injury (NSSI) is a common feature among adolescents with mood disorders. Although childhood maltreatment has shown to be associated with non-suicidal self-injury (NSSI), previous studies have yielded mixed results in terms of different subtypes of childhood maltreatment and only few studies have investigated the effects of gender. The present cross-sectional study investigated effects of different types of childhood maltreatment on NSSI, as well as the role of gender in these effects.

Methods

In this cross-sectional study, a total of 142 Chinese adolescent inpatients with mood disorders (37 males and 105 females) were consecutively recruited within a psychiatric hospital. Demographic and clinical characteristics were collected. Participants were administered the Childhood Trauma Questionnaire (CTQ), the Functional Assessment of Self-Mutilation (FASM).

Results

76.8% of the sample reported engaging NSSI in the previous 12  months. Female participants were more likely to engage in NSSI than males (p < 0.001). Participants in the NSSI group reported significantly more experiences of emotional abuse (p < 0.001) and emotional neglect (p = 0.005). With regards to gender differences, female participants who have experienced emotional abuse were more likely to engage in NSSI (p = 0.03).

Conclusion

As a whole, NSSI represents a frequent phenomenon among adolescent clinical populations and females were more likely to engage in NSSI than males. NSSI was significantly related to experiences of childhood maltreatment and specifically related to emotional abuse and emotional neglect over and above other types of childhood maltreatment. Females were more sensitive to emotional abuse than males. Our study highlights the importance of screening for subtypes of childhood maltreatment as well as considering the effects of gender.

Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die

The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one's personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.

Multifaceted risk for non-suicidal self-injury only versus suicide attempt in a population-based cohort of adults

BACKGROUND

Non-suicidal self-injury and suicide attempt represent significant public health concerns. While these outcomes are related, there is prior evidence that their etiology does not entirely overlap. Efforts to directly differentiate risk across outcomes are uncommon, particularly among older, population-based cohorts.

METHODS

This research has been conducted using the UK Biobank. Data on individuals' self-reported history of non-suicidal self-injury only versus suicide attempt (maximum N = 6643) were analyzed. Applying LASSO and standard logistic regression, participants reporting one of these outcomes were assessed for differences across a range of sociodemographic, behavioral, and environmental features.

RESULTS

Sociodemographic features most strongly differentiated between the outcomes of non-suicidal self-injury only versus suicide attempt. Specifically, Black individuals were more likely to report a suicide attempt, as were those of mixed race, those endorsing higher levels of depressive symptoms or trauma history, and those who had experienced financial problems (odds ratios 1.02-3.92). Those more likely to engage in non-suicidal self-injury only were younger, female, had higher levels of education, those who resided with a partner, and those who had a recently injured relative.

LIMITATIONS

Differences in timing across correlates and outcomes preclude the ability to establish causal pathways.

CONCLUSIONS

The factors identified in the current study as differentially associated with non-suicidal self-injury only versus suicide attempt provide further evidence of at least partially distinct correlates, and warrant follow-up in independent samples to investigate causality.

The contributions of injury deaths to the gender gap in life expectancy and life disparity in Eastern Mediterranean Region

BACKGROUND

Injury deaths constitute a major avoidable cause of death affecting life expectancy to a different degree in men and women. This study quantified the contributions of injury deaths to the gender gap in life expectancy (GGLE) and life disparity (GGLD) in nine Eastern Mediterranean Region (EMR) countries.

METHODS

We retrieved annual data on age-sex specific causes of death from the World Health Organization mortality database for EMR countries with at least 2-year consecutive data during 2010-2019. The injury-related deaths were categorized into five groups: transport accidents, other accidental injuries, intentional self-harm, assault and events of undetermined intent. Considering women as the reference, the GGLE and GGLD were decomposed by age and causes of death, using a continuous-change model.

RESULTS

The largest and smallest GGLE were observed in Kuwait (5.2 years) and Qatar (- 1.2 years), respectively. Qatar (- 2.2 years) and Oman (0.2 years) had the highest and lowest GGLD. The highest contributions of injury deaths to the GGLE/GGLD were seen in Libya (1.8/- 1.2 years), followed by Iran (1.2/- 0.8 years). Among injury causes, transport accidents were the leading cause of GGLE in all countries but Libya and Morocco, with Iran having the greatest contributions (0.6 years). Injury deaths in men aged 15-29 years accounted for 33% [41%] (Kuwait) to 55% [65%] (Oman) of total GGLE [GGLD] attributable to injury deaths.

CONCLUSIONS

High injury deaths, particularly transport accidents, among young men contributed substantially to the GGLE and GGLD across nine EMR countries in this study. This highlights the need for implementing preventing policies to reduce the burden of injury deaths specifically in young men.

