An unmatched case-control study of nearly lethal suicide attempts in Houston, Texas: research methods and measurements

Personal, Criminal and Social Predictors of Suicide Attempts in Prison

Previous epidemiological analyses indicate that specific demographic and criminal factors might be associated with suicide attempts during incarceration. However, there is a relative lack of research examining the role of social variables such as perceived social support. Data from 943 male inmates enrolled from three correctional facilities in Spain were collected. Participants completed self-report measures of the demographic, penitentiary and sentence-related, social support and suicide attempts variables. Approximately 1 in 11 inmates indicated that they had attempted suicide during incarceration. Inmates who were 50 years or above and who were serving longer sentences were significantly more likely to attempt suicide. Perceived social support was not associated with suicide attempts. These characteristics might be included in the development of intervention programs for incarcerated individuals.

Exploring suicidal behaviours by probation clients-a qualitative near-lethal study

Background

Existing research emphasizes that offenders serving community based sentences are at an increased risk of suicide compared with the general population, however, there is little understanding about the causes of this risk. The aim of the current research was to understand how to support probation clients and prevent suicide, by exploring the experiences of probation clients who carried out near-lethal suicide attempts whilst under probation supervision.

Methods

In-depth interviews were carried out with seven probation clients who made near-lethal suicide attempts whilst serving a probation sentence. Data were analysed using Interpretative Phenomenological Analysis.

Results

Participants recounted negative experiences which they perceived to be linked to their suicidal feelings and behaviours, such as experiencing bereavements, perceived loss of control over their mental state or situation, and difficulties relating to stages of their probation sentence. Participants expressed severe difficulties with trusting authorities, making disclosure of suicidal feelings problematic. However, participants emphasized the role that purposeful and meaningful activity can play in suicide prevention.

Conclusions

Suicide prevention strategies must be tailored to the needs of probation clients across the UK. Mandatory training for probation staff is recommended to help reduce suicides, and support from external agencies should be sought where possible.

Associations between childhood abuse, mental health problems, and suicide risk among male prison populations in Spain

BACKGROUND

There are few studies exploring associations between different types of childhood abuse and mental health problems among adult prisoners.

AIMS

To explore associations between history of childhood abuse, depression or anxiety, and near-lethal suicide attempts among adult prisoners, and test the hypothesis that post-traumatic stress disorder (PTSD) may be a mediator between childhood abuse and adult disorder among prisoners.

METHOD

We enrolled 943 men from three prisons in Spain. Childhood abuse was assessed with the Childhood Trauma Questionnaire at interview and current symptoms were assessed using the 21-item Depression Anxiety and Stress Scale (DASS-21). Self-reported histories of near-lethal suicide attempts were recorded.

RESULTS

Overall, 360 (40%) of the men reported at least one type of childhood abuse; 231 (24.5%) described exposure to emotional abuse, 236 (25%) to physical abuse, and 97 (10%) to sexual abuse. Survivors of all types of childhood abuse had over twice the prevalence of severe depression, anxiety, stress disorder, and near-lethal suicide attempts than men who had not been exposed. Survivors of sexual and emotional violence during childhood had more symptoms of PTSD than survivors of physical abuse. Statistically, PTSD had a mediating effect, but it was very small.

CONCLUSIONS

Although other studies have shown high rates of childhood abuse histories among prisoners, this is the first to link such a history to near-lethal suicide attempts in this population.

Risk Factors Associated With Near-Lethal Suicide Attempts During Incarceration Among Men in the Spanish Prison System

Studies conducted worldwide indicate that near-lethal suicide attempts are common among incarcerated populations. However, little research attention has been focused on the Spanish prison population. To address this gap in the literature, data were drawn from a sample of men ( N = 2,270) incarcerated in seven prisons in Spain. We compared sociodemographic, criminal/offense, health and mental health, and life events in prison variables between inmates who reported making near-lethal suicide attempts ( n = 616) and those who did not ( n = 1,654) during their current incarceration term. A series of binary and multiple logistic regression analyses indicated that a variety of variables were associated ( p values < .001) with near-lethal suicide attempts, including prior-to-prison employment status, family members in prison, recidivist in prison, childhood trauma, work status in prison, and disciplinary infractions. Our study findings are discussed in light of developing more effective strategies and prevention interventions to reduce attempted suicide in the Spanish Prison System.

