Suicidal people. One population or two?

The role of perceived social norms in non-suicidal self-injury and suicidality: A systematic scoping review

Social norms are an important influence on health-related behaviours and intention formation. As both suicidal behaviour and non-suicidal self-injury (NSSI) can be motivated by intentions, perceived social norms may have an important role in suicide and NSSI outcomes, although no existing reviews of this association exist. Following the PRISMA Scoping Review extension guidance, a scoping review based on systematic searches of key databases was conducted to identify published English language studies investigating the role of perceived social norms in suicidality and NSSI. Information regarding the types of social norms studied, their relationship to suicidality/NSSI outcomes, study samples and designs was charted. Thirty-six eligible studies (31 quantitative, 4 qualitative, 1 mixed methods) sampling various populations across mostly non-clinical settings were identified and narratively synthesised. Studies varied in how social norms were operationalised, measured, and investigated/explored. Most studies focused on the role of conformity to perceived masculine social norms or to some form of subjective, descriptive, or injunctive norms; there were limited studies on female/feminine norms, pro-social/protective norms, or broader gender/sexuality norms. Most studies (n = 31) were cross-sectional (quantitative) in design, few were based on existing theories of suicide/NSSI or social norms, and none concurrently tested theories of social norms and NSSI/suicidality. Perceived social norms and stronger conformity to norms were generally associated with worse NSSI/suicidality, although some pro-social norms appeared to be protective (e.g., perceived parental norms for adolescents). Whilst conformity to restrictive perceived social norms may be related to poorer suicide and NSSI outcomes, there is a lack of consistency in the literature in how social norms are defined and measured, a lack of theory-based hypothesis testing, and few longitudinal studies. There is a need for more nuanced, theory-based, investigations of how, when, where, why, and for whom, perceived norms have a causal role in NSSI and suicidality outcomes.

Comparison of the factors for suicidal ideation and suicide attempt: a comprehensive examination of stress, view of life, mental health, and alcohol use

This study was performed to examine the elements that cause suicidal ideation to develop into a suicide attempt by comparing the factors related to suicidal ideation and attempt. The subjects in the study were 5982 employees, who received mental health screening from January 2016 to December 2019 in Korea. Multivariate binary logistic regression analysis was performed with suicidal ideation and suicide attempt as dependent variables respectively. While suicidal ideation was associated with both moderate and severe grades of depression and alcohol consumption, only severe grades of depression and alcohol consumption were associated with suicide attempts. Among family, interpersonal, work-related, and financial stress, which were significant predictors of suicidal ideation, only family stress predicted suicide attempts. Whereas dissatisfaction with the present, regret for the past, and hopelessness for the future were all predictors for suicidal ideation, only regret for the past was a significant predictor of suicide attempts. The distinctive impact of family stress on suicide attempts suggests that family support can play a pivotal role in suicide prevention, and the significant impact of regret for the past on suicide attempts indicates the need for a cognitive approach in a high-risk population. Finally, the substantial impact of alcohol on suicide attempts compared to suicidal ideation suggests the importance of alcohol regulation in suicide prevention.

Risk of Self-harm in Children and Adults With Autism Spectrum Disorder: A Systematic Review and Meta-analysis

IMPORTANCE

Multiple studies have reported that people with autism spectrum disorder (ASD) are at a higher risk for self-injurious behavior and suicide. However, the magnitude of this association varies between studies.

OBJECTIVE

To appraise the available epidemiologic studies on the risk of self-injurious behavior and suicidality among children and adults with ASD.

DATA SOURCES

PubMed, Embase, CINAHL, PsycINFO, and Web of Science were systematically searched for epidemiologic studies on the association between ASD and self-injurious behavior and suicidality. Databases were searched from year of inception to April through June 2020. No language, age, or date restrictions were applied.

STUDY SELECTION

This systematic review and meta-analysis included studies with an observational design and compared self-injurious behavior (defined as nonaccidental behavior resulting in self-inflicted physical injury but without intent of suicide or sexual arousal) and/or suicidality (defined as suicidal ideation, suicide attempt, or suicide) in children (aged <20 years) or adults (aged ≥20 years) with ASD.

DATA EXTRACTION AND SYNTHESIS

Information on study design, study population, ASD and self-harm definitions, and outcomes were extracted by independent investigators. Study quality was assessed using the Newcastle-Ottawa Scale. Overall summary odds ratios (ORs) and 95% CIs were estimated using DerSimonian-Laird random-effects models.

MAIN OUTCOMES AND MEASURES

The ORs for the associations of ASD with self-injurious behavior and suicidality were calculated. Analyses were stratified by study setting and age groups as planned a priori.

RESULTS

The search identified 31 eligible studies, which were of moderate to high quality. Of these studies, 16 (52%) were conducted in children, 13 (42%) in adults, and 2 (6%) in both children and adults. Seventeen studies assessed the association between ASD and self-injurious behavior and reported ORs that ranged from 1.21 to 18.76, resulting in a pooled OR of 3.18 (95% CI, 2.45-4.12). Sixteen studies assessed the association between ASD and suicidality and reported ORs that ranged from 0.86 to 11.10, resulting in a pooled OR of 3.32 (95% CI, 2.60-4.24). In stratified analyses, results were consistent between clinical and nonclinical settings and between children and adults.

CONCLUSIONS AND RELEVANCE

This study found that ASD was associated with a substantial increase in odds of self-injurious behavior and suicidality in children and adults. Further research is needed to examine the role of primary care screenings, increased access to preventive mental health services, and lethal means counseling in reducing self-harm in this population.