Cognitive Flexibility and Impulsivity Deficits in Suicidal Adolescents

Although neurocognitive deficits have been documented in adolescents with suicidal ideation (SI) and suicide attempts (SA), it is unclear whether certain impairments differentiate these groups, potentially suggesting heightened risk for SA. Focus on specific facets of impulsivity and cognitive control may indicate distinctions between adolescents with SA vs. SI. The current study examined dimensions of impulsivity and cognitive control in 141 adolescents with SA (n = 41) vs. SI without SA (n = 49) vs. typically-developing controls (TDCs; n = 51). Adolescents completed cross-sectional neurocognitive tasks via the Cambridge Neuropsychological Testing Automated Battery, in addition to demographic and clinical measures. Analyses involved ANOVAs and ANCOVAs. Results indicated that adolescents with SA demonstrated less set shifting/cognitive flexibility (reduced ability to adapt to/disengage from stimuli) and greater impulsive decision making (reduced ability to collect/evaluate information before making decisions) compared to TDCs. In addition, both TDCs and adolescents with SA had greater response inhibition (increased ability to stop motor responses that have begun/become prepotent) than those with SI. Similar results were found when analyzing female adolescents separately. There were no significant differences for male adolescents, potentially due to the small subsample (n = 40). There were no significant findings for spatial planning/problem solving or visuospatial working memory. Findings suggest: 1) less set shifting/cognitive flexibility and greater impulsive decision making for adolescents with SA vs. TDCs; and 2) greater response inhibition for TDCs and adolescents with SA vs. SI. Such information may be useful for improving risk assessments (adding neurocognitive tasks) and targeted treatments (incorporating cognitive remediation) for this impaired population.

Finished with Life Anyway and Then Stigmatized for Attempting Suicide-An Overview

This article provides an overview of suicide and how society deals with it. Starting from early societal imprints through historical, religious and political influences, the origins of stigmatization are addressed. Even today, suicidal people experience stigmatization not only from society but also from the health system that treats suicidal people. This has far-reaching consequences for the people affected and runs counter to optimal treatment. Different approaches to a possibly improved handling of suicidality will be discussed.

Is Lethality Different between Males and Females? Clinical and Gender Differences in Inpatient Suicide Attempters

According to the gender paradox in suicidology, an important sex difference has been reported with a preponderance of females in nonfatal suicidal behavior and a preponderance of males in completed suicide. Furthermore, females and males present different risk factors for suicide. The present study explored possible clinical differences between male and female psychiatric inpatients who had recently attempted suicide. The study included 177 adult inpatients hospitalized following a suicide attempt at the University Psychiatric Clinic, Sant'Andrea Hospital, Sapienza University of Rome. Clinical features assessed included psychiatric diagnosis, method and lethality of suicide attempts using the Risk/Rescue Rating Scale, the history of suicide attempts, age at onset of psychiatric illness, the presence of substance or alcohol use, and the length of stay. The results found that males and females differed in the method used for the suicide attempt, the scores for risk and rescue, and the length of hospitalization post-suicide attempt. In conclusion, identifying gender characteristics of patients at higher risk of suicide is important for implementing specific suicide prevention strategies and reducing the risk of future suicidal behavior in psychiatric inpatients.

Suicidal ideation during adolescence: The roles of aggregate genetic liability for suicide attempts and negative life events in the past year

BACKGROUND

Suicidal thoughts and behaviors (STB) constitute a central public health concern in adolescence. Previous studies emphasized the difficulty to cope with negative life events during adolescence as a risk factor for STB. Familial and genetic liability has also been documented to explain STB risk. Nevertheless, less is known about aggregate genetic liability and its possible interaction with negative life events. Moreover, information is needed to understand how these factors differently affect STB in boys and girls.

METHODS

We evaluated suicidal ideation at 17 years old and examined the role of aggregate genetic liability, negative life events, and their interaction in a sample of 2,571 adolescents. Aggregate genetic liability was measured using a polygenic score (PGS) for suicide attempts. Negative life events were assessed in the past year and included parental divorce and hospitalizations, death of friends and relatives, bullying, failure-related events, and involvement with drugs. We conducted univariable and multivariable general linear models stratified by sex and evaluated the interactions between PGS and negative life events in subsequent models.

RESULTS

Analyses showed that suicidal ideation in boys is associated with failure to achieve something important (estimate = 0.198), bullying (estimate = 0.285), drug use (estimate = 0.325), and parental death (estimate = 0.923). In girls, both aggregate genetic liability (estimate = 0.041) and negative life events (failure at school [estimate = 0.120], failure to achieve something important [estimate = 0.279], drug use [estimate = 0.395], and bullying [estimate = 0.472]) were associated with suicidal ideation. Interaction analyses suggested that PGS interacted with drug use and failures at school, though this would need additional support.

CONCLUSIONS

These findings represent significant contributions to the fundamental understanding of STB in adolescence, suggesting to monitor the impact of negative life events during adolescence to better prevent suicide risk. Genetic liability is also of importance in girls and might influence the way they respond to environmental threats.

Emotional changes following discrimination induction in gender- and sexuality-diverse adolescents

Sexual and gender minority (SGM)-identifying adolescents are particularly vulnerable to negative psychological outcomes, including engagement in nonsuicidal self-injury (NSSI). However, little is known about why these relationships exist. We used experimental methods to test the psychological mediation framework in an online sample of 328 adolescents who reported female sex at birth and a range of sexual and gender identities. Participants reported on depressive symptoms, self-criticism (both self-report and implicit), NSSI, and discrimination. They also completed a discrimination-based mood induction to test emotional reactivity. At baseline, SGM participants reported higher levels of implicit and self-reported self-criticism, depressive symptoms, discrimination, and higher rates of NSSI compared with cisgender, heterosexual participants (ps < .03). Following the discrimination induction, SGM-identifying participants exhibited larger emotional reactivity compared with cisgender heterosexual participants, as measured by change in negative mood, F(1, 326) = 7.33, p = .01, ηp2 = .02, and state self-criticism, F(1, 326) = 4.67, p = .03, ηp2 = .014, but not implicit affect toward the self. This effect was associated with baseline depressive symptoms, self-criticism, NSSI history, and discrimination. Post hoc analyses revealed that participants who tended to reframe experiences of discrimination as opportunities for growth exhibited attenuated emotional reactivity to the induction; findings remained significant after adjusting for SGM status and event severity (ps < .001). Results indicate that adolescents identifying as SGM may experience elevated psychological distress compared with their cisgender heterosexual peers and that stigma-related stressors may increase emotion dysregulation and maladaptive cognitive styles, paralleling previously proposed psychological mediation models. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Factors Affecting Suicidal Thoughts in Breast Cancer Patients

