The reasons people give for taking overdoses: a further inquiry

The Study of Motivation in the Suicidal Process: The Motivational Interview for Suicidality

Introduction: Suicide is the outcome of a process starting with the experiences of an unbearable pain or hopelessness, passing from suicidal ideation and planning, to possible para-suicidal behaviors or actual attempts. Recent studies have evidenced the necessity to integrate approaches based on the identification of psychopathological diagnoses and other variables as possible predictors of suicidal conduct with a more clinically based approach. A clinical assessment is needed that focuses on the patients' mental state with respect to thoughts concerning death and suicide. In particular, a qualitative assessment of motivations underlying the suicidal process could represent an effective guide for clinicians engaged in the difficult field of preventing adolescents' suicidal gestures. Most instruments investigating the suicidal motivation are self-report measures, possibly resulting in a lack of sufficiently valid assessment of this area. In the present work, we present the Motivational Interview for Suicidality in Adolescence (MIS-A) aiming at identifying the motivational areas sustaining suicidal ideation and gestures in this phase of development. Materials and Methods: The identification of the different areas derives from a thorough review of the empirical literature subsequently vetted by expert clinicians who selected specific reasons behind suicidal ideation and gesture. Result: The MIS is a semi-structured clinician-report interview. The interview is composed of seven areas and 14 sub-areas, evaluated on a four-point Likert scale: illness motivated attempts area, chronic presence of internal pessimistic criticism area, sense of defeat and entrapment area, relational area, external motivated crisis area, extreme and unusual cases area, and lack of control area. Conclusions: The path followed in the creation of the MIS reflects both an empirically orientated and a clinically informed approach. Creating this MIS is the first step within a wider research project that will allow one to test the reliability of the instrument.

Motivations for attempting suicide in mid- and late-life

ABSTRACTObjectives:To understand pathways to suicide by investigating the association between personality and suicidal motivations in mid- and late-life attempts.

DESIGN

In a two-study approach, we measured different components of suicidal motivations using an existing self-report investigating reasons for suicide and a semi-qualitative assessment of motivational states preceding attempts.

SETTING

Inpatient and outpatient psychiatric services in Pittsburgh, PA.

PARTICIPANTS

Study 1 (n = 50, mean age at attempt = 60.4) was a smaller sample of suicide attempters included in Study 2 (n = 69, mean age at attempt = 60.9). Non-psychiatric healthy controls (n = 50, mean age = 67.1) were used as benchmarks for dispositional measures.

MEASUREMENTS

Motives for suicide were measured by the Reasons for Attempting Suicide Questionnaire (RASQ). Participants' written descriptions of the thoughts and feelings preceding their attempt captured motivational states. Measures of personality for both studies included assessments of impulsivity, five-factor model, interpersonal dysfunction, and borderline traits.

RESULTS

In study 1, escape/self-punishment motives on the RASQ were associated with multiple attempts and borderline pathology, while interpersonal motives were less frequently endorsed and associated with poorly planned attempts. In study 2, experiences of defeat (i.e. powerlessness, poor coping to threats to autonomy/status) were more frequently endorsed by men and associated with disagreeableness.

CONCLUSIONS

Study 1 revealed that attempters high in dysfunctional psychopathology were more likely to report self-oriented escape motives for suicide, while study 2 identified a putative pathway to suicide in men involving antagonism and the experience of defeat.

Public Perceptions of Self-Harm: Perceived Motivations of (and Willingness to Help in Response to) Adolescent Self-Harm

We investigated public perceptions of, and responses to, adolescent self-harm-an under-researched topic, given that the majority of self-harm in this group is not disclosed to formal support services. Participants (N = 355, aged 18-67 years) were presented with 1 of 10 vignettes and completed self-report measures assessing perceived motivations for self-harm and helping/rejecting responses. Vignettes were manipulated across conditions for stated motivation, controllability of stated cause, and presentation format. Results indicate that stated motivation for self-harm, controllability of stated cause, and presentation format affect perceived motivations. Further, participants demonstrate an understanding of the complex nature of self-harm, indicating an appreciation that an individual may hold multiple motivations simultaneously. Perceived motivations for self-harm are associated with the endorsement of helping/rejecting behaviors. These relationships are important to explore, given the critical importance of initial responses to self-harm on subsequent disclosures and help-seeking.

Using photo-elicitation to understand reasons for repeated self-harm: a qualitative study

BACKGROUND

Reasons for self-harm are not well understood. One of the reasons for this is that first-hand accounts are usually elicited using traditional interview and questionnaire methods. This study aims to explore the acceptability of using an approach (photo-elicitation) that does not rely on solely verbal or written techniques, and to make a preliminary assessment of whether people can usefully employ images to support a discussion about the reasons why they self-harm.

METHOD

Interviews with eight participants using photo elicitation, a method in which photographs produced by the participant are used as a stimulus and guide within the interview.

RESULTS

Participants responded positively to using images to support a discussion about their self-harm and readily incorporated images in the interview. Four main themes were identified representing negative and positive or adaptive purposes of self-harm: self-harm as a response to distress, self-harm to achieve mastery, self-harm as protective and self-harm as a language or form of communication.

CONCLUSIONS

Employing this novel approach was useful in broadening our understanding of self-harm.

Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted. Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care. These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.

Motivation factors for suicidal behavior and their clinical relevance in admitted psychiatric patients

Background

Suicidal behavior (SB) is a major, worldwide health concern. To date there is limited understanding of the associated motivational aspects which accompany this self-initiated conduct.

Aims

To develop a method for identifying motivational features associated with SB by studying admitted psychiatric patients, and to examine their clinical relevance.

Methods

By performing a factor analytic study using data obtained from a patient sample exhibiting high suicidality and a variety of SB methods, Motivations for SB Scale (MSBS) was constructed to measure the features. Data included assessments of DSM-IV psychiatric and personality disorders, suicide intent, depressive symptomatology, overt aggression, recent life events (RLEs) and methods of SB, collated from structured interviews. Association of identified features with clinical variables was examined by correlation analyses and MANCOVA.

Results

Factor analyses elicited a 4-factor solution composed of Interpersonal-testing (IT), Interpersonal-change (IC), Self-renunciation (SR) and Self-sustenance (SS). These factors were classified according to two distinctions, namely interpersonal vs. intra-personal directedness, and the level of assumed influence by SB or the relationship to prevailing emotions. Analyses revealed meaningful links between patient features and clinical variables. Interpersonal-motivations (IT and IC) were associated with overt aggression, low suicidality and RLE discord or conflict, while SR was associated with depression, high suicidality and RLE separation or death. Borderline personality disorder showed association with IC and SS. When self-strangulation was set as a reference SB method, self-cutting and overdose-taking were linked to IT and SS, respectively.

Conclusions

The factors extracted in this study largely corresponded to factors from previous studies, implying that they may be useful in a wider clinical context. The association of these features with SB-related factors suggests that they constitute an integral part of the process leading to SB. These results provide a base for further research into clinical strategies for patient management and therapy.

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.

Parasuicide among Indian Adolescents: Some Cultural Perspectives

From the significant amount of research devoted to parasuicide it is evident that parasuicidal adolescents experience many unique problems. There is however a paucity of research in this regard on South African Indian patients. Culturally oriented research is necessary in order to gain a better understanding of the problems facing these patients, and for appropriate management and ultimate prevention of parasuicide. Accordingly a preliminary study of parasuicide among Indian adolescents was undertaken. The patients ( N = 54) were mostly older adolescent females who engaged in self-poisoning by overdose of medicinal substances. Culturally rooted authoritarian parenting and the effects of acculturation emerged as important causal considerations and are discussed in relation to the aetiology of parasuicidal behaviour in this group of patients.

Why Do Adolescents Self-Harm?

BACKGROUND

Given the high rates of self-harm among adolescents, recent research has focused on a better understanding of the motives for the behavior.

AIMS

The present study had three aims: to investigate (a) which motives are most frequently endorsed by adolescents who report self-harm; (b) whether motives reported at baseline predict repetition of self-harm over a 6-month period; and (c) whether self-harm motives differ between boys and girls.

METHOD

In all, 987 school pupils aged 14-16 years completed a lifestyle and coping questionnaire at two time points 6 months apart that recorded self-harm and the associated motives.

RESULTS

The motive "to get relief from a terrible state of mind" was the most commonly endorsed reason for self-harm (in boys and girls). Interpersonal reasons (e.g., "to frighten someone") were least commonly endorsed. Regression analyses showed that adolescents who endorsed wanting to get relief from a terrible state of mind at baseline were significantly more likely to repeat self-harm at follow-up than those adolescents who did not cite this motive.

CONCLUSION

The results highlight the complex nature of self-harm. They have implications for mental health provision in educational settings, especially in relation to encouraging regulation of emotions and help-seeking.

Suicide, Suicide Attempts, and Suicidal Ideation

Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-to-action framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.

How do clinicians and suicide attempters understand suicide attempt impulsivity? A qualitative study

Inconsistencies in the definition of impulsive suicide attempts hamper research integration. To expand the currently limited data on how this construct is used in clinical practice, researchers interviewed eight suicide attempters to create timelines of their suicide process, then had seven experienced clinicians review these timelines. Thematic analysis of the patient and clinician data revealed three themes: "thinking out," build-up, and unclear intentionality. The results imply that assessing build-up of agitation and exhaustion symptoms can contribute to understanding acuteness of suicide risk. In addition, uncertainty about one's intentions during the attempt should not be equated to low intent to die.

Predictors of suicide attempt status: acquired capability, ideation, and reasons

The present study compared Non-Attempters, Recent Attempters, and Distant Attempters on the following three constructs: Acquired capability for suicide, reasons for attempting suicide (internal perturbation based reasons vs. extrapunitive/manipulative reasons), and suicidal ideation. Participants were 40 Non-Attempters, 28 Recent Attempters, and 32 Distant Attempters at three state psychiatric hospitals. The sample consisted of 63 males and 37 females ranging in age from 18 to 63 years (M = 35.84, SD = 11.44). All patients completed the self-report measures. There were significant differences between the groups on suicidal ideation and acquired capability for suicide. The results of the present study indicate that acquired capability and reasons for attempting suicide have considerable importance for understanding suicide risk. Integration of acquired capability for suicide and reasons for attempting suicide into assessment and treatment is warranted.

