Anxiety,impulsivity and depressed mood in relation to suicidal and violent behavior

Many different variables have been associated with suicidal behavior as well as with violent behavior. This study was designed to test a model that attempts to relate such variables to violence and suicide risk. Sixty psychiatric patients were evaluated and divided into suicidal and nonsuicidal groups and then into violent and nonviolent groups. Scores on suicide risk, violence risk, anxiety, anger, impulsivity and mood were then compared between these groups. In a second analysis, scores on suicide risk and violence risk were correlated with all the other variables. Anxiety and impulsivity were found to strongly correlate with suicide risk. Angry and resentful mood correlated with violence risk; trait anxiety correlated negatively with violence risk. The results contribute further insight into the authors' two-stage model of countervailing forces.     

Correlates of suicide risk in adolescent inpatients who report a history of childhood abuse

The study objective was to examine correlates of suicide risk in psychiatrically hospitalized adolescents with a reported history of childhood abuse. Predictors of suicide risk were examined in 74 subjects who reported a history of childhood abuse and 53 depressed subjects who did not report a history of childhood abuse. Subjects completed a battery of psychometrically well-established self-report instruments to assess childhood abuse, suicide risk, and internalizing and externalizing psychopathology. Correlational analyses showed that higher levels of depression, self-criticism, and hopelessness were significantly associated with suicide risk in both study groups and violence was significantly associated with suicide risk in the childhood abuse group. For the childhood abuse group, multiple regression analyses with seven predictor variables accounted for 54% of the variance in suicide risk; depression and alcohol problems made significant independent contributions, while violence and self-criticism were independent predictors at the trend level. For the depressed/nonabused group, multiple regression analyses with the seven predictor variables accounted for 60% of the variance in suicide risk; depression, hopelessness, and self-criticism were independent predictors. Our findings suggest that both internalizing (i.e., depression or self-criticism) and externalizing (i.e., violence or alcohol) factors predict suicide risk in adolescent inpatients who report childhood abuse. This profile appears different from the more internalizing pattern (i.e., depression, self-criticism, and hopelessness) observed for the depressed adolescent inpatients who reported no history of childhood abuse.     

Correlates of risk of suicide in violent and nonviolent psychiatric patients

OBJECTIVE: This study was designed to identify variables that correlate with the risk of suicide in two patient groups that differ mainly in their level of expressed aggression. METHOD: Twenty-eight psychiatric patients with a history of violent behavior who were in a forensic psychiatric facility were tested and compared to 28 psychiatric inpatients without a history of violence who were admitted to a large municipal hospital. Measures used included a battery of self-report questionnaires, with acceptable reliability and validity, that provided indices of risk of suicide, risk of violence, impulsivity, anger, anxiety, and various mood states. RESULTS: The two groups, matched on demographic variables and overall risk of suicide, differed significantly on the measured risk of violence. The two groups showed similar patterns of correlations between risk of suicide and such variables as risk of violence, anger, fear, state and trait anxiety, lack of impulse control, suspiciousness, and rebelliousness. They differed in the correlation between suicide risk and depression. In the nonviolent patients there was a high correlation between risk of suicide and sadness; in the violent patients there was no correlation between these variables. CONCLUSIONS: The low correlation between sadness and risk of suicide in the violent patients, and the low prevalence of affective disorder diagnoses in these patients compared to other patients, suggests that suicidal risk should be managed differently in highly violent patients than in others.     

Suicide and violence risk

Thirty suicidal psychiatric inpatients were compared with 30 nonsuicidal psychiatric inpatients. A battery of self-report tests was administered measuring suicide risk, violence risk and coping styles. The suicidal patients scored higher on both the suicide risk and violence risk. They also used almost all coping styles less frequently than the nonsuicidal patients. Among suicidal patients, suicide risk was negatively correlated with the coping styles of minimization, replacement and blame. Further, suicide risk and violence risk in suicidal patients were shown to be predicted by coping styles. These data indicate that suicidal patients have inadequate mental resources to deal with life problems. Besides their significance for assessing suicide risk, the findings may have possible clinical implications for case detection and early intervention with potential preventive value.     

