What family studies teach us about suicidal behavior: implications for research, treatment, and prevention

COVID-19 Pandemic Has Changed the Psychiatric Profile of Adolescents Attempting Suicide: A Cross-Sectional Comparison

The COVID-19 pandemic is having a major impact on the mental health of adolescents, leading to suicidal behaviors. However, it remains to be clarified whether the COVID-19 pandemic has changed the psychiatric profile of adolescent suicide attempters.

METHODS

a retrospective observational analytical study was conducted to assess age, gender and clinical characteristics of adolescents attempting suicide during the year before and the year after the global lockdown.

RESULTS

ninety adolescents (12-17 y.o.) were recruited consecutively from February 2019 to March 2021 at the emergency ward for having attempted suicide. Fifty-two (57.8%) attended before the lockdown (pre-pandemic group) and thirty-eight (42.2%) the year after (pandemic group). There were significant differences in diagnostic categories between the periods (p = 0.003). Adjustment and conduct disorders were more frequent in the pre-pandemic group, while anxiety and depressive disorders were more prevalent during the pandemic. Although the severity of suicide attempts did not show significant differences between the two study periods (0.7), the generalized linear model showed that the suicide attempt severity was significantly associated with current diagnosis (p = 0.01).

CONCLUSIONS

the psychiatric profile of adolescents attempting suicide was different before and during the COVID-19 pandemic. During the pandemic, the proportion of adolescents with a prior psychiatric history was lower, and most of them were diagnosed with depressive and anxiety disorders. These diagnoses were also associated with a greater severity in the intentionality of suicide attempt, regardless of the study period.

Understanding and change - Parents' perspectives of their self-poisoning children: A phenomenological study

PURPOSE

This study aimed to describe the experiences of parents of self-poisoning in Wenzhou, China.

BACKGROUND

Self-poisoning by a child results in severe trauma, placing parents at great risk for psychological and physical problems. However, few studies have examined the experiences of parents following the attempted suicide of their child through self-poisoning, limiting the ability to guide effective services through empirical research.

METHODS

The study adopted a qualitative design and 11 parents whose children harmed themselves through self-poisoning were included. Semi-structure, face-to-face interviews were conducted and Colaizzi's analysis method was followed.

RESULTS

Colaizzi's method identified three key themes: against expectations, sense of guilt, and self-growth.

CONCLUSIONS

The findings highlight the need to understand experiences of parents with self-poisoning children. Nursing staff play an important role in creating a pathway to connect parents with their children. There is a need to include the voices of parents so as to not only care for self-poisoning children but also understand their suicidal behavior.

Association of Religious Activity with Male Suicide Deaths

OBJECTIVE

To analyze the relationship between suicide in men and stratified measures of religiosity.

METHODS

We studied 192 suicides and 81 controls (nonsuicide, sudden, or accidental death). We employed the psychological autopsy method to compile diagnoses based on DSM-IV criteria. Overall, religiosity and participation in religious associations were determined using a Likert-type scale. Given the limited participation of women in the religious associations of southern Spain, only male subjects were included.

RESULTS

Religious participants had decreased risk of suicide compared to nonparticipants (OR = 0.148, 95% CI = 0.049-0.447). This lower risk was further associated with the degree of involvement in religious activity. Suicides accounted for 73.47% of subjects with no religious participation, 61.17% of those with some participation, and 56.52% of frequent participants (linear trend test Z = -2.0329, p = .042). Membership in a religious association was also associated with a lower rate of suicide compared to nonmembers (OR = 0.356, 95% CI = 0.172-0.736). This effect was similarly associated with the degree of involvement in the association. Suicides accounted for 74.67% of subjects who never participated in the activities of a religious association, 69.23% of those who sometimes participated, and 42.86% of frequent participants (linear trend test Z = -3.4082, p < .001).

CONCLUSIONS

Religiosity, either as general participation or through a religious association, was associated with protection against suicide proportional to the degree of involvement in religious activities.

Mediating role of borderline personality disorder traits in the effects of childhood maltreatment on suicidal behaviour among mood disorder patients

Background:

Substantial evidence supports an association between childhood maltreatment and suicidal behaviour. However, few studies have examined factors mediating this relationship among patients with unipolar or bipolar mood disorders.

