The Additive Effect on Suicidality of Family History of Suicidal Behavior and Early Traumatic Experiences

Family history of suicidal behavior and personal history of childhood abuse are reported risk factors for suicide attempts and suicide completion. We aim to quantify the additive effect of family history of suicidal behavior and different subtypes of childhood abuse on suicidal behavior. We examined a sample of 496 suicide attempters, comparing individuals with family history of suicidal behavior and personal history of childhood (physical or sexual) abuse, individuals with family history of suicidal behavior only, individuals with history of early traumatic experiences only, and individuals with none of these two risk factors with regards to suicidal features. An additive effect was found for the age at the first attempt in suicide attempters with both family history of suicidal behavior and either physical or sexual abuse. No significant interactions were found between family history of suicidal behavior and childhood trauma in relation to any characteristics of suicidal behavior. Subjects presenting family history of suicidal behavior and childhood abuse attempt suicide earlier in life than subjects with just one or none of them, particularly if they were sexually abused. Other suicidality indexes were only partially or not associated with this combination of risk factors. A careful assessment of patients with both family history of suicidal behavior and childhood abuse could help to prevent future suicide attempts, particularly in young people.     

Is impulsivity a link between childhood abuse and suicide?

Childhood abuse and neglect are known to affect psychological states through behavioral, emotional, and cognitive pathways. They increase the risk of having psychiatric diseases in adulthood and have been considered risk factors for suicidal behavior in all diagnostic categories. Early, prolonged, and severe trauma is also known to increase impulsivity, diminishing the capacity of the brain to inhibit negative actions and to control and modulate emotions. Many neurobiological studies hold that childhood maltreatment may lead to a persistent failure of the inhibitory processes ruled mainly by the frontal cortex over a fear-motivated hyperresponsive limbic system. Multiple neurotransmitters and hormones are involved in the stress response, but, to our knowledge, the two major biological consequences of the chronic exposure to trauma are the hypofunction of the serotonergic system and changes in the hypothalamic-pituitary-adrenal axis function. Some of these findings overlap with the neurobiological features of impulsivity and of suicidal behavior. Impulsivity has also been said to be both a consequence of trauma and a risk factor for the development of a pathological response to trauma. Thus, we suggest that impulsivity could be one of the links between childhood trauma and suicidal behavior. Prevention of childhood abuse could significantly reduce suicidal behavior in adolescents and adults, in part, through a decrease in the frequency of impulsive behaviors in the future.     

Early Childhood Environment and Genetic Interactions: the Diathesis for Suicidal Behavior

Adverse childhood experiences are associated with higher risk for suicide and suicidal behavior later in life. There are known associations between childhood trauma, particularly sexual abuse, and higher rates of suicide, non-lethal suicide attempts, and non-suicidal self-injurious behaviors in adolescence and adulthood. Emotional abuse/neglect, disrupted parental attachment, and cumulative effect of multiple forms of maltreatment, also increase risk. Yet, the causal relationship remains unclear. The diathesis-stress model provides a framework for understanding how early life adverse experiences contribute to suicide vulnerability. Current findings from the fields of biology, neurology, and genetics shed new light on mediating variables and possible causal links between early childhood trauma and suicide. In this paper, we review recent advances, particularly regarding the interaction of early life environmental adverse events with genetics factors, that increase the diathesis for psychological traits are associated with subsequent deliberate self-harm behaviors.     

The relationship of childhood abuse to impulsivity and suicidal behavior in adults with major depression.

