The Impact of Negative Life Events on Attempted Suicide in Rural China

When people die by suicide: Introducing unacceptable loss thresholds as a potential missing link between suicide readiness states and actively suicidal clinical states

INTRODUCTION

Contemporary models of suicide have largely overlooked why a person at high risk for suicide attempts suicide at a specific time. We propose the construct of unacceptable loss thresholds (i.e., a person's tolerance limit for a negative life event, which if violated results in an increase in suicide risk), which addresses many paradoxes in the literature related to suicide triggers. The aim of this paper is to provide preliminary proof of concept and to stimulate replication and further empirical study.

METHODS

We recruited an online community sample of individuals with a suicide attempt history (n = 144). These individuals answered questions about the time leading up to their most recent suicide attempt.

RESULTS

The majority (70.8% yes; 18.1% cannot remember; 11.1% no) reported creating a threshold of unacceptable loss, and that relatively small events were enough to trigger feelings that life was not worth living (63.9% yes; 30.6% maybe; 5.6% no). Further, the majority (57.6% yes; 21.5% yes, but only if asked; 20.8% - no) reported they would be willing to tell their therapist/doctor about their thresholds of unacceptable loss.

CONCLUSION

The construct of unacceptable loss deserves further empirical inquiry. Individuals contemplating suicide set them and if the loss occurs, it may trigger suicidal action in suicide ready individuals. Thresholds could provide risk assessment and safety planning data currently being overlooked.

Predicting the risk of suicide attempt in a depressed population: Development and assessment of an efficient predictive nomogram

The purpose of this study was to develop and validate a user-friendly suicide attempt risk nomogram in depression, supporting timely interventions by clinicians. We collected clinical data of 273 depressed patients from January 2020 to January 2021. Suicide attempt was assessed conducting the Mini International Neuropsychiatric Interview. First, optimized features were filtrated through the least absolute shrinkage and selection operator regression analysis. Subsequently, we selected variables with nonzero coefficients and entered them into multiple logistic regression model and nomogram function to construct a visual predicting suicide attempt model. Additionally, the C-index, calibration plot and decision curve analysis, were applied to assess discrimination, calibration, and clinical practicability. Finally, the bootstrapping validation was applied to assess internal validation. Finally, eleven clinical features are screened out in the prediction nomogram. The model presented tiptop calibration and pleasant discrimination with a C-index of 0.853. A towering C-index value, up to 0.799, could also be attained in the interval validation analysis. In addition, decision curve analysis exhibited that our predictive model is clinically effective when the threshold is no less than 1%. These results demonstrate this predictive model was helpful for clinicians assessing the inpatient's suicide attempt recently and implementing individualized treatment strategies.

Early marriage, stressful life events and risk of suicide and suicide attempt: a case-control study in Iran

BACKGROUND

Early Marriage (EM) and associated Stressful Life Events (SLEs) and consequences such as psychological and physical well-being issues can lead to suicide and suicide attempts (SA). The study aimed to investigate the risk of suicide and SA among early married people who experienced SLEs.

METHODS

A case-control study was conducted based on the registry for suicide in Malekan county in Iran during 2016-18. Cases included 154 SAs and 32 suicides. Simultaneously, 201 outpatients from the emergency department were chosen as controls. Holms and Rahe life event questionnaire was used to assess SLEs. Sub-group analysis (Mantel-Haenszel) by sex and age groups and multiple logistic regression were used to calculate adjusted Odds Ratios (ORs) with 95% Confidence Intervals (CIs) for the association between EM and suicide risk after adjusting for the potential confounders.

RESULTS

The proportion (female vs male) of EM among suicides, controls, and SAs was 31.25% (18.7 vs 12.5%), 15.92% (11.9 vs 4.0%), and 13.0% (11.7 vs 1.3%), respectively. In subgroup analyses by sex, EM was associated with an increased risk of suicide in both females and males 2.64 and 2.36 times, respectively. Likewise, subgroup analysis by age groups revealed that EM increased suicide risk in subjects aged 10-15 years, while no association was found for age groups of 26-40 and > 40. After adjusting for the potential confounders, EM (OR: 3.01; 95% CI: 1.15 -7.29), financial problems (OR = 4.50; 95% CI: 1.83 -9.07), and family problems (OR = 2.60; 95% CI: 1.19-9.59), were associated with an increased risk of suicide. However, no association was found between EM, various types of SLEs, and the risk of SA.

CONCLUSIONS

We found EM and SLEs were correlated with suicide risk, while no evidence found that EM increased the risk of SA. Progress in reducing EM and addressing its serious consequences can occur by a stronger political commitment and by sharing the experiences and voices of the early married. Our study provided preliminary findings to guide future studies; however, methodological and longitudinal studies are needed to understand and address the effect of EM on suicidal behaviors.

