Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder.

OBJECTIVE: This paper has 3 objectives. First, we review the epidemiologic evidence for the association between suicidal behaviour and suicide in individuals diagnosed with antisocial, borderline, or narcissistic personality disorder. Second, we examine whether any potentially modifiable risk factors are associated with these diagnoses, based on existing empirical evidence. Last, we discuss clinical approaches to assessing youth with antisocial, borderline, or narcissistic personality disorder presenting at risk for suicide. METHOD: We reviewed the English-language literature for the last 12 years (from January 1, 1991, to December 31, 2002), using as search terms the names of the 3 disorders, as well as the key words suicide, suicidal behaviour, youth, and adolescents. RESULTS: Patients with antisocial or borderline personality disorder are likely to be at increased risk for suicidal behaviour when they demonstrate such comorbid disorders as major depressive episodes or substance abuse disorders, when they experience recent negative life events, or when they have a history of childhood sexual abuse. CONCLUSIONS: For patients with antisocial personality disorder, the risk of violence has to be judged in addition to the risk of suicide or self-harm. For patients with borderline personality disorder, interventions are determined by differentiating acute-on-chronic from chronic risk of suicidal behaviour. Finally, patients with narcissistic personality disorder can be at high risk for suicide during periods when they are not suffering from clinical depression. These episodes can seem to be unpredictable.     

Youth suicide: prevention through risk management

Risk factors for childhood and adolescent suicidal behavior are reviewed to point out important issues to focus suicide prevention strategies. Youth and family psychopathology involving suicidal behavior, violence, psychiatric disorders, including major depression, substance abuse, and psychosis, are the most significant risk factors for youth suicide and non-fatal suicidal acts. The availability of lethal means to commit suicide, especially guns and firearms, is a significant risk factor for youths, especially those without psychiatric disorders. Traits of impulsivity and cognitive concerns related to hopelessness and poor social adjustment increase suicide risk. Demographic characteristics, especially gender, age, and race/ethnicity, are associated with higher youth suicide rates. Contextual issues, including media exposure to suicide presentations and exposure to suicide of a peer or relative, increase the likelihood for suicidal ideation or suicidal acts. Prevention strategies should aim to decrease these risk factors by reliable methods of identification of risk factors, which can be targets for effective interventions.     

Crucial elements in suicide prevention strategies

Ways of conceptualizing suicide prevention are reviewed briefly, and the preventive model: Universal, Selected, and Indicated prevention (USI) is chosen as the structure for the literature review, and the discussion. Universal preventive interventions are directed toward entire population; selective interventions are directed toward individuals who are at greater risk for suicidal behaviour; and indicated preventions are targeted at individuals who have already begun self-destructive behaviour.On the universal prevention level, an overview of the literature is presented with focus on restrictions in firearms and carbon monoxide gas. At the selective prevention level, a review of risk of suicide in homelessness and schizophrenia and risk factors for suicide in schizophrenia is conducted and possible interventions are mentioned together with the evidence for their effect. Suicide rate and preventive measures in affective disorder are also touched upon. At the indicated prevention level, studies of fatal and non-fatal suicide acts after suicide attempt are mentioned. The evidence of preventive measures to reduce repetition rates is presented.Finally, the state of the art is discussed with regard to prevention at the universal, the selected and the indicated level and clinical and research implications are outlined.     

Suicide risk in mood disorders

PURPOSE OF REVIEW: The aim of this review is to highlight the traditional and newly recognized suicide risk factors in patients with mood disorders. RECENT FINDINGS: Current research findings clearly suggest that suicidal behaviour in patients with mood disorder is a 'state-dependent' phenomenon. Recently, there is, however, a growing body of evidence that besides the well accepted clinically explorable suicide risk factors in mood disorders (e.g., severe depression, prior suicide attempt, comorbid anxiety, substance use, personality disorders and so on), mixed state of depression could also be an important precursor of suicidal behaviour. This might be particularly true in unrecognized cases of bipolar depressives, when antidepressant monotherapy (unprotected by mood stabilizers or atypical antipsychotics) can worsen the clinical picture and rarely induce an aggressive or self-destructive behaviour. SUMMARY: In the majority of patients with mood disorders, suicidal behaviour is predictable and preventable, with a good chance. A careful and systematic exploration of suicide risk factors in patients with mood disorder helps clinicians to identify patients at high suicide risk. A successful, acute and long-term treatment of these patients substantially reduces the suicidal behaviour even in this high-risk population.     

