Rumination and Lifetime History of Suicide Attempts

Association between rumination, suicidal ideation and suicide attempts in persons with depressive and other mood disorders and healthy controls: A systematic review and meta-analysis

INTRODUCTION

Suicidal ideation and behaviors are a leading cause of disability worldwide. Approximately 90 % of suicide completers have a diagnosable mood disorder. Extant literature reports rumination mediates functional impairment across mood disorders. Herein, we report the association between rumination and suicidality amongst persons with psychiatric disorders and healthy controls.

METHODS

Our systematic review and meta-analysis included relevant articles retrieved from Web of Science, OVID and PubMed from inception to March 20, 2024. Random effects model was used to calculate the correlation between rumination, suicidal ideation and attempt.

RESULTS

A total of 27 eligible studies were included in our systematic review and meta-analysis. Rumination (r = 0.25 [95 % CI: -0.03, 0.49]), reflection (r = 0.15 [-0.71, 0.83]) and brooding (r = 0.13 [-0.58, 0.73]) were nonsignificantly correlated with suicidal ideation in mood disorders. Suicide attempt history was significantly associated with greater odds of rumination in persons with depressive disorders (OR = 1.13 [0.42, 3.02]). In healthy controls, rumination (r = 0.30 [0.21, 0.38]), reflection (r = 0.23 [0.13, 0.32]) and brooding (r = 0.24 [0.12, 0.36]) were significantly correlated with suicidal ideation. Rumination also predicted lifetime history of suicide attempts in healthy controls (OR = 1.70 [1.16, 2.49]).

LIMITATIONS

There were inadequate sample sizes of persons with different mood and psychiatric disorders which may have underpowered our ability to detect clinically meaningful associations.

DISCUSSION

Our study reports a transdiagnostic association between measures of rumination and suicidality. Future research vistas should parse the neurobiological substrates subserving rumination and identify targeted therapies and their association with general cognition and treatment response.

Cognitive emotion regulation strategies among emerging adults with different self-harm histories

Background

Self-injurious behaviors have a high prevalence in emerging adulthood. People who engage in self-injury report more emotion regulation difficulties than their peers without self-injury. However, there is little research on how use of emotion regulation strategies varies over brief periods among emerging adults with differing self-harm histories. The current study examined variability in cognitive emotion regulation strategies between emerging adults with no self-harm, previous suicide attempts, or non-suicidal self-injury (NSSI).

Methods

Forty-one racially and ethnically diverse participants, ages 18-27, completed measures of cognitive emotion regulation once daily for one week.

Results

Data collected from 5 of these days were analyzed due to missing data on days 6 and 7. Growth curve analyses revealed differences in trajectories of rumination, acceptance, and catastrophizing, depending on self-harm histories. Specifically, participants with previous NSSI displayed increases in rumination, acceptance, and catastrophizing over time, compared to peers with a previous suicide attempt.

Limitations

The study design was limited by lack of assessment of self-harm during the daily diary, a limited assessment period of only one week, and distal time period of group classification.

Conclusions

These findings suggest that while emerging adults with NSSI histories use more emotion regulation strategies, they may need assistance in selecting when and how to use specific strategies.

Prospective Relation between Ruminative Subtypes and Suicide Ideation: Moderating Role of Problem Solving

Background

Although reflection has been characterized as a more adaptive subtype of rumination than brooding, evidence suggests that reflection is associated with suicide ideation. The present longitudinal study investigated the mediating role of hopelessness and depressive symptoms and the moderating role of problem solving in explaining why reflection may lead to suicide ideation.

Methods

Two hundred ninety-four undergraduates participated in the study and were followed up every 6 months over 18 months. Participants completed measures of brooding and reflection, hopelessness, depressive symptoms, problem solving, and suicide ideation.