Das Verstärkermodell der Suizidalität: Chronische Suizidalität bei der Borderline-Persönlichkeitsstörung verstehen und behandeln

Trotz großer Fortschritte in der evidenzbasierten Psychotherapie wird unser Versorgungssystem durch chronisch suizidale Patienten mit einer Borderline-Persönlichkeitsstörung (BPS) weiterhin stark herausgefordert. Die BPS ist mit einem hohen Suizidrisiko von 5–10% sowie einem hohen Selbstverletzungsrisiko von bis zu 80% behaftet. Therapeuten wie Angehörige fühlen sich oft überfordert und hilflos, wenn sie mit der Suizidalität der Patienten konfrontiert sind. Immer wieder kommt es so zu Therapieabbrüchen, Vorstellungen in Notaufnahmen oder akut-psychiatrischen Einweisungen. Bei der nichtsuizidalen Selbstverletzung (NSSV) – einem Verhaltensmuster, das gehäuft zusammen mit chronischer Suizidalität bei BPS auftritt – tragen Verstärkermechanismen (z.B. Nachlassen von Anspannung) dazu bei, dass sich Borderline-Patienten trotz längerfristig unangenehmen Folgen immer wieder selbst verletzen. Die Motive für NSSV und suizidales Verhalten können sehr unterschiedlich sein. Es spricht jedoch einiges dafür, dass die zugrunde liegenden Mechanismen ähnlich sind und sich hieraus wichtige therapeutische Interventionsmöglichkeiten ableiten lassen. In dieser Übersichtsarbeit werden die Hintergründe und Unterschiede von NSSV, Suizidideationen sowie Suizidversuchen bei chronisch suizidalen Borderline-Patienten dargestellt. Neuere Erkenntnisse der modernen Neuro- und Verhaltenswissenschaft werden in ein Verstärkermodell der Suizidalität integriert, von dem verhaltenstherapeutische Interventionen abgeleitet werden, die Therapeuten in ihrer Arbeit mit chronisch suizidalen Patienten unterstützen können.

Investigating the genetic and environmental aetiologies of non-suicidal and suicidal self-harm: a twin study

BACKGROUND

Self-harm is a major health concern, not only as a signal of distress but also as a strong predictor of later suicide. Self-harm can be further refined into suicidal self-harm (SSH, i.e. suicide attempt) and non-suicidal self-harm (NSSH). Understanding the aetiologies of NSSH and SSH can help inform suicide prevention strategies. Using a twin design, we investigated the phenotypic and aetiological relationships between NSSH and SSH, and their aetiological overlap with mental health problems.

METHODS

We analysed data from the Twins Early Development Study using structural equation modelling. At age 21 years, 9063 twins (62.4% female) answered questions related to self-harm. At age 16 years, 19 self- or parent-reported mental health measures were administered, including measures of internalising and externalising problems, psychotic-like experiences and substance abuse.

RESULTS

Prevalences for NSSH and SSH were 21.9% and 10.5%, respectively. Additive genetic factors explained half of the variance in NSSH (55%) and SSH (50%), with the rest explained by non-shared environmental factors. Phenotypically, NSSH and SSH were strongly correlated (r = 0.87) with their correlation explained by genetic (57%) and non-shared environmental (43%) factors. We found no evidence that NSSH and SSH differed in their phenotypic and aetiological relationships with mental health measures.

CONCLUSION

Our findings suggest no aetiological difference between NSSH and SSH. NSSH and SSH should be regarded as two different ends of a continuum, rather than as two distinct categories.

Test-retest & familial concordance of MDD symptoms

Psychopathology research has increasingly sought to study the etiology and treatment of individual symptoms, rather than categorical diagnoses. However, it is unclear whether commonly used measures have adequate psychometric properties for assessing individual symptoms. This study examined the test-retest reliability and familial concordance (an indicator of validity) of the symptoms of Major Depressive Disorder (MDD), a disorder consisting of nine core symptoms, most of which are aggregated (e.g., symptom 7 of the DSM criteria for MDD is worthlessness or guilt). Lifetime MDD symptoms were measured in 504 young adults (237 sibling pairs) using the Structured Clinical Interview for DSM-5 (SCID). Fifty-one people completed a second SCID within three weeks of their first SCID. Results indicated that aggregated and unaggregated symptoms demonstrated moderate to substantial test-retest reliability and generally significant, but slight to fair familial concordance (with the highest familial concordance being for markedly diminished interest or pleasure and its unaggregated components - decreased interest and decreased pleasure). Given the increasing focus on the differential validity of individual MDD symptoms, the present study suggests that interview-based assessments of depression can assess most individual symptoms with adequate levels of reliability and validity.

Function and Psychotherapy of Chronic Suicidality in Borderline Personality Disorder: Using the Reinforcement Model of Suicidality

Although great advancements in evidence-based therapies, chronic suicidal patients with borderline personality disorder (BPD) still challenge our mental health system. While BPD patients continue suffering from distress and aversive emotions, therapists and relatives feel often stunned and helpless when confronted with suicidality resulting in interruption of therapies, repeated presentations to emergency rooms and referrals to hospitals. Reviewing the current knowledge of the functions and background of non-suicidal self-injury, we learned that reinforcement mechanisms play an important role to understand why individuals act in deliberate self-mutilation. While individual motives for non-suicidal self-injury and suicidal behavior including suicidal ideations can differ, the principle mechanisms appear to be transferrable. Elucidating the individual motives and function of suicidal behavior is an important therapeutic step, giving us access to very central maladaptive schemes and false believes that we need to address in order to reduce chronic suicidality in BPD patients. This Perspective article aims to give a better idea of what is behind and what are the differences between non-suicidal self-injury, suicidal ideations and suicide attempts. It further integrates recent developments of behavioral science in a reinforcement model of suicidality that can provide therapists a practical armamentarium in their work with chronic suicidal clients.

Common genetic contributions to high-risk trauma exposure and self-injurious thoughts and behaviors

BACKGROUND

Prior research has documented shared heritable contributions to non-suicidal self-injury (NSSI) and suicidal ideation (SI) as well as NSSI and suicide attempt (SA). In addition, trauma exposure has been implicated in risk for NSSI and suicide. Genetically informative studies are needed to determine common sources of liability to all three self-injurious thoughts and behaviors, and to clarify the nature of their associations with traumatic experiences.

METHODS

Multivariate biometric modeling was conducted using data from 9526 twins [59% female, mean age = 31.7 years (range 24-42)] from two cohorts of the Australian Twin Registry, some of whom also participated in the Childhood Trauma Study and the Nicotine Addiction Genetics Project.

RESULTS

The prevalences of high-risk trauma exposure (HRT), NSSI, SI, and SA were 24.4, 5.6, 27.1, and 4.6%, respectively. All phenotypes were moderately to highly correlated. Genetic influences on self-injurious thoughts and behaviors and HRT were significant and highly correlated among men [rG = 0.59, 95% confidence interval (CI) (0.37-0.81)] and women [rG = 0.56 (0.49-0.63)]. Unique environmental influences were modestly correlated in women [rE = 0.23 (0.01-0.45)], suggesting that high-risk trauma may confer some direct risk for self-injurious thoughts and behaviors among females.