Suicidality among Norwegian youth: Review of research on risk factors and interventions

Background and Aim: Published research on suicidality among Norwegian youth and publications describing interventions were summarized in order to access the current status of knowledge building via empirical research. Method: A systematic Medline search identified 29 studies on risk factors on the entire spectrum of suicidal phenomena from self-harm without suicidal ideation to completed suicide with the mean age at/under 25 years. A specialist Norwegian journal, Suicidologi, was searched for additional matter, especially interventions. Result: Most studies focussed on psychological and psychiatric risk factors of attempted suicide. Other suicidal phenomena, psychosocial and societal risk factors, and impact of interventions were hardly studied. Depression, previous suicidal behaviour, alcohol use and non-intact parental unit were consistent significant risk factors found in suicide and attempted suicide studies. Conclusion: Supporting non-intact parental units and the maintenance of intact parental units along with early detection and management of suicide attempts, depression and alcohol use should be targeted as suicide prevention interventions among adolescents.     

Overview of community-based studies of depression screening interventions among the elderly population in Japan

Objectives: In most Western and Asian countries, a higher risk of suicide is found among elderly people than those in other age groups. However, the treatment needs of elderly people who are at risk of committing suicide are not well understood. We conducted an overview of studies that assessed the impact of suicide prevention interventions on suicide rates in elderly people in Japan. We interpreted the results of these studies, as well as prominent findings associated with other successful interventions, within a framework of the suicidal process and preventive strategies.

Method: We assessed six quasi-experimental studies of community-based interventions providing universal depression screening, subsequent care, and education to elderly people in Japan, and performed a combined analysis of outcome data.

Results: Screening interventions were associated with lower suicide rates. We also found a gender difference in the response to subsequent psychiatric or primary care. Two types of interventions decreased the rate of suicide among elderly people: crisis helplines and screening interventions. These interventions featured a close link between universal, selective, and indicated prevention strategies, which reflect different approaches tailored to the size and risk profile of the target individuals.

Conclusion: Successful interventions appear to hinge on systematic links between multi-level prevention interventions. Multi-level interventions for depression screening may result in lower suicide rates among elderly individuals in communities, although primary care interventions alone appear to be insufficient in men. The benefit of linked multi-level prevention interventions may highlight the importance of the multiple steps and components of the suicidal process.     

Suicide,suicidality and suicide prevention in affective disorders

OBJECTIVE: It is well known that functional psychiatric disorders are one of the main causes of suicidal behaviour. This paper discusses the epidemiology and risk factors of suicidal behaviour in affective disorders and goes on to describe the treatment and prevention of such suicidal behaviour. METHOD: A narrative overview of relevant epidemiological and drug studies. RESULTS: About 60-70% of patients with acute depression experience suicidal ideas. There is a high incidence of suicide (10-15%) in depressive patients. Psychopharmacological treatment with antidepressants and/or mood stabilizers is the most successful approach to avoid the risk of suicidal behaviour. In addition, psychotherapeutic and psychosocial interventions are of importance. CONCLUSION: Suicidal behaviour and suicide must be considered when treating patients with affective disorders. The complex causation of suicidality has to be borne in mind when considering methods of suicide prevention. In order to obtain the best results, psychosocial, psychotherapeutic and psychopharmacological approaches should be combined, depending on the risk factors of each individual patient.     