Serious Suicide Attempts: Systematic Review of Psychological Risk Factors

BACKGROUND

One of the main obstacles in studying suicide risk factors is the difference between cases in which the individual died by suicide and those in which the individual engaged in suicidal behavior. A promising strategy that overcomes this obstacle is the study of survivors of serious suicide attempt (SSA), i.e., an attempt that would have been lethal had it not been for the provision of rapid and effective emergency treatment. Serious suicide attempters are epidemiologically very much like those who died by suicide, and thus may serve as valid proxies for studying suicides. This paper aims to define the specific risk factors for SSAs by conducting a qualitative data synthesis of existing studies.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic search of the literature in PubMed, ProQuest, and Psychlit electronic research-literature databases. Search terms were "serious" "OR" "near lethal," combined with the Boolean "AND" operator with "suicide*." In addition, we performed a manual search on Google Scholar for further studies not yet identified.

RESULTS

The preliminary search identified 683 citations. A total of 39 research reports that met the predefined criteria were analyzed. Mental pain, communication difficulties, decision-making impulsivity, and aggression, as well as several demographic variables, were found to be major risk factors for SSAs.

LIMITATIONS

We found a variability of definitions for SSA that hamper the ability to draw a model for the risk factors and processes that facilitate it. Moreover, the role of suicide intent and planning in SSA is still unclear. Further studies should aim to clarify and refine the concepts and measures of SSA, thereby enabling more specific and concrete modeling of the psychological element in its formation.

CONCLUSION

SSA is a distinguishable phenomenon that needs to be addressed specifically within the scope of suicidal behavior. Interpersonal problems, as well as impulsivity and aggression, seem to facilitate SSA when mental pain serves as a secondary factor. Healthcare professionals should be aware of SSA, and familiar with its specific risk factors. Moreover, psychological and suicidal risk assessment should include a designated evaluation of these risk factors as part of intervention and prevention models for SSA.

Serious Suicide Attempts

BACKGROUND

Suicidal behavior comprises a diverse set of behaviors with significant differences among several behavioral categories. One noteworthy category includes individuals who have made serious suicide attempts, epidemiologically very similar to those completing suicide. This behavioral category is important, since interviewing survivors of a potentially lethal incident of self-harm enables a detailed investigation of the psychological process leading to the suicidal act.

AIM

To achieve a consensus definition and operational criteria of serious suicide attempts.

METHOD

We reviewed studies that included the term serious suicide attempt or related terms (e.g., highly lethal), with a focus on the variety of operational criteria employed across studies.

RESULTS

More than 60 papers addressing various types of serious suicide attempt were explored. We found a large variety of operational definitions, reflecting the lack of consensus regarding terminology and criteria related to the term.

CONCLUSION

We undertook the challenge of developing an integrative and comprehensive set of criteria of serious suicide attempt and suggest a definition comprising three key dimensions: medical lethality, potential lethality of the method used, and severity of the objective circumstances of the suicide intent. Clinicians and researchers are strongly encouraged to consider using the term serious suicide attempt with its attendant components.

Time trends in medically serious suicide-related behaviours in boys and girls

OBJECTIVE

To determine whether emergency department (ED) presentations for suicide-related behaviours (SRBs) in boys and girls were identified as more clinically acute in the ED in the period after the regulatory warnings against prescribing antidepressants and during the global economic recession, and to characterize the medical severity of SRBs among boys and girls to aid surveillance activities.

METHOD

Among Ontario boys and girls (aged 12 to 17 years) presenting to the ED with an incident (index) ED SRB event between fiscal years (FYs) 2002 to 2010, we compared the number of high (compared with lower) acuity events in FYs 2005 to 2010 to those in FYs 2002 to 2004. We described the SRB method by its acuity and tested the linearity of varying trends in the SRB method in boys and girls.