Prediction of suicidality and violence in hospitalized adolescents: comparisons by sex.

OBJECTIVE: To examine psychological correlates of suicidality and violent behaviour in hospitalized adolescents and the extent to which these associations may be affected by their sex. METHOD: A sample of 487 psychiatric inpatients (207 male, 280 female), aged 12 to 19 years, completed a battery of psychometrically sound self-report measures of psychological functioning, substance abuse, suicidality, and violent behaviour. We conducted multiple regression analyses to determine the joint and independent predictors of suicide risk and violence risk. In subsequent analyses, we examined these associations separately by sex. RESULTS: Multiple regression analysis revealed that 9 variables (sex, age, hopelessness, self-esteem, depression, impulsivity, alcohol abuse, drug abuse, and violence risk) jointly predicted suicide risk and that an analogous model predicted violence risk. However, we found several differences with respect to which variables made significant independent contributions to these 2 predictive models. Female sex, low self-esteem, depression, drug abuse, and violence risk made independent contributions to suicide risk. Male sex, younger age, hopelessness, impulsivity, drug abuse, and suicide risk made independent contributions to violence risk. We observed a few additional differences when we considered male and female subjects separately. CONCLUSIONS: We found overlapping but distinctive patterns of prediction for suicide risk and violence risk, as well as some differences between male and female subjects. These results may reflect distinct psychological and behavioural pathways for suicidality and violence in adolescent psychiatric patients and differing risk factors for each sex. Such differences have potential implications for prevention and treatment programs.     

Psychosocial risk factors associated with suicide attempts and violence among psychiatric inpatients

OBJECTIVES: To better understand the relationship between suicidal behavior and violence directed toward others among patients with major psychiatric disorders, this study examined how suicide attempts and violent behaviors were associated with various psychosocial problems. METHODS: Participants were inpatients in two psychiatric state hospitals. They included 216 inpatients who had physically assaulted another patient or a staff member and a comparison group of 81 inpatients who had not assaulted anyone. History of suicide attempts and historical information about various risk factors for violence and suicide were obtained through chart review and patient interviews. RESULTS: Patients in the violent group did not differ from those in the nonviolent group in whether they had attempted suicide. Suicide attempts and violence were associated with different historical variables. Suicide attempts were associated with a history of head trauma, harsh parental discipline, and parental psychopathology. Violence against others was associated with having a history of school truancy and foster home placement. CONCLUSIONS: Among inpatients with major psychiatric disorders, violence and suicide attempts were not related to each other and were associated with dissimilar psychosocial risk factors.     

Violence and suicide risk assessment in the psychiatric emergency room

Structured clinical rating scales covering 10 areas related to suicide and violence were constructed for use in a psychiatric emergency room (ER). Ninety-five ER patients were evaluated with the scales, 50 of whom were discharged after the visit and 45 of whom were admitted to the inpatient psychiatric wards of the hospital. The admitted patients were found to differ significantly from the discharged patients on every one of the 10 scales. Scores on the scales were also found to predict suicide precautions on the wards, harrassment of other patients as assessed from nursing notes, and indicators of violence on the wards. The scales were also found to have high internal reliability and high sensitivity and specificity. They appear to be helpful to clinicians in identifying patients in need of hospitalization and may also serve as limited predictors of hospital functioning.     