Results

Results revealed that after adjusting for baseline suicide ideation, the serial mediation path from brooding (but not reflection) to suicide ideation via hopelessness and depressive symptoms was significant. Baseline reflection predicted suicide ideation 18 months later through depressive symptoms at 12 months for people average in passive problem solving, and for those low or average in active problem solving. Brooding predicted suicide ideation through depressive symptoms, regardless of problem-solving.

Conclusions

Reflection may result in suicide ideation via depressive symptoms among people with poor problem-solving skills. Clinical and theoretical implications are discussed.

Mindfulness-Based Cognitive Therapy for Preventing Suicide in Military Veterans: A Randomized Clinical Trial

Objective: This study evaluated whether Mindfulness-Based Cognitive Therapy for Preventing Suicide Behavior (MBCT-S) effectively augmented treatment-as-usual enhanced for suicide prevention (eTAU).

Methods: From December 2013 through March 2018, veterans (N = 140) at high risk for suicide were recruited mostly (88.6%) during a suicide-related inpatient admission and randomly assigned to either (1) eTAU augmented with MBCT-S or (2) eTAU only. MBCT-S began during inpatient treatment (2 individual sessions emphasizing safety planning) and continued post-discharge (8 group sessions emphasizing mindfulness skills and elaborated safety planning). Four follow-up evaluations occurred over 12 months, and primary outcomes were (1) time to suicide event and (2) number of suicide events. Secondary outcomes were time to and number of suicide attempts, proportion with acute psychiatric hospitalization, and change in suicide-related factors (eg, depression, hopelessness, suicidal ideation).

Results: Relative to eTAU, MBCT-S did not significantly delay time to suicide event (hazard ratio = 0.86; 95% CI, 0.52-1.41; P = .54), but did reduce total number of suicide events (MBCT-S: 56 events; eTAU: 92 events; incident rate ratio = 0.59; 95% CI, 0.36-0.99; P < .05). There were no significant differences in time to or number of suicide attempts. In a post hoc analysis, however, MBCT-S significantly reduced the proportion of participants attempting suicide (P < .05). MBCT-S also reduced the proportion with a psychiatric hospitalization. No significant between-group differences emerged on any suicide-related factors.

Conclusions: Adding MBCT-S to system-wide suicide prevention efforts produced mixed findings on the primary outcome (suicide events) and promising findings on other important outcomes (suicide attempts, psychiatric hospitalizations). MBCT-S should continue to be examined in future research.

Trial Registration: ClinicalTrials.gov identifier: NCT01872338.

Global and reflective rumination are related to suicide attempts among patients experiencing major depressive episodes

BACKGROUND

Recent attention has focused on the role of rumination in suicidality, with evidence indicating that rumination may be positively related to suicidal ideation. There remains disagreement on the nature of the relationship between rumination and suicide attempts, especially in major affective disorders. This study was designed to identify whether rumination is a risk factor for attempted suicide.

METHODS

A total of 309 patients with major depressive episodes were recruited for this study, including 170 patients with major depression and 139 patients with bipolar disorder. All participants were categorized into two groups based on a series of clinical assessments: suicide attempters (n = 87) and non-suicide attempters (n = 222). Rumination was evaluated with the Ruminative Responses Scale. A binary logistic regression analysis was carried out to evaluate the relationship between rumination and suicide attempts.

RESULTS

Both global ruminative levels and the two subtypes of rumination, brooding and reflection, were significantly higher in the suicide attempters than the non-suicide attempters. After controlling for age, current depression and anxiety symptoms, and episode frequency, it was found that global rumination and reflection (but not brooding) were positively associated with suicide attempts.

CONCLUSION

These results suggest that rumination may be a risk factor for suicide attempts and highlight the maladaptive nature of reflection in patients with major depressive episodes.

Thought control strategies as predictors of borderline personality disorder and suicide risk

BACKGROUND

Borderline Personality Disorder (BPD) is characterized by a pattern of instability in interpersonal relationships, affect, self-image and is marked by behavioral impulsivity including suicidal ideation and attempts. Additionally, individuals with BPD tend to engage in maladaptive ruminative thinking that is also related to suicidal ideation and attempts. Given these relations, this study aims to understand the 5 strategies of thought control (distraction, punishment, reappraisal, worry, and social control) as predictors of BPD symptoms and suicide risk.

