Gender differences in clinical correlates of suicidality among young adults

Still With Me? Assessing the Persisting Relationship to a Deceased Loved-One - Validation of the "Continuing Bonds Scale" in a German Population

Continuing the bond (CB) to a deceased loved one plays a clinically significant role in grief. We validated the Continuing Bonds Scale (CBS) examining externalized CB (illusions and hallucinations) versus internalized CB (use of the deceased as a secure base) in relation to risk factors of complicated grief and bereavement-related adjustment. Data from 364 bereaved German participants on CBS, Inventory of Complicated Grief (ICG), and Posttraumatic Personal Growth Inventory (PPGI) entered an exploratory factor analysis. This yielded a two-factor-solution representing externalized and internalized CB (KMO = .89, χ2 = 2100.5, df = 120). Both factors demonstrated high internal consistency (Cronbach's α = .87). ICG and PPGI highly correlated with externalized and internalized CB. Cause of death and feelings of responsibility were associated with externalized CB. In the future, the use of the CBS could help predict problems in grief processing and consequently implement early interventions.

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

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Post-traumatic stress disorder as a comorbidity: impact on disease outcomes

Post-traumatic stress disorder (PTSD) is associated with many psychiatric and nonpsychiatric comorbidities. Growing evidence suggests that PTSD as a comorbidity may impair drug adherence, quality of life and sleep quality, as well as increase rehospitalization rates, disease relapses, intensity of symptoms, morbidity and mortality. The aim of this article is to examine the literature regarding the effects of PTSD comorbidity on physical and mental health.

A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression

OBJECTIVE

A considerable number of studies have reported an increased frequency of suicidal behaviors among individuals diagnosed with posttraumatic stress disorder (PTSD). This study aims, first, to provide a comprehensive systematic review and meta-analysis of the association between a PTSD diagnosis and frequency of suicidality and, second, to examine the role of comorbid depression in the association between suicidality and PTSD.

METHODS

Searches of Medline (June 2010), EMBASE (June 2010), PsycINFO (June 2010), PILOTS (June 2010), and Web of Science (June 2010) were conducted to identify studies that examined the association between PTSD and suicidality. The studies had to include an effect size of the association between PTSD and suicidality to be included in the meta-analysis. Sixty-three studies were eligible for inclusion in the meta-analysis. Overall and subgroup effect sizes were examined.

RESULTS

A highly significant positive association between a PTSD diagnosis and suicidality was found. The PTSD-suicidality association persisted across studies using different measures of suicidality, current and lifetime PTSD, psychiatric and nonpsychiatric samples, and PTSD populations exposed to different types of traumas. Comorbid major depression significantly compounded the risk for suicide in PTSD populations.

CONCLUSION

The current meta-analysis provides strong evidence that a PTSD diagnosis is associated with increased suicidality. The crucial role of comorbid major depression in the etiology of suicidality in PTSD is also supported.

Anger, anger expression, and suicidal ideation in Korean adolescents

This study described the levels of anger, anger expression, and suicidal ideation in Korean adolescents. Data from 18,752 adolescents were collected using a self-report questionnaire. Anger, anger expression, and suicidal ideation exhibited significant differences according to school level and gender. The group with higher anger and anger expression showed a higher average suicidal ideation score than that of the group with lower anger and anger expression, suggesting that school-based programs which alleviate anger may be needed to decrease suicidal ideation among Korean adolescents.

Longitudinal associations between community violence exposure and suicidality

PURPOSE

To examine longitudinal associations between community violence exposure and suicide ideation and attempt, and whether depressive symptoms and aggressive behavior are intervening variables in this association.

METHODS

Participants were 473 urban and predominantly African American adolescents who completed measures of community violence exposure, depressive symptoms, and suicide ideation and attempt in grades 6, 7, and 8; teachers reported about adolescents' aggressive behaviors in grades 6, 7, and 8. Path analysis was used to examine direct and indirect associations between community violence exposure in grade 6 and suicide ideation and attempt in grade 8. Depressive symptoms and aggressive behavior were examined as part of an indirect path from grade 6 community violence exposure to later suicide ideation and attempt.

RESULTS

Results revealed an indirect association between community violence exposure and later suicide ideation for males and females; community violence exposure in grade 6 was associated with depressive symptoms in grade 7, which in turn, were positively associated with suicide ideation in grade 8. For males, community violence exposure in grade 6 was associated with increases in aggressive behavior in grade 7, which in turn, were associated with suicide attempts in grade 8.