RESULTS

In both boys and girls, high acuity events were 50% greater after FY 2004 than before, regardless of subsequent admission, and most common among boys and girls who self-poisoned. In girls, opposing linear trends before and after FY 2004 were observed in the proportion of self-poisonings and cut (or) pierce SRB methods. Throughout the study period, there was a linear decline in the proportion of boys presenting to the ED with other methods.

CONCLUSIONS

The previously reported increase in hospital admissions after the warnings and during the recession is unlikely artifactual. An equivalent increase in high acuity events was also evident among those not subsequently admitted. The reasons for varying responses in boys and girls by SRB method warrant further study.

A Typology of Male Prisoners Making Near-Lethal Suicide Attempts

Background: Prisoners are at high risk of suicide. Aims: This study aimed to develop a typology of prison suicide. Method: We interviewed 60 male prisoners who made near-lethal suicide attempts in prison to obtain quantitative and qualitative data regarding psychiatric, psychological, social, and criminological factors. We analyzed this information to develop a typology to classify suicidal prisoners and validated it by having a prison psychiatrist independently rate each interview transcript. Results: We developed a typology of five subgroups: attempts that (1) were due to a prisoner being unable to cope in prison, (2) were motivated by psychotic symptoms, (3) had instrumental motives, (4) were ”unexpected” by the prisoners themselves, and (5) were associated with withdrawal from drugs. The interrater reliability as measured by Cohen’s was good to excellent at 0.81 (p < .001), 95% CI (0.69, 0.93). Conclusion: With further validation in other samples, this typology may assist suicide prevention initiatives in prisons as well as other forensic institutions by informing the assessment and formulation of suicide risk.

Psychosocial characteristics and social networks of suicidal prisoners: towards a model of suicidal behaviour in detention

Prisoners are at increased risk of suicide. Investigation of both individual and environmental risk factors may assist in developing suicide prevention policies for prisoners and other high-risk populations. We conducted a matched case-control interview study with 60 male prisoners who had made near-lethal suicide attempts in prison (cases) and 60 male prisoners who had not (controls). We compared levels of depression, hopelessness, self-esteem, impulsivity, aggression, hostility, childhood abuse, life events (including events occurring in prison), social support, and social networks in univariate and multivariate models. A range of psychosocial factors was associated with near-lethal self-harm in prisoners. Compared with controls, cases reported higher levels of depression, hopelessness, impulsivity, and aggression, and lower levels of self-esteem and social support (all p values <0.001). Adverse life events and criminal history factors were also associated with near-lethal self-harm, especially having a prior prison spell and having been bullied in prison, both of which remained significant in multivariate analyses. The findings support a model of suicidal behaviour in prisoners that incorporates imported vulnerability factors, clinical factors, and prison experiences, and underscores their interaction. Strategies to reduce self-harm and suicide in prisoners should include attention to such factors.

Medically serious versus non-serious suicide attempts: relationships of lethality and intent to clinical and interpersonal characteristics

BACKGROUND

The study of near-fatal suicide attempts may provide insight into the minds of suicidal subjects. The aim of the study was to investigate the relationship of intent and lethality in medically serious and medically non-serious suicide attempts and to examine relationship of specific psychological and clinical variables with the subjective and objective components of suicide intent.

METHODS

The study group included 102 participants, 35 consecutive subjects hospitalized for a medically serious suicide attempt and 67 subjects who presented to the same tertiary medical center after a medically non-serious suicide attempt. All were interviewed with the SCID-I and completed the Suicide Intent Scale (SIS), the Lethality Rating Scale, and instruments measuring mental pain and communication difficulties.

RESULTS

Patients who made medically serious suicide attempts had higher total SIS score and higher objective and subjective subscale scores. The objective component of the SIS was highly correlated with the lethality of the suicide attempt and communication difficulties; the subjective component was associated with mental pain variables. The interaction of mental pain and communication difficulties was predictive of the severity of the objective suicide intent.