METHODS

The sample was collected at a Southeastern University using a convenience sample of undergraduate participants. The final sample (n = 403) had an age range of 18 to 27 (M  = 19.67, SD = 1.45), was 74.4% female and 25.6% male, and was primarily Caucasian (69.7%) and African American (24.8%).

RESULTS

Results demonstrate that distraction was negatively associated with BPD and suicide risk while worry and punishment were positively associated with BPD and suicide risk across three different measures of BPD. Social control was negatively associated with suicide risk and BPD but only on one of the BPD measures. Lastly, reappraisal was positively related to BPD symptoms on two measures.

LIMITATIONS

Given the sample characteristics, there may be limitations in the generalizability of the findings.

CONCLUSIONS

The findings represent a first step towards examining thought control strategies as possible predictors of BPD symptoms and suicide that can inform clinical interventions designed to increase or decrease utilization of these specific strategies.

A multi factorial model of self-harm behaviors in Anorexia-nervosa and Bulimia-nervosa

BACKGROUND

Co-existence of eating disorders and NSSI, suicide attempts and ideations is well established yet much is not known about the personality traits and behavioral tendencies that maintain this relationship. To this date no empirical work has been produced that offers a multifactorial view on the contributing variables to the occurrence of self-harm behaviors in EDs.

METHOD

Binge eating, depression, impulsivity, ruminations and loss aversion were assessed in a sample of 93 patients diagnosed with Anorexia-Nervosa and Bulimia-Nervosa and other EDs with a history of NSSI and suicide attempts.

RESULTS

Binge eating was found to be a predictor of depression, which in turn was found to be related to NSSI frequency, suicide attempts and suicide ideations. Ruminations were found to mediate a relationship between depression and suicide ideations. Trait impulsivity predicted suicide attempts, while the attentional construct of impulsivity was associated to suicide ideations as well as attempts. Higher loss aversion was positively associated with NSSI frequency and suicide ideations.

CONCLUSION

Our findings suggest that trait and state aspects of impulsivity are related to different self-harm behaviors in EDs. Exploring these differences is potentially of great value in understanding the process of transition from suicidal ideation to suicide attempt and the process of NSSI and may assist clinicians formulate better interventions for patients with EDs at risk. Ways in which individual findings in our model correspond with previous research and future implications are discussed.

Rumination, Brooding, and Reflection: Prospective Associations with Suicide Ideation and Suicide Attempts

OBJECTIVE

Rumination is often cited as a risk factor for suicide, yet few studies of rumination have utilized clinical samples, and no studies have examined its prospective association with suicide attempts. The purpose of this study was to examine concurrent and prospective associations of brooding and reflection (the two components of rumination) with suicide ideation and suicide attempts among a high-risk clinical sample.

METHOD

Participants were 286 adolescents and young adults (77% Caucasian, 59% female) aged 13-25 seeking psychiatric emergency services. A majority (71%) were presenting with a primary complaint of suicide ideation or recent suicide attempt. Participants completed a baseline assessment at the index visit; 226 participants (79%) completed a 4-month follow-up assessment of suicidal thoughts and behaviors.

RESULTS

Brooding was associated with lifetime history of one or more suicide attempts, but not concurrent suicide ideation. Reflection was not associated with lifetime suicide attempts or concurrent suicide ideation. Furthermore, prospective associations of brooding and reflection with suicide ideation and suicide attempts were weak-to-small in magnitude and statistically nonsignificant.

CONCLUSIONS

Rumination appears to have a limited association with suicide-related outcomes within a high-risk clinical sample. Additional longitudinal studies utilizing clinical samples are critically needed to better understand these associations.