CONCLUSIONS

Individuals engaging in NSSI are at increased risk for suicide, and common heritable factors contribute to these associations. Preventing trauma exposure may help to mitigate risk for self-harm and suicide, either directly or indirectly via reductions in liability to psychopathology more broadly. In addition, targeting pre-existing vulnerability factors could significantly reduce risk for life-threatening behaviors among those who have experienced trauma.

The Frontiers of Suicide

Suicide is a serious public health problem in many countries and has always been a source of apprehension and quest to human mankind, which can be resolved with due diligence. Suicide is a hidden and silent epidemic, with many causative factors. Studying and researching on various causative factors have always been the subject of significance for the researchers. Psychiatric illnesses happen to be the primary reasons for the majority of suicide mortality cases. Not only this, there has been a consistent increase in the no. of cases of mental disorders as well as attempted and completed suicide cases. If one looks at global scenario, an approximate 70,000 people commit suicide, and further alarming is the fact that the rate of suicide attempt cases has gone up to 250% during last 18 years in conflict zones. Poisoning, hanging and self-immolation are some of the common methods to commit suicide. Physical and mental illness, disturbed emotional relationships and economic difficulties were the major reasons for suicide with the predisposed population being women, student and farmers. As per WHO's approximation, there is one suicide every minute and an attempted suicide every third second. It implies that the number of killed due to suicide is greater than that of the ones killed due to the armed conflict.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Suicidal patients presenting to secondary and tertiary emergency departments and referral to a psychiatrist: a population-based descriptive study from Japan

BACKGROUND

In Japan, although many suicidal studies were previously conducted in tertiary emergency department (ED) settings, no published studies have reported on suicidal patients presenting to the secondary EDs. The aim of the study was to describe the characteristics of suicidal patients and the referral rates to a psychiatrist overall and by type of facility.

METHODS

Questionnaires were sent to all secondary and tertiary EDs in Tochigi prefecture, Japan. Data were collected for cases who presented in September 2009. Chi-square, Fisher's exact, and t-tests compared the results by gender and type of ED.

RESULTS

All 74 EDs responded to the survey. There were 81 patients who attempted or died by suicide (36 men and 45 women). The most common method of suicide attempt was drug overdose (57%) followed by stabbing (17%). About a half used prescription drugs to attempt or die by suicide. The majority had a history of psychiatric disorders, and 35% had previous suicide attempt. About a half were admitted to medical or surgical unit; 33% were discharged home; and 9% died. After excluding those who died, 53% were referred to a psychiatrist, but 47% were not referred to a psychiatrist. The referral rate was lower for cases seen at secondary EDs (38%) compared to tertiary EDs (67%).

CONCLUSION

Although professional organizations suggest that suicidal patients are seen by a psychiatrist, many were not, especially at secondary EDs. Further research is needed to assure that suicidal patients presenting to EDs receive appropriate psychiatric assessment and follow-up after discharge.

Suicide Lethality: A Concept Analysis

PURPOSE

Suicide is a significant health problem internationally. Those who complete suicide may have different behaviors and risk factors than those who attempt a non-fatal suicide. The purpose of this article is to analyze the concept of suicide lethality and propose a clear definition of the concept through the identification of antecedents, attributes, and consequences.

METHODS

A literature search for articles published in the English language between 1970 and 2016 was conducted using MEDLINE, the Cochrane Library, Pubmed, Psychlit, Ovid, PsycINFO, and Proquest. The bibliographies of all included studies were also reviewed to identify additional relevant citations. A concept analysis was conducted on the literature findings using six stages of Walker and Avant's method.

FINDINGS

The concept analysis differentiated between suicide, lethality, suicidal behavior, and suicide lethality. Presence of a suicide plan or a written suicide note was not found to be associated with the majority of completed suicides included in the definition of suicide lethality. There are a few scales that measure the lethality of a suicide attempt, but none that attempt to measure the concept of suicide lethality as described in this analysis.

CONCLUSIONS

Clarifying the concept of suicide lethality encourages awareness of the possibility of different suicidal behaviors associated with different suicide outcomes and will inform the development of future nursing interventions. A clearer definition of the concept of suicide lethality will guide clinical practice, research, and policy development aimed at suicide prevention.

Neurocognitive Function and Suicide in U.S. Army Soldiers

This prospective cohort study used administrative data from the Army Study to Assess Risk and Resilience in Servicemembers to examine associations between neurocognitive functioning and subsequent suicidal events among Regular Army enlisted soldiers during the years 2004-2009. Cases were all soldiers who completed the Army's Automated Neuropsychological Assessment Metrics (ANAM) computerized testing battery prior to documented suicide attempt (n = 607), ideation (n = 955), or death (n = 57). Controls were an equal-probability sample of 9,893 person-months from other soldiers. Exploratory factor analysis of five ANAM tests identified a general neurocognitive factor that excluded the mathematic processing test (MTH). When examined separately in logistic regression analyses that controlled for sociodemographics and prior mental health diagnosis, both the general neurocognitive factor (logit [β] = -.197 to -.521; p < .01) and MTH (β = -.024 to -.064; p < .05) were associated with all outcomes. When both predictors were examined simultaneously, the general neurocognitive factor continued to be associated with all outcomes (β = -.164 to -.417; p < .05) and MTH continued to be associated with suicide attempt (β = -.015; p = .046) and ideation (β = -.014; p = .018). These small but robust associations suggest that future research must continue to examine the extent to which objective neurocognitive tests may enhance understanding and prediction of suicide risk.

Alcohol Involvement in Suicide and Self-Harm

Abstract. Background: Alcohol misuse and alcohol consumption are significant risk factors for suicidal behavior. Aims: This study sought to identify factors associated with alcohol consumption in cases of suicide and nonfatal self-harm presentations. Method: Suicide cases in Cork, Ireland, from September 2008 to June 2012 were identified through the Suicide Support and Information System. Emergency department presentations of self-harm in the years 2007–2013 were obtained from the National Self-Harm Registry Ireland. Results: Alcohol consumption was detected in the toxicology of 44% out of 307 suicide cases. Only younger age was significantly associated with having consumed alcohol among suicides. Alcohol consumption was noted in the case notes in 21% out of 8,145 self-harm presentations. Logistic regression analyses indicated that variables associated with having consumed alcohol in a self-harm presentation included male gender, older age, overdose as a method, not being admitted to a psychiatric ward, and presenting out-of-hours. Limitations: Data was limited to routinely collected variables by the two different monitoring systems. Conclusion: Alcohol consumption commonly precedes suicidal behavior, and several factors differentiated alcohol-related suicidal acts. Self-harm cases, in particular, differ in profile when alcohol is consumed and may require a tailored clinical approach to minimize risk of further nonfatal or fatal self-harm.