Risk factors and study designs used in research of youths’ suicide behaviour—An epidemiological discussion with focus on level of evidence

Abstract

Introduction: Many different epidemiology study designs have been used to analyse risk factors for suicide behaviour. The purpose of this study was to obtain an insight into the current study design used in research on youths’ risk factors for suicide behaviour and to rank the studies according to level of evidence (LoE). Methods: We searched PubMed and psycINFO in order to identify relevant individual studies. Results: We included 36 studies of children and youth on suicidal behaviour and ideation—many rank low on LoE. For suicide, cohort design was often used, and mental illness (depression, substance abuse and severity of mental illness) was the most common risk factor. Cohort studies are ranked 2b, which is high according to LoE. For suicide attempts, survey was often used, and psychopathology, substance abuse and being exposed to suicidal behaviour were the most common risk factors. For suicidal ideation, survey was the only design used, and substance abuse and psychopathology the most common risk factors. Surveys are ranked 4, which are low according to LoE. Many risk factors were broad and unspecific, and standard definitions of outcome and exposure were rarely used. Conclusion: A good study of risk factors for suicidal behaviour would need a high LoE, as a high-powered longitudinal epidemiological study (cohort or case–control) of very specific risk factors. The factors would have high prevention potential, compared with more broad and unspecific risk factors, to which many people are exposed. We would recommend a cohort design (in high-risk populations) or a case–control design to identify risk factors, using clinical and/or register data instead of self-reported information, reporting adjusted estimates and using standard definition of suicidal outcome and risk factors.     

Risk factors for suicide and attempted suicide among young people

OBJECTIVE: Suicide rates in young people have increased during the past three decades, particularly among young males, and there is increasing public and policy concern about the issue of youth suicide in Australia and New Zealand. This paper summarises current knowledge about risk factors for suicide and suicide attempts in young people. METHOD: Evidence about risk factors for suicidal behaviour in young people was gathered by review of relevant English language articles and other papers, published since the mid-1980s. RESULTS: The international literature yields a generally consistent account of the risk factors and life processes that lead to youth suicide and suicide attempts. Risk factor domains which may contribute to suicidal behaviour include: social and educational disadvantage; childhood and family adversity; psychopathology; individual and personal vulnerabilities; exposure to stressful life events and circumstances; and social, cultural and contextual factors. Frequently, suicidal behaviours in young people appear to be a consequence of adverse life sequences in which multiple risk factors from these domains combine to increase risk of suicidal behaviour. CONCLUSIONS: Current research evidence suggests that the strongest risk factors for youth suicide are mental disorders (in particular, affective disorders, substance use disorders and antisocial behaviours) and a history of psychopathology, indicating that priorities for intervening to reduce youth suicidal behaviours lie with interventions focused upon the improved recognition, treatment and management of young people with mental disorders.     

Suicidal behavior-advances in clinical and neurobiological research and improvement of prevention strategies

Suicide is the 14^th leading cause of death worldwide. It is responsible for 1%-5% of all mortality. This article highlights the latest developments in universal, selective, and indicated prevention strategies. Concerning universal suicide prevention, current research has shown that strategies such as restricting access to lethal means (e.g., control of analgesics and hot-spots for suicide by jumping) and school-based awareness programs are most efficacious. Regarding selective prevention, substantial progress can be expected in psychological screening methods for suicidal behavior. The measurement of implicit cognition proved to be more valid in predicting future suicide attempts than classic clinical assessment. Latest developments are smartphone-based interventions and real-time monitoring of suicidal behavior. Great effort has been made to establish valid neurobiological screening methods (e.g., genetic and epigenetic risk factors for suicide, hypothalamic-pituitary-adrenal axis) without yielding a major bre-akthrough. Potentially, multiple biomarkers rather than a single one are necessary to identify individuals at risk. With regard to indicated prevention in form of psychopharmacological treatment, recent pharmacoepidemiological studies and meta-analyses have supported a protective role of antidepressants, lithium, and clozapine. However, the data concerning a specific anti-suicidal effect of these drugs are currently not consistent. Promising results exist for ketamine in reducing suicidal ideation, independently of its antidepressant effect. Concerning psychotherapy, recent findings suggest that psychotherapeutic interventions specifically designed to prevent suicide re-attempts are most efficacious. Specifically, cognitive behavioral therapy and psychodynamic therapy approaches proved to decrease the number of suicide re-attempts significantly.     

