Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completions: a systematic review

Objective: Involvement of personality traits in susceptibility to suicidality has been the subject of research since the 1950s. Because of the diversity of conceptual and methodological approaches, the extent of their independent contribution has been difficult to establish. Here, we review conceptual background and empirical evidence investigating roles of traits in suicidal behaviors. Method: We selected original studies published in English in MEDLINE and PsycINFO databases, focusing on suicidal ideation, suicide attempts, or suicide completions, and using standardized personality measures. Results: Most studies focused on investigating risk for suicide attempts. Hopelessness, neuroticism, and extroversion hold the most promise in relation to risk screening across all three suicidal behaviors. More research is needed regarding aggression, impulsivity, anger, irritability, hostility, and anxiety. Conclusion: Selected personality traits may be useful markers of suicide risk. Future research needs to establish their contributions in relation to environmental and genetic variation in different gender, age, and ethnocultural groups.     

The prevalence of aborted suicide attempts among psychiatric in-patients

We report the prevalence of aborted suicide attempts in which the essential characteristics are (i) intent to kill oneself, (ii) a change of mind before making an actual suicide attempt and (iii) the absence of physical injury. The lifetime history of aborted suicide attempts was assessed by semi-structured interview of 733 patients, aged 18–59 years, who were consecutively admitted to a psychiatric hospital. In the study group, 46% of subjects had made a suicide attempt and 29% had made at least one aborted attempt during their lifetime. Subjects who had made aborted attempts were more likely to have made actual attempts. Approximately 11% of the subjects in the study group had a history of aborted attempts of potential high lethality, such as going to a height in order to jump, or holding a gun to the head. There were no major demographic differences between those with and without a history of aborted attempts. However, among those with no prior history of actual attempts, subjects with depression and a family history of suicide were more than twice as likely as those without such a history to have made an aborted attempt. Aborted suicide attempts are a common suicidal behaviour among psychiatric in-patients. Whether they predict actual attempts or suicide warrants prospective investigation.     

Untreated psychotic illness in the survivors of violent suicide attempts

Background: Recent studies suggest that violence is more common in the first episode of psychosis than after treatment. Aim: To estimate the proportion of survivors of violent suicide attempts during psychotic illness who had not previously received treatment with antipsychotic medication. Methods: An audit of the medical records of patients admitted to an inner city trauma centre after having survived a jump of more than 3 m or a self‐inflicted gunshot wound or stab wound to a vital body part. Results: There were 88 survivors of violent suicide attempts. Thirty‐seven of those had a psychotic illness, including 33 with a schizophrenia‐spectrum psychosis. Of the 37, 18 (48.6%, 95% confidence interval (CI) 32.3–65.0%) had never received treatment for psychosis. Conclusion: As first episode psychosis is less common than previously treated psychosis, there appears to be a higher risk of violent suicide attempts during the first episode of psychosis than later in the illness.     

Premenstrual symptoms and luteal suicide attempts

Abstract. Objective: If premenstrual symptoms (PMS) are temporally and specifically associated with suicidal attempts, suicide attempts in women with PMS should occur more frequently in the luteal phase. Method: In a general hospital, 125 fertile female suicide attempters (and 83 blood donors as controls) with regular menstrual cycles were prospectively studied. A retrospective DSM-IV diagnosis of Premenstrual Dysphoric Disorder (PMDD) was made. Results: Attempts during the luteal phase were not more frequent in females with PMDD (34%,23/68) than in those without PMDD (35%, 20/57). The sample had enough power to detect medium and large effect sizes. As expected, there was a significantly higher frequency of PMDD in suicide attempters than in the controls (54% vs 6%; Fishers exact test, p 0.001). Conclusion: This study was limited by the use of retrospective PMDD diagnosis but suggests that PMDD may not be associated with suicidal acts during the luteal phase,when PMS are present.     