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.

Animal models to improve our understanding and treatment of suicidal behavior

Worldwide, suicide is a leading cause of death. Although a sizable proportion of deaths by suicide may be preventable, it is well documented that despite major governmental and international investments in research, education and clinical practice suicide rates have not diminished and are even increasing among several at-risk populations. Although nonhuman animals do not engage in suicidal behavior amenable to translational studies, we argue that animal model systems are necessary to investigate candidate endophenotypes of suicidal behavior and the neurobiology underlying these endophenotypes. Animal models are similarly a critical resource to help delineate treatment targets and pharmacological means to improve our ability to manage the risk of suicide. In particular, certain pathophysiological pathways to suicidal behavior, including stress and hypothalamic-pituitary-adrenal axis dysfunction, neurotransmitter system abnormalities, endocrine and neuroimmune changes, aggression, impulsivity and decision-making deficits, as well as the role of critical interactions between genetic and epigenetic factors, development and environmental risk factors can be modeled in laboratory animals. We broadly describe human biological findings, as well as protective effects of medications such as lithium, clozapine, and ketamine associated with modifying risk of engaging in suicidal behavior that are readily translatable to animal models. Endophenotypes of suicidal behavior, studied in animal models, are further useful for moving observed associations with harmful environmental factors (for example, childhood adversity, mechanical trauma aeroallergens, pathogens, inflammation triggers) from association to causation, and developing preventative strategies. Further study in animals will contribute to a more informed, comprehensive, accelerated and ultimately impactful suicide research portfolio.

The association between cannabis use and suicidality among men and women: A population-based longitudinal study

BACKGROUND

Evidence regarding the role of sex differences in the association between cannabis use and suicidality is lacking. We explored sex differences in the bidirectional association between cannabis use and suicidality in a 3-year longitudinal study.

METHODS

Data were drawn from waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Bidirectional analyses were conducted separately by sex, exploring incidence of suicidality among cannabis users (n=963 vs. 30,586 non-users) as well as initiation of cannabis use among suicidal individuals (n=1805 vs. 25,729 non-suicidal). Cannabis use was categorized based on frequency of use. Multivariate logistic regression analyses controlling for multiple covariates were conducted.

RESULTS

Cannabis use was significantly associated with increased incidence of suicidality among men (Adjusted Odds Ratio [AOR] for any cannabis use =1.91[1.02-3.56]) but not among women (AOR=1.19[0.64-2.20]). Daily cannabis use was significantly associated with increased incidence of suicidality among men (AOR=4.28[1.32-13.82]) but not among women (AOR=0.75[0.28-2.05]). Conversely, baseline suicidality was associated with initiation of cannabis use among women (AOR=2.34[1.42-3.87]) but not among men (AOR=1.10[0.57-2.15]). Separate analyses of suicidal ideation and suicide attempts demonstrated a significant association between cannabis use and subsequent incidence of suicidal ideation in men, and a significant association between baseline suicidal ideation and subsequent initiation of cannabis use in women. No significant association was found for the bidirectional association between cannabis use and suicide attempts in either sex.

LIMITATIONS

Suicidality was assessed only in individuals reporting depressed mood and/or anhedonia.

CONCLUSIONS

Our findings support a longitudinal association between heavy cannabis use and the incidence of suicidality in men, but not in women. Conversely, baseline suicidality is longitudinally associated with the initiation of cannabis use in women, but not in men. This may have implications on clinical and social aspects of cannabis use and merit further research into the unique effects of sex differences on cannabis induced psychopathology.

Cognitive, Emotional, Temperament, and Personality Trait Correlates of Suicidal Behavior

Suicide is one of the leading causes of violent death in many countries and its prevention is included in worldwide health objectives. Currently, the DSM-5 considers suicidal behavior as an entity that requires further study. Among the three validators required for considering a psychiatric disorder, there is one based on psychological correlates, biological markers, and patterns of comorbidity. This review includes the most important and recent studies on psychological factors: cognitive, emotional, temperament, and personality correlates (unrelated to diagnostic criteria). We included classic factors related to suicidal behavior such as cognitive, inflexibility, problem-solving, coping, rumination, thought suppression, decision-making, autobiographical memory, working memory, language fluency, burdensomeness, belongingness, fearless, pain insensitivity, impulsiveness, aggressiveness, and hopelessness. The personality correlates reported are mainly based on the personality theories of Cloninger, Costa and McCrae, and Eysenck. Moreover, it explores conceptual links to other new pathways in psychological factors, emptiness, and psychological pain as a possible origin and common end path for a portion of suicidal behaviors.

Classifying nonsuicidal overdoses: Nonsuicidal self-injury, suicide attempts, or neither?

Self-injurious behaviors (SIBs) are leading causes of death and injury. Unfortunately, disagreement regarding whether and how to classify suicidal and nonsuicidal SIBs has contributed to their misclassification, likely hindering clinical care and impeding scientific progress. The present study utilized a data-driven approach to facilitate classification and measurement of three forms of SIBs, with a particular focus on one with scant clinical and scientific attention: nonsuicidal overdoses (i.e. intentional overdoses where the person states that they had no intention of dying from the overdose). Results from this study demonstrated that nonsuicidal overdoses were similar to suicide attempts in terms of age of onset, and similar to nonsuicidal self-injury (NSSI) in terms of suicidal thoughts and desire to die when engaging in these behaviors. Nonsuicidal overdoses were unique from NSSI and suicide attempts in terms of the reported likelihood of dying from the behavior. The present study highlighted that current definitions for nonsuicidal behaviors (including requirements that the person has zero intent to die) may not accurately represent people's intent when engaging in these behaviors. Additionally, the present study highlighted that empirical analysis of SIBs can provide important insights for classification of SIBs.

