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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Contextualizing Black Women's Mental Health in the Twenty-First Century: Gendered Racism and Suicide-Related Behavior

Despite predictions from the Black-White and gender paradoxes in suicide risk, there has been a recent growth in suicide rates among Black women and girls that requires special attention from social and behavioral researchers. In this review, we demonstrate how and why an intersectional framework is needed to understand and contextualize Black women's mental health and suicide risk. To begin, we outline data and existing literature on Black women's mental health outcomes. Next, we provide insights from intersectional and Black feminist scholars on the uniqueness of Black womanhood and the necessity of centering racism and sexism in studies of Black women. Third, we present clear links between mental health, gendered racism experienced by Black women, and the Strong Black Woman schema which they adopt to navigate society. Fourth, and finally, we discuss practical and scholarly applications for this work. To this end, this research agenda is about advocating for the consideration of psychosocial and sociocultural factors in practice and research on suicide-related behavior.

Intimate Partner Violence, Legal Systems and Barriers for African American Women

Although many African American IPV survivors need services, they often do not access care. Hopelessness may partially explain low rates in help-seeking for this population and serve as a significant barrier to care for African American IPV survivors particularly those who have had prior legal system involvement. In a sample of 185 African American women, we first examined whether hopelessness mediated the relation between IPV and barriers to services. If such a mediation effect was found, we then would explore whether legal system involvement moderated the mediated effect of hopelessness on the relation between IPV and barriers to services. As anticipated, hopelessness partially served to explain (i.e., mediated) the relation between IPV and barriers to services. Further, this mediated effect was moderated by legal system involvement such that when legal system involvement was included as a moderator, hopelessness mediated the association between IPV and barriers to services only for those survivors who had been involved with the legal system. These results underscore the critical role of hopelessness as a barrier to accessing services for African American IPV survivors, especially those with prior involvement with the legal system. Recommendations are offered that underscore the importance of interventions that empower African American women who have survived violence instead of penalizing them.

Suicide Rates Among 5–29-Year-Old African Americans, 1990–2018

Suicide is the 10th leading cause of death across all ages in the USA, and the 2nd leading cause for ages 10–34. The rate of suicide for ages 10–34 has been increasing from 1999 to 2017 for males and females, although this time-trend varied across subpopulations defined by gender and age. This study analyzed Centers for Disease Control and Prevention (CDC) data from 1990 to 2018 on suicide among African Americans aged 5–29 years. Suicide incidence in this population was greater in older groups and in males than females. For 9 of the 10 gender/age subpopulations, the time-trend of suicide over the three decades was U-shaped—decreasing during the first decade and increasing over the last decade of the study period. The exception was the increasing trend from 1990 to 2018 for Black females in the 10–14 age-group. These results reinforce the need for analyses of the data from specific subpopulations in order to design adequate suicide prevention programs for these African American subpopulations.

Risk factors for multiple suicide attempts among Roma in Hungary

In recent years, suicide rates in Hungary have been among the highest in the European Union. Attempted suicide rates in the Roma population are 2-3 times higher than in the non-Roma population. Since individuals making multiple attempts have a higher pro-bability of eventual death by suicide, and there are limited data on suicidal behaviour of the Roma population, the aim of this study was to explore the sociodemographic and psychological background factors of multiple suicide attempts in the Hungarian Roma population. Semistructured interviews were conducted with 150 individuals admitted to hospital toxicology departments, who made suicide attempts by deliberate self-poisoning, 65 of whom were multiple attempters. Detailed information regarding the current attempt and previous suicidal acts was recorded. Patients also completed the Shortened Beck Depression, the Beck Hopelessness Questionnaire, and the Social Support Questionnaire. Independent samples t-tests were used to evaluate differences in psychological variables between the Roma ( N = 90) and non-Roma ( N = 60) groups. Stepwise linear regression and odds ratios analyses were performed to identify potential background factors of multiple suicide attempts. There was a significantly higher level of previous suicidal events among the Roma in the sample population (3.53 vs. 0.84, p < .001). Roma ethnicity was found to be a strong predictor of multiple suicide attempts. Current major depression, hopelessness, and diagnosed mood disorder were identified as significant risk factors of repeated attempts. Smoking (OR = 5.4), family history of suicide (OR = 4.9), and long-term unemployment (OR = 4.6) were additional risk factors among Roma patients. A thorough understanding of the ethnicity-specific risk factors for multiple suicide attempts could facilitate the development of effective intervention and postvention programmes.