Rates and risk factors for suicidal ideation,suicide attempts and suicide deaths in persons with HIV: a systematic review and meta-analysis

BackgroundPeople living with HIV/AIDS (PLWHA) must contend with a significant burden of disease. However, current studies of this demographic have yielded wide variations in the incidence of suicidality (defined as suicidal ideation, suicide attempt and suicide deaths).AimsThis systematic review and meta-analysis aimed to assess the lifetime incidence and prevalence of suicidality in PLWHA.MethodsPublications were identified from PubMed (MEDLINE), SCOPUS, OVID (MEDLINE), Joanna Briggs Institute EBP and Cochrane Library databases (from inception to before 1 February 2020). The search strategy included a combination of Medical Subject Headings associated with suicide and HIV. Researchers independently screened records, extracted outcome measures and assessed study quality. Data were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted to explore the associated risk factors and to identify the sources of heterogeneity. Main outcomes were lifetime incidence of suicide completion and lifetime incidence and prevalence of suicidal ideation and suicide attempt.ResultsA total of 185 199 PLWHA were identified from 40 studies (12 cohorts, 27 cross-sectional and 1 nested case-control). The overall incidence of suicide completion in PLWHA was 10.2/1000 persons (95%CI: 4.5 to 23.1), translating to 100-fold higher suicide deaths than the global general population rate of 0.11/1000 persons. The lifetime prevalence of suicide attempts was 158.3/1000 persons (95%CI: 106.9 to 228.2) and of suicidal ideation was 228.3/1000 persons (95%CI: 150.8 to 330.1). Meta-regression revealed that for every 10-percentage point increase in the proportion of people living with HIV with advanced disease (AIDS), the risk of suicide completion increased by 34 per 1000 persons. The quality of evidence by Grading of Recommendations, Assessment, Development and Evaluations for the suicide deaths was graded as ‘moderate’ quality.ConclusionsThe risk of suicide death is 100-fold higher in people living with HIV than in the general population. Lifetime incidence of suicidal ideation and attempts are substantially high. Suicide risk assessments should be a priority in PLWHA, especially for those with more advanced disease.     

Clinical correlates of intent in attempted suicide.

The seriousness of suicide attempts was evaluated in 62 consecutive referrals in 2 general hospitals. As measured by the Suicide Intent Scale (SIS) the majority of cases had a low to moderate intention to die. Increasing age, psychosis and deliberate self-injury were associated with high suicidal intent. Hopelessness and a sense of isolation are significantly more frequent antecedent ideo-affective states in cases with high intent and anger and frustration are more prevalent in cases with low intent. Two other measures of seriousness, the medical condition on admission and lethality of the method used, correlate significantly with the degree of intent. The SIS can distinguish between relatively homogeneous subgroups of suicide attempters for depth studies of aetiology and management.     

Short-term stability of depressive symptoms and suicide attempts in Swedish adolescents.

The prevalence of depressive symptoms, suicidal ideation and their relationship to perceived health problems and social relations were examined in a sample of 605 Swedish adolescents aged 13-18 years. Short-term stability of depressive symptoms and the turnover rate from a nondepressed to a depressed state were examined for subsamples of 36 depressed and 71 nondepressed subjects, respectively, who were retested after 4 to 6 weeks. Using Beck's criteria for clinical depression, 9% of the adolescents experienced moderate to severe depressive symptom levels. However, a more conservative estimate, 4%, was obtained when DSM-III criteria for major depressive disorder were applied. Approximately 3% of the adolescents had pronounced suicidal ideation and had made at least one previous suicide attempt. There was a tendency for boys to show more stable depressive symptoms and suicidal ideation than girls. Furthermore, a set of 5 psychosocial variables concerning the students' satisfaction with their school and leisure time, conflictual level at home and number of close friends predicted 31% of the variance of the subjects' total depressive symptom scores. Although a 32% decrease of depressive symptoms was noted for the depressed subsample of adolescents, 44% of these subjects continued to experience moderate to severe depression at follow-up.     

Personality traits as prospective predictors of suicide attempts

Objective: To examine higher order personality factors of negative affectivity (NA) and disinhibition (DIS), as well as lower order facets of impulsivity, as prospective predictors of suicide attempts in a predominantly personality disordered sample. Method: Data were analyzed from 701 participants of the Collaborative Longitudinal Personality Disorders Study with available follow‐up data for up to 7 years. Cox proportional hazards regression analyses was used to examine NA and DIS, and facets of impulsivity (e.g. urgency, lack of perseverance, lack of premeditation and sensation seeking), as prospective predictors of suicide attempts. Results: NA, DIS and all facets of impulsivity except for sensation seeking were significant in univariate analyses. In multivariate models which included sex, childhood sexual abuse, course of major depressive disorder and substance use disorders, only NA and lack of premeditation remained significant in predicting suicide attempts. DIS and the remaining impulsivity facets were not significant. Conclusion: NA emerged as a stronger and more robust predictor of suicide attempts than DIS and impulsivity, and warrants greater attention in suicide risk assessment. Distinguishing between facets of impulsivity is important for clinical risk assessment.     

