Implicit Cognitions as a Behavioral Marker of Suicide Attempts in Adolescents

Using self-harm Implicit Association Tests (IATs), we sought to test whether (1) suicidal adolescents show implicit identification with self-harm and whether (2) IATs are reliable and sensitive to psychiatric change and (3) predict future suicide attempts. We administered 6 self-harm IATs to 71 adolescents from a psychiatric inpatient unit and assessed suicidal behaviors at admission, discharge and 3 months after discharge. Results were in the expected direction for each IAT but not statistically significant. After aggregating trials across IATs, suicide attempters showed increased implicit identification with self-harm, compared with non-suicidal controls. IATs showed good reliability and sensitivity to psychiatric change but did not prospectively predict suicide attempts. Adolescent suicide attempters may have stronger implicit associations with self-harm than non-suicidal controls.     

Suicidal behaviour,social networks and psychiatric diagnosis

Summary The aim of this investigation was to examine the relationship between social network deficits and the occurrence of suicidal behaviour, and to describe the short-term interpersonal consequences of a suicidal attempt. Two questionnaires, concerned with the extent and self-perceived adequacy of social network, formed the basis of a structured interview. Fifty-two suicide attempters were interviewed within 48 hours of their attempt, and again six weeks later, and undertook a weekly self-rating task. A group of 52 non-suicidal individuals of comparable age, sex, social class, and marital and employment status underwent the same interview programme. The results indicate that the social networks of suicide attempters are impaired relative to non-suicidal individuals, and that improvement in the social network following an attempt is limited to attempters with no formal psychiatric disorder, and to measures of perceived adequacy and satisfaction. The findings add support to the importance of psychiatric assessment of the nature and the adequacy of the social network in relation to suicidal individuals.     

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.     

Shame-proneness in attempted suicide patients

ABSTRACT: BACKGROUND: It has been suggested that shame may be an important feature in suicidal behaviors. The disposition to react with shame, "shame-proneness", has previously not been investigated in groups of attempted suicide patients. We examined shame-proneness in two groups of attempted suicide patients, one group of non-suicidal patients and one group of healthy controls. We hypothesized that the attempted suicide patients would be more shame-prone than non-suicidal patients and healthy controls. METHOD: The Test of Self-Conscious Affect (TOSCA), which is the most used measure of shame-proneness, was completed by attempted suicide patients (n = 175: 105 women and 3 men with borderline personality disorder [BPD], 45 women and 22 men without BPD), non-suicidal psychiatric patients (n = 162), and healthy controls (n = 161). The participants were convenience samples, with patients from three clinical research projects and healthy controls from a fourth research project. The relationship between shame-proneness and attempted suicide was studied with group comparisons and multiple regressions. Men and women were analyzed separately. RESULTS: Women were generally more shame-prone than men of the same participant group. Female suicide attempters with BPD were significantly more shame-prone than both female suicide attempters without BPD and female non-suicidal patients and controls. Male suicide attempters without BPD were significantly less shame-prone than non-suicidal male patients. In multiple regressions, shame-proneness was predicted by level of depression and BPD (but not by attempted suicide) in female patients, and level of depression and non-suicidality in male patients. CONCLUSION: Contrary to our hypothesis and related previous research, there was no general relationship between shame-proneness and attempted suicide. Shame-proneness was differentially related to attempted suicide in different groups of suicide attempters, with significantly high shame-proneness among female suicide attempters with BPD and a negative relationship between shame-proneness and attempted suicide among male patients. More research on state and trait shame in different groups of suicidal individuals seems clinically relevant.     

Fatal and Non-Fatal Suicidal Behavior in Israeli Adolescent Males

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18–21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.     

Fatal and non-fatal suicidal behavior in Israeli adolescent males

The objective of this study is examine the similarities and differences between adolescent suicide completers, adolescents with non-fatal suicidal symptoms, and non-suicidal psychiatric controls in an epidemiologic sample. Using the central Israeli military medical registry, 214 18-21 year old males from the same national service cohort were identified, consisting of 43 consecutive completed suicides and 171 consecutive central psychiatric clinic outpatients presenting with near-fatal suicide attempts, serious suicide attempts, para-suicidal gestures, threats, ideation, or other non-suicidal complaints. Systematic pre-induction and service data were available for all subjects, with detailed postmortem inquest data for suicides. Systematic clinical data, including the Kiddie-Schedule for Affective Disorders and Schizophrenia (K-SADS), Hamilton Depression Scale, and Eysenck Personality Inventory were obtained on all clinic subjects. Major depression was present in half of completers, near-lethal attempters, and ideators, but absent in the other clinic groups, whose commonest diagnosis was adjustment disorder. Depression scores increased across groups with increasing intent; ideators also had high scores. Completers and near-lethal attempters had higher I.Q. and medical fitness ratings and were in more demanding assignments than other groups. Prior attempts were commonest in completers, near-lethal attempters, and gesturers. Disciplinary history, ethnicity, family intactness, immigrant status, and Eysenck Personality Inventory scores did not differentiate the groups. The findings may not be generalizable to female adolescents or to other countries or time periods. The findings thus point to contrasts, as well as similarities, between groups of adolescents with different types of suicidal symptoms.     