Methods:

Depressive disorder and bipolar disorder (ICD-10-DCR) patients (n = 287) from the Helsinki University Psychiatric Consortium (HUPC) Study were surveyed on self-reported childhood experiences, current depressive symptoms, borderline personality disorder traits, and lifetime suicidal behaviour. Psychiatric records served to complement the information on suicide attempts. We examined by formal mediation analyses whether (1) the effect of childhood maltreatment on suicidal behaviour is mediated through borderline personality disorder traits and (2) the mediation effect differs between lifetime suicidal ideation and lifetime suicide attempts.

Results:

The impact of childhood maltreatment in multivariate models on either lifetime suicidal ideation or lifetime suicide attempts showed comparable total effects. In formal mediation analyses, borderline personality disorder traits mediated all of the total effect of childhood maltreatment on lifetime suicide attempts, but only one fifth of the total effect on lifetime suicidal ideation. The mediation effect was stronger for lifetime suicide attempts than for lifetime suicidal ideation (P = 0.002) and independent of current depressive symptoms.

Conclusions:

The mechanisms of the effect of childhood maltreatment on suicidal ideation versus suicide attempts may diverge among psychiatric patients with mood disorders. Borderline personality disorder traits may contribute to these mechanisms, although the influence appears considerably stronger for suicide attempts than for suicidal ideation.

Gender-based Multilevel Analysis of Influential Factors for Suicide Attempts among At-risk Non-referred Adolescents in Korea

Objective

Effective suicide prevention for at-risk adolescents requires increased access to medical treatment. Investigating the unique characteristics of suicide in this vulnerable at-risk non-referred sample can contribute to establishing effective suicide prevention policies. This study aimed to (a) examine at-risk non-referred adolescents’ suicide attempt rate, (b) investigate influential multilevel factors in predicting these adolescents’ suicide attempts, and (c) compare the results of (a) and (b) by gender.

Methods

A total of 401 samples (216 boys and 185 girls) were recruited through a school-based mental health project for at-risk adolescents. Multivariate hierarchical logistic regression analyses were performed at the individual-, contextual-, and protective levels to evaluate three multilevel models as well as to investigate predictabilities for the overall group and by gender.

Results

The suicide attempt rate of the overall sample was 29.4% (boys: 18.1%, girls: 42.7%), which was significantly higher than that of community samples. For boys, individual-level predictors (depression and conduct problems) had the most significant contribution in predicting suicide attempts. In contrast, for girls, protective-level predictors (family satisfaction) contributed the most to the prediction of suicide attempts, followed by contextual-level predictors (academic grades).

Conclusion

This study is an important step in understanding the unique characteristics of at-risk non-referred adolescents who have not yet been considered in mental health policies. Improving medical accessibility will be the first step in establishing effective suicide prevention policies for these vulnerable samples.

The Impact of Ayahuasca on Suicidality: Results From a Randomized Controlled Trial

Suicide is a major public health problem. Given increasing suicide rates and limitations surrounding current interventions, there is an urgent need for innovative interventions for suicidality. Although ayahuasca has been shown to target mental health concerns associated with suicidality (i.e., depression and hopelessness), research has not yet explored the impact of ayahuasca on suicidality. Therefore, we conducted secondary analyses of a randomized placebo-controlled trial in which individuals with treatment-resistant depression were administered one dose of ayahuasca (n = 14) or placebo (n = 15). Suicidality was assessed by a trained psychiatrist at baseline, as well as 1 day, 2 days, and 7 days after the intervention. A fixed-effects linear mixed model, as well as between and within-groups Cohen's d effect sizes were used to examine changes in suicidality. Controlling for baseline suicidality, we found a significant effect for time (p < .05). The effect of the intervention (i.e., ayahuasca vs. placebo) trended toward significance (p = .088). At all time points, we found medium between-group effect sizes (i.e., ayahuasca vs. placebo; day 1 Cohen’s d = 0.58; day 2 d = 0.56; day 7 d = 0.67), as well as large within-group (ayahuasca; day 1 Cohen's d = 1.33; day 2 d = 1.42; day 7 d = 1.19) effect sizes, for decreases in suicidality. Conclusions: This research is the first to explore the impact of ayahuasca on suicidality. The findings suggest that ayahuasca may show potential as an intervention for suicidality. We highlight important limitations of the study, potential mechanisms, and future directions for research on ayahuasca as an intervention for suicidality.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT02914769.