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

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

Psychiatric heterogeneity of recent suicide attempters: A latent class analysis

Presence of, and comorbidity between, psychiatric disorders is a risk factor for suicide attempts. No study to date has used a person-centered approach to determine whether there are subgroups of attempters showing differing patterns of psychiatric disorders. This study aimed to identify psychiatric subgroups amongst recent suicide attempters (i.e., hospitalized within 24h of their attempt) and to determine whether identified classes could be differentiated in terms of important clinical correlates. Participants included 97 adult patients who were hospitalized due to a recent suicide attempt at a large Trauma 1 hospital. A structured diagnostic interview assessed a range of psychiatric disorders, and a battery of measures assessed acute and distal clinical correlates and characteristics of the current attempt. The person-centered analytic approach of latent class analysis was used to identify psychiatric diagnostic subgroups, or classes, of attempters. Three psychiatric subgroups were identified: Major Depressive Disorder, High Externalizing Disorders, and High Internalizing High Externalizing Disorders. Classes were found to significantly differ on a range of acute and distal clinical correlates, but not by demographics. Identification of psychiatric subgroups of individuals who have recently attempted suicide has important practical implications for increasing subsequent treatment utilization and tailoring treatment interventions for this population.

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.

Emergency Department Screening for Suicide and Mental Health Risk

Suicide is the second leading cause of death among youth ages 10-24. An estimated 1.5 million US adolescents receive their primary health care in the emergency department (ED); this is particularly true for low-income and minority youths who often lack a regular source of care. ED visits can provide a window of opportunity to screen and identify youths with suicide and mental health risk, triage youths based on need, and facilitate effective follow-up care. Recently developed brief therapeutic assessment approaches have demonstrated success in improving rates of follow-up care after discharge from the ED. Furthermore, there is some data supporting clinical benefits when youths receive evidence-based outpatient follow-up care. ED screening combined with effective follow-up, therefore, may provide one strategy for improving mental health and reducing health disparities in our nation. This paper reviews the context in which ED screenings occur, available tools and strategies, and evidence for the effectiveness of tested approaches.

Risk and Protective Factors for Suicidal Ideation in African American Women With a History of Sexual Violence as a Minor

Compared with other ethnic groups, African Americans have the highest rate of childhood victimization. The literature is sparse with regard to suicidal ideation among African American women with a history of sexual violence as a minor. Using survey data, this study utilized logistic regression to investigate the roles of a risk factor, criminal justice involvement, and protective factors, ethnic identity, and spiritual well-being, in experiencing suicidal ideation. Findings suggest that criminal justice involvement and the interaction of ethnic identity and spiritual well-being are important factors in understanding which African American women may be at a greater risk of experiencing suicidal ideation.

Associations between reasons for living and diminished suicide intent among African-American female suicide attempters

African-American women are at high risk for suicide ideation and suicide attempts and use emergency psychiatric services at disproportionately high rates relative to men and other ethnic groups. However, suicide death rates are low for this population. Cultural variables in the African-American community may promote resilience and prevent fatal suicidal behavior among African-American women. The present study evaluated self-reported reasons for living as a protective factor against suicidal intent and suicide attempt lethality in a sample of African-American female suicide attempters (n = 150). Regression analyses revealed that reasons for living were negatively associated with suicidal intent, even after controlling for spiritual well-being and symptoms of depression. These results indicate that the ability to generate and contemplate reasons for valuing life may serve as a protective characteristic against life-threatening suicidal behavior among African-American women. Implications for research and clinical practice are further discussed.

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

INTRODUCTION

Individuals with multiple versus single suicide attempts present a more severe clinical picture and may be at greater risk for suicide. Yet group differences within military samples have been vastly understudied.