Behavioural activation and trial-based cognitive therapy may be beneficial to reduce suicidal ideation in major depressive disorder: A post hoc study from a clinical trial

WHAT IS KNOWN AND OBJECTIVE

The suicidality spectrum is a clinical challenge because of the difficulty of its management and its association with mortality. Few studies have investigated psychotherapies for reducing the components of suicidality. In this study, we compared the effect of behavioural activation (BA), trial-based cognitive therapy (TBCT) - both added to antidepressant (AD) treatment - and treatment as usual (TAU) in mitigating suicidal ideation in patients with major depressive disorder (MDD).

METHODS

A post hoc study was conducted with data from a randomized clinical trial. Secondary analyses compared the treatments using scores from the items that evaluated suicidal ideation with the HAM-D (HAM-D-3) and BDI (BDI-9). A composite measurement was constructed by summing the scores from the two items (HAM-D-3 plus BDI-9).

RESULTS AND DISCUSSION

Seventy-six patients were analysed (BA + AD = 24; TBCT + AD = 26 and TAU = 26). In HAM-D-3, the BA + AD group showed a statistically greater reduction than the TAU group. In BDI-9, the three groups did not show significant differences. In the HAM-D-3 plus BDI-9, TBCT + AD reduced ideations more than the TAU group. There were no differences among the psychotherapies in any of the measures. Sensitivity analyses showed improvement in suicidal ideation in both psychotherapies compared to TAU.

WHAT IS NEW AND CONCLUSION

This is one of the few studies that evaluated the effect of BA and TBCT in lowering suicidal ideation. Adding these therapies to ADs seems to decrease suicidal ideation. We suggest the possible beneficial effects of BA and TBCT in the management of suicidal ideation in patients with recurrent MDD. Our findings need further studies to confirm these results.

Efficacy of trial-based cognitive therapy, behavioral activation and treatment as usual in the treatment of major depressive disorder: preliminary findings from a randomized clinical trial

INTRODUCTION

Major depressive disorder (MDD) is a prevalent, debilitating and disabling disorder, and its prevalence is increasing. Antidepressants (AD), cognitive-behavioral therapy (CBT) and behavioral activation (BA) are the main treatments for MDD. Trial-based cognitive therapy (TBCT) addresses and restructures dysfunctional negative core beliefs (CBs) and is a novel and promising approach.

OBJECTIVE

The aim of this study was to compare the efficacy of TBCT, BA and treatment as usual (TAU) in the treatment of MDD.

METHODS

A total of 76 patients with MDD were randomized into 1 of 3 groups and evaluated at baseline, after 6 weeks and at week 12 (final evaluation). The primary outcome was changing in HAM-D scores, and the secondary outcomes included scores on the BDI, CD-Quest, Sheehan Disability Scale (SDS) and WHOQOL.

RESULTS

Both TBCT and BA (which also included AD) were different from TAU (which included antidepressants alone) in reducing the HAM-D and BDI scores and other measures. TBCT and BA were different from TAU in the reduction of disability in SDS and WHOQOL physical domain scores. Besides limited by a small sample size, the dropout rate in the TAU arm was higher, and only 10 patients completed the 3 evaluations.

CONCLUSION

This trial provides evidence that TBCT and BA combined with antidepressants were more efficacious than the TAU (drug alone) in reducing the severity of depressive symptoms and disability, showing that this combination can be useful for clinical practice.

Examining the mechanisms by which adverse life events affect having a history of self-harm, and the protective effect of social support

BACKGROUND

Psychological models of suicide emphasize perceptions of negative stressors, hopelessness and self-harm as key antecedents to suicidal thoughts/acts. Such models also emphasize the potential protective role of social support in these pathways. However, such pathways have not been tested using population level data. Hence, this study aimed to redress this gap.

METHODS

Questionnaire data regarding 24,444 patient suicide deaths were analysed. All individuals died between 1996 and 2015 and were seen by secondary mental health services in England within 12 months before their death. Mediation analyses, using fitted logistic regression models, investigated direct and indirect pathways between negative stressors, hopelessness and a proxy measure of suicide, namely, self-harm history. In addition, the buffering effects of social support were examined in these pathways.

RESULTS

There was a direct effect of negative life events on suicidal behaviors. Supporting contemporary psychological models of suicide, a mediated effect via hopelessness and a protective effect of social support were identified. Social support buffered the pathway between stressful life events and hopelessness, with hopelessness decreasing as social support increased.

LIMITATIONS

Causal inferences are inappropriate as the design was cross-sectional. A proxy measure of suicidality was utilized (history of self-harm) as all individuals had died by suicide.

CONCLUSIONS

This is the first time that population data has been used to test psychological pathways to suicidal acts involving negative stressors, hopelessness and social support. Psychological interventions should focus on increasing social support following negative life events together with ameliorating perceptions of hopelessness.