CHILD SUICIDE: FAMILY’S REACTIONS

Introduction: Suicide is a major public health problem, in which relatives play an important role in the prevention of the said problem. However, suicide and suicidal behavior affect the relatives’ lives profoundly, both emotionally and socially. Aim: This study is an initial investigation of families’ emotional and behavioral responses to adolescents’ suicide Methodology: An extensive literary review of relevant articles for the period 2000-2017, was performed using Medline, PubMed and Google databases, with the following key words: “child suicide, parent’s reactions, bereavement, risk factors, warnings sign, and mental health problems”. Results: Suicide is uncommon in childhood but becomes an extremely serious issue among adolescents. Several risk factors have been identified and include the presence of psychiatric illness, a previous suicide attempt, family factors, substance abuse, sexual and physical abuse, or bullying. The death of a child of any age is extremely painful for parents. Most parents experience a profound sense of guilt, shame, pain, depression when harm comes to their child, even if through no fault of their own. The same feelings are often present and are associated with help seeking in siblings bereaved by suicide. All of these factors lead to a devastating grief that is much longer lasting than most people realize. Conclusion: Families that have experienced a suicide present severe prolonged grief with many psychological and physical symptoms such as depression, feelings of guilt, shame, pain, heart failure, hypertension, diabetes. However, the psychosocial impact on families is a very important issue who needs further investigation.

Whole-exome sequencing data of suicide victims who had suffered from major depressive disorder

Suicide is one of the leading causes of mortality worldwide; it causes the death of more than one million patients each year. Suicide is a complex, multifactorial phenotype with environmental and genetic factors contributing to the risk of the forthcoming suicide. These factors first generally lead to mental disorders, such as depression, schizophrenia and bipolar disorder, which then become the direct cause of suicide. Here we present a high quality dataset (including processed BAM and VCF files) gained from the high-throughput whole-exome Illumina sequencing of 23 suicide victims – all of whom had suffered from major depressive disorder - and 21 control patients to a depth of at least 40-fold coverage in both cohorts. We identified ~130,000 variants per sample and altogether 442,270 unique variants in the cohort of 44 samples. To our best knowledge, this is the first whole-exome sequencing dataset from suicide victims. We expect that this dataset provides useful information for genomic studies of suicide and depression, and also for the analysis of the Hungarian population.

Genetic and other risk factors for suicidal ideation and the relationship with depression

BACKGROUND

There is a genetic contribution to the risk of suicide, but sparse prior research on the genetics of suicidal ideation.

METHODS

Active and passive suicidal ideation were assessed in a Sri Lankan population-based twin registry (n = 3906 twins) and a matched non-twin sample (n = 2016). Logistic regression models were used to examine associations with socio-demographic factors, environmental exposures and psychiatric symptoms. The heritability of suicidal ideation was assessed using structural equation modelling.

RESULTS

The lifetime prevalence of any suicidal ideation was 13.0% (11.7-14.3%) for men; 21.8% (20.3-23.2%) for women, with no significant difference between twins and non-twins. Factors that predicted suicidal ideation included female gender, termination of marital relationship, low education level, urban residence, losing a parent whilst young, low standard of living and stressful life events in the preceding 12 months. Suicidal ideation was strongly associated with depression, but also with abnormal fatigue and alcohol and tobacco use. The best fitting structural equation model indicated a substantial contribution from genetic factors (57%; CI 47-66) and from non-shared environmental factors (43%; CI 34-53) in both men and women. In women this genetic component was largely mediated through depression, but in men there was a significant heritable component to suicidal ideation that was independent of depression.

CONCLUSIONS

These are the first results to show a genetic contribution to suicidal ideation that is independent of depression outside of a high-income country. These phenomena may be generalizable, because previous research highlights similarities between the aetiology of mental disorders in Sri Lanka and higher-income countries.

Suicide Ideation and Attempts among First Nations Peoples Living On-Reserve in Canada: The Intergenerational and Cumulative Effects of Indian Residential Schools

OBJECTIVE

Suicide rates among Indigenous peoples in Canada are at least twice that of their non-Indigenous counterparts. Although contemporary stressors contribute to this increased risk, historical experiences such as the Indian Residential School (IRS) system may also have continuing links with the risk for suicidal thoughts and behaviors. The current investigation examined the intergenerational and cumulative links between familial IRS attendance in relation to lifetime suicide ideation and attempts among First Nations adults living on-reserve.