Predicting Risk for Suicide: A Preliminary Examination of Non-Suicidal Self-Injury and the Acquired Capability Construct in a College Sample

The interpersonal psychological theory of suicide provides a useful framework for considering the relationship between non-suicidal self-injury and suicide. Researchers propose that NSSI increases acquired capability for suicide. We predicted that both NSSI frequency and the IPTS acquired capability construct (decreased fear of death and increased pain tolerance) would separately interact with suicidal ideation to predict suicide attempts. Undergraduate students (N = 113) completed self-report questionnaires, and a subsample (n = 66) also completed a pain sensitivity task. NSSI frequency significantly moderated the association between suicidal ideation and suicide attempts. However, in a separate model, acquired capability did not moderate this relationship. Our understanding of the relationship between suicidal ideation and suicidal behavior can be enhanced by factors associated with NSSI that are distinct from the acquired capability construct.

Comparison of Suicide Attempters and Decedents in the U.S. Army: A Latent Class Analysis

A clearer understanding of risk factors for suicidal behavior among soldiers is of principal importance to military suicide prevention. It is unclear whether soldiers who attempt suicide and those who die by suicide have different patterns of risk factors. As such, preventive efforts aimed toward reducing suicide attempts and suicides, respectively, may require different strategies. We conducted a latent class analysis (LCA) to examine classes of risk factors among suicide attempters (n = 1,433) and decedents (n = 424). Both groups were represented by three classes: (1) External/Antisocial Risk Factors, (2) Mental Health Risk Factors, and (3) No Pattern. These findings support the conceptualization that military suicide attempters and decedents represent a single population.

Suicide

Suicide is a major mental health problem in the United States and an issue that significantly impacts the mental health treatment community. Although the suicide rate remains relatively stable, the discipline of counseling psychology has broadened in scope and work settings have diversified. Thus, counseling psychology trainees are increasingly exposed to suicidal clients. Despite this reality, research suggests that comprehensive, systematic training in suicidology in counseling psychology programs rarely occurs. One reason for this state of affairs may be that the suicide literature is spread across a variety of disciplines, making it difficult for educators and practitioners to stay informed about the knowledge base in suicidology. The purpose of this contribution, therefore, is to provide counseling psychology educators and practitioners with an overview of the field of suicidology as it applies to the training and practice of counseling psychology.

Relations between Nonsuicidal Self-Injury and Suicidal Behavior in Adolescence: A Systematic Review

Nonsuicidal self-injury (NSSI) and suicidal behaviors, both important issues in adolescent health care, are frequently associated and possibly clinically related. Our objective was to explore the views of relations between nonsuicidal self-injury and suicidal behaviors during adolescence and young adulthood (11–25 years) expressed in the scientific (medical and psychological) literature. We adopted a textual approach to the process of synthesis to tell the story of the findings from the included studies. Our narrative systematic review of 64 articles found that they share the same risk factors. Integrated models envision nonsuicidal self-injury as a gateway enabling teens to acquire the capability for suicide. Because suicidal behavior short-circuits thought, it is difficult to conceive an intention to die during adolescents' acts of self-injury. Intention is constructed by the narrative of the act, influenced by numerous elements from the psychopathologic, cultural, religious, and philosophic context. Techniques of mentalizing-based treatments and work on the meaning that adolescents attribute to their behaviors might improve care.

Self-Reported Psychopathology, Trauma Symptoms, and Emotion Coping Among Child Suicide Attempters and Ideators: An Exploratory Study of Young Children

This study examined self-reported psychopathology, trauma symptoms, and emotion coping in 7 to 12 year old children with suicidal ideation and attempts. This study compared 70 psychiatric inpatient children with current suicidal ideation to 59 psychiatric inpatient children with recent suicide attempts on measures of depression, anxiety, anger, emotional intelligence, and family/contextual factors. Results revealed greater self-reported anger as well as psychological distress associated with traumatic experiences (dissociation, anger, depression), among children who attempted suicide, in addition to increased reports of special education utilization, when compared to ideators only. These relationships were not affected by age or gender. Overall, the findings suggest self-reports of younger children who attempt suicide share similarities with older children and adolescent attempters, when compared with ideators who do not attempt. Implications for assessment and treatment are discussed.

Risk factors for suicide attempt among Israeli Defense Forces soldiers: A retrospective case-control study

BACKGROUND

A major risk factor for suicide is suicide attempts. The aim of the present study was to assess risk factors for nonfatal suicide attempts. Methods The study's cohort consisted of 246,814 soldiers who were divided into two groups: soldiers who made a suicide attempt (n=2310; 0.9%) and a control group of soldiers who did not (n=244,504; 99.1%). Socio-demographic and personal characteristics as well as psychiatric diagnoses were compared. Results The strongest risk factors for suicide attempt were serving less than 12 months (RR=7.09) and a history of unauthorized absence from service (RR=5.68). Moderate risk factors were low socioeconomic status (RR=2.17), psychiatric diagnoses at induction (RR=1.94), non-Jewish religion (RR=1.92), low intellectual rating score (RR=1.84), serving in non-combat unit (RR=1.72) and being born in the former Soviet Union (RR=1.61). A weak association was found between male gender and suicide attempt (RR=1.36). Soldiers who met more frequently with a primary care physician (PCP) had a higher risk for suicide attempt, as opposed to a mental health professional (MHCP), where frequent meetings were found to be a protective factor (P<0.0001). The psychiatric diagnoses associated with a suicide attempt were a cluster B personality disorder (RR=3.00), eating disorders (RR=2.78), mood disorders (RR=2.71) and adjustment disorders (RR=2.26).

LIMITATIONS

Mild suicidal behavior constitutes a much larger proportion than among civilians and may have secondary gain thus distorting the suicidal behavior data.

CONCLUSIONS

Training primary care physicians as gatekeepers and improved monitoring, may reduce the rate of suicide attempts.

Suicidal ideation and suicide attempts in older adults: Influences of chronic illness, functional limitations, and pain

This study aimed to examine the associations between suicidal behavior in older Korean adults and chronic illnesses, functional limitations, and pain. Data were obtained and analyzed for 8500 adults over 65 years of age from the 2007-2012 Korea National Health and Nutrition Examination Survey IV and V. Multivariate logistic regression analyses were conducted to examine the associations between suicidal behavior, chronic illness, functional limitations, and pain. The presence of arthritis and renal failure were significantly associated with a higher risk of suicidal ideation and suicide attempts. Moderate limitation in usual activities and extreme pain significantly increased the risk of both suicidal ideation and suicide attempts, over and above the existence of chronic illnesses and depression status.

Suicidal protests: self-immolation, hunger strikes, or suicide bombing

Following Lankford's persuasive argument that suicide bombers are indeed suicidal, the next question to ask is why individuals choose one form of suicidal protest over others. Why choose suicide bombing rather than a hunger strike or self-immolation? Some suggestions are provided.