Posttraumatic stress disorder after implantation of a Mechanical Assist Device Followed by Heart Transplantation: Evaluation of Patients and Partners

AIM

We sought to investigate the prevalence of posttraumatic stress disorder, anxiety, and depression in patients and their partners after implantation of a mechanical assist device as a bridge to heart transplantation.

METHODS

This was a retrospective assessment of 41 patients (age 46.3 +/- 12.0 years; male-female ratio, 38:3; time since transplantation, 55.3 +/- 34.2 months [range, 7-122 months) and 27 partners (male-female ratio 2:25) by standardized instruments (Impact of Event Scale, Hospital Anxiety and Depression Scale), in 2 University Heart Transplant Centers (Vienna, Austria, Munster, Germany). The duration of the support systems (MicroMed DeBakey-VAD in 17 patients, Novacor in 10, Thoratec in 8, TCI HeartMate in 5, and Berlin Heart Incor in 1 patient) ranged from 28 to 711 (176 +/- 146) days.

RESULTS

None of the patients, but 23% of the partners (n = 6), met the criteria for posttraumatic stress disorder (Maercker cutoff >0). The Impact of Event Scale (IES) sum scales differed significantly between the 2 groups (21.2 +/- 15.1, mean +/- SD) for the patients versus 38.1 +/- 27.8 for the partners, respectively; P = .001). Two percent of the patients, but 19% of the partners, showed mild to moderate depression; 4% of patients, but 23% of their partners, reported mild to moderate anxiety. None of the results were significantly influenced by the time since transplantation, patient age, diagnoses, type of assist device, or indication for heart transplantation.

CONCLUSIONS

Despite patients being much closer to a life threat, their partners experience significantly more psychologic distress even in the long run. Our findings highlight the need for attention to the supporting persons.

Psychiatric and characterological factors relevant to excess mortality in a long-term cohort of prostitute women

We previously reported on the causes of death in a 30-year open cohort of 1,969 prostitute women. Excess mortality was mostly accounted for by homicide, suicide, drug and alcohol toxicity, and AIDS, with AIDS deaths occurring in prostitutes identified as injecting drug users. Presently, we examine observed mortality trends in light of the literature on personality and psychopathological characteristics reported for prostitute women, and with reports linking such personality characteristics to excess mortality. We observed consistency between the observed pattern of mortality in prostitute women and mortality that would be expected in a sample of persons at high risk for antisocial and borderline personality disorder.

The contribution of epidemiology to the study of traumatic stress

Post-traumatic stress disorder (PTSD) has been a controversial construct because of the complex set of factors that have been hypothesized to influence its onset and prevalence, such as compensation and withdrawal from combat duty. Epidemiology has done much to objectively clarify these controversies in the study of stratified population samples. The symptoms characterizing PTSD have been repeatedly described in large population samples where compensation is not a confounding issue and this has done much to support the validity of the construct. Epidemiology has also highlighted that the prevalence of exposure to traumatic events is far greater than was previously estimated. Emphasizing the importance of these events is accounting for the major burden of disease. Kessler (2000) has suggested the socio-economic effects of PTSD represent a burden of disease not dissimilar to that associated with depression. Traumatic events provide a unique opportunity to implement a preventative and public health approach to the management of psychiatric morbidity. Of particular importance is the apparent longevity of the influence that these events have on psychological adjustment.

Familial aggregation of suicidal ideation in psychiatric patients: influence of gender

To investigate the role of familial factors for suicidal ideation, 48 psychiatric patients belonging to 20 nuclear and three-generation families were personally interviewed. The effect of familiality on suicidal ideation was estimated through the use of mixed model analysis with family as random effect and gender, age and depressive score as fixed effects (covariates). The effect of family was found to be statistically significant (p=0.024) for the whole group of patients and for the subgroup of males (p=0.048), but not female patients; significance persisted for the whole group (p=0.030) and was reduced to indicative level for males (p=0.069), when psychiatric diagnosis was also considered as an additional potentially confounding factor. These results show that the occurrence of suicidal ideation has a familial component, stronger among males than females. This may be an additional explanation (besides those related to various other biological and sociocultural factors) for gender differences in suicidal behavior.

Do extenuating circumstances influence African American women's attitudes toward suicide?

African American women commit suicide less than other U.S. women and men, perhaps partly due to strong, anti-suicide attitudes. To see if suicide attitudes might be softened by extenuating circumstances such as terminal illness, 192 African American and European American women imagined themselves in one of four extenuating circumstances, then completed measures of suicide acceptability and religiosity. Both ethnic groups reported a greater likelihood of suicide when imagining depression, regardless of religiosity. Religiosity, but not extenuating circumstances, corresponded with negative attitudes toward suicide and physician assisted suicide. These African American and European American young women remained steadfastly against suicide, regardless of circumstance.