Reliability and validation of the Hebrew Version of the Reasons for Attempting Suicide Questionnaire (RASQ-H) and its importance for mental pain

This study evaluated the Hebrew Reasons for Attempting Suicide Questionnaire (RASQ-H) and its application for suicidality, and mental pain and its tolerance. The sample comprised 97 participants who were inpatient suicide attempters, inpatient nonattempters, or nonpatient controls. Differentiation of the RASQ into internal perturbation-based reasons and extrapunitive/manipulative motivations factors was confirmed, with each scale demonstrating strong internal reliability. While the internal perturbation-based reasons factor related positively to some suicidal manifestations, to mental pain, and to lower mental pain tolerance, the extrapunitive/manipulative motivations factor mostly associated with lower suicidality and had fewer and smaller associations with mental pain and its tolerance.

Concordance of clinical estimation of suicidal intent

Objective: The aim of this paper is to assess the level of agreement between clinical estimates of suicidal intent based entirely on information recorded in the Accident and Emergency acute assessment and Beck's Suicide Intent Scale (SIS) scores.

Method: As part of the WHO/EURO Multicentre Study of Parasuicide, cases of deliberate self-harm (DSH) in Cork city hospitals were monitored. Over the period 1995-1997, the information recorded in the Accident and Emergency acute assessment was examined by a psychiatrist and, if possible on the available evidence, clinical estimates were made at three levels of suicidal intent: minimal, moderate and definite. Seventy-nine of these cases had fully completed Beck's SIS. Statistical comparison was made between the results of the SIS and the clinical estimate of suicide intent.

Results: The agreement (Kappa = 0.146, p = 0.046) and concordance (Lin's concordance coefficient = 0.330, p = 0.001) between the two ratings are statistically significant but both are low. The overlap between those identified as high or low intent is low.

Conclusions: These findings indicate low agreement between a clinician's rating of suicide intent based on clinical records and Beck's SIS. This is especially relevant given the increasing reliance on psychometric instruments in assessment in psychiatry. However, further investigation is necessary to clarify which is the more valid method.

Deliberate self-harm: a comparison of first-time cases and cases with a prior history

Objective: Eighty one patients admitted following deliberate self-harm were assessed using a semi-structured interview. The aim of the study was to compare clinical and social profiles of the 42 patients who had committed self harm for the first time with those of the 39 who had committed self harm in the past.

Method: The patients were assessed jointly by a psychiatrist and either a community psychiatric nurse or a social worker. A description of past suicidal behaviour, socio demographic information, medical and psychiatric history were recorded. Suicide intent was assessed both from the clinical interview and rated objectively using Pierce's suicide intent scale. Psychiatric diagnoses were made using the ICD 9 classification.

Results: The entire group had experienced difficulties in sustaining relationships. This problem was significantly more widespread in repeaters with increased use of physical violence in their relationship. More patients with a previous history claimed to have death wishes at the time of self harm, and asserted that they would harm themselves again compared with patients without a previous history. Clinical predictions regarding future self harming behaviour were in line with the patient's stated intentions.

Conclusion: The persistent desire to commit self harm and more widespread relational difficulties amongst the patients with a previous history suggests a need for different treatment strategies and outcome measures for the two groups.

Reasons for attempting suicide among a community sample of adolescents

The motives of suicide attempts among a community sample of 99 U.S. high school students were explored. Participants completed an in-depth computer-assisted self interview about their most recent attempts as well as additional psychosocial measures. Results indicated that nearly 75% of the adolescents engaged in suicide attempts for reasons other than killing themselves and that depressive symptoms and premeditation prior to the attempt were significantly associated with increased risk for engaging in the attempts with death as a clear motive. Linking motive for an attempt (death, interpersonal communication, emotion regulation) and treatment approach may improve prevention of subsequent attempts and completed suicides.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Assessing motivations for suicide attempts: development and psychometric properties of the inventory of motivations for suicide attempts

This study describes the psychometric properties of the Inventory of Motivations for Suicide Attempts (IMSA). The IMSA was designed to comprehensively assess motivations for suicide emphasized by major theories of suicidality. The IMSA was administered to two samples of recent suicide attempters, undergraduates (n = 66) and outpatients (n = 53). The IMSA exhibited a reliable two-factor structure in which one factor represented Intrapersonal motivations related to ending emotional pain, and the second represented Interpersonal motivations related to communication or help-seeking. Convergent validity and divergent validity of IMSA scales were supported by expected patterns of correlations with another measure of suicide motivations. In addition, the IMSA scales displayed clinical utility, in which greater endorsement of intrapersonal motivations was associated with greater intent to die, whereas greater endorsement of interpersonal motivations was associated with less lethal intent and greater likelihood of rescue. Findings suggest the IMSA can be of use for both research and clinical purposes when a comprehensive assessment of suicide motivations is desired.