METHOD

Data from the 2008-2010 First Nations Regional Health Survey were analyzed, and participants comprised a representative sample of First Nations adults older than 18 years (weighted N = 127,338; IRS attendees were excluded). Of those who knew their familial IRS history, 38.0% had no history of attendance, 19.3% had a grandparent who attended, 16.2% had a parent who attended, and 26.5% had a parent and grandparent who attended.

RESULTS

Exposure of one previous familial generation to the IRS experience was associated with increased risk for lifetime suicide ideation (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.16 to 1.84; P = 0.001) and attempts (OR, 1.44; 95% CI, 1.07 to 1.94; P < 0.016) compared with those with no IRS history. Having 2 generations of IRS familial history was associated with greater odds of reporting a suicide attempt compared with having one generation (OR, 1.35; 95% CI, 1.05 to 1.75; P = 0.022), which was reduced when current levels of distress and ideation were accounted for.

CONCLUSION

Findings support the existence of linkages between intergenerational exposure to IRS and risk for suicidal ideation and attempts and for a potential cumulative risk in relation to suicide attempts across generations.

Positive and negative life events and reasons for living modulate suicidal ideation in a sample of patients with history of suicide attempts

BACKGROUND

The influence of life events on suicidal behavior remains inconclusive, while reasons for living (RFL) may be protective.

OBJECTIVES

To analyze the association between positive and negative life events and suicidal ideation (SI) and the interaction between life events and RFL on SI.

METHOD

Patients with history of suicide attempts (n = 338) underwent a comprehensive clinical evaluation, including SI (Beck's Suicidal Ideation scale), RFL (Reasons for Living Inventory, RFLI) and life events (family, school, student or professional, social, health and religion-related and other life events) during the last twelve months.

RESULTS

The only negative life events associated with SI were health-related events (OR = 2.01 95%CI[1.04;3.92]). Family-related positive life events and RFL were negatively associated with SI (OR = 0.73 95%CI[0.58;0.91] and OR = 0.98 95%CI[0.97;0.98], respectively). No significant interaction between the number of positive life events and RFLI total score with current SI (p = 0.57) was detected. Family-related positive life events and RFL did not have any additive effect on SI. Positive life events did not moderate the association between health-related negative life events and SI.

LIMITATIONS

This was a retrospective study, the presence of axis II disorders was not investigated and results cannot be generalized due to the sample choice (only suicide attempters).

CONCLUSIONS

Patients with history of suicide attempts could be less sensitive to negative life events, except for those related to health. Clinicians should pay more attention to somatic problems in patients at risk of suicide. Family support, positive psychology and therapies that strengthen RFL should be developed to prevent suicide.

Attachment Styles and Suicide-Related Behaviors in Adolescence: The Mediating Role of Self-Criticism and Dependency

Insecure attachment and the personality dimensions of self-criticism and dependency have been proposed as risk factors for suicide in adolescents. The present study examines whether self-criticism and dependency mediate the relationship between insecure attachment styles and suicidality. A sample of 340 high-school students (73.2% females), ranging in age from 13 to 20 years (M = 16.47, SD = 1.52), completed the Depressive Experiences Questionnaire for Adolescents, the Depressive Experiences Questionnaire for Adolescents, the Attachment Style Questionnaire, and the Suicidal Behaviors Questionnaire-Revised. The results partially support the expected mediation effects. Self-criticism, but not dependency, mediates the link between insecure attachment (anxiety and avoidance) and suicide-related behaviors. Implications for suicide risk assessment and management are discussed.

Biting the hand that feeds: current opinion on the interpersonal causes, correlates, and consequences of borderline personality disorder

Borderline personality disorder (BPD) is a complex psychiatric diagnosis characterized by dysregulated behaviors, emotions, cognitions, and interpersonal relationships. In recent years, developmental psychopathologists have sought to identify early origins of BPD, with the ultimate goal of developing and providing effective preventative interventions for those at highest risk. In addition to heritable biological sensitivities, many scholars assert that environmental and interpersonal risk factors contribute to the emergence and maintenance of key borderline traits. Nonetheless, many BPD researchers examine only affected individuals, neglecting the family, peer, couple, and other dynamic contextual forces that impinge upon individual-level behavior. In the past decade, however, theoretical and empirical research has increasingly explored the interpersonal causes, correlates, and consequences of BPD. Such work has resulted in novel research and clinical theories intended to better understand and improve interpersonal dynamics among those with borderline traits. A major objective for the field is to better characterize how interpersonal dynamics affect (and are affected by) the behaviors, emotions, and thoughts of vulnerable individuals to either reduce or heighten risk for BPD.