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews

Objective:

We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts.

Methods:

Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings.

Results:

No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%.

Conclusions:

Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.     

Suicide in mood disordered children and adolescents

This article reviews the risk factors for fatal and nonfatal suicidal behavior in children and adolescents. Numerous empirical studies suggest that mood disorders are among the most important risk factors for youth suicidal behavior. In addition, other psychosocial factors increase risk for youth suicidal behavior independent of mood disorders. Prevention strategies for suicidal behavior should incorporate methods to identify children and adolescents who suffer from major depressive, dysthymic, and bipolar disorders. Such strategies should identify children and adolescents who have a history of suicidal ideation and/or suicide attempts.     

Suicide risk in first episode psychosis: a selective review of the current literature

Many studies have confirmed that the risk of suicide in patients with first-episode psychosis (FEP) is high, and high rates of premature mortality, particularly from suicide, may occur in the early phases of schizophrenia. However, suicide rates are difficult to measure in FEP patients, even in carefully defined samples, and there is relatively little specific information about the risk of suicide at illness onset or retrospectively concerning the untreated psychotic period. This selected review of the literature investigates suicidal behaviour with particular regard to severe suicidality (plans and attempts) and risk factors associated with suicide in FEP patients. A search was performed to identify all papers and book chapters during the period 1965-2010, and approximately 100 studies met the inclusion criteria. Most of evidence suggests that risk of suicidal behaviour is relatively high in FEP patients. The research reports highlight the need for universal, comprehensive, public mental health interventions aimed, not only toward early detection, but also toward the rapid engagement in treatment of people with psychoses. These interventions should include an adequate assessment of suicidal behaviour in patients with FEP, and an examination of the efficacy of specific components of the interventions.     

Resilience as a focus of suicide research and prevention

Suicide is a major medical and social problem. Decades of suicide research have mostly focused on risk factors for suicidal behaviour while overlooking protective factors such as resilience that may help to address this important public health issue. Resilience is the capacity and dynamic process of adaptively overcoming stress and adversity while maintaining normal psychological and physical functioning. Studies conducted over the past 10–15 years suggest that resilience is a protective factor against suicide risk. Resilience is becoming a focus of suicide research and prevention. Building resilience should be a part of universal, selective, and indicated suicide prevention interventions. Promoting resilience may reduce suicide risk in the general population, in groups at elevated suicide risk, and among high‐risk individuals. Building resilience in the general population may reduce the incidence of stress‐related disorders and, consequently, suicidal behaviour. Improving resilience should be a part of a treatment plan of every psychiatric patient. Mental health professionals will probably have the best success in reducing suicide risk in psychiatric patients if they actively concentrate on increasing stress resilience using both psychosocial and pharmacological interventions. It is critically important to move forward the development of pharmacological and psychological interventions for enhancing resilience.     

Suicidal Behaviour Among Youth in Five Public Sectors of Care

Background:  Rates of suicidal ideation and behaviours as well as associated risk factors are examined among youth recruited from five public sectors of care (i.e. child welfare, juvenile justice, special education services, alcohol and drug services, and county mental health).
Method:  1057 youth (ages 11–18) completed a diagnostic interview and questionnaires assessing relevant suicide risk factors at baseline and 2-year follow-up.
Results:  While past year thoughts about death (28%) and talking about killing oneself (7.1%) were comparable to community norms, rates of lifetime suicide attempts (20.1%) were considerably higher in this sample. However, youth in the special education sector reported significantly more suicidal thoughts and behaviours relative to the other sectors. In multivariate analyses, longitudinal predictors of suicidality included major depression, female gender, and involvement in the special education sector.
Conclusions:  Efforts to implement screening and evidence based interventions for depression and suicide in the public sector, particularly special education services, are necessary.     