Background and Objectives: Women diagnosed with breast cancer experience severe trauma. Psychological help for breast cancer patients is not sufficient because of limited professional resources. The goal of this study was to identify groups of breast cancer patients with the greatest suicidal risk, who could be the first target for psychosocial interventions. Materials and Methods: The study included 421 women with stage T1–T3/N0–N3/M0 breast cancer. We provided women with a set of questionnaires 1–2 days prior to breast surgery and one year after surgery. One hundred eighty-eight patients completed the questionnaires after one year. We used the Beck Depression Inventory Second Edition (BDI-II) item Suicidal Thoughts or Intentions for the assessment of suicidal risk. The Impact of Event Scale-Revised (IES-R) was used to measure the risk of PTSD and the Vrana–Lauterbach Traumatic Events Questionnaire-Civilian, TEQ-C (TEQ-CV) was used to measure whether patients had experienced other traumatic events in their lifetime. Results: The incidence of suicidal ideation one year after surgery increased from 4.3% to 12.8% of patients. Patients who lived in rural areas had a two times greater risk of suicidal thoughts than patients who lived in urban areas. Working patients were 2.5 times more likely to have suicidal thoughts prior to surgery. Severely traumatic events increased the chances of suicidal ideation (OR 7.72; 95% CI 1.63–36.6; p = 0.01). The symptoms of PTSD showed a threefold increase in the likelihood of suicidal ideation (OR 2.89; 95% CI 0.98–8.55; p = 0.05). Conclusions: Living in the countryside, having a history of traumatic experience, having a paid job and having symptoms of post-traumatic stress disorder influence suicidal ideation in breast cancer patients. Particular attention should be drawn to individuals with multiple risk factors.

Attempted Suicide in the Older Adults: A Case Series From the Psychiatry Ward of the University Hospital Maggiore Della Carità, Novara, Italy

Introduction: As suicide rates increase with age, it is mandatory to carefully assess old age suicidal behaviors. Our aim was to describe the main socio-demographic and clinical features of a sample of suicide attempters aged 65 years and older, and to assess differences within the sample (men vs. women; patients with vs. without a previous history of suicide attempt; patients with vs. without a previous psychiatric history).

Methods: Retrospective study conducted at the Maggiore della Carità University Hospital, Novara, Italy.

Results: A higher percentage of female patients in our sample were treated by or referred to mental health services, while a greater percentage of male patients required a prolonged clinical observation in the Emergency Room (ER) or in non-psychiatric wards before psychiatric admission. The percentage of patients without previous psychiatric history taking anxiolytic and sedative medications was 25%.

Conclusion: It is likely that different clusters and types of suicide attempters exist. Women in our sample appeared more proactive in asking for help, and more likely to be already treated by or referred to a psychiatric service, suggesting the need to facilitate the access to psychiatric services for the male population aged 65 years and older, or to offer support and care for the non-psychiatric reasons (comorbidities, pain, and loss of autonomy) possibly underlying suicidal behavior in this specific group. The use of medications deserves more attention considering the possible critical diagnostic issues in this age group.

Does Nonsuicidal Self-Injury Predict Later Suicidal Attempts? A Review of Studies

Co-occurrence of nonsuicidal self-injury (NSSI) and suicide attempts (SA) might occur because they share common risk factors, or alternatively because one leads to the other. Using search terms salient to NSSI and SA, we screened 555 studies to identify 17 that presented temporal data about NSSI and SA. Much of the evidence indicates that NSSI predates SA, especially among females and individuals with depressive symptoms, or diagnosed with borderline personality disorder or mood disorders. However, in some studies, associated risk factors likely accounted for the effect. Greater NSSI frequency to a threshold increases risk for later SA. Findings suggest that the behaviors have common predisposing factors, but that there is also a potent gateway effect whereby NSSI precedes SA.

Risk factors for non-suicidal self-injury (NSSI) in adolescents: A meta-analysis

BACKGROUND

Non-suicidal self-injury (NSSI) in adolescents is a significant mental health problem around the world. Here, we performed a meta-analysis to systematically delineate the risk factors for NSSI.

METHOD

We searched Medline, Embase, Web of Science and Cochrane for relevant articles and abstracts published prior to 12 November 2021. Pooled odds ratios (ORs) and 95% confident intervals (CIs) were used to assess various risk factors, and publication bias was assessed by Egger's test, the trim and fill method and meta-regression. This study is registered with PROSPERO, CRD42021265885.

RESULTS

A total of 25 articles were eventually included in the analysis. Eighty risk factors were identified and classified into 7 categories: mental disorders (ORs, 1·89; 95% CI, 1·60-2·24), bullying (ORs, 1·98; 95% CI, 1·32-2·95), low health literacy (ORs, 2·20; 95% CI, 1·63-2·96), problem behaviours (ORs, 2·36; 95% CI, 2·00-2·77), adverse childhood experiences (ORs, 2·49; 95% CI, 1·85-3.34), physical symptoms (ORs, 2·85; 95% CI, 1·36-5·97) and the female gender (ORs, 2·89; 95% CI, 2·43-3·43). The range of heterogeneity (I²) was from 20·3% to 99·2%.

