When people die by suicide: Introducing unacceptable loss thresholds as a potential missing link between suicide readiness states and actively suicidal clinical states

Ethological Problems with the Interpersonal Theory of Suicide

Joiner and colleagues' Interpersonal Theory of Suicide (IPTS), a prominent "desire-capability" model of suicide-based on the common-sense idea that people take their own lives because they want to, and can-is critiqued from a biological perspective. Tinbergen's ethological "four questions" guide the analysis: evolution, survival value, ontogeny, and proximate causation, each addressing a different aspect of biological understanding. Problems for IPTS emerge with all four. As a parsimonious solution, the desire-capability hypothesis is reconceived as an ultimate, instead of proximate, mode of explanation. By this light, desire and capability for suicide combined in our species' ancestral past, thus making suicide a recurrent survival threat, and driving the evolution of special-purpose defensive adaptations. This stance tallies with the pain-brain theory of the evolution of suicide, and with Joiner and colleagues' own investigation into organismic anti-suicide defenses, which appears to conflict conceptually with IPTS. These defenses' evolved algorithm may make suicide an intrinsically aleatory phenomenon, opaque to usefully accurate prediction. Positive implications for prevention and research are proposed.

Elevated interoceptive deficits in individuals with eating disorders and self-injurious thoughts and behaviors: A replication and extension

INTRODUCTION

People with eating disorders (EDs) frequently report self-injurious thoughts and behaviors (SITBs). We aimed to replicate and extend findings demonstrating greater interoceptive deficits according to SITB severity. We predicted that interoceptive deficits would be greater among people with versus without lifetime SITBs and among those with multiple suicide attempts compared with single attempts or nonsuicidal self-injury. We also predicted that interoception would be increasingly impaired with greater current suicidality severity.

METHOD

Adults (N = 118) seeking ED treatment reported current and lifetime SITBs upon admission to treatment. We used planned contrasts to compare interoceptive deficits (self-reported using the Eating Disorders Inventory) by SITB and current suicidality groups (assessed by self-report and clinical interview).

RESULTS

Interoceptive deficits were greater among people with any SITB history compared to those without. People with multiple suicide attempts did not differ in interoceptive deficits from those with single attempts or only nonsuicidal self-injury. Interoceptive deficits were elevated among those with any current suicidality compared to those with no suicidal symptoms; interoceptive deficits did not differ according to severity of suicidality.

CONCLUSION

Among those with EDs, interoceptive deficits are elevated among those with concurrent SITBs. Interventions aimed at improving interoception may reduce the risk for SITBs.

Fluidity in capability: Longitudinal assessments of suicide capability using ecological momentary assessments

INTRODUCTION

Suicide capability is posited to facilitate the movement from ideation-to-action. Emerging evidence suggests capability comprises both trait- and state-like facets. This study examined fluctuations in and associations of acquired, dispositional, practical, and perceived capabilities, and suicidal mental imagery, and suicidal ideation.

METHOD

Seventy-five adults (48 females, Mage = 36.53 years) with lived experience of suicidal ideation and/or attempt responded to four prompts per day for 2 weeks that assessed suicide capability and suicidal ideation. Mean-squared successive differences and probability of acute change indices and multilevel models were used for analyses.

RESULTS

All facets of suicide capability fluctuated. Acquired and dispositional capabilities were trait-like, with practical and perceived capabilities being state-like. Suicidal mental imagery was the only facet of suicide capability that distinguished participants with a suicide attempt in the past 12 months from participants with a suicide attempt more than 1 year ago and suicide ideators. Suicidal mental imagery was associated with concurrent suicidal ideation and predictive of next assessment suicidal ideation.

CONCLUSION

Suicidal mental imagery may be uniquely associated with suicide capability. This study suggests there are trait- and state-like facets of capability that can combine to potentially ready an individual to engage in suicidal behaviors.

Potential neuropsychological mechanism involved in the transition from suicide ideation to action - a resting-state fMRI study implicating the insula

BACKGROUND

Understanding the neural mechanism underlying the transition from suicidal ideation to action is crucial but remains unclear. To explore this mechanism, we combined resting-state functional connectivity (rsFC) and computational modeling to investigate differences between those who attempted suicide(SA) and those who hold only high levels of suicidal ideation(HSI).

METHODS

A total of 120 MDD patients were categorized into SA group (n=47) and HSI group (n=73). All participants completed a resting-state functional MRI scan, with three subregions of the insula and the dorsal anterior cingulate cortex (dACC) being chosen as the region of interest (ROI) in seed-to-voxel analyses. Additionally, 86 participants completed the balloon analogue risk task (BART), and a five-parameter Bayesian modeling of BART was estimated.

RESULTS

In the SA group, the FC between the ventral anterior insula (vAI) and the superior/middle frontal gyrus (vAI-SFG, vAI-MFG), as well as the FC between posterior insula (pI) and MFG (pI-MFG), were lower than those in HSI group. The correlation analysis showed a negative correlation between the FC of vAI-SFG and psychological pain avoidance in SA group, whereas a positive correlation in HSI group. Furthermore, the FC of vAI-MFG displayed a negative correlation with loss aversion in SA group, while a positive correlation was found with psychological pain avoidance in HSI group.

CONCLUSION

In current study, two distinct neural mechanisms were identified in the insula which involving in the progression from suicidal ideation to action. Dysfunction in vAI FCs may gradually stabilize as individuals experience heightened psychological pain, and a shift from positive to negative correlation patterns of vAI-MFC may indicate a transition from state to trait impairment. Additionally, the dysfunction in PI FC may lead to a lowered threshold for suicide by blunting the perception of physical harm.

Reflexive thematic analysis of job-related problems associated with pharmacist suicide, 2003-2019

BACKGROUND

Few qualitative studies have focused on suicide and specific job-related problems associated with suicide in pharmacists. Greater knowledge of specific work-related stressors amongst pharmacists could inform suicide prevention strategies.

OBJECTIVE

To identify job-related stressors associated with pharmacist suicides and compare stressors to those previously reported in physicians and nurses.

METHODS

Free-text law enforcement and medical examiner data for pharmacist suicides were extracted from the National Violent Death Registry (NVDRS) for 2003-2019. Reflexive thematic analysis was deployed via a deductive approach utilizing codes and themes found in previous research on nurse and physician suicides. New codes were also identified through inductive coding.

RESULTS

A total of 291,872 suicides occurred between 2003 and 2019, of which 392 were pharmacist deaths. Of these, 62 pharmacist suicides were coded with job-related problems. Almost all deductive themes/codes extracted from nurses and physicians were present in pharmacists. Common codes found in the pharmacist dataset that were also found previously in physicians and nurses were: history of mental health, substance use disorder, hopelessness impending or proceeding job loss, and access to lethal weapons and/or drugs. Novel codes were added through inductive content analysis. Codes novel to pharmacists were: verbalized suicidal ideation (SI) or intent, diversion for the purpose of suicide, and the fear of job loss. Disciplinary action at the institutional level was associated with the fear of job loss and cited as the event triggering suicide completion.

CONCLUSION

Pharmacists have similar job-related stressors associated with suicide as physicians and nurses. Evaluating the process of disciplinary action is warranted. Future research is indicated to evaluate causal relationship between work-related stressors and mental health outcomes leading to suicide in pharmacists.