Suicidality in the Veterinary Profession

Background: Suicide rates are elevated in the veterinary profession in several countries, yet little is known about possible contributory and preventive factors. Aims: To obtain information from veterinarians with a history of suicidal ideation or behavior about the factors associated with suicidality in their profession. Methods: We conducted a mixed-methods interview study with 21 UK veterinarians who had attempted suicide or reported recent suicidal ideation. Interview topics included work and nonwork contributory factors, coping mechanisms, and preventive factors. Results: Self-poisoning was the most common method used or considered by participants. Common contributory factors were workplace relationships, career concerns, patient issues, number of hours and volume of work, and responsibility, although two-thirds of participants reported co-occurring difficult life events. Around half had received a psychiatric diagnosis following their suicidal behavior. Several possible preventive measures were suggested by participants. Conclusions: Several work- and non-work-related contributory factors to suicidality in the veterinary profession were identified. Future preventive measures may involve better promotion of support services, formal support for recent graduates, and improving employers’ attitudes toward work-life balance.

What can be done to reduce mortality from paracetamol overdoses? A patient interview study

BACKGROUND

Paracetamol (acetaminophen) is the most common self-poisoning agent in the UK and a leading cause of fatal hepatotoxicity. Following legislation in 1998 to limit pack sizes, beneficial effects on paracetamol-related mortality and morbidity were reported in England. However, there are still over 100 deaths a year and evidence of breaches of sales guidelines.

AIM

To investigate characteristics of people taking larger paracetamol overdoses and compliance with sales guidelines, to inform possible further initiatives to reduce paracetamol fatalities.

DESIGN AND METHODS

Interview study of 60 general hospital patients who took overdoses of over 16 paracetamol tablets (8 g).

RESULTS

Half of all paracetamol overdoses involved over 16 tablets. Patients were predominantly young (three-quarters aged 16-40 years) and female (58.3%); over half (53.3%) had taken a previous paracetamol overdose. Three-quarters said they wanted to die. Half took the overdose within an hour of first thinking of it, half (53.3%) took tablets already in the home and 58.3% bought tablets specifically for the overdose. Ten people tried to buy more than 32 tablets in one transaction; four succeeded. Most knew that a paracetamol overdose could cause death or permanent damage (88.3%) and harm the liver (80.0%) but 70.0% thought they would lose consciousness. Warnings on packs had little deterrent effect. Media and internet influences were identified. Patients chose paracetamol because it was cheap and easily available.

CONCLUSIONS

Further measures to reduce breaches of sales guidelines and the dangers of paracetamol overdose are required. Media and internet site producers should follow guidelines on reporting suicide.

["Suicidal intentions": literature review and perspectives]

INTRODUCTION

Fifteen years ago, Baechler presented his "strategic theory of suicide". Following a viewpoint initiated at the end of the 1950's by Stengel and Cook, he proposed the more accomplished theoretical development of suicidal functions. We propose a critical review of international empiric literature following this approach.

METHOD

We carried out a bibliographic research on PsychINFO(®) databank, crossing terms of suicide attempt, deliberate self-harm and parasuicide, to reasons, motivations, functions, intentions. Thirty-one articles were selected. They cover a period ranging from 1971 to 2008, and from Europe to the USA.

RESULTS

Few studies have been conducted in France, but international literature has grown since 1970, and some questionnaires have been created: e.g. the Motives for Parasuicide Questionnaire (MPQ, Kerkhof et al., 1993 [28]) and the Reasons for Attempting Suicide Questionnaire (RASQ, Holden et al., 1998 [24]). The first intentions mentioned are internal perturbations type: to get relief, to escape, cannot endure situation or thoughts any longer, loss of control. They are often blended with interpersonal intentions: to make people understand what they felt, to seek help, to make things easier for others, while more aggressive, punitive or manipulative functions are seldom reported. Women report more reasons than men, but do not differ in their pattern of intentions. Suicide attempters report varying desire to die across studies. Some inconsistent distinctions can be made from age and gender but few from subjects' suicidal history.

DISCUSSION

One can wonder if subject's answers are really honest, particularly in regards to social desirability. Links between internal perturbations and suicidal intent, hopelessness, and depression are logically found, which aims to give evidence that, at least for this dimension, subjects give true answers, but which also point out the redundant aspect of some items of the suicidant functions scales (e.g. "to die"). Today, it turns out that this kind of research should be managed in France, by creating tools and questionnaires, validating existing ones and, internationally, by taking into account gender, age, and subjects' suicidal history to obtain more clear results.

CONCLUSION

So far, to our knowledge, this kind of review has never been conducted. Suicidal functions appear to be a rich and relevant approach to better understand suicide attempts, notably in a "suicidal crisis" perspective. In the future, some links with coping strategies and cathartic effect of the attempts could be made. We also point out that it could be relevant for psychotherapeutic care.

Reassessment of suicide attempters at home, shortly after discharge from hospital

BACKGROUND

Assessment of suicide attempters in a general hospital may be influenced by the condition of the patient and the unfavorable circumstances of the hospital environment.

AIMS

To determine whether the results of a reassessment at home shortly after discharge from hospital differ from the initial assessment in the hospital.

METHODS

In this prospective study, systematic assessment of 52 suicide attempters in a general hospital was compared with reassessment at home, shortly after discharge.

RESULTS

Reassessments at home concerning suicide intent, motives for suicide attempt, and dimensions of psychopathology did not differ significantly from the initial hospital assessment. However, patients' motives for the suicide attempt had changed to being less impulsive and more suicidal, worrying was significantly higher, and self-esteem was significantly lower. A third of the patients had forgotten their aftercare arrangements and most patients who initially felt no need for additional help had changed their mind at reassessment.