CONCLUSION

This meta-analysis found that mental disorders, low health literacy, adverse childhood experiences, bullying, problem behaviours, the female gender and physical symptoms appear to be risk factors for NSSI.

The relationship between daily positive future thinking and past-week suicidal ideation in youth: An experience sampling study

Reduced positive future thinking has been associated with suicidal ideation and behavior in adults, and appears to be exacerbated by negative affect. Yet, this has received little attention in youth. Prior research has also focused on longer-term future thinking, e.g., months and years, and relied on lab-based assessments. Using the experience sampling method (ESM), we investigated whether short-term future thinking in daily life was associated with suicidal ideation in youth and explored the role of affect in the future thinking-suicidal ideation relationship. A community sample of N = 722 adolescent twins and their non-twin siblings completed ESM as part of the TwinssCan study (n = 55 with, and n = 667 without, past-week suicidal ideation). Participants completed self-report questionnaires, including on past-week suicidal ideation as part of the SCL-90. Subsequently, daily future thinking was assessed each morning for six days with ESM. To investigate the relationship between daily positive future thinking and past-week suicidal ideation, we estimated a mixed-effects linear regression model with a random intercept for participant, including age and sex as covariates. The relationship between daily positive future thinking, past-week suicidal ideation, and average positive and negative affect from the previous day was investigated by estimating two separate mixed-effects linear regression models (one for negative affect, one for positive affect), with a random intercept for participant, and random slopes for average positive and negative affect. Our results showed that participants reporting higher past-week suicidal ideation also reported significantly less daily positive future thinking during the ESM period, and this association remained significant when controlling for previous-day average positive and negative affect. Higher average positive affect from the previous day was significantly associated with higher positive future thinking. Although average negative affect from the previous day was associated with lower positive future thinking, this association was not statistically significant. Our findings indicate that short-term future thinking relates to suicidal ideation among a non-clinical sample of adolescents. Future research should investigate the directionality of the future thinking-suicidal ideation relationship, in order to investigate whether impaired future thinking may be an early warning signal for escalating suicidal ideation in youth.

Invited Commentary: New Directions in Machine Learning Analyses of Administrative Data to Prevent Suicide-Related Behaviors

This issue contains a thoughtful report by Gradus et al. (Am J Epidemiol. 2021;190(12):2517-2527) on a machine learning analysis of administrative variables to predict suicide attempts over 2 decades throughout Denmark. This is one of numerous recent studies that document strong concentration of risk of suicide-related behaviors among patients with high scores on machine learning models. The clear exposition of Gradus et al. provides an opportunity to review major challenges in developing, interpreting, and using such models: defining appropriate controls and time horizons, selecting comprehensive predictors, dealing with imbalanced outcomes, choosing classifiers, tuning hyperparameters, evaluating predictor variable importance, and evaluating operating characteristics. We close by calling for machine-learning research into suicide-related behaviors to move beyond merely demonstrating significant prediction-this is by now well-established-and to focus instead on using such models to target specific preventive interventions and to develop individualized treatment rules that can be used to help guide clinical decisions to address the growing problems of suicide attempts, suicide deaths, and other injuries and deaths in the same spectrum.

Associations between Suicidal Thoughts and Behaviors and Genetic Liability for Cognitive Performance, Depression, and Risk-Taking in a High-Risk Sample

Background

Suicidal thoughts and behaviors (STBs) and nonsuicidal self-injury (NSSI) behaviors are moderately heritable and may reflect an underlying predisposition to depression, impulsivity, and cognitive vulnerabilities to varying degrees.

Objectives

We aimed to estimate the degrees of association between genetic liability to depression, impulsivity, and cognitive performance and STBs and NSSI in a high-risk sample.

Methods

We used data on 7,482 individuals of European ancestry and 3,359 individuals of African ancestry from the Collaborative Study on the Genetics of Alcoholism to examine the links between polygenic scores (PGSs) for depression, impulsivity/risk-taking, and cognitive performance with 3 self-reported indices of STBs (suicidal ideation, persistent suicidal ideation defined as ideation occurring on at least 7 consecutive days, and suicide attempt) and with NSSI.

Results

The PGS for depression was significantly associated with all 4 primary self-harm measures, explaining 0.6-2.5% of the variance. The PGS for risk-taking behaviors was also associated with all 4 self-harm behaviors in baseline models, but was no longer associated after controlling for a lifetime measure of DSM-IV alcohol dependence and abuse symptom counts. Polygenic predisposition for cognitive performance was negatively associated with suicide attempts (q = 3.8e-4) but was not significantly associated with suicidal ideation nor NSSI. We did not find any significant associations in the African ancestry subset, likely due to smaller sample sizes.

Conclusions

Our results encourage the study of STB as transdiagnostic outcomes that show genetic overlap with a range of risk factors.