Non-Suicidal Self-Injury and Interpersonal Violence in Suicide Attempters

The current study compared characteristics of suicidal behavior and interpersonal violence in suicide attempters with and without a history of non-suicidal self-injury (NSSI). A total of 100 suicide attempters were assessed with Karolinska Interpersonal Violence Scale (KIVS) and Karolinska Suicide History Interview concerning interpersonal violence and NSSI. There was a high degree of comorbid NSSI in suicide attempters (44%). Suicide attempters with NSSI-history reported more interpersonal violence as adults and more severe suicidal behavior compared to suicide attempters without NSSI. Comorbid NSSI was related to severity of suicidal behavior in a gender specific manner. Comorbid NSSI in suicide attempters may increase suicide and violence risk.     

Salivary cortisol and suicidal behavior--a follow-up study

INTRODUCTION: Hyperactivity of the hypothalamic-pituitary-adrenal (HPA)-axis is a common finding in major depressive disorder. Similar studies on suicide attempters are less abundant, and the results are divergent. The main aim of the present study was to investigate HPA-axis parameters by the time of a suicide attempt and at follow-up in search for associations between HPA-axis function and suicidal behavior. METHODS: Thirty-five suicide attempters and 16 non-suicidal controls were admitted to a psychiatric ward between the years of 1986 and 1992. Corticotrophin-releasing hormone (CRH) in cerebrospinal fluid and urinary cortisol were obtained for the suicide attempters. The patients were followed up approximately 12 years after the index admission. Cortisol was measured in saliva, and additional suicide attempts and current psychiatric symptoms were registered. RESULTS: At follow-up, evening salivary cortisol was lower in suicide attempters compared to controls. Low cortisol levels at follow-up were associated with severe psychiatric symptoms. Among women, repeated suicide attempts were associated with low morning and lunch salivary cortisol, and in this subgroup we also found significant correlations between salivary cortisol at follow-up, and CRH as well as urinary cortisol at index. CONCLUSION: We found evidence for an association between low HPA-axis activity and suicidal behavior. This could be due to long-lasting and severe psychiatric morbidity, which in turn has exhausted the HPA-axis of these patients. The potential role of hypocortisolism should be given more attention in studies on suicidal patients.     

Characteristics of out-patient adolescents with suicidal tendencies

Suicidal adolescent out-patients were compared with non-suicidal subjects with respect to background factors, psychopathology and treatment received. Data for suicidal ideation, suicide attempts, psychiatric diagnoses (DSM-III-R) and other patient-related factors were collected prospectively during treatment of 122 male and 138 female out-patients aged 12–22 years. In total, 42% of subjects displayed suicidal tendencies, and 18% had attempted suicide. According to polychotomous regression, mood disorder, previous psychiatric treatment arid low level of psychosocial functioning at treatment entry were associated with suicide attempts and with suicidal ideation for both sexes. Suicidal patients were more often receiving psychotropic medication and had more total appointments (mean number 15 vs. 9) than non-suicidal patients. Suicidal and non-suicidal patients kept their scheduled appointments to the same extent (66% vs. 65%). Treatments which meet the needs of disordered suicidal adolescents need to be developed.     

Personal and family risk factors for adolescent suicidal ideation and attempts.

Despite research indicating that suicidal ideation is strongly related to future suicide attempts, there is limited data on variables associated with continued suicidal ideation and behaviors in adolescents. The objective of this study is to investigate whether personal, cognitive and family risk factors can differentiate adolescent suicidal ideation and attempts. Twenty-four attempters, 50 ideators and 50 non-suicidal adolescents (aged 14 to 25 years) were asked during an interview to complete individual and psychosocial measures. Both suicidal groups reported greater personal vulnerability and perceived their family as less functional than did the non-suicidal group. However, no differences were found between both suicidal groups. The results suggest the presence of common factors in both adolescent suicidal ideators and attempters.     

Psychiatric Diagnoses and Comorbidity in Relation to Suicidal Behavior Among Psychiatrically Hospitalized Adolescents

This study examined relations between suicidal behavior history (i.e., no suicidality, suicidal ideation, single attempters, and multiple attempters) and psychiatric functioning. Adolescents, aged 12-17, admitted to an inpatient psychiatric unit, were categorized by suicidal behavior history based on self- and clinician-report data. Groups were examined for differences in suicidal ideation and psychiatric diagnosis. Severity of suicidal ideation increased with severity of suicidal behavior history. Females were disproportionately represented among multiple attempters. Multiple attempters were more likely to be diagnosed with at least one externalizing disorder, particularly substance use disorders, and to have more than one comorbid diagnosis than adolescents with no suicidal behavior or a history of ideation only. Clinicians should be alerted to the particularly high-risk nature of adolescents with multiple suicide attempts.     