Post-traumatic stress disorder in women: current concepts and treatments

In the US, 13% of women develop post-traumatic stress disorder (PTSD) during their lifetime. An accurate diagnosis of PTSD requires screening for trauma and symptoms of PTSD. Current research in the neurobiologic and psychologic responses to traumatic stress supports the use of pharmacologic and psychosocial interventions. Selective serotonin reuptake inhibitors are the current first-line pharmacotherapy. Efficacious psychosocial interventions include exposure therapy and cognitive processing therapy.

Sex-specific predictors of suicidality among runaway youth

Examined predictors of suicidality (ideation and attempts) among 348 adolescent runways (197 boys; 56% African American; M age = 16) using sex-specific models that tested the impact of the three domains of the Social Action Model: individual characteristics, interpersonal influences, and life events. Twenty-five percent of the girls and 14% of the boys had attempted suicide at least once. Male suicidality was mainly predicted by individual characteristics: identifying as gay, emotional distress, fewer conduct problems, and avoidant reasons for drug use. The interpersonal influence of suicidal friends also predicted suicidality. Variables from all three domains influenced girls: individual characteristics of lower age, lower self-esteem, and emotional distress; interpersonal influence of suicidal friends; and life events of having lived on the streets and assaults. Findings suggest some sex-specific interventions, but decreasing emotional distress and lessening the influence of suicidal friends may be useful for both boys and girls.

Promoting screening and early detection of cancer in men

Gender is a factor in the risk assessment for many diseases. It may also impact on the way in which men assess their personal health or illness status and take action to prevent illness or promote well-being. This paper is focused on three objectives: (i) to foster an understanding of gender differences in health promoting behaviors; (ii) to review three health issues affecting males for which dissemination of health education, increased personal awareness and early detection may be beneficial in the reduction of morbidity and mortality; and (iii) to offer suggestions for nurses and other health care professionals to promote positive patient-provider interactions within a health-care framework for action.

Perceived threat to life predicts posttraumatic stress disorder after major trauma: risk factors and functional outcome

BACKGROUND

The importance of psychological morbidity after major trauma, such as posttraumatic stress disorder (PTSD), is continuing to gain attention in trauma outcomes research. The Trauma Recovery Project is a large prospective epidemiologic study designed to examine multiple outcomes after major trauma, including quality of life (QoL) and PTSD. The specific objectives of the present report are to examine risk factors for PTSD and to assess the impact on QoL at the 6-, 12-, and 18-month follow-up time points in the Trauma Recovery Project population.

METHODS

Between December 1, 1993, and September 1, 1996, 1,048 eligible trauma patients triaged to four participating trauma center hospitals in the San Diego Regionalized Trauma System were enrolled in the study. The enrollment criteria for the study included age 18 years and older, admission Glasgow Coma Scale score of 12 or greater, and length of stay > 24 hours. QoL was measured after injury using the Quality of Well-being scale, a sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Early symptoms of acute stress reaction (SASR) at discharge were assessed using the Impact of Events Scale (score > 30 = SASR). PTSD at 6-month follow-up was diagnosed using standardized Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria. Patient outcomes were assessed at discharge and at 6, 12, and 18 months after discharge.

RESULTS

PTSD was diagnosed in 32% (261 of 824) patients at 6-month follow-up. Perceived threat to life predicted PTSD onset (odds ratio [OR], 1.6; p < 0.01) and early SASR (OR, 2.2; p < 0.001). PTSD was more frequent in women (39%) than in men (29%) and in younger low-income patients. Other major risk factors were penetrating trauma (OR, 2.3; p < 0.001) and assaults (OR, 1.5; p < 0.05). PTSD had a major impact on QoL at 6-, 12-, and 18-month follow-up (Quality of Well-being scale score: 6 months, 0.576 vs. 0.658; 12 months, 0.620 vs. 0.691; 18 months, 0.620 vs. 0.700; p < 0.0001).

CONCLUSION

These results provide new and provocative evidence that perceived threat to life and mechanism predict PTSD after major traumatic injury. PTSD had a prolonged and profound impact on short- and long-term outcome and QoL.