Evaluation of clinical prognostic models for suicide attempts after a major depressive episode

Objective: In this study, we compare the performance of prognostic models of increasing complexity for prediction of future suicide attempt. Method: Using data from a 2‐year prospective study of 304 depressed subjects, a series of Cox proportional hazard regression models were developed to predict future suicide attempt. The models were evaluated in terms of discrimination (the ability to rank subjects in order of risk), calibration (accuracy of predicted probabilities of attempt), and sensitivity and specificity of risk group stratification based on cross‐validated predicted probabilities. Results: Although an additive model with past attempt, smoking status, and suicidal ideation achieved 75% (cross‐validated) sensitivity and specificity, models that performed best in terms of discrimination included interactions between predictor variables. Conclusion: As several models had similar predictive power, clinical considerations and ease of interpretation may have a significant role in the final stage of model selection for assessing future suicide attempt risk.     

Attempted suicide predicts suicide risk in mood disorders

Suicide risk was studied in a sample of 346 mood disorder inpatients, 92 of whom were admitted after a current suicide attempt. The overall suicide mortality after a mean observation period of 6 years was 8%. The potential of attempted suicide to predict suicide risk in hospitalized patients with mood disorders was studied by survival analysis after subgrouping on the basis of whether a current suicide attempt had occurred or not. The suicide risk the first year after attempting suicide was 12% (11/92), compared with 2% (4/254) in the mood disorder subgroup with no current suicide attempt. The long-range suicide risk after a current suicide attempt in depression was 15% (14/92) as compared with 5% (13/254) among those without a current suicide attempt. It is concluded that a current suicide attempt in mood disorder inpatients predicts suicide risk particularly within the first year and should be taken very seriously.     

Age and attempted suicide

Clinical and demographic factors associated with suicide attempts admitted to the West Midlands Poisons Unit over a 2-year period were compared by age group. Risk factors for future suicide (living alone, physical illness, psychiatric illness and high suicidal intent in the attempt) were significantly more common among elderly patients (65 years and over) than middle-aged patients (35-64 years) and significantly less common among young patients (under 35 years) than middle-aged patients. Elderly patients that attempted suicide resemble elderly patients that completed suicide and should be considered at high risk of future suicide.     

Attempted suicide in hospitalised schizophrenics

A group of 25 hospitalised schizophrenics who had attempted suicide within the past year was compared with another group of 30 hospitalised schizophrenics who had not attempted suicide, using the PSE symptoms. The former had a significantly higher number of symptoms indicative of a depressive disorder. It is concluded that suicidal risk in schizophrenia is significantly raised when there are concomitant depressive symptoms.     

Survival analysis of suicide risk after attempted suicide

Survival analysis of suicide risk by sex and age after attempted suicide was studied in a cohort of 1573 suicide attempters referred to the psychiatric emergency room at the Karolinska Hospital from 1981 to 1988. The time course of suicide risk and the overall prognosis after attempted suicide and, in particular, the possible usefulness of sex and age as risk factors for the prediction of suicide risk after attempted suicide was analyzed. Nearly two thirds of the sample were women and most of the suicide attempters were young (in their twenties and thirties), and the median age was 35 years. The overall mortality after a 5-year mean observation period after attempted suicide was 11%, and the suicide mortality was 6 %. The suicide risk after attempted suicide among men (8.3%) was nearly twice the female suicide risk (4.3%). Age as a possible suicide risk factor was analyzed for each sex separately by median split subgrouping. It was concluded that both older and younger male suicide attempters are at high risk of suicide (7% and 10% respectively), and older women are at higher risk than younger (6%, vs 2%). The suicide risk is particularly high during the first year after the suicide attempt. The high suicide risk group of young adult male suicide attempters is one of the main feasible targets of psychiatric intervention research programs on suicidal behavior. Suicide among young men is a major cause of years of life lost.     

Age-specific characteristics of attempted suicide in adolescence

A total of 422 suicide attempts of adolescents (15 to 19 years of age) were investigated and compared with 327 suicide attempts of young adults. Adolescents had more serious social problems than young adults. Their adaptive problems became worse while growing older until the age of 20. Adolescents made suicide attempts with serious intent more often than young adults, but their suicide attempts were not as often lethal as in young adults. Although repeated suicide attempts were relatively common in both groups, only 10 people were part of both materials. Adolescents were as often psychotic when attempting suicide as young adults were. Twenty-four percent of adolescents and 26% of young adults were admitted to a psychiatric hospital as treatment.     