Serious suicidal behaviors: socio-demographic and clinical features in a multinational, multicenter sample

BACKGROUND

Declared suicidal intent and physical danger are both considered important components in defining suicidal behaviors (SB).

AIMS

1) To investigate characteristics of serious suicidal behaviors (SSB), defined by either suicidal intent or lethality; 2) To determine any difference in terms of socio-demographic, clinical and/or service usage variables between SSB and non-serious suicidal behaviors (NSSB).

METHODS

A total of 2631 contacts for SB were registered in the context of the MONSUE (Monitoring Suicidal Behavior in Europe) study project. Demographic and clinical information were registered. ICD-10 was used for classifying data about psychiatric diagnoses, methods used for SB and injuries reported. Clear intentionality, high-case fatality methods and serious injuries all defined SSB (n = 1169; 44.4%)

RESULTS

SSB were more often preceded by a contact with an inpatient (either psychiatric or somatic) rather than an outpatient service. Among those having a previous history of SB, SSB subjects had fewer contacts with health services before the previous attempt. The strongest predictors for SSB appeared to be older age and not professing a religion.

CONCLUSION

Many of the known factors contributing to the risk of completed suicide were also present for SSB. Our findings on service usage by suicide attempters show which aspects of mental health services should be strengthened in order to improve suicide prevention.

Clinical features associated with suicide attempts versus suicide gestures in an inpatient sample

The objective of this study was to test whether suicide attempters and suicide gesturers can be clinically differentiated. A total of 150 subjects who had attempted suicide at least once, had made a suicide gesture, had suicidal ideation, and/or had engaged in non-suicidal self-injury were recruited from the inpatient service of the Jiménez Díaz Foundation (Madrid, Spain). A multinomial regression analysis was conducted. Histrionic and antisocial personality disorders were risk factors specific to suicide gestures. Narcissistic personality disorder was specifically associated with suicide attempts. Borderline personality disorder was associated with both suicide gestures and attempts. A high level of impulsiveness was a risk factor specific to suicide attempts.

CONCLUSION

Suicide attempters and suicide gesturers are two distinct, although partially overlapping, populations.

Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison

BACKGROUND

Whether suicide attempters and completers represent the same population evaluated at different points along a progression towards suicide death, overlapping populations, or completely different populations is a problem still unresolved.

METHODS

446 Adult suicide attempters and knowledgeable collateral informants for 190 adult suicide probands were interviewed. Sociodemographic and clinical data was collected for both groups using semi-structured interviews and structured assessments. Univariate analyses and logistic regression models were conducted to explore the similarities and differences between suicide attempters and completers.

RESULTS

Univariate analyses yielded significant differences in sociodemographics, recent life events, impulsivity, suicide intent, and distribution of Axis I and II disorders. A logistic regression model aimed at distinguishing suicide completers from attempters properly classified 90% of subjects. The most significant variables that distinguished suicide from attempted suicide were the presence of narcissistic personality disorder (OR=21.4; 95% CI=6.8-67.7), health problems (OR=20.6; 95% CI=5.6-75.9), male sex (OR=9.6; 95% CI=4.42-20.9), and alcohol abuse (OR=5.5; 95% CI=2.3-14.2).

LIMITATIONS

Our study shares the limitations of studies comparing suicide attempters and completers, namely that information from attempters can be obtained from the subject himself, whereas the assessment of completers depends on information from close family or friends. Furthermore, different semi-structured instruments assessed Axis I and Axis II disorders in suicide attempters and completers. Finally, we have no data on inter-rater reliability data.

CONCLUSIONS

Suicide completers are more likely to be male and suffer from alcohol abuse, health problems (e.g. somatic illness), and narcissistic personality disorder. The findings emphasize the importance of implementing suicide prevention programs tailored to suicide attempters and completers.

Differential effect of lithium on spermidine/spermine N1-acetyltransferase expression in suicidal behaviour

An altered polyamine system has been suggested to play a key role in mood disorders and suicide, a hypothesis corroborated by the evidence that lithium inhibits the polyamine mediated stress response in the rat brain. Recent post-mortem studies have shown that spermidine/spermine N1-acetyltransferase (SAT1), the key regulator of cellular polyamine content, is under-expressed in brains from suicide victims compared to controls. In our study we tested the effect of in vitro lithium treatment on SAT1 gene and protein expression in B lymphoblastoid cell lines (BLCLs) from bipolar disorder (BD) patients who committed suicide (and for which BLCLs were collected prior to their death), BD patients with high and low risk of suicide and a sample of non-psychiatric controls. Baseline mRNA levels were similar in the four groups of subjects (p > 0.05). Lithium had no effect in suicide completers (p > 0.05) while it significantly increased SAT1 expression in the high risk (p < 0.001) and low risk (p < 0.01) groups as well as in controls (p < 0.001). Protein and mRNA levels were not correlated; lithium significantly reduced protein levels only in the control sample (p < 0.05). Our findings suggest that SAT1 transcription is influenced by lithium and that this effect is altered in BD patients who completed suicide, further supporting a role for polyamines in suicide.

Involvement in bullying as predictor of suicidal ideation among 12- to 15-year-old Norwegian adolescents

The aim of this study was to examine relationships between bullying and suicidal ideation. A total of 2,464 adolescents in Norway were assessed at two time points, 1 year apart [i.e., at ages 14 (T1) and 15 (T2)], with identical questionnaires. Suicidal ideation was measured by four items including both active and passive suicidal thoughts. ANOVA and standard linear regression methods were applied. Both bullied adolescents and adolescents who were aggressive toward others had significantly higher levels of suicidal ideation (p < 0.001) at age 14 (T1) than noninvolved adolescents. In the group being bullied, girls had higher levels of suicidal ideation than boys did. This was not the case for the group of adolescents who were the aggressors. In cross-sectional multivariate analyses, both being bullied and being aggressive toward others were significant (p < 0.001) predictors of suicidal ideation at age 14 (T1), when gender, age and socioeconomic status, and depressing symptom levels were controlled for. In the controlled longitudinal multivariate analyses, being bullied (p < 0.001) at age 14 (T1) predicted suicidal ideation at age 15 (T2), while aggressiveness toward others did not. Bullied adolescents (both genders) were at risk for suicidal ideation, and having an additional risk if they were depressed.