OBJECTIVE: This study investigated whether a higher frequency of reported childhood trauma would be found in depressed adults with higher levels of trait impulsivity, aggression, and suicidal behavior. METHOD: In 136 depressed adult inpatients, the authors assessed trait impulsivity, aggression history, and number of lifetime suicide attempts as well as the medical lethality and the intent to die associated with the most lethal attempt. These variables were then compared between those with and those without a reported history of childhood physical or sexual abuse. RESULTS: Subjects who reported an abuse history were more likely to have made a suicide attempt and had significantly higher impulsivity and aggression scores than those who did not report an abuse history. Impulsivity and aggression scores were significantly higher in subjects with a history of at least one suicide attempt. A logistic regression analysis revealed that abuse history remained significantly associated with suicide attempt status after adjustment for impulsivity, aggression history, and presence of borderline personality disorder. Among those who attempted suicide, there were no significant differences in severity of suicidal behavior between those with and without a childhood history of abuse. CONCLUSIONS: Abuse in childhood may constitute an environmental risk factor for the development of trait impulsivity and aggression as well as suicide attempts in depressed adults. Alternatively, impulsivity and aggression may be inherited traits underlying both childhood abuse and suicidal behavior in adulthood disorders. Additional research is needed to estimate the relative contributions of heredity and environmental experience to the development of impulsivity, aggression, and suicidal behavior.     

Sexual Abuse and Suicide: Why We May Not Know What We Think We Know

This article reviews the research on the relationship between a reported history of sexual abuse and subsequent suicidal behavior. Based on this review, it is suggested that a conclusion that childhood sexual abuse (CSA) is a significant risk factor for subsequent suicidal ideation, attempts, and completed suicides is premature. Identified limitations of the existing research include the lack of consistency in definitions of CSA and suicidality, issues related to sample selection and causality interpretations, and the absence of theoretical grounding.     

Preliminary report on childhood sexual abuse, suicidal ideation, and suicide attempts among middle-aged and older depressed women.

OBJECTIVE: Authors examined the relationship between childhood sexual abuse histories and suicidal ideation and behavior among depressed women age 50 years and older. METHODS: After admission to a psychiatric unit, participants were administered the Structured Clinical Interview for DSM-III-R and measures of suicidal ideation and behavior. RESULTS: Women who reported abuse histories were more likely to report suicidal ideation at the time of hospitalization and a history of multiple suicide attempts. CONCLUSIONS: These preliminary findings underscore the need for more study of how childhood abuse amplifies risk for suicidal ideation and behavior among women across the life course.     

Risk factors for suicide attempts among African American women

The aim of this study was to examine psychological and interpersonal risk factors for suicidal behavior in low income, African American women; 285 African American women who reported being in a relationship with a partner in the past year were studied, 148 presented to the hospital following a suicide attempt, and 137 presented for general medical care. Cases were compared to controls with respect to psychological symptoms, alcohol and drug abuse, family violence (intimate partner abuse, childhood trauma), relationship discord, and social support. Psychological risk factors for suicide attempts at the univariate level included psychological distress [Crude Odds Ratio (COR) = 6.5], post traumatic stress disorder (PTSD) symptoms (COR = 3.8), hopelessness (COR = 7.7), and drug abuse (COR = 4.2). Interpersonal risk factors at the univariate level included relationship discord (COR = 4.0), physical partner abuse (COR = 2.5), nonphysical partner abuse (COR = 2.8), childhood maltreatment (COR = 3.2), and low levels of social support (COR = 2.6). A multivariate logistic regression model identified four variables that were strongly and independently associated with an increased risk for suicide attempts: psychological distress, hopelessness, drug abuse, and relationship discord. The model predicted suicide attempt status correctly 77% of the time. The results reveal that African American women who report high levels of psychological distress, hopelessness, drug use, and relationship discord should be assessed carefully for suicidal ideation and referred for appropriate mental health care.     

Posttraumatic stress disorder comorbid with major depression: factors mediating the association with suicidal behavior

