Understanding ambivalence in help-seeking for suicidal people with comorbid depression and alcohol misuse

Understanding people's experiences of the formal health and social care system for co-occurring heavy alcohol use and depression through the lens of relational autonomy: A qualitative study

BACKGROUND AND AIMS

Heavy alcohol use and depression commonly co-occur. However, health and social care services rarely provide coordinated support for these conditions. Using relational autonomy, which recognizes how social and economic contexts and relational support alter people's capacity for agency, this study aimed to (1) explore how people experience formal care provision for co-occurring alcohol use and depression, (2) consider how this context could lead to adverse outcomes for individuals and (3) understand the implications of these experiences for future policy and practice.

DESIGN

Semi-structured qualitative interviews underpinned by the methodology of interpretive description.

SETTING

North East and North Cumbria, UK.

PARTICIPANTS

Thirty-nine people (21 men and 18 women) with current or recent experience of co-occurring heavy alcohol use ([Alcohol Use Disorders Identification Test [AUDIT] score ≥ 8]) and depression ([Patient Health Questionnaire test ≥ 5] screening tools to give an indication of their current levels of alcohol use and mental score).

MEASUREMENTS

Semi-structured interview guide supported in-depth exploration of the treatment and care people had sought and received for heavy alcohol use and depression.

FINDINGS

Most participants perceived depression as a key factor contributing to their heavy alcohol use. Three key themes were identified: (1) 'lack of recognition' of a relationship between alcohol use and depression and/or contexts that limit people's capacity to access help, (2) having 'nowhere to go' to access relevant treatment and care and (3) 'supporting relational autonomy' as opposed to assuming that individuals can organize their own care and recovery. Lack of access to appropriate treatment and provision that disregards individuals' differential capacity for agency may contribute to delays in help-seeking, increased distress and suicidal ideation.

CONCLUSIONS

Among people with co-occurring heavy alcohol use and depression, lack of recognition of a relationship between alcohol use and depression and formal care provision that does not acknowledge people's social and economic context, including their intrinsic need for relational support, may contribute to distress and limit their capacity to get well.

Event-Related Potential Markers of Suicidality in Adolescents

BACKGROUND

Implicit cognitive markers may assist with the prediction of suicidality beyond clinical risk factors. The aim of this study was to investigate neural correlates associated with the Death/Suicide Implicit Association Test (DS-IAT) via event-related potentials (ERP) in suicidal adolescents.

METHODS

Thirty inpatient adolescents with suicidal ideations and behaviors (SIBS) and 30 healthy controls from the community were recruited. All participants underwent 64-channel electroencephalography, DS-IAT, and clinical assessments. Hierarchical generalized linear models with spatiotemporal clustering were used to identify significant ERPs associated with the behavioral outcome of DS-IAT (D scores) and group differences.

RESULTS

Behavioral results (D scores) showed that the adolescents with SIBS had stronger implicit associations between "death" and "self" than the healthy group (P = .02). Within adolescents with SIBS, participants with stronger implicit associations between "death" and "self" reported more difficulty in controllability of suicidal ideation in the past 2 weeks based on the Columbia-Suicide Severity Rating Scale (P = .03). For the ERP data, the D scores and N100 component over the left parieto-occipital cortex had significant correlations. Significant group differences without behavioral correlation were observed for a second N100 cluster (P = .01), P200 (P = .02), and late positive potential (5 clusters, all P ≤ .02). Exploratory predictive models combining both neurophysiological and clinical measures distinguished adolescents with SIBS from healthy adolescents.

CONCLUSIONS

Our results suggest that N100 may be a marker of attentional resources involved in the distinction of stimuli that are congruent or incongruent to associations between death and self. Combined clinical and ERP measures may have utility in future refinements of assessment and treatment approaches for adolescents with suicidality.

Five-year mortality after hospitalisation for suicide attempt with a violent method

OBJECTIVE

This study aimed to estimate the 5-year mortality among people admitted into a transdisciplinary unit providing combined psychiatric and somatic rehabilitation treatment.

METHODS

In this retrospective study, we analyzed the clinical records of all individuals admitted into the transdisciplinary unit from 01/01/2011 to 12/31/2017 after a suicide attempt using violent means. Vital status was ascertained for these 215 people, a standardized mortality ratio (SMR) was calculated and Log-rank tests were used to identify factors associated with mortality.

RESULTS

The crude mortality rate was 5.12% (11 deaths) and the SMR was 15.45 (95% CI = [7.71-27.65]; p < 0.001) 5.40 years after admission into the transdisciplinary unit. Factors associated with mortality were: older age (29.91 years versus 25.30 years, p < 0.001), a longer stay in acute care (p = 0.002) and a shorter stay in the transdisciplinary unit (p < 0.001).

CONCLUSION

Long-term mortality among people who have attempted suicide using violent means is 15 times higher than in the corresponding general young adult population. This study supports the hypothesis that the severity of a suicide attempt is associated with subsequent excess mortality. Therefore, there is a need to consolidate outpatient facilities that provide appropriate support for this specific population after discharge. These programmes need to ensure the continuity of coordinated psychiatric and somatic care and psychosocial rehabilitation in order to prevent the risk of suicide.

Late-life suicide in an aging world

Suicide is an important problem among older adults and in particular older men. Risk factors for suicide in older adults include the loss of a loved one, loneliness and physical illness. Suicide in older adults is often attributed to the development of depression due to bereavement or loss of physical health and independence. However, suicide prevention in old age requires avoiding overly simplistic therapeutic approaches. This Perspective discusses the impact of social determinants of health, cultural narratives and the coronavirus disease 2019 (COVID-19) pandemic on suicide among older adults and proposes strategies for a multifaceted approach to suicide prevention.

Suicide in late life: A viewpoint

Suicide in old age represents a sad public health concern. Despite the global decline in rates of suicide and the general amelioration of quality of life and access to health care for older adults, their rates of suicide remain the highest virtually in every part of the world. With the aging of the world population and the growing number of mononuclear families, the risk of an increase in isolation, loneliness and dependency does not appear ungrounded. The Covid-19 pandemic is claiming the life of many older persons and creating unprecedented conditions of distress, particularly for this segment of the population. This article briefly examines the main characteristics of suicidal behavior in late life, including observations deriving from the spread of the Sars-2 coronavirus and possible strategies for prevention.

Thematic Co-occurrence Analysis: Advancing a Theory and Qualitative Method to Illuminate Ambivalent Experiences

Ambivalence is a phenomenon that transcends disciplinary divides and is associated with a myriad of mixed outcomes. Yet, identifying and representing the complexities of ambivalent experiences can be difficult using traditional qualitative methods. Thus, the goal of the present study was to advance a qualitative method, thematic co-occurrence analysis, to address this issue. To illustrate the usefulness of this method, I present a case study detailing 35 estranged adult children's ambivalent responses and reactions to their parents' (non)contact during the COVID-19 pandemic. Findings reveal seven themes and four (non)relationships between them that reflect (a) theme independence, (b) unilateral co-occurrence, (c) unbalanced co-occurrence, and (d) complementary co-occurrence. These findings advance a theory of ambivalence and corresponding method to aid in the future investigations of ambivalent phenomena.