Psychiatric morbidity and suicidal behaviour in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Psychiatric disorders are reported to be present in 80% to 90% of suicide deaths in high-income countries (HIC), but this association is less clear in low- and middle-income countries (LMIC). There has been no previous systematic review of this issue in LMIC. The current study aims to estimate the prevalence of psychiatric morbidity in individuals with suicidal behaviour in LMIC.

METHODS AND FINDINGS

PubMed, PsycINFO, and EMBASE searches were conducted to identify quantitative research papers (any language) between 1990 and 2018 from LMIC that reported on the prevalence of psychiatric morbidity in suicidal behaviour. We used meta-analytic techniques to generate pooled estimates for any psychiatric disorder and specific diagnosis based on International classification of disease (ICD-10) criteria. A total of 112 studies (154 papers) from 26 LMIC (India: 25%, China: 15%, and other LMIC: 60%) were identified, including 18 non-English articles. They included 30,030 individuals with nonfatal suicidal behaviour and 4,996 individuals who had died by suicide. Of the 15 studies (5 LMIC) that scored highly on our quality assessment, prevalence estimates for psychiatric disorders ranged between 30% and 80% in suicide deaths and between 3% and 86% in those who engaged in nonfatal suicidal behaviour. There was substantial heterogeneity between study estimates. Fifty-eight percent (95% CI 46%-71%) of those who died by suicide and 45% (95% CI 30%-61%) of those who engaged in nonfatal suicidal behaviour had a psychiatric disorder. The most prevalent disorder in both fatal and nonfatal suicidal behaviour was mood disorder (25% and 21%, respectively). Schizophrenia and related disorders were identified in 8% (4%-12%) of those who died by suicide and 7% (3%-11%) of those who engaged in nonfatal suicidal behaviour. In nonfatal suicidal behaviour, anxiety disorders, and substance misuse were identified in 19% (1%-36%) and 11% (7%-16%) of individuals, respectively. This systematic review was limited by the low number of high-quality studies and restricting our searches to databases that mainly indexed English language journals.

CONCLUSIONS

Our findings suggest a possible lower prevalence of psychiatric disorders in suicidal behaviour in LMIC. We found very few high-quality studies and high levels of heterogeneity in pooled estimates of psychiatric disorder, which could reflect differing study methods or real differences. There is a clear need for more robust evidence in order for LMIC to strike the right balance between community-based and mental health focussed interventions.

Negative life events as triggers on suicide attempt in rural China: a case-crossover study

This study aims to investigate the potential triggering of negative life events (NLEs) on suicide attempt in rural China. A case-crossover design was used to study 1200 suicide attempters aged 15-70 years. NLEs were assessed by a modification of Paykel's Interview for Recent Life Events. NLEs had significant triggering effects on the day of and month of suicide attempt. Marriage/love, family/home, and friend/relationship were the types of NLEs found to trigger suicide attempt when occurring on the day and month of suicide attempt. Specifically, increased risk of suicide attempt was associated with quarreling with a partner or family member on the day and month of suicide attempt. Being disappointed in a love affair, fighting with a partner, family poverty and loss of face during the month of attempts were linked to increase odds of suicide attempt. Further, when month of suicide attempt was assigned as the case period, the impact of NLEs on suicide attempt was greater among those who were younger and without mental disorders. These findings provide knowledge of the triggering of NLEs on suicide attempt, especially among the young and those without mental disorders. Further, family conflicts should be a greater focus of attention in suicide prevention.

Stressful life events, insomnia and suicidality in a large sample of Chinese adolescents

AIMS

This study aimed to examine the associations between stressful life events, insomnia, and suicidality including suicidal ideation (SI), suicide plan (SP) and suicide attempt (SA) in a large sample of Chinese adolescents.

METHODS

A total of 11,831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior and Health Cohort were included for the analysis. Participants were sampled from 8 middle/high schools in 3 counties of Shandong, China. Participants completed a structured behavior and health questionnaire, including suicidality, demographics, depression/anxiety, stressful life events (SLEs), and insomnia in November-December 2015. A series of logistic regression models and mediation analyses were performed to examine the associations between SLEs, insomnia and suicidality.

RESULTS

The prevalence rates of overall suicidality, SI, SP and SA in the last year were 13.1%, 12.5%, 3.3%, and 1.5%, respectively. SLEs were significantly associated with overall suicidality, SI, and SP. Insomnia was an independent risk factor of suicidality and a mediator of the association between SLEs and suicidality. The total effect of SLEs on overall suicidality was 0.597 (95%CI: 0.534-0.661), including 0.457 (95%CI: 0.391-0.523) for direct effect and 0.158 (95%CI: 0.138-0.178) for indirect effect. Insomnia also mediated the associations of SLEs with SI, SP and SA, respectively.