OBJECTIVE: The purpose of the study was to determine if patients with a history of major depressive episode and comorbid posttraumatic stress disorder (PTSD) have a higher risk for suicide attempt and differ in other measures of suicidal behavior, compared to patients with major depressive episode but no PTSD. In addition, to explore how PTSD comorbidity might increase risk for suicidal behavior in major depressive episode, the authors investigated the relationship between PTSD, cluster B personality disorder, childhood sexual or physical abuse, and aggression/impulsivity. METHOD: The subjects were 230 patients with a lifetime history of major depressive episode; 59 also had lifetime comorbid PTSD. The demographic and clinical characteristics of subjects with and without PTSD were compared. Multivariate analysis was used to examine the relationship between suicidal behavior and lifetime history of PTSD, with adjustment for clinical factors known to be associated with suicidal behavior. RESULTS: Patients with a lifetime history of PTSD were significantly more likely to have made a suicide attempt. The groups did not differ with respect to suicidal ideation or intent, number of attempts made, or maximum lethality of attempts. The PTSD group had higher objective depression, impulsivity, and hostility scores; had a higher rate of comorbid cluster B personality disorder; and were more likely to report a childhood history of abuse. However, cluster B personality disorder was the only independent variable related to lifetime suicide attempts in a multiple regression model. CONCLUSIONS: PTSD is frequently comorbid with major depressive episode, and their co-occurrence enhances the risk for suicidal behavior. A higher rate of comorbid cluster B personality disorder appears to be a salient factor contributing to greater risk for suicidal acts in patients with a history of major depressive episode who also have PTSD, compared to those with major depressive episode alone.     

Protective factors against suicidal behavior in depressed adults reporting childhood abuse

Most previous studies compared suicidal behavior in subjects with and without a history of childhood abuse, whereas less attention was paid to the comparison of suicide attempters and nonattempters among subjects reporting childhood abuse. To identify risk and protective factors against suicidal behavior, we compared suicide attempters with nonattempters among the sample of 119 depressed inpatients who reported childhood abuse. Compared with nonattempters, suicide attempters were younger, had more self-rated depression severity and suicidal ideation, higher trait aggression and more cluster B personality disorder comorbidity, less coping potential, and fewer moral objections to suicide (MOS)/religious beliefs. Logistic regression showed that more severe suicidal ideation and fewer MOS/religious beliefs were associated with suicidal acts in subjects with reported childhood abuse. Furthermore, suicidal ideation and MOS/religious beliefs were significantly inversely correlated. The results of this clinical study add support to previous reports that religious/spiritual coping could serve as an additional resource in prevention of suicidal behavior for subjects with reported childhood abuse.     

Violence against Native women in substance abuse treatment

Many mental health problems among substance abusing populations are directly linked to high rates of abuse and trauma. There is increasing evidence of associations between childhood physical and sexual abuse to adult substance use and HIV-risk behavior. The relationship of abuse, mental health problems, substance abuse, and high-risk sexual behavior has rarely been studied in the female Native American population. Significant relationships were found among childhood abuse, trauma, substance abuse, and high-risk sexual behavior among urban Native women.     

Risk factors for suicide attempts among alcohol dependent patients.

Suicidal behavior is a common and important problem among alcohol dependent patients. The study was designed to examine risk factors for attempting suicide in 499 alcohol dependent patients. Those who had attempted suicide (N = 198) were more likely to be female, report a family history of suicidal behavior, report more childhood trauma, report greater levels of aggressive behavior, began heavy drinking earlier, and were more likely to have received antidepressant medication. Logistic regression analysis showed that gender, family history, and childhood sexual abuse history made significant and independent contributions to the risk of a suicide attempt. Thus, developmental, personality, family history, social, and comorbidity risk factors may differentiate alcohol dependent patients who have attempted suicide from those who have not.     

Risk Factors for Suicide Attempts Among Alcohol Dependent Patients

Suicidal behavior is a common and important problem among alcohol dependent patients. The study was designed to examine risk factors for attempting suicide in 499 alcohol dependent patients. Those who had attempted suicide (N = 198) were more likely to be female, report a family history of suicidal behavior, report more childhood trauma, report greater levels of aggressive behavior, began heavy drinking earlier, and were more likely to have received antidepressant medication. Logistic regression analysis showed that gender, family history, and childhood sexual abuse history made significant and independent contributions to the risk of a suicide attempt. Thus, developmental, personality, family history, social, and comorbidity risk factors may differentiate alcohol dependent patients who have attempted suicide from those who have not.     