Repetitive negative thinking and suicide: a burgeoning literature with need for further exploration

Extant research has found a significant overlap between various repetitive negative thinking (RNT) patterns, such as rumination and worry, across different affective disorders implicating that the process of repetitive negative thinking is likely trans-diagnostic. Furthermore, RNT patterns at the core of psychiatric disorders associated with suicide (e.g., rumination and worry) have been found to be associated with suicide even after accounting for the disorder. A synthesis of existing literature on repetitive negative thoughts suggest that following negative emotional experiences, RNTs may lead to a sense of entrapment and hopelessness that may contribute to the onset of suicidal ideation and then facilitate the transition from thinking about suicide to making a suicide attempt by increasing an individual's capability for suicide through repetitive exposure to violent thoughts and imagery associated with suicide.

Rumination, Suicidal Ideation, and Suicide Attempts: A Meta-Analytic Review

Rumination has been implicated as a risk factor for suicidal ideation and attempts, yet the literature to date has not been synthesized. We conducted a meta-analysis of the association between rumination and both suicidal ideation and attempts to consolidate the existing literature ( k = 29). Results indicated that the relationships between global rumination ( k = 13; Hedge's g = .74, p < .001, 95% CI [.45, 1.04]), brooding ( k = 12; Hedge's g = .63, p < .001, 95% CI [.35, .90]), and reflection ( k = 12; Hedge's g = .38, p = .002, 95% CI [.10, .65]) with suicidal ideation were significant. Associations between global rumination ( k = 3; Hedge's g = .26, p < .001, 95% CI [.08, .44]) and brooding ( k = 4; Hedge's g = .47, p = .004, 95% CI [.02, .91]) and suicide attempts were significant, but reflection ( k = 4; Hedge's g = .09, p = .646, 95% CI [−.54, .72]) was unrelated. However, given the limited studies included in suicide attempt analyses—and the exclusive use of cross-sectional designs and heterogeneity with regard to samples and measures—these parameters should be taken with caution. Generally, age, gender, race/ethnicity, and year of publication were not moderators, and there was little evidence for publication bias across effects, with the exception of the effect of global rumination on suicidal ideation. Several future research directions are discussed.

Rumination, Entrapment and Suicide Ideation: A Mediational Model

Rumination has been shown to be positively associated with suicide ideation. Yet, only few studies have attempted to explain potential mediators of this association. Perceptions of entrapment are a core component of recent psychological models of suicidality and might mediate the relationship between rumination and suicide ideation. Possible mediator effects were investigated in an online sample (n = 142) and a clinical sample (n = 226) of adults receiving outpatient psychotherapy. Results demonstrated that perceptions of entrapment fully mediated the association between ruminative thinking and suicide ideation. However, the reverse relationship, where the association between entrapment and suicide ideation is mediated by ruminative thinking, was not supported. These findings suggest that the relationship between rumination and suicide ideation is explained by perceptions of entrapment. Theoretical and clinical implications are discussed. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Ruminative thinking and perceptions of entrapment are associated with suicidal ideation and suicidal behavior. Perceptions of entrapment fully mediate the association between ruminative thinking and suicide ideation. Clinically, it could be useful to incorporate perceptions of entrapment into the psychosocial risk assessment of persons contemplating suicide.

Emotional intelligence as a mediator between rumination and suicidal ideation among depressed inpatients: The moderating role of suicidal history

Suicide is a substantial public health problem, and it remains a serious cause of death in the world. Therefore, this study was designed to examine the relationships between brooding, reflection, emotional intelligence (assessed by performance-based test), and suicidal ideation; the mediation role of emotional intelligence on the relationships between brooding and reflection with suicidal ideation; and the moderating role of suicidal history on the relationships between brooding, reflection, and emotional intelligence with suicidal ideation among Iranian depressed adolescents. The study consisted of a cross-sectional sample of 202 depressed adolescent inpatients from five public hospitals in Tehran, Iran completed measures of depression, rumination, emotional intelligence, and suicide attempt history as indices of suicidal ideation. Structural Equation Modelling estimated that depressed adolescent inpatients with high levels of brooding and reflective rumination, and low levels of emotional intelligence were more likely to report suicidal ideation. Moreover, emotional intelligence partially mediated the relationships between brooding and reflective rumination with suicidal ideation. Suicidal history moderated the relationships between brooding, reflection, and emotional intelligence with suicidal ideation. These findings reinforce the importance of emotional intelligence as an influencing factor against the deleterious effects of rumination styles and suicidal ideation. The results indicate that brooding and reflection have detrimental effects on suicidal ideation in depressed inpatients.