Teenagers' attitudes about coping strategies and help-seeking behavior for suicidality

OBJECTIVE: To identify youths' attitudes about coping and help-seeking strategies for suicidal ideation/behavior and examine their demographic and clinical correlates. METHOD: A self-report survey was completed by high school students (N = 2,419) in six New York State schools from 1998 through 2001. The relationship between suicide attitudes and gender, depression, substance problems, serious suicidal ideation/behavior, and first-hand experience with a suicidal peer was examined. RESULTS: Two factors that approximate avoidance and approach coping responses, maladaptive coping strategies and help-seeking strategies, respectively, were identified. Boys scored higher than girls (t = 7.96, df = 2341, p < .001), and depressed youths (t = 15.56, df = 2323, p < .001), students with substance problems (t = 11.07, df = 2340, p < .001), and suicidal youths (t = 15.14, df = 2341, p < .001) scored significantly higher than their healthy counterparts on the maladaptive coping strategies factor. Students with first-hand experience with a suicidal peer scored significantly higher on the maladaptive coping strategies factor than those without this experience (t = 7.95, df = 2321, p < .001). Lower risk groups scored significantly higher on an adaptive help-seeking strategies factor. CONCLUSIONS: High-risk adolescents' attitudes are characterized by core beliefs that support the use of maladaptive coping strategies in response to depression and suicidal thoughts and behaviors. Targeting such attitudes is a recommended component of youth suicide prevention efforts.     

Suicide and its prevention among older adults.

OBJECTIVE: To review the research on the epidemiology, risk and resiliency, assessment, treatment, and prevention of late-life suicide. METHOD: I reviewed mortality statistics. I searched MEDLINE and PsycINFO databases for research on suicide risk and resiliency and for randomized controlled trials with suicidal outcomes. I also reviewed mental health outreach and suicide prevention initiatives. RESULTS: Approximately 12/100,000 individuals aged 65 years or over die by suicide in Canada annually. Suicide is most prevalent among older white men; risk is associated with suicidal ideation or behaviour, mental illness, personality vulnerability, medical illness, losses and poor social supports, functional impairment, and low resiliency. Novel measures to assess late-life suicide features are under development. Few randomized treatment trials exist with at-risk older adults. CONCLUSIONS: Research is needed on risk and resiliency and clinical assessment and interventions for at-risk older adults. Collaborative outreach strategies might aid suicide prevention.     

Adolescent suicide: assessment and intervention

Understanding how to prevent suicide, the third leading cause of adolescent death, is the focus of this article. To prevent suicide, the nurse assesses risk factors, covert messages, overt suicide clues, and intervenes with the adolescent and family. Suicide risk and hopelessness decrease as suicidal youths learn to clarify problems, rally significant others, expand resources and use safe coping strategies. Interventions include a no-suicide contract, family therapy and school suicide prevention programs. Nurses can identify the youth at risk for suicide and, in many cases, provide the therapy that helps prevent suicide. Vignettes illustrate strategies that effectively reduce suicide risk.     

Suicide behaviour among Guyanese orphans: identification of suicide risk and protective factors in a low- to middle-income country

Objective: Suicide is the leading cause of death among youth in Guyana, a low- and middle-income country (LMIC), which globally ranks first in female adolescent suicides over the last decade. Worldwide, Guyana has experienced the largest increase in youth suicide, despite focused public health efforts to reduce suicide. Further, youth in Guyana, who are clients of the orphanage system and have faced early childhood trauma, may have an additive risk for suicide. Guided by an ideation-to-action theoretical framework for suicide prevention, the goal of the proposed research study is to describe and identify risk and protective factor correlates of youth suicidal behaviour among those at highest risk for suicide – orphans who reside in a LMIC institutional setting. Methods: In a preliminary sample of 25 orphan youth, one licensed psychologist and two social workers administered the DSM-5 Level 1 Cross-Cutting Symptom Measure and Behavioural Assessment Schedule for Children, 2nd Edition (BASC-2) during a semi-structured interview. Results: Nine of the 25 (36%) orphans reported a previous suicide attempt. Youth who endorsed suicidal behaviour had clinically elevated interpersonal relations scale scores when compared to youth who did not. Conclusions: Interpersonal skills may be protective for youth at highest risk for suicide.