Suicidal ideation in medical inpatients: psychosocial and clinical correlates

Objective

To identify psychosocial and clinical correlates of suicidal ideation in medical inpatients.

Method

In a cross-sectional study, all adults consecutively admitted to the medical wards of a University Hospital had their names recorded and were randomized and evaluated during the first week of admission. Suicidal ideation was assessed using Item 9 of Patient Health Questionnaire-9. The Beck Depression Inventory, the Beck Anxiety Inventory, the WHO Subjective well-being scale, the Charlson Comorbidity Index and other numerical rating scales (pain and self-reported physical illness severity) were used. Patients with less than four confidants were considered with poor social support. The Student's t test, Mann-Whitney U test, chi-square test and stepwise logistic regression analysis were used.

Results

Of the 1092 patients who composed the sample, 7.2% reported having suicidal ideation. After adjusting for psychosocial and clinical confounders, prior suicide attempts (OR: 4.41; 95% CI: 2.12–9.15; P<.001), depressive symptoms (OR: 1.11; 95% CI: 1.06–1.17; P<.001), severe anxiety symptoms (OR: 3.04; 95% CI: 1.47–6.26; P=.003) and poor social support (OR: 2.02; 95% CI:1.03–3.96; P=.04) were independently associated with suicidal ideation.

Conclusions

Three out of the four correlates of suicidal ideation in medical inpatients are potentially modifiable factors: severe anxiety, depressive symptoms and poor social support. The fourth variable, prior suicide attempts, is not modifiable but should serve as a red flag to suspect and investigate current suicide risk. These findings highlight the importance of suicidal ideation as a proxy for the distress that is incumbent upon physicians to manage if they wish to provide excellent and comprehensive inpatient care.     

Paranoia, persecutory delusions and attributional biases

An influential model of persecutory delusions put forward by Bentall and colleagues hypothesizes that persecutory-deluded patients avoid the activation of negative self-beliefs by making externalising, personalising attributions for negative events. The first study reported here used a new instrument for the measurement of persecutory ideation, the Paranoid, Persecutory and Delusion-Proneness Questionnaire, to investigate whether attributional biases are associated with subclinical persecutory ideation. The second study extended this investigation by re-examining associations between attributional biases and persecutory delusions. Both studies used the Internal, Personal and Situational Attributions Questionnaire to measure attributional style. No evidence was found for a connection between attributional biases and subclinical persecutory ideation. Furthermore, there was no support for an association between persecutory delusions and an externalising bias, and only marginal support for the hypothesized relationship between persecutory delusions and a personalising bias. These results suggest that the putative link between persecutory ideation and attributional biases only manifests (if at all) when persecutory ideation is of delusional intensity, and that it is confined to a personalising bias.     

Suicidal ideation and correlates in Taiwanese adolescent methamphetamine users

The aim of this study was to evaluate the prevalence of suicidal ideation and its correlates in adolescent methamphetamine (MAMP) users. Using the Epidemiological Version of the Kiddie Schedule for Affective Disorders and Schizophrenia, 200 adolescent MAMP users were assessed for suicidal ideation and psychiatric disorders during the preceding year. Demographic variables, family and peer interaction, characteristics of MAMP use, and personality were also evaluated. Factors correlating to suicidal ideation in adolescent MAMP users were analyzed by logistic regression. In the preceding year, 16% of adolescent MAMP users had suicidal ideation, and multiple factors, including illicit drug use among family members, depressive disorder, adjustment disorder, and emotional instability, correlated with suicidal ideation. Multiple factors, including family, psychopathology, and personality correlate with suicidal ideation in adolescent MAMP users. Subjects showing these characteristics should be monitored for suicidal ideation.     

Suicidal ideation and attempts in adolescents: associations with depression and six domains of self-esteem

This study aimed to disentangle the influence of depression and self-esteem on suicidal behaviour in adolescence. Grades 8 and 11 students in Cape Town, South Africa (n = 939) completed questionnaires assessing suicidal ideation and behaviour, depression, and self-esteem with respect to family, peers, school, sports/athletics, body image and global self-worth. Data were analysed using a series of multinomial logistic regression models adjusted for gender, grade, race and the sampling strategy. Results indicated that depression and low self-esteem in the family context were independently associated with suicide ideation and attempts. Moreover, low family self-esteem significantly differentiated suicide attempters from ideators. Screening for depression and low self-esteem in the family context is discussed as a possible strategy for helping to identify adolescents at risk for suicide attempts.     