LIMITATIONS

Relatively small number of patients with medically serious suicide attempt and the relatively large number of questionnaires which may to some extent have diminished informant reliability.

CONCLUSIONS

Suicidal individuals with depression and hopelessness who cannot signal their pain to others are at high risk of committing a medically serious suicide attempts.

Impact on prisoners of participating in research interviews related to near-lethal suicide attempts

BACKGROUND

Prisoners have a high risk of suicide. Research studies have investigated factors contributing to this, some through interviews with survivors of suicide attempts, others with informants such as family and friends of suicide victims. However, there is little information regarding the effects of participating in such interviews.

AIMS

To investigate the effects on participants of taking part in detailed interviews about suicidal behaviour and contributory factors.

METHOD

Case-control studies of 120 prisoners who made near-lethal suicide attempts (cases) and 120 prisoners who had never carried out near-lethal suicide attempts in prison (controls) were conducted. Information regarding effects on prisoners of participating in the interviews was collected using quantitative and qualitative methods.

RESULTS

For both male cases and controls, and female controls, self-reported mood levels improved significantly by the end of the interviews. For female cases, the interviews had no negative effect on their self-reported mood. Whilst some prisoners found the interviews upsetting, nearly all said they were pleased to have participated.

LIMITATIONS

The same researchers carried out the interviews and collected data on the effects of participation. Also, several potential participants were excluded from the study and the likely effect of the interview on them is unknown.

CONCLUSIONS

We found little evidence that participation of prisoners in interview-based research on suicidal behaviour has negative effects on them; indeed, it can be beneficial. Inclusion of similar instruments to measure the effects of research participation in future investigations could provide valuable feedback to researchers and ethics committees.

Factors influencing the decision to use hanging as a method of suicide: qualitative study

BACKGROUND

Hanging is the most frequently used method of suicide in the UK and has high case fatality (>70%).

AIMS

To explore factors influencing the decision to use hanging.

METHOD

Semi-structured qualitative interviews with 12 men and 10 women who had survived a near-fatal suicide attempt. Eight respondents had attempted hanging. Data were analysed thematically and with constant comparison.

RESULTS

Hanging was adopted or contemplated for two main reasons: the anticipated nature of a death from hanging; and accessibility. Those favouring hanging anticipated a certain, rapid and painless death with little awareness of dying and believed it was a 'clean' method that would not damage the body or leave harrowing images for others. Materials for hanging were easily accessed and respondents considered it 'simple' to perform without the need for planning or technical knowledge. Hanging was thus seen as the 'quickest' and 'easiest' method with few barriers to completion and sometimes adopted despite not being a first choice. Respondents who rejected hanging recognised it could be slow, painful and 'messy', and thought technical knowledge was needed for implementation.

CONCLUSIONS

Prevention strategies should focus on countering perceptions of hanging as a clean, painless and rapid method that is easily implemented. However, care is needed in the delivery of such messages as some individuals could gain information that might facilitate fatal implementation. Detailed research needs to focus on developing and evaluating interventions that can manage this tension.

Psychiatric disorders in male prisoners who made near-lethal suicide attempts: case-control study

BACKGROUND

Although male prisoners are five times more likely to die by suicide than men of a similar age in the general population, the contribution of psychiatric disorders is not known.

AIMS

To investigate the association of psychiatric disorders with near-lethal suicide attempts in male prisoners.

METHOD

A matched case-control study of 60 male prisoners who made near-lethal suicide attempts (cases) and 60 prisoners who had never carried out near-lethal suicide attempts in prison (controls) was conducted. Psychiatric disorders were identified with the Mini International Neuropsychiatric Interview (MINI), and information on sociodemographic characteristics and criminal history was gathered using a semi-structured interview.

RESULTS

Psychiatric disorders were present in all cases and 62% of controls. Most current psychiatric disorders were associated with near-lethal suicide attempts, including major depression (odds ratio (OR) = 42.0, 95% CI 5.8-305), psychosis (OR = 15.0, 95% CI 2.0-113), anxiety disorders (OR = 6.0, 95% CI 2.3-15.5) and drug misuse (OR = 2.9, 95% CI 1.3-6.4). Lifetime psychiatric disorders associated with near-lethal attempts included recurrent depression and psychoses. Although cases were more likely than controls to meet criteria for antisocial personality disorder, the difference was not statistically significant. Comorbidity was also significantly more common among cases than controls for both current and lifetime disorders.