LIMITATIONS

Causal relationship could not be concluded because this study is cross-sectional.

CONCLUSIONS

Stressful life events and insomnia are directly associated with suicidality in adolescents. The association between SLEs and suicidality is partially mediated by insomnia.

Validating the Life Events Scale for the Elderly with proxy-based data: A case-control psychological autopsy study in rural China

AIM

The present study aimed to evaluate the validity of proxy informants' reports on Life Event Scale for the Elderly (LESE) by using psychological autopsy method among rural older adults in China.

METHODS

A multistage stratified cluster sampling method was used to select research sites. Using a case-control psychological autopsy study, face-to-face interviews were carried out to collect information from 242 suicide cases and 242 living controls. We compared the intensity and number of life events to assess the validity and reliability of LESE with proxy data reported by different informants. Data from proxy respondents of the living controls were compared with data reported by the targets (gold standards). Intraclass correlation coefficients were computed to evaluate the consistency of informants. Spearman's correlation analysis was used to analyze the convergent validity and discriminate validity of the LESE.

RESULTS

The number of life events between different informants showed higher intraclass correlation coefficients values than the intensity of life events, but the results of correlation analysis was similar. The LESE was positively correlated with depression, loneliness and hopelessness, and negatively correlated with quality of life, family function and social support both in suicide cases and living controls.

CONCLUSIONS

The LESE has good convergent validity and discriminant validity. LESE is a valid instrument for measuring life events in psychological autopsy studies. We suggest using the number of life events to assess the validity and reliability with proxy data in a psychological autopsy study, which is more reliable than using the intensity of life events. Geriatr Gerontol Int 2019; 19: 547-551.

Factors associated with help-seeking behavior among medically serious attempters aged 15-54 years in rural China

Increasing help-seeking behavior was one of the effective methods for suicide prevention. However, help-seeking behavior was less explored in rural China. In this study, we aimed to analyze the factors which were associated with help-seeking behavior among medically serious suicide attempters in rural China. Subjects were 791 medically serious suicide attempters aged 15-54 years in rural China. A face-to-face interview was conducted to evaluate the age, gender, education years, marital status, occupation, religious belief, living alone, physical disease, pesticide at home, family suicide history, negative life events, social support, impulsivity, mental disorder, prior suicide act, suicide intent and suicide method for the attempters. The results supported that there were 29.2% of attempters seek help before suicide behavior, and factors that male (OR = 1.45), experiencing negative life events (OR = 1.12), impulsivity (OR = 1.05), suicide intent (OR = 0.92) and suicide by pesticide (OR = 0.68) were associated with increased help-seeking behavior. It is helpful for us to understanding the features of suicide attempters who do not seek help before suicide behavior, and we also should pay more attention on people with these factors in Chinese suicide prevention.

Association between Perceived Stressfulness of Stressful Life Events and the Suicidal Risk in Chinese Patients with Major Depressive Disorder

Background

Patients with major depressive disorder (MDD) usually have high risk of suicidality. Few studies have investigated the effects of stressful life events (SLEs) on the risk of suicide in Chinese patients who have developed MDD. This study aimed to investigate the impact of SLEs on suicidal risk in Chinese patients with MDD.

Methods

In total, 1029 patients with MDD were included from nine psychiatric hospitals to evaluate the impact of SLEs on suicidal risk. Patients fulfilling the Mini-International Neuropsychiatric Interview (MINI) criteria for MDD were included in the study. Patients were excluded if they had lifetime or current diagnoses of psychotic disorder, bipolar disorder, and alcohol or substance dependence. Depressive symptoms were assessed by the 17-item Hamilton Depression Scale (HAMD-17). The suicidal risk of MDD patients was determined by the suicide risk module of MINI. SLEs were assessed by the Life Events Scale.

Results

No gender difference was found for suicidal risk in MDD patients. Patients with suicidal risk had younger ages, lower education levels, more drinking behavior, and lower marriage rate, and fewer people had child and more severe depressive symptoms than nonsuicidal risk group. High-level perceived stressfulness (HPS) and number of SLEs that patients were exposed to were significantly greater in patients with suicidal risk than patients without. In multivariate logistic analysis, HPS of SLEs (odds ratio [OR] = 1.54, 95% confidence interval [CI]: 1.16-2.05, P = 0.003) and depressive symptoms (OR = 1.08, 95% CI: 1.05-1.11, P < 0.001) were associated with suicidal risk even after adjustment of gender, age, marriage, drinking behavior, and childless.

Conclusions

HPS of SLEs is associated with suicide risk in Chinese patients with MDD. Further suicide prevention programs targeting this risk factor are needed.

Trial Registration

ClinicalTrials.gov: NCT02023567; https://clinicaltrials.gov/ct2/show/NCT02023567?term=NCT02023567&rank=1.