Exploring psychological abuse in childhood: II. Association with other abuse and adult clinical depression

A new retrospective interview assessment of childhood psychological abuse, an extension to the Childhood Experience of Care and Abuse (CECA) instrument, is described in a companion article (Moran, Bifulco, Ball, Jacobs, & Benaim, 2002). The purpose of the present article is to examine the relationship of childhood psychological abuse to other adverse childhood experiences and to major depression and suicidal behavior in adult life. Childhood experience and lifetime disorder were assessed retrospectively in a high-risk, community series of London women (n = 204). Psychological abuse from parents was examined in relation to seven other parental behaviors (neglect, antipathy, role reversal, discipline, supervision, physical abuse, and sexual abuse). Psychological abuse was significantly related to all seven behaviors. The highest associations found were to antipathy (gamma = .76), neglect (.73), and sexual abuse (.72). Factor analysis showed the existence of two factors reflecting care and control, with psychological abuse associated with both factors. Childhood psychological abuse was highly related to chronic or recurrent adult depression, with a "dose-response" evident for severity of abuse. The rates ranged from 83% for "marked" to 55% for "mild" abuse and 37% for "little/no" psychological abuse (p < .002). Psychological abuse was also related to lifetime suicidal behavior but here any level of abuse from marked to mild had similar rates (36% overall vs. 18% with no psychological abuse, p < .04). There was no evidence of specificity of childhood experience to adult depression; nearly all types of childhood adversity examined were significantly related. An analysis using an index of multiple abuse, including psychological abuse, showed a clear dose-response relationship to disorder. Somewhat fewer forms of maltreatment were related to suicidal behavior, but again multiples showed a clear dose-response effect.     

Family history of suicidal behavior and mood disorders in probands with mood disorders

OBJECTIVE: First-degree relatives of persons with mood disorder who attempt suicide are at greater risk for mood disorders and attempted or completed suicide. This study examined the shared and distinctive factors associated with familial mood disorders and familial suicidal behavior. METHOD: First-degree relatives' history of DSM-IV-defined mood disorder and suicidal behavior was recorded for 457 mood disorder probands, of whom 81% were inpatients and 62% were female. Probands' lifetime severity of aggression and impulsivity were rated, and probands' reports of childhood physical or sexual abuse, suicide attempts, and age at onset of mood disorder were recorded. Univariate and multivariate analyses were carried out to identify predictors of suicidal acts in first-degree relatives. RESULTS: A total of 23.2% of the probands with mood disorder who had attempted suicide had a first-degree relative with a history of suicidal behavior, compared with 13.2% of the probands with mood disorder who had not attempted suicide (odds ratio=1.99, 95% CI=1.21-3.26). Thirty percent (30.8%) of the first-degree relatives with a diagnosis of mood disorder also manifested suicidal behavior, compared with 6.6% of the first-degree relatives with no mood disorder diagnosis (odds ratio=6.25, 95% CI=3.44-11.35). Probands with and without a history of suicide attempts did not differ in the incidence of mood disorder in first-degree relatives (50.6% versus 48.1%). Rates of reported childhood abuse and severity of lifetime aggression were higher in probands with a family history of suicidal behavior. Earlier age at onset of mood disorder in probands was associated with greater lifetime severity of aggression and higher rates of reported childhood abuse, mood disorder in first-degree relatives, and suicidal behavior in first-degree relatives. CONCLUSIONS: Risk for suicidal behavior in families of probands with mood disorders appears related to early onset of mood disorders, aggressive/impulsive traits, and reported childhood abuse in probands. Studies of such clinical features in at-risk relatives are under way to determine the relative transmission of these clinical features.     

Depressed Suicide Attempters with Posttraumatic Stress Disorder

Posttraumatic stress disorder and major depressive disorder are well-established risk factors for suicidal behavior. This study compared depressed suicide attempters with and without comorbid posttraumatic stress disorder with respect to additional diagnoses, global functioning, depressive symptoms, substance abuse, history of traumatic exposure, and suicidal behavior. Adult patients consecutively admitted to a general hospital after a suicide attempt were interviewed and assessed for DSM-IV diagnosis and clinical correlates. Sixty-four patients (71%) were diagnosed with depression; of them, 21 patients (32%) had posttraumatic stress disorder. There were no group differences in social adjustment, depressive symptoms, or suicidal intent. However, the group with comorbid depression and posttraumatic stress disorder had more additional Axis I diagnoses, a higher degree of childhood trauma exposure, and more often reported previous suicide attempts, non-suicidal self-harm, and vengeful suicidal motives. These findings underline the clinical importance of diagnosis and treatment of posttraumatic stress disorder in suicide attempters.     