Death ideation and its correlates: survey of an over-65-year-old population

The presence of dissatisfaction with life or thoughts of death or suicide has been variously surveyed in adolescent samples and in the general population, but there is a paucity of research on the elderly. The aim of this study was to assess, in an elderly community-dwelling population: a) the prevalence of death and/or suicidal feelings and thoughts and any attempted suicides; and b) factors associated with these experiences. A total of 611 over-65-year-old subjects were interviewed at home. Seventeen percent of the total (F:M = almost 2:1) responded affirmatively to at least one of the questions on suicidality. Elderly people reporting suicidal feelings presented markedly higher levels of physical and psychological distress, such as depression, anxiety, and hostility. Results indirectly confirm that depressive symptomatology is not adequately treated. Greater attention is warranted in psychological evaluation of the elderly to take into account those risk factors that, if identified and managed, could reduce the frequency of suicidal thoughts and, probably, associated actions.

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

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

Street music or the blues? The lived experience and social environment of depression

Life's complexity is a haunting melody of continuously interacting variables .... Professional practice in nursing seeks to promote symphonic interaction between man [sic] and environment. . . (Rogers, 1970, pp. 41, 122). The purpose of this phenomenological study was to explore the lived experience of clinical depression for women in the context of their social relations and environment. Twelve ethnically diverse female friend dyads were interviewed and completed the Beck Depression Inventory (BDI). Seventeen of these women had experienced a major depression in the past or were in treatment for clinical depression at the time of the study. This depression was characterized by dissonance experienced in childhood abuse and incest, uncontrollable moods despite self-medication, abusive or negligent therapy, failed social relationships in adulthood, and a lack of resources in the environment. In contrast, seven healthy women described their social environment as generally resonant and connected. Prevention of childhood abuse and racism, relief from economic hardships, early diagnosis, and safe, effective treatment are essential in helping women to survive clinical depression. Nurses in the community are in a unique position to affect this public health problem.

Influence of traumatic grief on suicidal ideation among young adults

OBJECTIVE

The purpose of this study was to examine the influence of traumatic grief on suicidal ideation.

METHOD

The Beck-Kovacs Scale for Suicidal Ideation was administered to 76 young adult friends of suicide victims.

RESULTS

Traumatic grief was associated with a 5.08 times greater likelihood of suicidal ideation, after control for depression. Comorbid traumatic grief and depression were not associated with a greater likelihood of suicidal ideation.

CONCLUSIONS

Syndromal traumatic grief heightens vulnerability to suicidal ideation.

Posttraumatic stress disorder in injured adults: etiology by path analysis

OBJECTIVE

Posttraumatic Stress Disorder (PTSD) impairs outcome from injury. We present a path analysis of factors related to the development of PTSD in injured adults.

METHODS

A prospective cohort of 250 patients without severe neurotrauma was evaluated by interview during admission and by mailed self-report 6 months later. Data were gathered from the trauma registry (age, injury mechanism, and Injury Severity Score), social history (gender, income, education, and social support), and survey instruments. Baseline assessment used the Michigan Critical Events Perception Scale (peritraumatic dissociation and subjective threat to life), the Life Experience Survey (stressful exposure history), and the SF36 (general and mental health). PTSD at 6 months was identified with the civilian Mississippi Scale for PTSD. Data are listed as mean +/- SEM or percent (%). Path analysis was conducted by linear regression and significant (p<0.05) variables are shown. Factors are listed with the standardized beta. A negative beta suggests a protective effect.

RESULTS

The 176 patients (72%) who completed the 6-month follow-up were 37.7+/-0.88 years old; 75% were men; and blunt (70%), penetrating (13.5%), and burn (16.4%) mechanisms caused the injuries. Assault was involved in 14.5% of the cases. Average income was $44,300+/-2,700/yr, education was 13.0+/-0.15 years, and Injury Severity Score was 13.9+/-0.50. A total of 42.3% of the patients developed PTSD. The 39.7% of the variance in PTSD explained by the model was due to intentional injury (beta = 0.27), male gender (beta = -0.21), age (beta = -0.20), peritraumatic dissociation (beta = 0.174), baseline mental health (beta = -0.21), and prior life-threatening illness (beta = -0.29). Peritraumatic dissociation was due to the patient's sense of threat to life (beta = -0.47), and threat was related to Injury Severity Score (beta = 0.2), assault(beta = 0.14), education (beta = -0.15), and age (beta = -0.19). Baseline SF36 mental health was related to social support (beta = 0.27) and income (beta = 0.21). Income was contingent on education (beta = 0.21).

CONCLUSION

PTSD occurred in 42.3% of injured adults 6 months after trauma and was related to assault, dissociation, female gender, youth, poor mental health, and prior illness. By modeling PTSD, we may learn more of the etiology, risk stratification, and potentials for the treatment of this common and important morbidity of injury.