CONCLUSIONS

Results from this group of suicide attempters suggest that a brief reassessment at home shortly after discharge from hospital should be considered.

Non-suicidal and suicidal self-injurious behavior among Flemish adolescents: A web-survey

The present study investigated the prevalence of non-suicidal self-injury (NSSI) and suicidal self-injury (SSI) in a sample of 1,417 Flemish adolescents aged 12 to 18, as well as psychosocial differences between adolescents engaging in NSSI and adolescents engaging in SSI. Participants completed an anonymous online survey inquiring about NSSI and SSI functions, sociodemographic correlates, help seeking behaviors, and stressful life events. Lifetime prevalence of NSSI was 13.71% and SSI was 3.93%. No gender or age differences appeared between adolescents engaging in NSSI or SSI; however, differences in educational level were observed. Significant differences in functions of the behavior and number of stressful life events were noted between groups. Finally, the likelihood of receiving professional help differed between adolescents engaging in NSSI and adolescents engaging in SSI. Implications of the findings for assessment and treating NSSI and SSI are discussed.

How adolescents who cut themselves differ from those who take overdoses

The aims of this study were to identify in what ways adolescents who cut themselves differ from those who take overdoses, and to investigate the role of contagion in these behaviours. Data from an anonymous self-report questionnaire survey of 6,020 adolescents in 41 schools were analysed. Comparison of 220 adolescents who reported self-cutting in the previous year with 86 who had taken overdoses in the previous year as the sole method of deliberate self-harm (DSH) showed that far more of those who cut themselves had friends who had also engaged in DSH in the same period (OR 2.84, 95% CI 1.5-5.3, P < 0.001), and fewer had sought help from friends before cutting (OR 0.5, 95% CI 0.3-0.9, P < 0.02). Self-cutting usually involved less premeditation. Analyses at both the individual and school level showed that the association between engaging in DSH and exposure to DSH amongst peers was largely confined to girls who cut themselves. There are important differences between adolescents who cut themselves and those who take overdoses. Contagion may be an important factor in DSH by adolescents, especially in girls who cut themselves. These findings are relevant to the design of prevention and treatment programmes.

Distinguishing suicidal from non-suicidal deliberate self-harm events in women with Borderline Personality Disorder

OBJECTIVE

Deliberate self-harm (DSH) is common in Borderline Personality Disorder, may be due to a variety of reasons, and is associated with different degrees of suicidal intent. Understanding the reasons for episodes of DSH in this population may be helpful in developing interventions to reduce the rate of DSH or to assist in the clinical judgement of suicidal intention after DSH has occurred.

METHODS

The Parasuicide History Interview, version 2 (PHI-2) was used to determine the reasons for DSH events in 70 Australian women diagnosed with Borderline Personality Disorder. Factor analysis of the responses identified four empirically derived component factors. Multivariate models were developed to identify the independent predictors of suicidal deliberate self-harm (S-DSH) versus non-suicidal deliberate self-harm (NS-DSH) events.

RESULTS

Participants and raters showed strong agreement in classifying S-DSH and NS-DSH events. Methods used that involved self-poisoning, jumping or stabbing showed increased risk for S-DSH, adjusted odds ratio 12.07 (95% CI 2.17, 67.29), compared to the referent group, external damage to skin with no rescue contact being sought. Although no grouping of reasons were independently significant, the lower the effectiveness of the DSH event to resolve the reasons for the event, the higher the risk of it having been a S-DSH event.

CONCLUSION

In clinical situations, any Borderline Personality Disorder patient seeking help or medical attention, using any method other than superficial external injury to skin, or reporting a failure to effectively resolve the reasons for the DSH event, should be considered as likely to have had a S-DSH event (greater suicidal intention). However, specific reasons for the DSH event, or individual subject characteristics, did not meaningfully distinguish S-DSH from NS-DSH events.

Reasons for adolescent deliberate self-harm: a cry of pain and/or a cry for help? Findings from the child and adolescent self-harm in Europe (CASE) study

The present study examines reasons for adolescent deliberate self-harm. A cross-sectional survey using an anonymous self-report questionnaire was carried out in seven countries (Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway). Data on 30,477 school pupils between the ages of 14-17 were analysed. Past year and lifetime deliberate self-harm were assessed, along with the self-reported reasons for deliberate self-harm. The results showed that 'wanted to get relief from a terrible state of mind' and 'wanted to die' were most commonly reported. Principal component analysis indicated two underlying dimensions in the reasons for deliberate self-harm, i.e. a cry of pain motive and/or a cry for help motive. The majority of self-harmers reported at least one cry of pain motive ('to die', 'to punish myself', and 'to get relief from a terrible state of mind') and an additional cry for help motive ('to show how desperate I was feeling', to frighten someone', 'to get my own back on someone', 'to find out whether someone really loved me', and 'to get some attention'). Females reported more reasons than males. Only females showed an age difference, with girls aged 16-17 more frequently reporting a cry for help motive. There was considerable consistency in choice of motives across countries and genders. Systematic assessment of the reasons for deliberate self-harm can help clinicians to better understand the meaning of self harming behaviour, select appropriate treatment, suggest alternative coping strategies, and hopefully prevent future suicidal behaviour.