The psychological effect of an urban environment on individuals with persecutory delusions: the Camberwell walk study

BACKGROUND: Epidemiological studies have found that individuals who live in urban areas are at increased risk of developing psychosis. However it is unknown whether exposure to urban environments exacerbates psychotic symptoms in people who have a diagnosed psychotic disorder. The aim of the study was to examine the psychological and clinical effects of exposure to one specific deprived urban environment on individuals with persecutory delusions. It was predicted that the urban environment would affect emotional and reasoning processes highlighted in a cognitive model of persecutory delusions and would increase paranoia. METHOD: Thirty patients with persecutory delusions were randomised to exposure to a deprived urban environment or to a brief mindfulness relaxation task. After exposure, assessments of symptoms, reasoning, and affective processes were taken. Thirty matched non-clinical participants also completed the study measures to enable interpretation of the test scores. RESULTS: In individuals with persecutory delusions, exposure to the urban environment, rather than participation in a mindfulness task, increased levels of anxiety, negative beliefs about others and jumping to conclusions. It also increased paranoia. The individuals with persecutory delusions scored significantly differently from the non-clinical group on all measures. CONCLUSIONS: For individuals with psychosis, spending time in an urban environment makes them think more negatively about other people and increases anxiety and the jumping to conclusions reasoning bias. Their paranoia is also increased. A number of processes hypothesised in cognitive models to lead to paranoid thoughts are exacerbated by a deprived urban environment. Further research is needed to clarify which aspects of urban environments cause the negative effects. Methodological challenges in the research area are raised.     

Attentional and memory bias in persecutory delusions and depression

BACKGROUND: Previous research has indicated that persecutory delusions and depression may share similar cognitive biases at implicit levels of processing, but differentiate at explicit levels, supporting the theory that paranoia may have a protective function against underlying negative schemata. The study aimed to investigate attentional bias and both implicit and explicit memory biases for personally salient and standardised emotional stimuli in persecutory delusions and depression. SAMPLING: 36 participants, with 12 in each group, were interviewed in order to generate personally salient stimuli to be employed within the cognitive tests. Standardised emotional stimuli were additionally employed as a control. Participants completed two probe detection tasks, one including personally salient stimuli and one including standard emotional stimuli. Memory for the stimuli presented in this task was assessed by a free recall task (explicit memory) followed by a word completion task (implicit memory). RESULTS: On an implicit memory task, both the deluded and depressed groups displayed comparable retrieval of positive and negative words. However, on the explicit memory task, the depressed group demonstrated a bias for negative stimuli, whereas the deluded group demonstrated a bias for positive stimuli. The groups did not demonstrate an attentional bias for personally salient information. However, an attentional bias for standardised emotional stimuli was found in the depressed group, although this was not specific to either negative or positive stimuli. CONCLUSION: The results indicate that depression and persecutory delusions may share similar patterns of processing at an implicit level but differentiate at the explicit level, which may be indicative of cognitive avoidance of threatening stimuli in psychosis. However, this does not seem to be a feature of automatic attentional processes in people with persecutory delusions. Implications for further research are discussed.     

Virtual reality and persecutory delusions: safety and feasibility

OBJECTIVE: Virtual reality (VR) has begun to be used to research the key psychotic symptom of paranoia. The initial studies have been with non-clinical individuals and individuals at high risk of psychosis. The next step is to develop the technology for the understanding and treatment of clinical delusions. Therefore the present study investigated the acceptability and safety of using VR with individuals with current persecutory delusions. Further, it set out to determine whether patients feel immersed in a VR social environment and, consequently, experience paranoid thoughts. METHOD: Twenty individuals with persecutory delusions and twenty non-clinical individuals spent 4 min in a VR underground train containing neutral characters. Levels of simulator sickness, distress, sense of presence, and persecutory ideation about the computer characters were measured. A one-week follow-up was conducted to check longer-term side effects. RESULTS: The VR experience did not raise levels of anxiety or symptoms of simulator sickness. No side effects were reported at the follow-up. There was a considerable degree of presence in the VR scenario for all participants. A high proportion of the persecutory delusions group (65%) had persecutory thinking about the computer characters, although this rate was not significantly higher than the non-clinical group. CONCLUSIONS: The study indicates that brief experiences in VR are safe and acceptable to people with psychosis. Further, patients with paranoia can feel engaged in VR scenes and experience persecutory thoughts. Exposure to social situations using VR has the potential to be incorporated into cognitive behavioural interventions for paranoia.     