Clinical and psychological consequences for the families of suicide victim

A lot of attention is paid to people in suicidal crisis, while the problems of helping the relatives of the suicide victim are studied less extensively. To offer expert support to the family it is necessary to understand the aims of psychological work. The article presents analysis of protective factors and risk factors that may affect the intensity of the emotional state after the loss. Characteristics of children’s experience of relative’s suicide are described. In contrast to the experience of natural death, relatives of a suicide experience more feelings of guilt and social stigmatization that prevents them from getting informal support. Relatives of a suicide are at risk of developing depression, symptoms of post-traumatic stress disorder, physical illness, drug addiction and suicidal behavior. Literature data shows the need to develop a program of prevention that should be based on the relationship between the survivor and the person who committed suicide, to consider the stage of grief and coping skills he/she possesses.

Impulsive aggression, delay discounting, and adolescent suicide attempts: effects of current psychotropic medication use and family history of suicidal behavior

OBJECTIVE

Impulsive-aggressive behaviors have been consistently implicated in the phenomenology, neurobiology, and familial aggregation of suicidal behavior. The purpose of this study was to extend previous work by examining laboratory behavioral measures of delayed reward impulsivity and impulsive aggression in adolescent suicide attempters and never-suicidal comparison subjects.

METHODS

Using the Point Subtraction Aggression Paradigm (PSAP) and the Delay Discounting Task (DDQ), the authors examined delay discounting and impulsive aggression in 40 adolescent suicide attempters, ages 13-18, and 40 never-suicidal, demographically matched psychiatric comparison subjects.

RESULTS

Overall, suicide attempters and comparison subjects performed similarly on the PSAP and DDQ. There was a significant group by current psychotropic medication use interaction (p=0.013) for mean aggressive responses on the PSAP. Group comparisons revealed that attempters emitted more aggressive responses per provocation than comparison subjects, only in those not on psychotropic medication (p=0.049), whereas for those currently treated with psychotropic medication, there were no group differences (p>0.05). This interaction effect was specific to current antidepressant use. Among all subjects, family history of suicidal behavior (suicide or suicide attempt) in first degree relatives was significantly correlated with both delay discounting (r=-0.22, p=0.049), and aggressive responding (r=0.27, p=0.015). Family history of suicidal behavior was associated with delay discounting, but not with aggressive responding on the PSAP, after controlling for relevant covariates.

CONCLUSIONS

In this study, impulsive-aggressive responding was associated with suicide attempt only in those not being treated with antidepressants. Future work to replicate and extend these findings could have important therapeutic implications for the treatment of depressed suicide attempters, many of whom are affected by impulsive aggression.

An overview of the neurobiology of suicidal behaviors as one meta-system

Suicidal behaviors (SB) may be regarded as the outmost consequence of mental illnesses, or as a distinct entity per se. Regardless, the consequences of SB are very large to both society and affected individuals. The path leading to SB is clearly a complex one involving interactions between the subject's biology and environmental influences throughout life. With the aim to generate a representative and diversified overview of the different neurobiological components hypothesized or shown implicated across the entire SB field up to date by any approach, we selected and compiled a list of 212 gene symbols from the literature. An increasing number of novel gene (products) have been introduced as candidates, with half being implicated in SB in only the last 4 years. These candidates represent different neuro systems and functions and might therefore be regarded as competing or redundant explanations. We then adopted a unifying approach by treating them all as parts of the same meta-system, using bioinformatic tools. We present a network of all components connected by physical protein-protein interactions (the SB interactome). We proceeded by exploring the differences between the highly connected core (~30% of the candidate genes) and its peripheral parts, observing more functional homogeneity at the core, with multiple signal transduction pathways and actin-interacting proteins connecting a subset of receptors in nerve cell compartments as well as development/morphology phenotypes and the stress-sensitive synaptic plasticity processes of long term potentiation/depression. We suggest that SB neurobiology might also be viewed as one meta-system and perhaps be explained as intrinsic unbalances acting within the core or as imbalances arising between core and specific peripheral components.