New Developments in the Understanding and Treatment of Suicidal Behaviour

Recent developments in the understanding, assessment and treatment of suicidal behaviour are reviewed. The accumulated social and demographic knowledge of suicidal populations has proved to be clinically useful in shaping the general level of concern, but at the individual level an understanding of the psychological processes involved in suicidal behaviour is required. Studies examining psychological processes involved in suicidal behaviour is required. Studies examining psychological processes in parasuicidal groups have revealed a number of deficits, including poor interpersonal problem solving, hopelessness about the future, and reduced ability to regulate affect. Research has also begun to look at some of the processes underlying these deficits, such as over-general retrieval of autobiographical memories and reduced anticipation of specific positive experiences. The clinical picture is now more optimistic, with therapies, such as Dialectical Behaviour Therapy, which focus on using problem solving strategies with those clients who are most vulnerable to repeat parasuicide episodes, producing demonstrable delays in parasuicide and reduced risk of repetition. The importance of the relationship between research and clinical practice is emphasized.

The influence of cognitive emotion regulation strategies and depression severity on deliberate self-harm

Elaborating on previous studies on emotion regulation and deliberate self-harm (DSH), in the present study we distinguish between strategies of cognitive content (e.g., suicidal cognitions of perceived burdensomeness, helplessness, poor distress tolerance) and cognitive process (e.g., nonacceptance of emotional responses, lack of awareness of emotional responses). Young women who harmed themselves (n = 85) were compared with young women without a history of DSH (n = 93) across a broad range of strategies. Significant group differences were found for all measures, even when depression severity was controlled for. In addition, logistic regression analyses showed that both cognitive content strategies and cognitive process strategies made significant independent contributions to the prediction of group membership. Controlling for depression severity, suicidal cognitions, and nonacceptance of emotional responses independently predicted DSH. The strong association between suicidal cognitions and DSH seems to indicate the important role of these cognitions in recurrent and chronic DSH. The strong association between nonacceptance of emotional responses and DSH underscores the notion that DSH can be a way to avoid emotional problems. These findings are discussed in relation to recent cognitive-behavioral interventions and specific therapeutic techniques to further insight into how these interventions might work.

Deliberate self-harm within an international community sample of young people: comparative findings from the Child & Adolescent Self-harm in Europe (CASE) Study

BACKGROUND

Deliberate self-harm among young people is an important focus of policy and practice internationally. Nonetheless, there is little reliable comparative international information on its extent or characteristics. We have conducted a seven-country comparative community study of deliberate self-harm among young people.

METHOD

Over 30,000 mainly 15- and 16-year-olds completed anonymous questionnaires at school in Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway. Study criteria were developed to identify episodes of self-harm; the prevalence of self-harm acts and thoughts, methods used, repetition, reasons given, premeditation, setting for the act, associations with alcohol and drugs, hospitalisation, and whether other people knew, were examined.

RESULTS

Self-harm was more than twice as common among females as males and, in four of the seven countries, at least one in ten females had harmed herself in the previous year. Additional young people had thought of harming themselves without doing so. More males and females in all countries except Hungary cut themselves than used any other method, most acts took place at home, and alcohol and illegal drugs were not usually involved. The most common reasons given were 'to get relief from a terrible state of mind' followed by 'to die', although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime.

CONCLUSIONS

Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally.

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

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

Paracetamol (acetaminophen) pack size restrictions and poisoning severity: time trends in enquiries to a UK poisons centre

BACKGROUND AND OBJECTIVE

In September 1998, legislation was introduced in the United Kingdom to limit paracetamol pack sizes to 16 tablets of 500 mg at general sales outlets and 32 tablets of 500 mg at pharmacies. The effect of the regulations on severity of paracetamol poisoning is unclear. The aim of this study was to describe trends in the severity of paracetamol poisoning and to assess the impact of the 1998 Regulations on the enquiries to a UK poisons centre.

METHODS

We extracted data about the age, sex and number of tablets or capsules of paracetamol ingested by patients notified to Guy's and St Thomas' Poisons Unit (London, UK) between 1996 and 2004.

RESULTS AND DISCUSSION

During the study period, there were approximately 140 000 patients with suspected paracetamol poisoning, accounting for around 11% of all patients reported to the poisons unit. The median number of tablets fell from 25 to 20 for males and 20 to 16 for females after 1998. There was also a reduction in the proportion of patients who ingested 17-32 tablets (from 36% to 30%) and 33-100 tablets (from 25% to 19%).

CONCLUSION

Following the 1998 Regulations there was a decline in the severity, but not frequency, of paracetamol poisoning cases reported to Guy's and St Thomas' Poisons Unit. It is unclear whether the decline in severity was a direct consequence of the regulations.

A study of self-harm in older people: mental disorder, social factors and motives

Data was collected on seventy-six older people who presented to a specialist self-harm team. Data included: diagnosis, suicide intent, motives for self-harm, social contacts and life events and difficulties. The majority of elderly who harmed themselves had high suicide intent and 69% were depressed. Patients were frequently living alone with an isolated life-style and poor physical health. Depressed self-harm subjects had higher suicide intent scores than non-depressed and to gain relief from an unbearable state of mind was a frequently recorded motive for these patients. Other motives for self-harm appear to be similar between depressed and non-depressed self-harmers. It is important that older people who self-harm receive an appropriate assessment of both risk and need by an experienced mental-health professional skilled at recognising depression in later life. The need for adequate recognition and management of depression in older people in primary care is also highlighted.