CONCLUSIONS

In male prisoners, psychiatric disorders, especially depression, psychosis, anxiety and drug misuse, are associated with near-lethal suicide attempts, and hence probably with suicide.

Drinking to cope as a statistical mediator in the relationship between suicidal ideation and alcohol outcomes among underage college drinkers

Etiological models of alcohol use that highlight the role of negative affect and depression have not been applied to the association of suicidality and alcohol use. The authors examined whether a motivational model of alcohol use could be applied to understand the relationship between suicidal ideation and alcohol outcomes in a sample of underage college drinkers who had a history of passive suicidal ideation (n = 91). In this cross-sectional study, regression analyses were conducted to examine whether drinking to cope with negative affect statistically mediated or was an intervening variable in the association between suicidal ideation and alcohol outcomes. Results revealed that drinking to cope was a significant intervening variable in the relationships between suicidal ideation and alcohol consumption, heavy episodic drinking, and alcohol problems, even while controlling for depression. These results suggest that the relationship between suicidal ideation and alcohol outcomes may be due to individuals using alcohol to regulate or escape the distress associated with suicidal ideation. Consideration of alcohol-related models can improve the conceptualization of research on suicidality and alcohol use.

Emergency department visits for suicidality in three hospitals

The purposes of this study were to describe suicidal persons who come to the emergency department (ED) and to examine the relationship between clinical and health service characteristics and decisions regarding post-ED care. Data were collected from three hospital EDs by means of a retrospective review of records. During the 1-month study period, 163 ED visits were for suicidal ideation (f = 110) or behavior (f = 53). The mean age of the patients was 36.5 years (range = 5-87 years); 51% were female patients. Clinical decisions about post-ED care tended to be cautious, regardless of a patient's level of suicidality, with 71% of patients either transferred for psychiatric evaluation or admitted to the psychiatric unit. Emergency department staff tended to be slightly more conservative than mental health professionals, but the difference in their decisions about disposition was not significant.

Involvement in physical activity and risk for nearly lethal suicide attempts

BACKGROUND

Although substantial research suggests that involvement in physical activity is associated with mental health benefits, relatively little is known about the association between physical activity and suicidal behavior. This study compared reports of recent physical activity among those surviving a nearly lethal suicide attempt to reports from community controls.

METHODS

Analyses were conducted on data collected between November 1992 and July 1995 for a population-based, case-control study of nearly lethal suicide attempts among people aged 13 to 34 years. Logistic regression analyses were used to test the association between suicide attempts and physical activity, including the intensity, frequency, and duration of activity, while controlling for demographic factors and potential explanatory variables, such as depression, alcoholism, and the presence of a serious medical condition.

RESULTS

Suicide attempters were far less likely than controls to report involvement in physical activity in the past month (48% vs 85%, respectively). Intensity, frequency, and duration of activity did not affect this association. The association persisted after adjusting for demographics and potential explanatory variables.

CONCLUSIONS

Additional research is needed to explain the process through which the association occurs. The strong protective association observed is consistent with other research on the mental health benefits of physical activity and recommendations of involvement in regular physical activity.

If suicide is a public health problem, what are we doing to prevent it?

Although not a disease, suicide is a tragic endpoint of complex etiology and a leading cause of death worldwide. Just as preventing heart disease once meant that specialists treated myocardial infarctions in emergency care settings, in the past decade, suicide prevention has been viewed as the responsibility of mental health professionals within clinical settings. By contrast, over the past 50 years, population-based risk reduction approaches have been used with varying levels of effectiveness to prevent morbidity and mortality associated with heart disease. We examined whether the current urgency to develop effective interventions for suicide prevention can benefit from an understanding of the evolution of population-based strategies to prevent heart disease.