The molecular bases of the suicidal brain

Suicide ranks among the leading causes of death around the world and takes a heavy emotional and public health toll on most societies. Both distal and proximal factors contribute to suicidal behaviour. Distal factors - such as familial and genetic predisposition, as well as early-life adversity - increase the lifetime risk of suicide. They alter responses to stress and other processes through epigenetic modification of genes and associated changes in gene expression, and through the regulation of emotional and behavioural traits. Proximal factors are associated with the precipitation of a suicidal event and include alterations in key neurotransmitter systems, inflammatory changes and glial dysfunction in the brain. This Review explores the key molecular changes that are associated with suicidality and discusses some promising avenues for future research.

Increased severity of suicidal behavior in impulsive aggressive patients exposed to familial adversities

BACKGROUND

The mechanisms by which childhood abuse and family history of suicidal behavior (FHS) lead to an increased risk of suicidal behavior are still unknown. Impulsive aggression may play an intermediate role. We investigated whether greater scores for aggression and impulsivity might be associated with the effects of FHS and/or childhood abuse on the severity of suicidal behavior.

METHOD

We examined the scores of three scales measuring impulsive aggression in a sample of 696 suicide attempters. We compared the highest and lowest scores with regard to reports of childhood abuse and FHS using adjusted multinomial regression models. Genetic polymorphisms of the serotonergic system known to be associated with impulsive aggression were also analyzed.

RESULTS

Patients with high impulsive aggressive scores showed significant differences in sociodemographic, clinical and suicidal features compared with patients with low impulsive aggressive scores. Adjusted results showed that combinations of some types of childhood abuse and FHS, particularly emotional abuse and emotional neglect, are associated with high impulsivity and hostility scores. The SS genotype of the serotonin transporter gene (5-HTTLPR) was associated with high levels of impulsivity when the subjects reported emotional abuse [odds ratio (OR) 5.55, 95% confidence interval (CI) 1.75-17.5] or physical abuse (OR 5.03, 95% CI 1.50-16.9) in their childhood.

CONCLUSIONS

Our results support the role of impulsive aggression as one of the links that may connect childhood abuse and FHS with severity of suicidal behavior.

History of sexual abuse and suicide attempts in alcohol-dependent patients

History of child abuse is considered one of the important risk factors of suicide attempt in general population. At the same time it has been shown that suicide attempts appear significantly more frequently in alcoholics than in healthy individuals. The objective of this study was to investigate associations between history of childhood sexual abuse and suicide attempts in a sample of Polish alcohol dependent patients. A sample of 364 alcohol-dependent subjects was recruited in alcohol treatment centers in Warsaw, Poland. Information was obtained about demographics, family history of psychiatric problems, history of suicide attempts, sexual and physical abuse during childhood and adulthood and severity of alcohol problems. When analyzed by gender, 7.4% of male and 39.2% of female patients had a lifetime history of sexual abuse; 31.9% of the study group reported at least one suicide attempt during their lifetime. Patients who reported suicide attempts were significantly younger (p=0.0008), had greater severity of alcohol dependence (p=0.0002), lower social support (p=0.003), and worse economic status (p=0.002). Moreover, there was a significant association between history of suicide attempts and family history of psychiatric problems (p=0.00025), suicide attempts in the family (p=0.0073), childhood history of sexual abuse (p=0.009) as well as childhood history of physical abuse (p=0.002). When entered into linear regression analysis with other dependent variables history of childhood sexual abuse remained a significant predictor of suicide attempt (OR=2.52; p=0.035). Lifetime experience of sexual abuse is a significant and independent risk factor of suicide attempts in alcohol-dependent individuals.

Childhood sexual abuse and suicidal behavior: a meta-analysis

BACKGROUND AND OBJECTIVE

Self-inflicted injuries are one of the major causes of disease burden and death globally. Understanding the extent to which this is associated with childhood sexual abuse (CSA) exposure can help inform prevention strategies. We aimed to quantify to what extent CSA was associated with incident suicide attempts in men and women.