Motives and suicide intent underlying hospital treated deliberate self-harm and their association with repetition

The association between motives for deliberate self-harm (DSH), level of suicide intent, and history of DSH is poorly understood. As part of the WHO/EURO Multicentre Study on Suicidal Behavior, the Suicide Intent Scale, and the Motives for Parasuicide Questionnaire were administered to 146 patients presenting with DSH in the Cork region in Ireland. DSH patients reporting high suicide intent were more motivated to escape from their problem (M = 3.15, p < .001) compared to those with low suicide intent, who were more motivated to appeal to others (M = 1.61, p < .001) and to get a temporary break from their problem (M = 2.47, p < .001). Repeaters more often reported motives aimed at escape (M = 2.98, p < .01), revenge (M = .60, p < .005), and appeal (M = 1.43, p = <.05). Selfharming patients are characterized by ambivalence and struggle with aversive thoughts and situations. Therapeutic approaches should include distress management and coping strategies.

Suicide terrorists: are they suicidal?

Are suicide terrorists suicidal? A review of the worldwide literature on suicide terrorism uncovered five published empirical studies describing data collected from potential suicide terrorists or the surviving friends and families of deceased terrorists. The many discrepancies uncovered between suicide terrorists and other suicides on key factors known to underpin suicidality, suggest that such terrorists are not truly suicidal and should not be viewed as a subgroup of the general suicide population. Nonetheless, methods developed by suicidologists, such as the psychological autopsy, will help increase our understanding of the individual and group factors that underpin suicide terrorism.

Hope theory: a framework for understanding suicidal action

This article examines C. R. Snyder's (1994, 2000a) theory of hope and its application for understanding suicide. Strengths, weaknesses, and gaps in the suicide literature are outlined, and A. T. Beck's theory of hopelessness is compared with Snyder's hope theory. Hope theory constructs are used to examine the relationship of suicide to hope/hopelessness, goals, pathways thinking, and agency thinking. This critical review is intended to broaden our theoretical understanding of suicide and is meant to form the basis for future empirical investigation of suicide-related behavior using the framework of hope theory. Implications for suicide prevention programs and approaches to treating suicidal individuals are outlined.

The prevalence of suicidal phenomena in adolescents: a systematic review of population-based studies

The results of a systematic review of the international literature on the prevalence of suicidal phenomena in adolescents, including the influence of survey method, gender, and ethnicity are reported. The literature was searched using six electronic databases to identify all population-based studies of self-reported suicidal phenomena; 128 studies were included, comprising 513,188 adolescents. The mean proportion of adolescents reporting they had attempted suicide at some point in their lives was 9.7% (95% CI, 8.5-10.9), and 29.9% (95% CI, 26.1-33.8) of adolescents said they had thought about suicide at some point. Females were significantly more likely than males to report most suicidal phenomena. A lower prevalence of some suicidal phenomena was found for Asian populations. The prevalence of suicidal phenomena varied depending on the terminology used and tended to be higher in studies employing anonymous questionnaires than in studies employing non-anonymous methods (questionnaires or interviews), although most of these differences were not statistically significant.

A Comparative Study of Young and Adult Deliberate Self-Harm Patients

Abstract. Research has shown that the prevalence of deliberate self-harm (DSH) is higher in adolescents than in adults, but little is known about other differences. In this study we compare adolescent and adult DSH-patients regarding factors contributing to the suicidal act. In two regions in Norway, 98 persons under 20 years of age and 83 older persons were interviewed following an act of DSH. They were compared regarding intentions involved in the DSH, precipitating circumstances, level of suicidal intent, medical seriousness of the act, depression, hopelessness, and self-esteem. Few differences were found. The adults more often wanted to escape from unbearable thoughts or situations, or to receive care and attention. Adults also reported a slightly higher level of medical seriousness of the DSH act, more psychiatric problems, and substance abuse. The similarities between young and adult DSH-patients are striking. The differences found are most likely related to factors of age itself, such as cognitive immaturity, impulsivity, and lack of experience in enduring problems.

Psychological and Psychosocial Interventions After Attempted Suicide

Summary: A literature search was conducted to collect randomized controlled studies evaluating the outcome of psychological and psychosocial interventions after attempted suicide and deliberate self-harm. Twenty-five studies meeting the inclusion criteria were identified. The studies are grouped according to the psychological approach chosen for the intervention. They are discussed with regard to both the various therapeutic strategies and models used, and the repetition of self-harming behavior as the main outcome.

Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study

BACKGROUND

The aim of this study was to comprehensively examine clinical risk factors, including suicide intent and hopelessness, for suicide and risk of death from all causes after attempted suicide over a 12-year follow-up period.

METHODS

A systematic sample of 224 patients from consecutive cases of attempted suicide referred to health care in four Finnish cities between 1 January and 31 July 1990 was interviewed.