PURPOSE

The objective is to determine demographic, diagnostic, and psychosocial differences, based on suicide attempt status, among military inpatients admitted for suicide-related events.

METHOD

A retrospective chart review design was used with a total of 423 randomly selected medical records of psychiatric admissions to a military hospital from 2001 to 2006.

RESULTS

Chi-square analyses indicated that individuals with multiple versus single suicide attempts were significantly more likely to have documented childhood sexual abuse (p =.025); problem substance use (p=.001); mood disorder diagnosis (p=.005); substance disorder diagnosis (p =.050); personality disorder not otherwise specified diagnosis (p =.018); and Axis II traits or diagnosis (p=.038) when compared to those with a single attempt history. Logistic regression analyses showed that males with multiple suicide attempts were more likely to have problem substance use (p=.005) and a mood disorder diagnosis (p =.002), while females with a multiple attempt history were more likely to have a history of childhood sexual (p =.027).

DISCUSSION

Clinically meaningful differences among military inpatients with single versus multiple suicide attempts exist. Targeted Department of Defense suicide prevention and intervention efforts that address the unique needs of these two specific at-risk subgroups are additionally needed.

Suicide reattempters: a systematic review

The aim of this study is to identify the characteristic features of suicide reattempters. The recognition of the suicide reattempters population as a distinct clinical population may encourage future preventive and clinical work with this high-risk subgroup and thus reduce deaths. A systematic literature review was carried out in order to identify the key demographic, psychological, and clinical variables associated with the repetition of suicide attempts. In addition, we wished to analyze the operational definitions of the repetition of suicide attempts proposed in the scientific literature. Studies published from 2000 to 2012 were identified in PubMed, PsycINFO, and Web of Science databases and were selected according to predetermined criteria. We examined a total of 1480 articles and selected 86 that matched our search criteria. The literature is heterogeneous, with no consensus regarding the operational definitions of suicide reattempters. Comparison groups in the literature have also been inconsistent and include subjects making a single lifetime attempt and subjects who did not reattempt during a defined study period. Suicide reattempters were associated with higher rates of the following characteristics: unemployment, unmarried status, diagnosis of mental disorders, suicidal ideation, stressful life events, and family history of suicidal behavior. Additional research is needed to establish adequate differentiation and effective treatment plans for this population.

Correlates of proximal premeditation among recently hospitalized suicide attempters

BACKGROUND

Different conceptualizations of an impulsive suicide attempt (ISA) have not been studied systematically and there is no standard assessment of an ISA. This lack of clarity hinders the advancement of suicidological research and knowledge. The aim of the current study was to examine clinical correlates of different facets of an ISA (reduced proximal contemplation, planning, and decision to act) across divergent methodologies.

METHODS

Participants included 212 recent suicide attempters presenting to a Level 1 trauma hospital. The Suicide Intent Scale and the Timeline Follow-Back Interview for suicide attempts were used to assess different facets of an ISA and their associations with other attempt characteristics, and proximal and distal clinical correlates.

RESULTS

A large percentage of patients had an ISA using facets of varying severity (ranging from 42% [contemplation] to 85% [decision]). Multivariate analyses revealed unique associations between a particular ISA facet and the following: hopelessness and depressive symptoms (contemplation), subjective expectation of fatality (planning), and acute negative life events (decision).

LIMITATIONS

Validated self-report screening measures were used to assess current psychopathology and future studies should include structured interviews to assess diagnostic features.

CONCLUSIONS

Our results suggest that a fine-grained approach is needed for furthering our understanding of the ISA construct. In light of the current findings, ISA should be seriously considered given clinicians' task of determining whether a particular patient is at imminent risk for suicide.

Depressive characteristics of adult psychiatric inpatients with a history of multiple versus one or no suicide attempts

BACKGROUND

A growing body of research suggests that individuals with a history of multiple suicide attempts exhibit more severe psychopathology than individuals with only one or no previous suicide attempts. Given the strong link between diagnoses of major depression and suicide risk, our primary goal was to determine which specific depressive characteristics differentiate multiple attempters from patients with one or no previous attempts.