Comparison of Stigmatization of Suicidal People by Medical Professionals with Stigmatization by the General Population

Stigmatization of suicide (SOS) affects help-seeking for suicidality and impedes successful treatment. This study aimed to identify different types of stigmatization and understand the causes and glorification of suicide by comparing three groups; within each of the following groups, the impact of age and gender was explored: (1) practicing medical professional in direct contact with suicidality (psychotherapists, psychiatrists, related medical professions (nurses, etc.)), (2) future medical professionals still in training, (3) and the general population with no professional contact with suicidality. German adults completed an online survey with a total of 742 participants. A MANCOVA was calculated with age and gender being controlled as covariates, due to different distribution. Practicing professionals showed significantly higher levels of SOS than the other groups, while the future professionals showed no differences in SOS from the general population. The understanding of suicide causes was similar across all groups. Men showed higher levels of SOS than women, while women scored higher at understanding of causes and glorification of suicide. Within the individual groups, female professionals in the age group "36-65 years" stigmatized suicide most, while showing the least glorification. The results suggest that tendencies towards SOS are promoted by practical experience with suicidality. Therefore, special training is recommended to reduce SOS.

Internalizing and externalizing symptoms and aggression and violence in men and women

Literature linking aggressive behavior across internalizing and externalizing disorders support the co-occurrence of aggression and various mental health diagnoses. However, research has yet to examine relationships between aggression and dimensional psychopathology models that cut across diagnostic boundaries (e.g., internalizing, externalizing composites) and capture shared liability across common disorders. The role of gender has also been largely ignored in prior work, despite evidence that men and women manifest psychopathology differently. The present study examined cross-sectional and longitudinal relationships between psychopathology composites (i.e., Internalizing, Externalizing) and different manifestations of physical aggression (i.e., aggressive traits, general violence, physical intimate partner violence, and self-directed aggression), as well as moderation by gender. Internalizing (INT) and Externalizing (EXT) lifetime symptoms and various physically aggressive behaviors were assessed at baseline and at 6 months and 1 year follow up in a sample of 319 adults with violence and/or substance use histories. Cross-sectional results showed that INT was associated with all forms of aggression, and women showed stronger relationships between INT and both physical intimate partner violence (IPV) and self-directed aggression. EXT was specifically linked to general violence, and a stronger relationship between EXT and self-directed aggression emerged in men compared to women. Longitudinal relationships were mostly small and nonsignificant. Results support the co-occurrence of aggression with distinct forms of psychopathology, as well as gender-dependent relationships, but do not support the predictive validity of symptom composites in aggression risk. Findings implicate the need for aggression interventions tailored within gender.

Sex Differences in US Army Suicide Attempts During the Wars in Iraq and Afghanistan

OBJECTIVE

To examine sex differences in risk for administratively documented suicide attempt (SA) among US Army soldiers during the Iraq/Afghanistan wars.

METHOD

Using administrative person-month records of Regular Army enlisted soldiers from 2004 to 2009, we identified 9650 person-months with a first documented SA and an equal-probability control sample (n=153,528 person-months). Person-months were weighted to the population and pooled over time. After examining the association of sex with SA in a logistic regression analysis, predictors were examined separately among women and men.

RESULTS

Women (an estimated 13.7% of the population) accounted for 25.2% of SAs and were more likely than men to attempt suicide after adjusting for sociodemographic, service-related, and mental health diagnosis (MHDx) variables (odds ratio=1.6; 95% confidence interval, 1.5-1.7). Women with increased odds of SA in a given person-month were younger, non-Hispanic White, less educated, in their first term of enlistment, never or previously deployed (vs. currently deployed), and previously received a MHDx. The same variables predicted SA among men. Interactions indicated significant but generally small differences between women and men on 6 of the 8 predictors, the most pronounced being time in service, deployment status, and MHDx. Discrete-time survival models examining risk by time in service demonstrated that patterns for women and men were similar, and that women's initially higher risk diminished as time in service increased.

CONCLUSIONS

Predictors of documented SAs are similar for US Army women and men. Differences associated with time in service, deployment status, and MHDx require additional research. Future research should consider stressors that disproportionately affect women.

Sociodemographic and Clinical Characteristics Associated with Suicidal Behaviour and Relationship with a Nurse-Led Suicide Prevention Programme

Suicidal behaviour is a major public health problem that needs to be tackled by all health agents including mental health nurses. Aims: The purpose of this study was to analyse the relationship between demographic and clinical characteristics and different kinds of suicidal behaviour with a nurse-led suicide prevention programme. Methods: The design was a cross-sectional study, performed in the region of Osona (Catalonia) in the five-year period 2013–2017. Suicidal behaviour was classified as suicidal ideation, interrupted self-directed violence, suicide attempt or completed suicide. Results: The sample included 753 patients (of whom 53 completed suicide) who experienced 931 suicidal behaviour episodes. Men represented only 38.4% of the sample but 81.1% of completed suicides. Mental disorders were associated with suicidal behaviour in 75.4% of the sample. Two thirds (66.4%) of the individuals (0.8% (n = 4) of whom completed suicide) were participants in a nurse-led suicidal behaviour case management programme. Conclusion: The main risk factors were being a woman for suicidal behaviour and being a man and being older for completed suicide. Mental disorders, widowhood and retirement were also associated with completed suicide. The completed suicide rate was lower among participants in the nurse-led programme.