Suicide attempts by battered wives.

During an 8-month period a total of 117 battered wives, all seeking emergency surgical care, were identified. Twenty-two of the battered wives were found to have made 82 suicide attempts during the 16-year study period. This corresponds to an incidence more than 8 times that of an unselected population of women being treated because of attempted suicide in the same hospital. The suicide attempts were predominately passive methods. Although conflict with the husband was the most common triggering factor for the attempt, mental disorder of the woman was another main cause. It is concluded that the doctor, when confronted with a patient who has attempted suicide, always should consider the possibility of ongoing physical abuse. Although battering generally is not the only explanation, the physician should remember this possibility and the patient should, if necessary, be referred to proper care services.     

Selection of patients who attempted suicide for psychiatric consultation.

A total of 1018 self-poisoned patients were treated during one year (1983) at the emergency room of Helsinki University Central Hospital for 1207 suicide attempts; 46% were left without psychiatric consultation. Women were consulted more frequently than men. Patients with previous psychiatric treatment were referred more often for psychiatric consultation. The use of alcohol was more frequently present in suicide attempts that did not lead to psychiatric consultation. Somatic seriousness was also less severe in this group. It was assumed that those left without consultation were not in mortal danger. There were no differences in the suicide mortality of these 2 groups during a 5-year follow-up.     

抑郁症自杀未遂患者血清总胆固醇水平研究

目的:对抑郁症自杀未遂患者的血清胆固醇水平与自杀行为的关系进行研究。方法:对抑郁症患者进行血清胆固醇水平测定,其中伴自杀未遂行为者26例,不伴自杀行为者32例,以正常健康者30名为对照。结果:抑郁症伴自杀未遂行为组血清胆固醇水平明显低于无自杀行为组和正常对照组。血清胆固醇水平与自杀的严重程度呈明显负相关。结论:低血清胆固醇水平可增加抑郁症自杀的风险。推测低血清胆固醇导致的自杀行为可能与中枢5-羟色胺(5-HT)功能降低有关。     

Attempted suicide and suicide in functional psychoses.

A total of 2,243 first admissions to Gaustad Hospital between 1938 and 1961 diagnosed as functional psychotics were either followed up to the time of their death within 5 years, or observed over a period of 5 years, and then reexamined. Of these patients, 325 had attempted suicide prior to their admission. The frequency of attempted suicide was equal in both sexes. Men appeared to use more dangerous methods, and to have more serious intentions. The psychosis appears to have been of importance when considering whether, but not how the suicide should be attempted. The greatest risk of attempted suicide was to be found amongst patients with psychoses of a depressive nature. Twenty-eight of the 2,243 patients in this study committed suicide within 5 years following their discharge, and a further 20 took their own lives prior to the reexamination. A certain connection can be seen between attempted suicide and psychotic symptoms.     

Association of personal and familial suicide risk with low serum cholesterol concentration in male lithium patients.

OBJECTIVE: We sought to establish whether low cholesterol concentration may be associated with a personal history of attempted suicide or a family history of completed suicide in psychiatric out-patients on maintenance lithium treatment, who represent a population at risk for suicide. METHOD: We retrospectively reviewed charts regarding 783 out-patients consecutively admitted to a lithium clinic from 1976 to 1999. Individual age- and gender-specific quartile of serum cholesterol concentration were correlated against personal lifetime suicide attempts and completed suicide in first-degree relatives. RESULTS: The proportion of men with a personal lifetime history of attempted suicide, especially if violent, and that of men with history of completed suicide in a first-degree relative were significantly higher among the group with cholesterol concentration in the lowest quartile compared to the group with cholesterol levels above the 25th percentile. CONCLUSION: Low cholesterol concentration should be studied further as a potential biological/genetic marker of suicide risk.     

Personality disorder and suicide intent

Studies of suicide intent have found a link between seriousness of the attempt and personality. Following a parasuicide, 60 patients were assessed using measures of depression, suicide intent and personality. Personality disorder was found to be present in over 65% of these and was mainly of explosive type. It was significantly more common in men than women and the dimension measuring sociopathy was equivocally linked to male gender. There were no other associations between gender and the other dimensions measured. Using a categorical approach to personality, suicide intent was not significantly different between the categories of personality; there was no correlation between dimensional or categorical measures of personality and suicide intent, when the severity of depression was controlled. By itself personality did not contribute significantly in determining variance in intent but it did interact significantly with age.