A comparison of the clinical characteristics of women with recurrent major depression with and without suicidal symptomatology

BACKGROUND

The relationship between recurrent major depression (MD) in women and suicidality is complex. We investigated the extent to which patients who suffered with various forms of suicidal symptomatology can be distinguished from those subjects without such symptoms.

METHOD

We examined the clinical features of the worst episode in 1970 Han Chinese women with recurrent DSM-IV MD between the ages of 30 and 60 years from across China. Student's t tests, and logistic and multiple logistic regression models were used to determine the association between suicidality and other clinical features of MD.

RESULTS

Suicidal symptomatology is significantly associated with a more severe form of MD, as indexed by both the number of episodes and number of MD symptoms. Patients reporting suicidal thoughts, plans or attempts experienced a significantly greater number of stressful life events. The depressive symptom most strongly associated with lifetime suicide attempt was feelings of worthlessness (odds ratio 4.25, 95% confidence interval 2.9-6.3). Excessive guilt, diminished concentration and impaired decision-making were also significantly associated with a suicide attempt.

CONCLUSIONS

This study contributes to the existing literature on risk factors for suicidal symptomatology in depressed women. Identifying specific depressive symptoms and co-morbid psychiatric disorders may help improve the clinical assessment of suicide risk in depressed patients. These findings could be helpful in identifying those who need more intense treatment strategies in order to prevent suicide.

Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model

Self-injurious behaviors (SIB) refer to behaviors that cause direct and deliberate harm to oneself, including nonsuicidal self-injury (NSSI), suicidal behaviors, and suicide. Although in recent research, NSSI and suicidal behavior have been differentiated by intention, frequency, and lethality of behavior, researchers have also shown that these two types of self-injurious behavior often co-occur. Despite the co-occurrence of NSSI and suicidal behavior, however, little attention has been given as to why these self-injurious behaviors may be linked. Several authors have suggested that NSSI is a risk factor for suicidal behavior, but no comprehensive review of the literature on NSSI and suicidal behavior has been provided. To address this gap in the literature, we conducted an extensive review of the research on NSSI and suicidal behavior among adolescents and adults. First, we summarize several studies that specifically examined the association between NSSI and suicidal behavior. Next, three theories that have been proposed to account for the link between NSSI and suicidal behavior are described, and the empirical support for each theory is critically examined. Finally, an integrated model is introduced and several recommendations for future research are provided to extend theory development.

The neuroscience of suicidal behaviors: what can we expect from endophenotype strategies?

Vulnerability to suicidal behavior (SB) is likely mediated by an underlying genetic predisposition interacting with environmental and probable epigenetic factors throughout the lifespan to modify the function of neuronal circuits, thus rendering an individual more likely to engage in a suicidal act. Improving our understanding of the neuroscience underlying SBs, both attempts and completions, at all developmental stages is crucial for more effective preventive treatments and for better identification of vulnerable individuals. Recent studies have characterized SB using an endophenotype strategy, which aims to identify quantitative measures that reflect genetically influenced stable changes in brain function. In addition to aiding in the functional characterization of susceptibility genes, endophenotypic research strategies may have a wider impact in determining vulnerability to SB, as well as the translation of human findings to animal models, and vice versa. Endophenotypes associated with vulnerability to SB include impulsive/aggressive personality traits and disadvantageous decision making. Deficits in realistic risk evaluation represent key processes in vulnerability to SB. Serotonin dysfunction, indicated by neuroendocrine responses and neuroimaging, is also strongly implicated as a potential endophenotype and is linked with impulsive aggression and disadvantageous decision making. Specific endophenotypes may represent heritable markers for the identification of vulnerable patients and may be relevant targets for successful suicide prevention and treatments.

Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population

OBJECTIVES

We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample.

METHODS

Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004-2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder.

RESULTS

Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0).

CONCLUSIONS

Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.

A population-based longitudinal study of risk factors for suicide attempts in major depressive disorder

No longitudinal study has examined risk factors for future suicide attempts in major depressive disorder in a nationally representative sample. The objective of this study was to investigate baseline sociodemographic characteristics, comorbid mental disorders, specific depressive symptoms, and previous suicidal behavior as potential risk factors for suicide attempts at 3 years follow-up. Data came from the national epidemiologic survey on alcohol and related conditions (NESARC), a large nationally representative longitudinal survey of mental illness in adults [Wave 1 (2001-2002); Wave 2 (2004-2005) n=34,653]. Logistic regression examined associations between risk factors present at Wave 1 and suicide attempts at Wave 2 (n=169) among individuals with major depressive disorder at baseline assessment (n=6004). Risk factors for incident suicide attempts at Wave 2 (n=63) were identified among those with major depressive disorder at Wave 1 and no lifetime history of suicide attempts (n=5170). Results revealed specific comorbid anxiety, personality, and substance use disorders to be associated with incident suicide attempts at Wave 2. Comorbid borderline personality disorder was strongly associated with suicide attempts in all models. Several comorbid disorders were strongly associated with suicide attempts at Wave 2 even after adjusting for previous suicidal behavior, notably posttraumatic stress disorder (adjusted odds ratio (AOR)=2.20; 95% confidence interval (95% CI) 1.27-3.83) and dependent personality disorder (AOR=4.43; 95% CI 1.93-10.18). These findings suggest that mental illness comorbidity confers an increased risk of future suicide attempts in major depressive disorder that is not solely accounted for by past suicidal behavior.

Collective efficacy, family attachment, and urban adolescent suicide attempts

The suicide rate among American adolescents between the ages of 14-25 has dramatically increased during the last 50 years, and this fact has been the focus of extensive social-scientific investigation. To date, however, research focusing on the joint effects of mental health, family, and contextual-level predictors on adolescents' suicidal behaviors is scarce. Drawing on Durkheim's classic macro-level approach to suicide and collective efficacy theory, we use data from the Project on Human Development in Chicago Neighborhoods (PHDCN) to examine the effect of informal social controls on adolescents' suicide attempts. Analyzing reports from 990 youth, we examine the hypothesis that neighborhood-level collective efficacy and family-level integration and social control independently affect suicide attempts. We also examine the extent to which they interact in their effects on suicidal behavior. Overall, results from multilevel logit models support the Durkheimian expectation that family attachment reduces the probability that adolescents will attempt suicide. The effect of collective efficacy is interactive in nature. Specifically, we find that collective efficacy significantly enhances the protective effect of family attachment and support on adolescent suicidal behaviors. We discuss findings within the context of social control theory.