A proposed model of the development of suicidal ideations

BackgroundSuicidal ideations may precede suicide attempts. They are of particular concern in psychiatric populations because psychopathology is a major risk factor for suicide. The factors affecting the development of suicide ideations may differ among psychiatric patients with and without a previous suicide attempt and individuals without a psychiatric diagnosis.ObjectivesThe aim of this study is to develop a model of suicide ideation in psychiatric patients and the general population.MethodThe study included 196 participants: 92 psychiatric patients with a previous suicide attempt (“attempters”); 47 psychiatric patients who had never attempted suicide (“non-attempters”); and 57 healthy control subjects. Data were collected on socio-demographic parameters, clinical history, and details of the suicide attempts. Participants completed a battery of psychological instruments assessing aggression–impulsivity, mental pain (including depression and hopelessness) and communication difficulties, in addition to negative life events. Findings were correlated with suicidal ideation by group.ResultsThe correlations of the different variables with suicidal ideation differed between suicide attempters and non-attempters; therefore, the model was analyzed separately for each group. The study yielded three major findings: negative life events had a significant effect on both anger-in and impulsivity in non-attempters but not in attempters; hopelessness moderately contributed to suicidal ideations in attempters but not in non-attempters; loneliness contributed significantly to depression in non-attempters but was less distressing in attempters.ConclusionThe mechanism underlying suicidal ideation appears to differ between psychiatric patients who have previously attempted suicide and those who have not, supporting a dual model of suicidal ideation. Although this is only a preliminary study, these findings are important for furthering our understanding of the process of transition of suicidal thoughts to completion of suicide. These results need further replication with a larger cohort of subjects.     

Neurocognitive functioning and suicidality in schizophrenia spectrum disorders

Objective

The aim of this study was to investigate whether suicide attempters had higher IQ, better executive functioning, or were more impulsive as measured by neuropsychological tests than non-attempters in a group of patients with schizophrenia spectrum disorders.

Method

One hundred seventy-four patients with schizophrenia spectrum disorders were assessed with a clinical interview for diagnosis, suicidality, symptoms and function, and underwent an extensive neurocognitive test battery.

Results

There were no statistically significant differences in any neurocognitive domains between lifetime suicide attempters and non-attempters, or between patients with different rates of suicide attempts. Currently suicidal patients were significantly more impulsive (had poorer inhibitory control) than currently non-suicidal patients, but this difference was mediated by positive psychotic symptoms.

Conclusion

The findings indicate that among patients with schizophrenia spectrum disorders, there are no significant differences in IQ or neurocognitive functioning between suicide attempters and non-attempters.     

A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders

Objectives:  Among mood disorders, bipolar disorder (BPD) is often noted to involve the highest rates of suicide attempts and possibly of completion. This study sought to determine whether suicide attempters with BPD exhibit suicide attempts with higher lethality than attempters with major depressive disorder (MDD) and to explore differences in clinical features associated with suicidal acts.
Methods:  Mood disordered suicide attempters were interviewed about Axis I and II diagnoses, lifetime history of suicide attempts, suicidal intent, suicidal ideation, the medical lethality of their most severe suicide attempt, severity of depression, hopelessness, lifetime aggression, and impulsivity.
Results:  The maximum lethality of suicidal acts tended to be higher among BPD attempters compared with those with MDD. However, there were no differences in the number of suicide attempts, intent to die or suicidal ideation. Suicide attempters with BPD reported higher levels of aggression and impulsivity but less hopelessness compared with MDD attempters. These differences could not be explained by Cluster B personality disorder comorbidity. Of note, within the BPD group, but not the MDD group, males reported suicidal acts with higher lethality. Multivariate analyses suggested that risk for more lethal suicide attempts is associated with BPD and male sex and that bipolar males appear to be especially vulnerable to these behaviors.
Conclusions:  Males with BPD make more lethal suicide attempts than females with BPD, an effect not observed among the MDD sample. Our findings suggest that higher rates of suicidal behavior in BPD may be due to a specific effect of BPD on males, leading to more dangerous suicidal behaviors. This effect, together with the larger proportion of males in the BPD group compared with the MDD group may lead to higher rates of reported attempted and completed suicide.     

What are the characteristics of adolescent hospitalized suicide attempters?