Characteristics of Cocaine Dependent Patients Who Attempt Suicide

There have been few studies examining risk factors for attempting suicide among cocaine dependent patients. Therefore, a large group of 406 abstinent cocaine dependent patients had a psychiatric interview and completed the Childhood Trauma Questionnaire. Patients who had or had never attempted suicide were compared on putative suicide risk factors. The results showed that 43.5% of the patients had attempted suicide. Attempters were younger; more were female; more reported childhood trauma, a family history of suicidal behavior, a history of aggression, treatment with antidepressant medication, and comorbidity with alcohol and opiate dependence. Logistic regression revealed that childhood physical abuse, childhood emotional negelect, comorbidity with alcohol dependence, and treatment with antidepressant medication were significant predictors of attempting suicide. Thus these results suggest that attempting suicide is common among cocaine dependent patients and that both distal and proximal risk factors may play a role.     

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.     

Neurobiology of suicidal behavior. An integration of biological and clinical findings.

Suicide is among the top ten leading causes of death in individuals of all ages. An explanatory model for suicidal behavior that links clinical and psychological risk factors or endophenotypes, to the underlying neurobiological abnormalities associated with suicidal behavior may enhance prediction, help identify treatment options and have heuristic value. Our explanatory model proposes that developmental factors that are biological (genetics) and psychological or clinical (early childhood adversity) may have causal relevance to the disturbances found in subjects with suicidal behavior. In this way, our model integrates findings from several perspectives in suicidology and attempts to explain the relationship between various neurobiological, genetic, and clinical observations in suicide research, offering a comprehensive hypothesis to facilitate understanding of this complex outcome.     

Diagnosis of childhood and adolescent suicidal behavior: unmet needs for suicide prevention.

This article highlights strategies for diagnosing risk for childhood and adolescent suicidal behavior. Empirical studies identifying risk factors for childhood and adolescent suicidal behavior guided recommendations for suicide risk assessment. Diagnostic assessment involves identification of multiple factors including demographic characteristics, suicidal behavior, psychopathology, interpersonal problems, family discord, family psychopathology, accessibility of lethal suicide methods, exposure to suicide, and protective factors. Interview methods and self-report questionnaires are reliable and valid in identifying suicidal risk but are limited by low base rates of suicide. Identification of risk factors as foci for intervention is important for suicide prevention.     

Prospective prediction of first lifetime suicide attempts in a multi-site study of substance users

Although considerable empirical work has been devoted to identifying risk factors for suicide attempts, most longitudinal research has studied recurrent attempts rather than first lifetime attempts. The present study sought to examine prospective predictors of first lifetime suicide attempts among adults receiving treatment for substance use. Data were drawn from the National Treatment Improvement Evaluation Study, a study of addiction treatment programs. Data were collected at treatment intake, treatment exit, and one year post-treatment. Patients (n = 3518) with no lifetime history of suicide attempts at treatment intake were followed at treatment exit and one year post-treatment, when they reported on the occurrence of suicide attempts since the prior assessment. Prospective suicidal behavior was assessed using logistic regression in relation to sociodemographic variables, health-related work impairment, history of psychiatric treatment utilization, history of suicidal ideation, history of depressive symptoms, substance use, and childhood abuse, assessed at intake. Health-related work impairment, history of suicidal ideation, and childhood physical abuse significantly predicted first lifetime attempts in a multivariate analysis. Suicidal ideation, health-related functional impairments, and childhood physical abuse may be particularly important in assessing risk for first lifetime suicide attempts. Findings suggest that future clinical work and research would benefit from considering these factors when identifying individuals at heightened risk of making a first suicide attempt.