Age-specific characteristics of serious suicide attempters in China

Characteristics of four age groups of patients with medically serious suicide attempts from nine general hospitals in China (N = 617) were compared. There were no significant age-group differences by residence (rural vs. urban), method of attempt, proportion with prior attempts, or level of family functioning. Attempters < or = 20 years of age were less likely to use alcohol at the time of the attempt. Attempters age 20-44 years had less regular contact with family members but were more likely to make the attempt in the presence of someone else. And attempters > or = 45 years were more likely to have high suicidal intent, lower quality of life, mood disorders, and substance abuse disorders. These results highlight the need for age-specific intervention programs for suicide attempters.

Completed versus attempted suicide in psychiatric patients: a psychological autopsy study

The aims of this study were to identify specific risk factors associated with completed suicide in a sample of suicide victims diagnosed with mental illness and to discriminate completed suicides from attempted suicide in individuals who did not kill themselves for at least the next 2 years after the index attempt. Ninety-four adults (34 women; 60 men; mean age = 50.81 [SD = 18.08]) admitted to the Division of Psychiatry of the Department of Neurosciences of the University of Parma who died by suicide between 1994-2004 were matched for sex and age (+/- 2 years) with 94 outpatients (mean age = 50.70 [SD = 18.08]) who made at least one suicide attempt during the years of the study. Data were gathered by proxy-based interviews with referring psychiatrists and general practitioners and from examination of medical records. Suicide victims were more likely to be not married, have poor social support (OR = 5.28), and have more voluntary and compulsory admissions to hospitals (1 admission: OR = 5.44; > 1 admissions: OR= 8.84) than suicide attempters. Suicide victims were also less likely to have had stressful life events during their childhood and adolescence (OR = 0.09) and to be divorced or widowed than were the attempters.

Inhalant use and suicidality among incarcerated youth

Studies consistently indicate that inhalant use is associated with increased mental health problems in adolescents, but few investigations have focused on the potential relationship of inhalant use to suicidality (ideation or attempt). This study examined how different levels of volatile solvent use relate to suicidal ideation and attempted suicide among 723 incarcerated youth (mean age=15.5, S.D.=1.2; 87% male) in Missouri, and whether any associations between solvent use and suicidality differ by gender. In bivariate analyses, severity of inhalant use was positively associated with histories of suicidal ideation and suicide attempt for both boys and girls. In multivariate analyses, inhalant use disorders remained significantly associated with suicidal ideation and suicide attempt histories even after adjusting for general level of psychiatric symptoms, prior trauma, other substance use, gender, and additional potential confounders. Inhalant use without abuse or dependence also significantly related to suicidal ideation in multivariate analyses, but an interaction between gender and inhalant use signified this relationship was stronger for girls. Inhalant use disorders in incarcerated youth, as well as inhalant use without abuse or dependence (particularly in girls), may signal elevated suicide risk. Suicide risk assessments should, therefore, include questions about inhalation of volatile solvents such as paint, gasoline, and household cleaners.

Nonfatal suicide-related behavior among inmates: testing for gender and type differences

Suicide-related behavior (SRB) is significantly more prevalent among female (40.8%) than among male (28%) inmates, although suicide risk is higher among the latter. When instrumental behavior (IB) is excluded and only suicidal acts (SA) considered, rates for the two groups are more comparable (11.9% and 16%, respectively). Compared with other female inmates, the SRB group is more suicidal, hostile, and impulsive and more likely to have been previously victimized and to be diagnosed with Axis I and II disorders. Women with IB are not significantly different from those with SA, except that their behavior provides significantly greater tension release.

Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury

The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.

Suicidal behaviors and personality structure

In this paper we suggest the potential clinical usefulness of two projective tests (Rorschach and Object Relation Technique) and of a clinical interview focused on the pathway to suicide, life events, and major life difficulties to better define subtypes of patients attempting suicide. Thirty-three hospitalized subjects who had attempted suicide in the previous 6 months were examined using an in-depth assessment of the pathway to suicide. The aims of this study were: (1) to compare, within a clinical sample of suicidal attempters, the psychopathological, personality, and psychosocial characteristics of subjects with mood disorders alone, personality disorders and dysfunctional personality alone, and mood disorders with personality disorders and/or dysfunctional personality; and (2) to analyze the relationship between the method chosen and the clinical characteristics of the subgroups.

Comparison of completed and attempted suicide in Akita, Japan

To determine the factors underlying suicide in Akita prefecture, a questionnaire survey was conducted among members of the Akita Prefectural Medical Association (APMA), regarding suicide cases they attended. During the investigation period (1 July 2001-30 June 2002), the total number of suicide cases was 243 (138 completed, 105 attempted). Significant differences were identified between completed and attempted suicide groups in terms of gender, age distribution, and suicidal methods. Specifically, in the completed suicide group, the number of male completers exceeded that of female completers, the number of middle-aged or elderly completers was high, and the majority of completed suicide cases involved hanging as the suicide method. Conversely, in the attempted suicide group, the number of female attempters exceeded that of male attempters, younger attempters were frequent, hanging was rare, and drug overdose or cutting was common. In addition, the number of cases involving a history of previous suicide attempts was significantly higher in the attempted suicide group than in the completed suicide group. The results of the present study support the concept that the completed and attempted suicide groups are essentially of a different nature. Furthermore, the number of cases involving a history of previous suicide attempts was found to be significantly lower in the completed suicide group than in the attempted suicide group. This result indicates the difficulty in decreasing the number of completed suicides by simply providing intervention and care for individuals who have attempted suicide.

The Self-Injury Questionnaire: evaluation of the psychometric properties in a clinical population

This paper presents the findings, from a clinical study, on the reliability and validity of a new measure for intentions in self-harm behaviour, the Self-Injury Questionnaire (SIQ). Eighty-three patients, who had presented to an emergency department with an episode of self-harm/suicidal behaviour, were given the SIQ as part of a battery of measures to evaluate differentiation in self-harm intentions based upon a history of childhood physical and/or sexual abuse. The internal consistency for the total scale was strong (alpha = 0.83). Construct validity demonstrated significant correlations with standardized measures. A principle component analysis of responses yielded a five-factor solution with 'affect regulation' items loading on the first factor. Cronbach's alphas were adequate for each subscale (alpha = 0.72-0.77). These preliminary findings indicate that the SIQ is a valid and reliable measure for research in an acute self-harming population.