RESULTS

After 12 years of follow-up 22% of these patients had died, 8% by committing suicide. The only statistically significant risk factor for eventual suicide was high scores on Beck's Suicidal Intention Scale. Male gender, older age, physical illness or disability and high scores on Beck's Suicidal Intention Scale predicted death overall.

CONCLUSIONS

Following attempted suicide, high intention to kill oneself is a significant risk factor for both death from all causes and suicide.

Life events, motives, and precipitating factors in parasuicide among borderline patients

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.

Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents

OBJECTIVE

To compare motives and premeditation between adolescent deliberate self-poisoners and self-cutters.

METHOD

In a sample of 6,020 pupils aged 15 and 16 years who completed a self-report questionnaire, those who had deliberately cut themselves in the previous year (n = 220) were compared with those who had taken overdoses (n = 86).

RESULTS

More adolescents who took overdoses than those who cut themselves said that they had wanted to die (66.7% versus 40.2%, chi2 = 14.94, p <.0001) and had wanted to find out if someone loved them (41.2% versus 27.8%, chi2 = 4.14, p =.042). Female self-cutters were more likely than male self-cutters to say that they had wanted to punish themselves (51.0% versus 25.0%, chi2 = 9.25, p =.002) and had tried to get relief from a terrible state of mind (77.2% versus 60.9%, chi2 = 4.78, p =.029). More self-cutters than self-poisoners had thought about the act of self-harm for less than an hour beforehand (50.9% versus 36.1%, chi2 = 5.25, p =.021).

CONCLUSIONS

There are differences between adolescents' motives for overdoses and for self-cutting, and also gender differences in the reasons for self-cutting. The often impulsive nature of these acts (especially self-cutting) means that prevention should focus on encouraging alternative methods of managing distress, problem-solving, and help-seeking before thoughts of self-harm develop.

Why people engage in parasuicide: a cross-cultural study of intentions

Information obtained at interview from 1,646 parasuicide patients in 14 regions in 13 European countries participating in the WHO/EURO Multicentre Study on Suicidal Behaviour was used to study self-reported intentions involved in parasuicide. Comparisons were made across cultures, genders, and age groups. Although some statistically significant differences were found, the effect sizes were very small. The main finding from this study is thus that parasuicide patients in different countries tend to indicate that similar types of intentions are involved in their acts of parasuicide, and that the intentions do not vary greatly with gender or age. The hypothesis that rates of suicide and parasuicide vary between regions with the frequency with which suicidal intention is indicated by the patients was also tested, but was supported only for women and in relation to national suicide rates. The findings from this study are likely to be generalizable to other settings and have implications for clinical practice.

The Communicative Aspect of Nonfatal Suicidal Behavior— Are There Gender Differences?

Summary: Data from the Norwegian part of the WHO/EURO Multicenter Study on Suicidal Behavior were used to investigate gender differences in the communicative aspect of nonfatal suicidal behavior by means of analyzing precipitating factors, intentions involved in and effects of the suicidal act within the frame of Qvortrup's interpretation of speech-act theory. Eighty-nine patients (48 women and 41 men) were included in the analyses. Virtually no gender differences were found. Thus, in general, the results did not support the view that persons engaging in nonfatal suicidal behavior should receive different treatment or follow-up as a group based on their gender. The results gave some support to Qvortrup's speech-act theory and his four categories of suicidal behavior: emotional toward others, regulative toward others, emotional toward oneself and regulative toward oneself.

Studying survivors of nearly lethal suicide attempts: an important strategy in suicide research

The series of articles in this special issue of SLTB from the Centers for Disease Control and Prevention (CDC) study of nearly lethal suicide attempts represents an important contribution to research on suicidal behavior. The investigative approach used is attractive, yet also challenging in terms of research methodology. In this commentary I take the opportunity to highlight certain aspects of this line of research as well as to comment on the specific findings of the CDC study and their relationship to existing knowledge. I also discuss the future potential for this research approach and further questions that might be addressed by it.

Attempted suicide. Do we understand the patients' reasons?

This explorative study compared the patients', doctors', and nurses' views regarding their attribution of reasons for attempting suicide and the patients' emotional state immediately preceding their suicide attempts. A sample of 30 out of 94 consecutive patients seen in the emergency room of University Hospital were examined shortly after they had attempted suicide. Immediately after the routine clinical interview, conducted by a psychiatric resident and a nurse, patients filled in a questionnaire giving 14 possible reasons for attempting suicide as well as 8 feelings characterizing the emotional state preceding the suicide attempt. In the meantime, and without prior discussion of the case, the resident and the nurse independently completed the same questionnaire. In addition, sociodemographic and clinical data were obtained. Intrapersonal reasons such as to get relief from a terrible state of mind or from an unbearable situation were most frequently chosen by patients, nurses, and doctors alike. The most striking difference was found for "loss of control": this item was chosen significantly more often by patients than by nurses and doctors. Accordingly, patients reported significantly more often feelings of anxiety/panic and emptiness (mental vacuum), whereas feelings of despair and powerlessness/hopelessness were mentioned most frequently by nurses and doctors. Mental health professionals should bear in mind that many suicide attempters experience feelings of anxiety/panic prior to their suicidal act, and that a majority report having lost control over themselves, thus indicating a state of emotional crisis.