AIM: To study the specificity of hospitalized adolescent suicide attempters. METHOD: Among a national sample of students (n = 11,718, mean age = 16.6 years) studied in 1999, 9.2% (n = 1078) made at least one suicide attempt during their life (SA); 21.9% (n = 234) of them were hospitalized (HSA). We identified the risk factors (family, school, behavioral and psychological) of SA and HSA by comparing (by gender) a) suicide attempters to non-suicide attempters and b) hospitalized suicide attempters to non-hospitalized suicide attempters. RESULTS: Both for girls and boys, the risk factors for SA varied. However, certain risk factors, particularly depressive mood, low self-esteem and poor parent-child relationships, were not associated with hospitalization. Hospitalized suicide attempters had more personal and social problems. But there is an important difference according to gender: in boys, hospitalization is related to physical fighting (OR = 2.2) and offences (OR = 3.4), in girls to running away (OR = 1.7), consumption of illegal drugs other than cannabis (OR = 2.0), having a living standard outside average (OR = 2.0) and going to a private school (OR = 1.7). CONCLUSION: Suicide attempters with problem behavior are more at risk of being hospitalized than others. However, the difference between hospitalized and non-hospitalized subjects was smaller than expected.     

Cholesterol concentrations in violent and non-violent women suicide attempters.

The aim of this study was to evaluate whether women with a history of violent suicide attempts have lower serum cholesterol concentrations than those who attempted suicide by non-violent methods. Our retrospective study used a case-control design to compare serum total cholesterol concentration, hematocrit, red blood cell count and body mass index (BMI) in women with a history of violent (n = 19) or non-violent (n = 51) suicide attempts and of non-suicidal controls (n = 70) matched by diagnosis and age. Analysis of covariance (ANCOVA) with age as the covariate was used to analyze differences in cholesterol levels in groups according to violence. Violence was found to be a significant factor (P = 0.016). Using the Scheffé test, a significant difference (P = 0.011) was revealed between the group of violent and non-violent suicide attempters and between the violent suicide attempters and the control group. Patients with a violent suicidal attempt have significantly lower cholesterol levels than patients with non-violent attempts and the control subjects. Our findings suggest that suicide attempts should not be considered a homogeneous group. They are consistent with the theory that low levels of cholesterol are associated with increased tendency for impulsive behavior and aggression and contribute to a more violent pattern of suicidal behavior.     

Alexithymia in suicide attempters

Taiminen TJ, Saarijärvi S, Helenius H, Keskinen A, Korpilahti T. Alexithymia in suicide attempters. Acta Psychiatr Scand 1996: 93: 195–198. © Munksgaard 1996. Alexithymia seems to share some common features with psychological constriction, a phenomenon described in suicidal individuals. Fifty suicide attempters were interviewed within 24 h after arrival at a hospital, and measures of lethality of the attempt, suicidal intent, depression and alexithymia were carried out with structured instruments. Almost all the attempters were depressive, and about half of them were also alexithymic. However, alexithymia was not more prevalent in this population than in non-suicidal depressive patients. Depression and alexithymia correlated significantly with each other, but there was no correlation between alexithymia and lethality of the suicide attempt or suicidal intent. The authors conclude that alexithymia in suicide attempters seems to be associated with depression, but not with suicidality per se. Therefore, measurement of alexithymia may not yield extra information in suicide risk assessment.     

Family history of suicide and high motor impulsivity distinguish suicide attempters from suicide ideators among college students

Suicide in college students has become an important public health issue in China. The aim of this study was to identify the differences between suicide attempters and suicide ideators based on a cross-sectional survey. Our results indicate that although female gender, positive screening for psychiatric illness, positive family history of suicide, elevated overall impulsivity, and elevated motor impulsivity were correlated with suicidal ideation, only positive family history of suicide and high motor impulsivity could differentiate suicide attempters from suicidal ideators. Future research with a longitudinal and prospective study design should be conducted to confirm these findings.     

Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.     

The familial aggregation of adolescent suicide attempts

The objective of this study was to determine whether the familial aggregation of suicidal behaviour is explained by the familial aggregation of personality disorder and aggression. The relatives of 62 clinically referred adolescent suicide attempters were compared with 70 never-suicidal psychiatric controls. The first-degree relatives of the suicide attempters had a higher rate of suicide attempts/completion than those of the psychiatric controls. This rate remained significantly higher after controlling for Axis I and II differences in the probands and the relatives, but familial personality disorder was significantly associated with suicidal risk in probands. Among the adolescent attempters, high scores on a measure of assaultiveness were associated with significantly higher familial rates of suicide attempts/completion. Our results support the hypothesis that suicidal behaviour may be transmitted as a trait independent of Axis I and II psychopathology but that, in addition, personality disorder has a role in the transmission of suicidal behaviour. An interrelationship between proband assaultiveness and the familial aggregation of suicidality was noted.