Classification trees identify shared and distinct correlates of nonsuicidal self-injury and suicidal ideation across gender identities in emerging adults

College students have an elevated risk for self-injurious thoughts and behaviours (SITBs), and there are robust differences in prevalence rates for SITBs across gender identities. Although numerous constructs have been implicated as risk factors, researchers have not significantly improved at predicting SITBs, possibly owing to constraints of confirmatory analyses. Classification trees are exploratory, person-centred analyses that enable joint examination of numerous correlates and their interactions. Thus, classification trees may discern previously unstudied risk factors and identify distinct subpopulations with elevated risk for SITBs. We tested classification trees that evaluated 298 potential correlates of nonsuicidal self-injury and suicidal ideation across self-identified women and men. Data came from 5,131 college students who completed the National College Health Assessment, which assesses a wide range of health-related constructs. Models produced parsimonious decision trees that accounted for a substantial amount of outcome variability (38.3-51.5%). Psychopathology, poorer psychological well-being, and other SITBs emerged as important correlates for all participants. Trauma, disordered eating, and heavy alcohol use were salient among women, whereas alcohol use norms were important correlates among men. Importantly, models identified several constructs that may be amenable to intervention. Results support the use of exploratory analyses to explicate heterogeneity among individuals who engage in SITBs and suggest that gender identity is an important moderator for certain risk factors.

Sex, Gender, and Suicidal Behavior

This chapter reviews gender differences in suicide, commonly known as the gender paradox in suicide. While men are more likely to complete suicide, suicide attempts are more frequent in women. Although there are exceptions, this paradox occurs in most countries over the world, and it is partially explained by the preference of men for more lethal methods. Nevertheless, there are differences in the known risk factors for suicide between men and women, and this chapter summarizes the more relevant findings for the gender paradox. Apart from previous attempts, which still is the strongest predictor of death by suicide, with a higher rate in males than in females, we will emphasize in the role of male depression. It is commonly recognized that over 90% of people who die by suicide had a psychiatric diagnosis, mostly depression, and male depression seems to be a distinct clinical phenotype challenging to recognize, which might contribute to the gender paradox. Finally, in light of all the information reviewed, some recommendations on prevention of suicide from a gender perspective in the clinical setting will be made.

Risk factors for self-harm in prison: a systematic review and meta-analysis

BACKGROUND

Self-harm is a leading cause of morbidity in prisoners. Although a wide range of risk factors for self-harm in prisoners has been identified, the strength and consistency of effect sizes is uncertain. We aimed to synthesise evidence and assess the risk factors associated with self-harm inside prison.

METHODS

In this systematic review and meta-analysis, we searched four electronic databases (PubMed, Embase, Web of Science, and PsycINFO) for observational studies on risk factors for self-harm in prisoners published from database inception to Oct 31, 2019, supplemented through correspondence with authors of studies. We included primary studies involving adults sampled from general prison populations who self-harmed in prison and a comparison group without self-harm in prison. We excluded studies with qualitative or ecological designs, those that reported on lifetime measures of self-harm or on selected samples of prisoners, and those with a comparison group that was not appropriate or not based on general prison populations. Data were extracted from the articles and requested from study authors. Our primary outcome was the risk of self-harm for risk factors in prisoners. We pooled effect sizes as odds ratios (OR) using random effects models for each risk factor examined in at least three distinct samples. We assessed study quality on the basis of the Newcastle-Ottawa Scale and examined between-study heterogeneity. The study protocol was registered with PROSPERO, CRD42018087915.

FINDINGS

We identified 35 independent studies from 20 countries comprising a total of 663 735 prisoners, of whom 24 978 (3·8%) had self-harmed in prison. Across the 40 risk factors examined, the strongest associations with self-harm in prison were found for suicide-related antecedents, including current or recent suicidal ideation (OR 13·8, 95% CI 8·6-22·1; I2=49%), lifetime history of suicidal ideation (8·9, 6·1-13·0; I2=56%), and previous self-harm (6·6, 5·3-8·3; I2=55%). Any current psychiatric diagnosis was also strongly associated with self-harm (8·1, 7·0-9·4; I2=0%), particularly major depression (9·3, 2·9-29·5; I2=91%) and borderline personality disorder (9·2, 3·7-22·5; I2=81%). Prison-specific environmental risk factors for self-harm included solitary confinement (5·6, 2·7-11·6; I2=98%), disciplinary infractions (3·5, 1·2-9·7; I2=99%), and experiencing sexual or physical victimisation while in prison (3·2, 2·1-4·8; I2=44%). Sociodemographic (OR range 1·5-2·5) and criminological (1·8-2·3) factors were only modestly associated with self-harm in prison. We did not find clear evidence of publication bias.

INTERPRETATION

The wide range of risk factors across clinical and custody-related domains underscores the need for a comprehensive, prison-wide approach towards preventing self-harm in prison. This approach should incorporate both population and targeted strategies, with multiagency collaboration between the services for mental health, social care, and criminal justice having a key role.

FUNDING

Wellcome Trust.

Self-injurious thoughts and behaviors that differentiate soldiers who attempt suicide from those with recent suicide ideation

BACKGROUND

Risk for suicide attempt (SA) versus suicide ideation (SI) is clinically important and difficult to differentiate. We examined whether a history of self-injurious thoughts and behaviors (SITBs) differentiates soldiers with a recent SA from nonattempting soldiers with current/recent SI.

METHODS

Using a unique case-control design, we administered the same questionnaire (assessing the history of SITBs and psychosocial variables) to representative U.S. Army soldiers recently hospitalized for SA (n = 132) and soldiers from the same Army installations who reported 30-day SI but did not make an attempt (n = 125). Logistic regression analyses examined whether SITBs differentiated attempters and ideators after controlling for previously identified covariates.