Cerebrospinal fluid monoamine metabolites and suicide

Prospective studies of the serotonergic system and suicide report that low 5-hydroxyindolacetic acid (5-HIAA) in the cerebrospinal fluid (CSF) and a history of attempted suicide predict suicide risk. Low CSF homovanillic acid (HVA) is reported to be associated with past and future lethality of suicide attempts but not with suicide. The interrelationships between monoamine metabolites, violent method, suicide intent and lethality of suicidal behaviour are complex. We hypothesized that CSF 5-HIAA and HVA levels are related to suicide intent, violence and lethality of suicidal behaviour. Fifteen male suicide attempters admitted to a psychiatric ward at the Karolinska University Hospital and eight healthy male volunteers were submitted to lumbar puncture and CSF 5-HIAA and HVA were assayed. Suicide intent with the Beck Suicide Intent Scale (SIS), lethality and violence of suicidal behaviour were assessed. All patients were followed up for causes of death. Six suicides and one fatal accident were identified with death certificates. Mean CSF 5-HIAA but not CSF HVA differed between suicides and survivors. Violent suicides had higher suicide intent and CSF 5-HIAA than non-violent suicides. In violent suicides, CSF 5-HIAA levels were negatively correlated with SIS. Greater suicide intent may be associated with greater aggressive intent and predicts a violent suicide method.     

Smoking and the risk of suicide

OBJECTIVE: To estimate the relationship between cigarette smoking and the risk of suicide. METHOD: The mortality of 36527 adult men and women was monitored for the mean 14.4 years. Information on deaths caused by suicide was obtained from the National Mortality Register. Suicides were subclassified by the level of violence used. Current smokers of 1-20 cigarettes per day were considered light/moderate smokers and heavy smokers were defined as those smoking > or =21 cigarettes per day. RESULTS: There were 134 suicides among 17798 men and 31 suicides among 18729 women. The most common suicide methods were hanging, firearms and drug overdose. According to the Cox model the adjusted relative risk of both violent and non-violent suicide was significantly and linearly increased among light/moderate and heavy smokers compared with non-smokers. CONCLUSION: Smoking was associated with an increased risk of suicide irrespective of the level of violence used.     

Psychopathology,self-esteem,sexual and ego functions as correlates of suicide and violence risk

The present study focused on the nature of the correlations between such ego functions as self-esteem. reality testing, and ego-strength and measures of suicide and violence risk. Also included were measures of sexual drive and conflict, as well as depression and impulsivity. Significant positive correlations were found between suicide risk and poor reality testing, sexual conflict, depression and impulsivity. Violence risk was significantly related only to the measure of sexual drive. Inverse correlations were found between suicide risk and both ego-strength and self-esteem. These findings arc interpreted in terms of a two-stage model of countervailing forces.     

Latent variable model for suicide risk in relation to social capital and socio-economic status

Background

There is little evidence on the association between suicide outcomes (ideation, attempts, self-harm) and social capital. This paper investigates such associations using a structural equation model based on health survey data, and allowing for both individual and contextual risk factors.

Methods

Social capital and other major risk factors for suicide, namely socioeconomic status and social isolation, are modelled as latent variables that are proxied (or measured) by observed indicators or question responses for survey subjects. These latent scales predict suicide risk in the structural component of the model. Also relevant to explaining suicide risk are contextual variables, such as area deprivation and region of residence, as well as the subject's demographic status. The analysis is based on the 2007 Adult Psychiatric Morbidity Survey and includes 7,403 English subjects. A Bayesian modelling strategy is used.

Results

Models with and without social capital as a predictor of suicide risk are applied. A benefit to statistical fit is demonstrated when social capital is added as a predictor. Social capital varies significantly by geographic context variables (neighbourhood deprivation, region), and this impacts on the direct effects of these contextual variables on suicide risk. In particular, area deprivation is not confirmed as a distinct significant influence. The model develops a suicidality risk score incorporating social capital, and the success of this risk score in predicting actual suicide events is demonstrated.

Conclusions

Social capital as reflected in neighbourhood perceptions is a significant factor affecting risks of different types of self-harm and may mediate the effects of other contextual variables such as area deprivation.     

Suicide and Auto-aggression,Depression, Hopelessness,Self-communication-- Results of a Prospective Study

From a cross-national perspective, the practice of combining suicide and homicide rates into (1) lethal violence rates and (2) the proportion of lethal violence expressed as suicide is questioned. Using age standardized data on suicide and homicide rates from 21 developed countries during 1955-1994, results show that, for both males and females, lethal violence rates are so closely correlated to suicide rates that the former offers no unique information. However, the proportion of lethal violence expressed as suicide is a variable worth exploring.     

Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt

An objective way to measure the severity of suicide attempt is to use different psychometric scales. Aspects of suicide risk like suicidal intent, depression, hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure. The aims of current study were: 1) to analyse the association between the severity of suicide attempt measured by suicidal intent scale and characteristics of emotional status of suicide attempters measured by depression, hopelessness and well-being scales in different gender and age groups; 2) to test the applicability of well-being measured by the World Health Organisation well-being index (WHO-5) in suicide risk assessment. The data on suicide attempters (n=469) was obtained in Estonia (Tallinn) by the WHO Suicide Prevention-Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used to measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression Inventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). All psychometric scales correlated well with each other (P<0.05). Low level of well-being associated with high level of suicidal intent, depression and hopelessness. Suicidal intent correlated the most strongly with well-being. Analysis by gender and age groups revealed also significant correlations with two exceptions only: correlation between suicidal intent and hopelessness did not reach the significant level in males and in older adults (40+). The WHO-5 well-being scale, which is a short and emotionally positively loaded instrument measuring protective factors, can be used in settings without psychological/psychiatric expertise in preliminary suicide risk assessment.     

Core schemas and suicidality in a chronically traumatized population

The Young Schema Questionnaire (YSQ) has been demonstrated to tap into core beliefs, or maladaptive schemas, of clinical populations. This study used the YSQ to investigate maladaptive schemas of 137 chronically traumatized patients seeking outpatient psychiatric treatment and to assess whether specific schemas might be associated with suicide risk in this population. Participants completed a modified version of the YSQ-S (short form), post-traumatic diagnostic scale, dissociative experiences scale and self-harm and risk behaviors questionnaire-revised at treatment intake. Significant correlations were found between most YSQ scales and the post-traumatic diagnostic scale, and between all YSQ scales and the dissociative experiences scale. Suicide risk variables were most highly correlated with the social isolation/alienation, defectiveness/shame and failure YSQ scales, suggesting that these schemas may mark individuals at particularly high risk for suicidal ideation and suicide attempts. These results offer important implications for the assessment and treatment of high-risk traumatized patients.     

Comparisons of Prisoners Who Make or Do Not Make Suicide Attempts and Further Who Make One or Multiple Attempts

Suicidal behavior among prisoners is a major problem. The objective of this study was to compare prisoners who have made an attempt at suicide vs non-attempters and further to compare single vs multiple suicide attempts. Among 1,537 prisoners, 200 (13%) had a lifetime history of attempting suicide and 92 (6%) had made multiple attempts. Those who had made multiple or single attempts were compared on socio-demographic, developmental, personality, forensic, and psychiatric variables. In a re-analysis we also compared non-attempters with attempters in this larger sample. The comparison showed that prisoners who had made multiple attempts had experienced significantly more childhood trauma, were more introverted, less resilient, had a history of self-mutilation, and had more suicidal ideation. Anger and hostility scores and criminal and violence histories significantly differentiated prisoners who had attempted from those who had never attempted but they did not differentiate multiple from single attempters. Having a history of multiple attempts may be indicative of more severe psychopathology in prisoners, as found in other populations. These findings may be helpful in predicting which prisoner is at increased risk of exhibiting suicidal behavior while incarcerated and after release.     

Treated and untreated suicide attempts in substance abuse patients

Suicidal behavior is a relatively common and serious problem in those with alcohol and drug problems. We compared demographic and clinical characteristics of 123 alcohol rehabilitation patients with and without a history of suicide attempts, using the Schedule for Affective Disorders and Schizophrenia-Lifetime version. Younger age was significantly related to suicide attempts, as were drug disorders, panic attacks, antisocial symptoms, and alcohol-related problems such as violence, withdrawal symptoms, and personal or occupational loss. Untreated suicide attempts were characterized by less serious suicidal intent and medical threat to life. However, alcohol- or drug-abusing individuals who have not sought treatment for suicidal behavior but who continue to drink or use drugs may be at special risk for completed suicide.     