Advances in understanding and treating persecutory delusions: a review

Purpose

Persecutory delusions are a central psychotic experience, at the severe end of a paranoia spectrum in the general population. The aim of the review is to provide an introduction to the understanding of persecutory delusions, highlight key putative causal factors that have the potential to be translated into efficacious treatment, and indicate future research directions.

Methods

A narrative literature review was undertaken to highlight the main recent areas of empirical study concerning non-clinical and clinical paranoia.

Results

Six main proximal causal factors are identified: a worry thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Each has plausible mechanistic links to the occurrence of paranoia. These causal factors may be influenced by a number of social circumstances, including adverse events, illicit drug use, and urban environments.

Conclusions

There have been numerous replicated empirical findings leading to a significant advance in the understanding of persecutory delusions, now beginning to be translated into cognitive treatments. The first trials specifically focussed on patients who have persecutory delusions in the context of psychotic diagnoses are occurring. Initial evidence of efficacy is very promising.     

The use of intuitive and analytic reasoning styles by patients with persecutory delusions

Background and objectivesA previous study has shown an association of paranoid thinking with a reliance on rapid intuitive (‘experiential’) reasoning and less use of slower effortful analytic (‘rational’) reasoning. The objectives of the new study were to replicate the test of paranoia and reasoning styles in a large general population sample and to assess the use of these reasoning styles in patients with persecutory delusions.Method30 Patients with persecutory delusions in the context of a non-affective psychotic disorder and 1000 non-clinical individuals completed self-report assessments of paranoia and reasoning styles.ResultsThe patients with delusions reported lower levels of both experiential and analytic reasoning than the non-clinical individuals (effect sizes small to moderate). Both self-rated ability and engagement with the reasoning styles were lower in the clinical group. Within the non-clinical group, greater levels of paranoia were associated with lower levels of analytic reasoning, but there was no association with experiential reasoning.LimitationsThe study is cross-sectional and cannot determine whether the reasoning styles contribute to the occurrence of paranoia. It also cannot be determined whether the patient group's lower reasoning scores are specifically associated with the delusions.ConclusionsClinical paranoia is associated with less reported use of analytic and experiential reasoning. This may reflect patients with current delusions being unconfident in their reasoning abilities or less aware of decision-making processes and hence less able to re-evaluate fearful cognitions. The dual process theory of reasoning may provide a helpful framework in which to discuss with patients decision-making styles.     

Suicidal ideation among patients with gender identity disorder

In this study, we tried to clarify the prevalence of suicidal ideation and self-mutilation including suicide attempts among patients with gender identity disorder (GID) and the relationship of those behaviors to demographic characteristics. A total of 500 consecutive Japanese GID patients without any other psychiatric comorbidity were evaluated at the outpatient GID Clinic of Okayama University Hospital. The lifetime rate of suicidal ideation was 72.0% of the total sample. There were no significant differences in the prevalence of suicidal ideation among groups divided by sex, age, age at onset or education. The lifetime prevalence of self-mutilation including suicide attempts was 31.8% of the total sample. Low level of education was significantly related to self-mutilation among both male-to-female and female-to-male GID patients. Younger age at onset was a significant factor affecting self-mutilation only among MTF GID patients. A lack of strategies to cope with severe distress among persons with lower education might induce a high frequency of self-mutilation including suicidal attempt. GID patients with a low level education might be at high risk of self-mutilation and should be watched with special attention to self-mutilation.     