RESULTS

In separate models that weighted for systematic nonresponse and controlled for gender, education, posttraumatic stress disorder, and intermittent explosive disorder, SA was positively and significantly associated with the history of suicide plan and/or intention to act (odds ratio [OR] = 12.1 [95% confidence interval {CI} = 3.6-40.4]), difficulty controlling suicidal thoughts during the worst week of ideation (OR = 3.5 [95% CI = 1.1-11.3]), and nonsuicidal self-injury (NSSI) (OR = 4.9 [95% CI = 1.3-18.0]). Area under the curve was 0.87 in a full model that combined these SITBs and covariates. The top ventile based on predicted risk had a sensitivity of 24.7%, specificity of 99.8%, and positive predictive value of 97.5%.

CONCLUSIONS

History of suicide plan/intention, difficult to control ideation, and NSSI differentiate soldiers with recent SA from those with current/recent SI independent of sociodemographic characteristics and mental disorders. Longitudinal research is needed to determine whether these factors are prospectively associated with the short-term transition from SI to SA.

Suicide deaths among diagnostic medical radiation workers in South Korea, 1996–2017

Objectives

Suicide is a leading cause of death in the working-age population. We investigated suicide mortality among diagnostic medical radiation workers in relation to their demographic and occupational factors in South Korea.

Methods

The study population consisted of all diagnostic medical radiation workers enrolled in the National Dosimetry Registry from 1996 to 2011. The registry data were linked with mortality data through the end of 2017. We calculated age-standardised suicide rates, standardised mortality ratios (SMRs) and rate ratios (RRs) by demographic and occupational factors.

Results

A total of 207 suicides were identified among 94 367 medical radiation workers, exhibiting a suicide rate of 14.0 per 100 000 person-years. Compared with the general population, suicide rates were lower for both male and female workers (SMR 0.49, 95% confidence interval (CI) 0.42 to 0.57; SMR 0.54, 95% CI 0.41 to 0.70, respectively). Similarly, decreased SMRs were observed across job titles and other work-related factors. However, a shorter duration of employment was positively associated with RRs for suicide; risks were 2.74 (95% CI 1.56 to 4.81) and 4.66 (95% CI 1.53 to 14.20) times higher in male and female workers with less than 1 year of employment, respectively, than in those with at least 10 years of employment.

Conclusions

Diagnostic medical radiation workers in South Korea showed lower suicide rates than in the general population. However, a shorter duration of employment was associated with higher risk of suicide. Suicide prevention efforts could target workers engaged in short-term employment.

A systematic review of daily life studies on non-suicidal self-injury based on the four-function model

Non-suicidal self-injury (NSSI) is a prevalent, impairing, and trans-diagnostic behavior that can be comprehensively assessed in daily life studies. We conducted a systematic literature review of 35 Ambulatory Assessment and Daily Diary studies of NSSI, to achieve three aims. First, we reviewed descriptive evidence on NSSI acts. On average, studies observed 1.6 acts per participant, but evidence regarding methods, pain, and context was sparse. Second, we reviewed evidence on NSSI urges. On average, studies reported 4.3 urges per participant. Urges were also associated with increased negative affect and predicted later acts. Third, we reviewed evidence on the Four-function Model of NSSI. Eight studies partially supported negative intrapersonal reinforcement, showing increased negative affect pre NSSI, but, of these, only four studies supported decreased negative affect post NSSI. Additionally, only three studies supported positive intrapersonal reinforcement, showing decreased positive affect pre and increased positive affect post NSSI. Evidence for the interpersonal functions was limited to two studies and inconclusive. We recommend assessing the intensity, frequency, and context of acts and urges, as well as pain and urge duration in future studies. We also recommend follow-up prompts after acts and urges to better track affect trajectories, and a detailed assessment of interpersonal events.

From Urges to Action: Negative Urgency and Nonsuicidal Self-Injury in an Acute Transdiagnostic Sample

Urgency-rash action during strong emotion-is a robust correlate of nonsuicidal self-injury (NSSI). This study tested whether urgency is associated with time between NSSI urges and NSSI, and sought to replicate the finding that urgency is associated with NSSI history. Participants attending a partial hospitalization program (N = 669) completed self-report measures of urgency, NSSI history and latency, and psychiatric symptoms. Consistent with previous research in clinical samples, rates of lifetime engagement in NSSI were high. Using logistic regression to predict short vs. long latency between urges and NSSI, no significant relationship emerged between negative urgency and latency to self-injure. Negative urgency more than doubled the likelihood of NSSI history (p < .001, OR = 2.39). In addition, exploratory analyses revealed several links between NSSI latency and negative urgency. Results confirm that urgency is robustly related to NSSI, yet also suggest that more research is needed to understand how urgency relates to the parameters of NSSI within those who self-injure. Use of retrospective self-report measures may limit the ability to test links between urgency and latency of NSSI.

Sex differences in text-mined possible adverse drug events associated with drugs for psychosis

BACKGROUND

Understanding sex differences in adverse drug reactions to drugs for psychosis could potentially guide clinicians in optimal drug choices.

AIMS

By applying a text-mining approach, this study aimed to investigate the relationship between drugs for psychosis and biological sex differences in frequencies and co-occurrences of potential adverse drug events (ADEs).

METHODS

Electronic patient records of a psychiatric population (1427 men and 727 women) were text mined for potential ADEs. The relative risk of experiencing specific ADEs and co-occurrence of ADEs were calculated for each sex.