Negative cognitive styles synergistically predict suicidal ideation in bipolar spectrum disorders: a 3-year prospective study

Rates of suicidal ideation and behavior are extremely high in bipolar spectrum disorders (BSDs). However, relatively little work has evaluated potentially synergistic relationships between cognitive and emotion-regulatory processes proposed by theoretical models of suicidality in BSDs. The present study evaluated whether negative cognitive style and subtypes of rumination would exacerbate the impact of self-criticism on suicidal ideation in a prospective study of individuals with BSDs. Seventy-two young adults with BSDs (bipolar II, bipolar NOS, or cyclothymia) completed diagnostic interviews and trait measures of self-criticism, negative cognitive style, and brooding and reflective rumination at a baseline assessment. The occurrence of suicidal ideation was assessed as part of diagnostic interviews completed every 4 months for an average of 3 years of follow-up. Negative cognitive style and reflective rumination strengthened the association between self-criticism and the prospective occurrence of suicidal ideation across follow-up. Individuals with high levels of self-criticism in conjunction with negative cognitive style or reflective rumination were most likely to experience the onset of suicidal ideation. Self-criticism may work synergistically with negative cognitive style and rumination to confer risk for suicidal ideation in bipolar spectrum disorders. These results support theoretical models of suicidality in BSDs and indicate that evaluating and understanding negative cognitive styles may help to identify individuals who are at risk of suicide.

Influence of maternal depression on children's brooding rumination: Moderation by CRHR1 TAT haplotype

There is growing evidence that brooding rumination plays a key role in the intergenerational transmission of major depressive disorder (MDD) and may be an endophenotype for depression risk. However, less is known about the mechanisms underlying this role. Therefore, the goal of the current study was to examine levels of brooding in children of mothers with a history of MDD (n = 129) compared to children of never depressed mothers (n = 126) and to determine whether the variation in a gene known to influence hypothalamic-pituitary-adrenal axis functioning--corticotropin-releasing hormone receptor 1 (CRHR1)--would moderate the link between maternal MDD and children's levels of brooding. We predicted children of mothers with a history of MDD would exhibit higher levels of brooding than children of mothers with no lifetime depression history but that this link would be stronger among children carrying no copies of the protective CRHR1 TAT haplotype. Our results supported these hypotheses and suggest that the development of brooding among children of depressed mothers, particularly children without the protective CRHR1 haplotype, may serve as an important mechanism of risk for the intergenerational transmission of depression.

The Effect of Sleep Problems on Suicidal Risk among Young Adults in the Presence of Depressive Symptoms and Cognitive Processes

We aimed to investigate the effect of sleep problems, depression, and cognitive processes on suicidal risk among 460 young adults. They completed self-report questionnaires assessing suicidal behavior, sleep quality, depressive symptoms, emotion regulation, rumination, and impulsivity. Suicidal participants exhibited higher rates of depressive symptoms, sleep problems, expressive suppression, rumination, and impulsivity. A confirmatory factor analysis model revealed pathways to suicidal risk that showed no direct pathways between sleep problems and suicidal risk. Instead, sleep was related to suicidal risk via depression and rumination, which in turn increased suicidal risk. These results suggest that addressing sleep problems will be useful in either the treatment or prevention of depressive and rumination symptoms and reduction in suicidal risk.