Attributional style in schizophrenia: an investigation in outpatients with and without persecutory delusions

The attributional style of outpatients with schizophrenia with and without persecutory delusions was investigated. Thirty individuals with schizophrenia were divided into persecutory-deluded and non-persecutory-deluded groups based on a score of 5 or higher on the suspiciousness item from the Expanded Brief Psychiatric Rating Scale (BPRS-E). The two resulting groups, and a nonclinical control group, were administered a battery of attributional measures, and their attributional responses were coded by both the subjects themselves and a pair of independent raters. The results showed evidence of a self-serving bias for subjects with persecutory delusions; however, this bias was not unique to those with persecutory delusions, and it disappeared when independent raters evaluated subjects' causal statements on a reliable measure of attributional style. Subjects with persecutory delusions tended to show a stronger bias toward blaming others rather than situations for negative outcomes, and there was a linear association between persecutory ideation and a self-serving attributional style. Finally, there were significant discrepancies between the attributional ratings of the persecutory-deluded subjects and those of independent judges. Implications for future research are discussed.     

Suicidal ideation and risk factors in Korean migraine patients

Population-based studies have reported an increased risk of suicidal ideation in patients with migraine. However, there is some controversy as to whether migraine itself is a risk factor for suicidal ideation after adjusting for psychiatric comorbidities. We calculated the frequency of suicidal ideation among patients with migraine visiting a tertiary care hospital and determined its risk factors. Patients with migraine and healthy controls completed self-report questionnaires to assess depression, anxiety, and suicidal ideation, and the frequency of suicidal ideation. Risk factors for suicidal ideation were investigated in terms of demographic, clinical, and psychiatric variables. One hundred eighty-five patients with migraine (156 females and 29 males; mean age 39.1 years) and 53 age and education-matched healthy controls participated in the study. The frequency of suicidal ideation was significantly greater in patients with migraine than healthy controls (odds ratio [OR] = 5.09, 95% confidence interval [CI] 1.17–22.10, p = 0.003), but this significance was not sustained after adjusting for comorbid depression and anxiety. The risk of suicidal ideation in patients with migraine was associated with lower education levels, higher frequency of migraine attacks, stronger intensity of headaches, and presence of phonophobia, chronic migraine, depression, and anxiety. The strongest predictor was depression (OR = 15.36, 95% CI 5.39–43.78, p < 0.001), followed by the intensity of headache while completing the questionnaire (OR = 1.293, 95% CI 1.077–1.553; p = 0.006). The contribution of migraine-specific variables to suicidal ideation is trivial compared to that of depression and headache intensity.     

Self-attacking and self-reassurance in persecutory delusions: A comparison of healthy,depressed and paranoid individuals

Previous research has found that reduced self-reassurance and heightened verbal ‘self-attacking’ of a sadistic and persecutory nature are both associated with greater subclinical paranoia. Whether these processes are also linked to clinical paranoia remains unclear. To investigate this further, we asked 15 people with persecutory delusions, 15 people with depression and 19 non-psychiatric controls to complete several self-report questionnaires assessing their forms and functions of self-attacking. We found that people with persecutory delusions engaged in more self-attacking of a hateful nature and less self-reassurance than non-psychiatric controls, but not people with depression. Participants with persecutory delusions were also less likely than both healthy and depressed participants to report criticising themselves for self-corrective reasons. Hateful self-attacking, reduced self-reassurance and reduced self-corrective self-criticism may be involved in the development or maintenance of persecutory delusions. Limitations, clinical implications and directions for future research are discussed.     

大中学生自杀意念及相关心理变量研究

目的:探讨大中学生自杀意念与相关心理变量的关系。方法:采用分层取样法,对某市初二到硕士研究生一年级828名被试进行自杀意念量表(SSI)等量表测试。结果:①随年龄增长,大中学生自杀意念、企图呈下降趋势。女生自杀意念比男生多,而男生自杀行为能力比女生强;②有无自杀意念者在临床症状、人格因素、应对风格及生活满意度上差异均有统计学意义;③自杀意念与症状自评量表(SCL-90)各分量表、艾森克个性问卷(EPQ)神经质、精神质、应对检查表(COPE)诸多应对风格显著相关。结论:大中学生自杀意念与临床症状、应对方式、人格和生活满意度存在相关。