METHODS

We searched 20 health and social science databases from first record until February 2009 and updated the search in Medline from February 2009 to February 1, 2013. Longitudinal studies and cotwin analyses from twin studies in any population from any year were eligible for inclusion. Of 22 235 abstracts screened as part of a series of reviews, 9 studies met the inclusion criteria for this review. Characteristics, effect estimates, and quality data were extracted. Random-effects meta-analysis was used to generate pooled odds ratios (ORs).

RESULTS

Seven longitudinal and 2 twin studies with 8733 participants met the inclusion criteria. The overall pooled estimate for longitudinal studies was OR = 2.43 (95% confidence interval: 1.94-3.05), I(2) = 87.5%, P < .0001. The pooled OR from cotwin analysis was 2.65 (95% confidence interval: 0.82-4.49, I(2) = 0%, P = .867). Studies adjusted for a range of confounders, but baseline suicidal behavior was not well-controlled. Too few studies met the inclusion criteria to quantitatively examine sources of heterogeneity.

CONCLUSIONS

CSA exposure is associated with suicide attempts when a range of different confounders are controlled for, but the temporality of the association is not well established, and the association is highly heterogeneous.

Genetic risk of suicidal behavior in bipolar spectrum disorder: analysis of 737 pedigrees

OBJECTIVES

Suicide is a significant cause of mortality in patients with major affective disorders (MAD), and suicidal behavior and MAD co-aggregate in families. However, the transmission of suicidal behavior is partially independent from that of MAD. We analyzed the lifetime prevalence of completed and attempted suicides in a large sample of families with bipolar disorder (BD), its relation to family history of MAD and BD, and the contribution of clinical and treatment factors to the risk of suicidal behavior.

METHODS

We studied 737 families of probands with MAD with 4919 first-degree relatives (818 affected, 3948 unaffected, and 153 subjects with no information available). Lifetime psychiatric diagnoses and suicidal behavior in first-degree relatives were assessed using semi-structured interviews, family history methods, and reviews of clinical records. Cox proportional hazard and logistic regression models were used to investigate the role of clinical covariates in the risk of suicidal behavior, and in the prevalence of MAD and BD.

RESULTS

The estimated lifetime prevalence of suicidal behavior (attempted and completed suicides) in 737 probands was 38.4 ± 3.0%. Lithium treatment decreased suicide risk in probands (p = 0.007). In first-degree relatives, a family history of suicidal behavior contributed significantly to the joint risk of MAD and suicidal behavior (p = 0.0006).

CONCLUSIONS

The liability to suicidal behavior is influenced by genetic factors (particularly family history of suicidal behavior and MAD). Even in the presence of high genetic risk for suicidal behavior, lithium treatment decreases suicide rates significantly.

Parental schizophrenia and increased offspring suicide risk: exploring the causal hypothesis using cousin comparisons

BACKGROUND

Little is known about suicide risk among offspring of parents hospitalized for schizophrenia and the mechanisms behind this association.

METHOD

We applied a nested case-control design based on linkage of Swedish population-based registers. Among 12- to 30-year-old offspring, we identified 68 318 offspring with suicidal behavior (attempted and completed suicide) and their parents. Five healthy control-parent pairs were matched to each suicidal case-parent pair and conditional logistic regression used to obtain odds ratios (ORs). Further, to disentangle familial confounding from causal environmental mechanisms, we compared the population-based suicide risk with the risk found within full-cousins and half-cousins differentially exposed to parental schizophrenia.

RESULTS

Offspring of parents with schizophrenia had significantly increased suicide risk after accounting for socio-economic status, parental suicidal behavior and offspring mental illness [OR 1.68, 95% confidence interval (CI) 1.53-1.85]. Suicide risks in offspring of schizophrenic mothers and fathers were similar in magnitude; so were risks across different developmental periods. Importantly, offspring suicide risk remained essentially unchanged across genetically different relationships; offspring of siblings discordant for schizophrenia had equivalent risk increases within full-cousins (OR 1.96, 95% CI 1.66-2.31) and half-cousins (OR 1.69, 95% CI 1.17-2.44).

CONCLUSIONS

Parental schizophrenia was associated with increased risk of offspring suicidal behavior, independent of gender of the schizophrenic parent, and persisting into adulthood. The suicide risk in offspring remained at a similar level when comparing genetically different relationships, which suggests that at least part of the association is due to environmental mechanisms. These findings should inspire increased attention to suicidal ideation and prevention efforts in offspring of parents with schizophrenia.