RESULTS

Findings included 55 potential ADEs with significantly different frequencies between the two sexes. Of these, 20 were more frequent in men, with relative risks of 1.10-7.64, and 35 were more frequent in women, with relative risks of 1.19-21.58. Frequent potential ADEs were psychiatric symptoms, including sexual dysfunction and disturbances in men, and gastrointestinal symptoms, suicidal and self-injurious behaviour and hyperprolactinemia-related events in women. Mention of different hyperprolactinemia-related ADEs often co-occurred in female patients but not in male patients.

CONCLUSION

Several known sex-related ADEs were identified, as well as some previously not reported. When considering the risk-benefit profile of drugs for psychosis, the patient's sex should be considered.

Factors Associated With Suicide Ideation in US Army Soldiers During Deployment in Afghanistan

IMPORTANCE

Understanding suicide ideation (SI) during combat deployment can inform prevention and treatment during and after deployment.

OBJECTIVE

To examine associations of sociodemographic characteristics, lifetime and past-year stressors, and mental disorders with 30-day SI among a representative sample of US Army soldiers deployed in Afghanistan.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, soldiers deployed to Afghanistan completed self-administered questionnaires in July 2012. The sample was weighted to represent all 87 032 soldiers serving in Afghanistan. Prevalence of lifetime, past-year, and 30-day SI and mental disorders was determined. Logistic regression analyses examined risk factors associated with SI. Data analyses for this study were conducted between August 2018 and August 2019.

MAIN OUTCOMES AND MEASURES

Suicide ideation, lifetime and 12-month stressors, and mental disorders were assessed with questionnaires. Administrative records identified sociodemographic characteristics and suicide attempts.

RESULTS

A total of 3957 soldiers (3473 [weighted 87.5%] male; 2135 [weighted 52.6%] aged ≤29 years) completed self-administered questionnaires during their deployment in Afghanistan. Lifetime, past-year, and 30-day SI prevalence estimates were 11.7%, 3.0%, and 1.9%, respectively. Among soldiers with SI, 44.2% had major depressive disorder (MDD) and 19.3% had posttraumatic stress disorder in the past 30-day period. A series of analyses of the 23 grouped variables potentially associated with SI resulted in a final model of sex; race/ethnicity; lifetime noncombat trauma; past 12-month relationship problems, legal problems, and death or illness of a friend or family member; and MDD. In this final multivariable model, white race/ethnicity (odds ratio [OR], 3.1 [95% CI, 1.8-5.1]), lifetime noncombat trauma (OR, 2.1 [95% CI, 1.1-4.0]), and MDD (past 30 days: OR, 31.8 [95% CI, 15.0-67.7]; before past 30 days: OR, 4.9 [95% CI, 2.5-9.6]) were associated with SI. Among the 85 soldiers with past 30-day SI, from survey administration through 12 months after returning from deployment, 6% (5 participants) had a documented suicide attempt vs 0.14% (6 participants) of the 3872 soldiers without SI.

CONCLUSIONS AND RELEVANCE

This study suggests that major depressive disorder and noncombat trauma are important factors in identifying SI risk during combat deployment.

Racial/Ethnic Discrimination and Suicidal Ideation in Emerging Adults: The Role of Traumatic Stress and Depressive Symptoms Varies by Gender not Race/Ethnicity

Drawing from Race-Based Traumatic Stress theory, the present study examined whether traumatic stress and depressive symptoms differentially help explain the relation between racial/ethnic discrimination and suicidal ideation across gender and racial/ethnic groups. A racially/ethnically diverse group of emerging adults (N = 1344; M_age = 19.88, SD = 2.25; 72% female; 46% Hispanic) completed a battery of self-report measures. A cross-sectional design was employed with a series of hierarchical linear regression models and bootstrapping procedures to examine the direct and indirect relation between racial/ethnic discrimination and suicidal ideation through traumatic stress and depressive symptoms across gender and race/ethnicity. The findings suggest an indirect relation through depressive symptoms, but not traumatic stress, and a serial indirect relation through traumatic stress to depressive symptoms in young women and young men, the latter of which was stronger in young women. The indirect relations did not vary by racial/ethnic group. Cumulative experiences of racial/ethnic discrimination may impact suicide-related risk via increases in psychiatric symptomology (i.e., traumatic stress and depressive symptoms), particularly in young women. Racial/ethnic discrimination experiences should be accounted for as a potential source of psychological distress in the assessment, diagnosis, and treatment of suicidal thoughts and behavior, especially among young women endorsing traumatic stress and depressive symptoms. Further research is warranted to better understand the gender difference in the relation between racial/ethnic discrimination and suicide-related risk.

Nonsuicidal Self-Injury and Suicidal Behaviors in Girls: The Case for Targeted Prevention in Preadolescence

Non-suicidal self-injury (NSSI) affects 15-20% of adolescents-disproportionately girls-and is a strong predictor of eventual suicide attempts and suicide. Many girls now initiate NSSI before age 10. These early-starters exhibit greater frequency of NSSI, use more diverse methods, and are hospitalized more often, yet there are no empirically supported prevention programs for preadolescents. Obstacles to prevention include ascertaining who is sufficiently vulnerable and specifying mechanistic intervention targets. Recent research indicates that (1) preadolescent girls with ADHD who are also maltreated are at alarming risk for NSSI and suicide attempts by adolescence, and (2) the conjoint effects of these vulnerabilities are sufficiently potent for targeted prevention. Research also indicates that existing interventions are effective in altering child- and family-level mechanisms of NSSI. These interventions alter neurobiological markers of vulnerability, which can be used as proximal efficacy signals of prevention response, without waiting for NSSI and suicide attempts to emerge.