METHODS

Participants were 121 depressed adult psychiatric inpatients. Participants were administered diagnostic interviews to assess the course and characteristics of their depression history as well as measures of suicidal ideation, suicide attempts, depressive symptoms, hopelessness, and dysfunctional attitudes.

RESULTS

Patients with a history of multiple suicide attempts exhibited higher levels of suicidal ideation and depressive symptoms, but not hopelessness or dysfunctional attitudes, than the other two groups. In addition, multiple attempters reported an earlier age of major depression onset.

CONCLUSIONS

The current results add to a growing body of research suggesting that multiple attempters may represent a distinct patient population.

Assessing the wish to die: a 30-year review of the suicide intent scale

This analysis drew from decades of published research to evaluate the Suicide Intent Scale (SIS), the dominant research tool for assessing intent to die in apparent suicide attempts. The review sought to 1) synthesize findings related to the scale's normative scores, reliability, and validity (factorial, convergent, and predictive), and 2) examine the objective and subjective subscales' performance. A literature search yielded 158 studies reporting findings for the SIS. Psychometric properties were summarized. Studies supported the scale's reliability, especially that of the subscale assessing self-reported (versus circumstantial indicators) of intent. Mixed findings emerged regarding convergent and predictive validity. The review identified shortcomings in factorial validity and the subscales' performance, especially for adolescents. The Suicide Intent Scale has some strengths, but the weaknesses require further investigation into how to better measure intent to die in attempted suicide.

Suicide attempt characteristics, diagnoses, and future attempts: comparing multiple attempters to single attempters and ideators

OBJECTIVE

To compare psychiatric diagnoses and future suicide attempt outcomes of multiple attempters (MAs), single attempters (SAs), and ideators.

METHOD

Two hundred twenty-eight teens who reported recent ideation or a lifetime suicide attempt in a screening of 1,729 high school students completed the Adolescent Suicide Interview, which provided information on attempt number and characteristics and mood, anxiety, and substance use disorder modules of the Diagnostic Interview Schedule for Children; 191 were reinterviewed 4 to 6 years later to ascertain interval attempts and psychiatric disorder. Between screening and follow-up, 33 (17%) teens made an attempt, 12 of whom were previously classified as lifetime MAs (more than one attempt) and six as SAs.

RESULTS

MAs more often met criteria for any one of the DSM diagnoses assessed at baseline (mood, anxiety, or substance use disorder; 71%), compared with SAs (39%) and ideators (41%), and at follow-up (mood, anxiety, substance use, or disruptive behavior disorder; 69%) compared with SAs (36%) (p <.05). As reported at baseline, MAs (versus SAs) more often wished to die during their attempt (53% versus 23%), less often planned their attempt for intervention (44% versus 76%), and more often regretted recovery (26% versus 7%; p <.05). Baseline MAs had significantly higher odds of making a later attempt compared to ideators (odds ratio 4.0, 95% confidence interval 1.5-10.2) and SAs (odds ratio 4.6, 95% confidence interval 1.0-20.2). No participants committed suicide during follow-up. SAs who made another attempt (versus those who did not) more often met criteria for a baseline anxiety disorder and more often wished to die during their baseline attempt.

CONCLUSIONS

MAs more strongly predict later suicidality and diagnosis than SAs and ideation. Forms that assess past suicide attempts should routinely inquire about frequency of attempts. The similarity between the present findings and those of clinical samples suggests that screening may yield a representative sample of suicide attempters and ideators.

A re-examination of cultural factors that mitigate risk and promote resilience in relation to African American suicide: a review of the literature and recommendations for future research

Suicide among African Americans has been acknowledged by the U.S. Surgeon General as a growing crisis. However, suicide remains understudied in this population. In this article, the authors examine the literature related to cultural protective factors that buffer African Americans from suicide risk. They present an overview of suicide among African Americans, review the culture and world-view of African Americans, and examine the degree to which these cultural variables protect against suicide risk. Finally, they discuss the limitations of the extant research on African American suicide, set an agenda for future research, and discuss its implications for clinical practice and public policy.