Brooding, Reflection, and Distraction: Relation to Non-Suicidal Self-Injury versus Suicide Attempts

The present study examined the relation between cognitive response styles (i.e., brooding, reflection, distraction) and cognitive inflexibility in differentially predicting history of non-suicidal self-injury (NSSI) only, suicide attempt (SA) only, or both (NSSI + SA). College students (N = 352) completed self-report measures of rumination, distraction, and self-harm history, a diagnostic interview, and a computerized task measuring cognitive flexibility. Brooding uniquely predicted SA-only history, while reflection uniquely predicted history of NSSI-only and NSSI + SA. Distraction was associated with lower odds of NSSI-only and NSSI + SA. Cognitive inflexibility was not significantly associated with self-harm history. Cognitive vulnerabilities may help identify individuals who are at risk for self-harm and may differentiate between NSSI and SA.

The psychology of suicidal behaviour

The causes of suicidal behaviour are not fully understood; however, this behaviour clearly results from the complex interaction of many factors. Although many risk factors have been identified, they mostly do not account for why people try to end their lives. In this Review, we describe key recent developments in theoretical, clinical, and empirical psychological science about the emergence of suicidal thoughts and behaviours, and emphasise the central importance of psychological factors. Personality and individual differences, cognitive factors, social aspects, and negative life events are key contributors to suicidal behaviour. Most people struggling with suicidal thoughts and behaviours do not receive treatment. Some evidence suggests that different forms of cognitive and behavioural therapies can reduce the risk of suicide reattempt, but hardly any evidence about factors that protect against suicide is available. The development of innovative psychological and psychosocial treatments needs urgent attention.

Gender differences in rumination: A meta-analysis

Starting in adolescence and continuing through adulthood, women are twice as likely as men to experience depression. According to the response styles theory (RST), gender differences in depression result, in part, from women's tendency to ruminate more than men. A meta-analysis was performed to evaluate gender differences in rumination in adults (k = 59; N = 14,321); additionally, an analysis of subtypes of rumination - brooding and reflection - was conducted (k = 23). Fixed effects analyses indicated that women scored higher than men in rumination (d = .24, p < .01, SEd = .02), brooding (d = .19, p < .01, SEd = .03) and reflection (d = .17, p < .01, SEd = .03); there was no evidence of heterogeneity or publication bias across studies for these effect sizes. Although statistically significant, the effect sizes for gender differences in rumination were small in magnitude. Results are discussed with respect to the RST and gender differences in depression.

Rumination and pessimistic certainty as mediators of the relation between lifetime suicide attempt history and future suicidal ideation

This study examined whether rumination and certainty about pessimistic future-event predictions (P-Certainty) would mediate the relation between lifetime suicide attempt history and future suicidal ideation. Young adults, ages 18-25 (N = 143), with a suicide attempt history (n = 32) or no previous suicide attempt history (n = 111) at baseline, were followed up 2-3 years later and completed measures of rumination, depressive symptoms, hopelessness, suicidal ideation, and pessimistic future-event certainty. Lifetime suicide attempts at baseline were associated with higher suicidal ideation at follow up, and this relation was mediated by rumination and P-Certainty. Suicide attempters may be vulnerable to later ideation due to higher levels of rumination and also certainty in their pessimistic future expectations.

Brooding rumination and risk for depressive disorders in children of depressed mothers

The goal of the current study was to examine the role of brooding rumination in children at risk for depression. We found that children of mothers with a history of major depression exhibited higher levels of brooding rumination than did children of mothers with no depression history. Examining potential mechanisms of this risk, we found no evidence for shared genetic influences (BDNF or 5-HTTLPR) or modeling of mothers' rumination. However, we did find that children with a history of prior depressive disorders exhibited higher current levels of brooding rumination than children with no depression history. Importantly, children's brooding predicted prospective onsets of new depressive episodes over a 20-month follow-up even when we statistically controlled for depressive symptom levels at the initial assessment, suggesting that the predictive effect of brooding rumination in children was not due simply to co-occurring depressive symptoms.