Suicidal ideation and the subjective aspects of depression

BACKGROUND

Suicidal ideation is common in depression, but only moderately related to depression severity - in part because certain clusters of symptoms, such as those related to core mood disturbance, have a differential relationship to suicidal thinking.

METHODS

400 medication free participants with current major depression were assessed with either or both the Hamilton Depression Rating Scale (HDRS, n=396) and Beck Depression Inventory (BDI, n=366), and the Scale for Suicide Ideation (SSI). Depression rating scales were decomposed into symptoms clusters previously reported (Grunebaum et al., 2005), in order to evaluate their association to suicidal thinking.

RESULTS

Correlations between overall depression severity ratings and the measure of suicidal ideation were modest, and reduced when specific items assessing suicidal thinking on these depression scales were removed. Symptom clusters assessing Psychic Depression (HDRS), Subjective Depression (BDI), and Self-Blame (BDI) were the strongest correlates of suicidal ideation; other somatic and vegetative symptoms had little or no association to suicidal ideation. Severity of these symptom clusters effectively discriminated those with (SSI>0) and without (SSI=0) ideation; severity of these symptom clusters was less strongly associated with the severity of ideation once ideation was present.

LIMITATIONS

This is a cross-sectional study, and the dynamic relationship between changes in the severity of various depressive symptoms and change in suicidal thinking remains to be explored.

CONCLUSIONS

Depression severity is moderately associated with suicidal ideation, and accounted for primarily by core mood disturbance symptoms and self-punitive thinking. These associations may explain why suicide risk might remain high during treatment even though somatic and vegetative symptoms improve.

Suicide method runs in families: a birth certificate cohort study of adolescent suicide in Taiwan

Suicide method used by adolescents was examined to determine if it was the same as that employed by their suicidal parents. Six hundred eighty adolescents completed suicide between 1997 and 2007, of whom 12 had parents who had previously died by suicide. The suicide method used by these adolescents was compared with that employed by their suicidal parent and that of a matched peer control adolescent with no exposure to parental suicide and living in the same area. In 10 of the 12 suicidal parent-adolescent dyads, the same suicide method was employed by parent and adolescent. Of seven adolescents whose age at parental suicide was 15 years or above, six used the same suicide method as their suicidal parent had. On the contrary, of 12 exposure-nonexposure suicidal adolescent dyads, the same method was used in only four. Adolescents exposed to parental suicide are more likely to use the suicide method employed by their suicidal parents than the method used by adolescent peers with no exposure to parental suicide.

Familial clustering of suicide risk: a total population study of 11.4 million individuals

BACKGROUND

Research suggests that suicidal behaviour is aggregated in families. However, due to methodological limitations, including small sample sizes, the strength and pattern of this aggregation remains uncertain.

METHOD

We examined the familial clustering of completed suicide in a Swedish total population sample. We linked the Cause of Death and Multi-Generation Registers and compared suicide rates among relatives of all 83 951 suicide decedents from 1952-2003 with those among relatives of population controls.

RESULTS

Patterns of familial aggregation of suicide among relatives to suicide decedents suggested genetic influences on suicide risk; the risk among full siblings (odds ratio 3.1, 95% confidence interval 2.8-3.5, 50% genetic similarity) was higher than that for maternal half-siblings (1.7, 1.1-2.7, 25% genetic similarity), despite similar environmental exposure. Further, monozygotic twins (100% genetic similarity) had a higher risk than dizygotic twins (50% genetic similarity) and cousins (12.5% genetic similarity) had higher suicide risk than controls. Shared (familial) environmental influences were also indicated; siblings to suicide decedents had a higher risk than offspring (both 50% genetically identical but siblings having a more shared environment, 3.1, 2.8-3.5 v. 2.0, 1.9-2.2), and maternal half-siblings had a higher risk than paternal half-siblings (both 50% genetically identical but the former with a more shared environment). Although comparisons of twins and half-siblings had overlapping confidence intervals, they were supported by sensitivity analyses, also including suicide attempts.

CONCLUSIONS

Familial clustering of suicide is primarily influenced by genetic and also shared environmental factors. The family history of suicide should be considered when assessing suicide risk in clinical settings or designing and administering preventive interventions.