Coping styles and suicide risk

A total of 30 psychiatric in-patients admitted because of suicidal behaviour were compared with 30 non-suicidal psychiatric in-patients and 32 healthy controls on measures of suicide risk and coping styles. The three groups were similar with regard to demographic variables, but the suicidal group scored higher on the suicide risk scale. Suicidal patients were significantly less likely to use the coping styles of minimization and mapping. They were unable to de-emphasize the importance of a perceived problem or source of stress. They also lacked the ability to obtain new information required to resolve stressful life events. Four coping styles correlated negatively with the suicide risk (minimization, replacement, mapping and reversal), while another three (suppression, blame and substitution) correlated positively. These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in these high-risk patients.     

Non-suicidal self-injury and suicidal ideation as predictors of suicide attempts in adolescent girls: A multi-wave prospective study

Although both suicide ideation (SI) and non-suicidal self-injury (NSSI) are known risk factors for suicidal behavior, few longitudinal studies have examined whether having a history of one or both of these factors prospectively predicts increased risk for suicide attempts. According to the theory of acquired capability for suicide, engagement in NSSI may reduce inhibitions around self-inflicted violence, imparting greater risk for suicide attempts among those with SI than would be observed in those with SI who do not have a history of NSSI. We used prospective data from the Pittsburgh Girls Study, a large community sample, to compare groups of girls reporting no SI or NSSI, SI only, or both NSSI and SI between early to late adolescence on any lifetime or recent suicide attempts in late adolescence and early adulthood. As compared to girls with no SI or NSSI history and those with only an SI history, girls with a history of both NSSI and SI were significantly more likely to subsequently report both lifetime and recent suicide attempts. Results are consistent with the acquired capability theory for suicide and suggest that adolescent girls who have engaged in NSSI and also report SI represent a particularly high-risk group in need of prevention and intervention efforts.     

Suicidal ideations and attempts among adolescents subjected to childhood sexual abuse and family conflict/violence: The mediating role of anger and depressed mood

Based on a sample of 9085 16- to 19-year-old students attending all high schools in Iceland in 2004, the current study examines depressed mood and anger as potential mediators between family conflict/violence and sexual abuse, on the one hand, and suicidal ideations and suicide attempts on the other. Agnew's general strain theory provides the theoretical framework for the study. Structural equation modelling (SEM) was conducted allowing explicit modelling of both direct and mediating effects using observed and latent variables. The findings showed that both depressed mood and anger mediated the relationship between family conflict/violence and sexual abuse and suicidal attempts. However, when testing the mediating pathways between sexual abuse and family conflict/violence and suicidal ideations, only depressed mood but not anger turned out to be a significant mediator. The authors discuss how these finding may inform and facilitate the design and development of interventions to reduce the likelihood of suicide attempts among young people.     

Suicide and violence in patients with major psychiatric disorders

The relationship between violence directed at the self and violence directed at others has intrigued psychiatrists for several decades. The goal of this study was to examine the relationship between suicide and violence against others in patients with major psychiatric disorders and to compare psychiatric symptoms associated with suicide in violent and non-violent patients. Subjects included physically assaultive psychiatric inpatients and a nonviolent comparison group. Physical and verbal assaults were recorded prospectively for 4 weeks. History of suicide attempts was obtained through chart review and patient interviews. The Brief Psychiatric Rating Scale was administered at the end of the 4 weeks by raters who were blind to both suicidal and violent behavior. The suicide attempters did not differ from the non-attempters on any measure of violent behavior or hostility. Suicide attempts were not accompanied by different symptoms in violent and non-violent patients; however, violence and suicide attempts were accompanied by dissimilar psychiatric symptoms. The physically assaultive patients presented with more severe positive psychotic symptoms than the non-assaultive patients. The suicide attempters, on the other hand, did not differ from non-attempters on psychotic symptoms, but presented with more severe depression and anxiety. The relationship between these symptoms and suicide attempts was noteworthy in its temporal stability, as most of the patients had attempted suicide many years prior to this study.