Correlates of suicide risk in juvenile detainees and adolescent inpatients

OBJECTIVE: To compare correlates of risk for suicidal behavior in juvenile detainees with those in another high-risk group, adolescent psychiatric inpatients. METHOD: Eighty-one adolescents in a short-term juvenile detention center were contrasted with a matched group of 81 adolescent psychiatric inpatients on a clinical assessment battery of established instruments including a measure for risk of suicidal behavior. RESULTS: Juvenile detainees and adolescent psychiatric inpatients reported similar levels of distress on measures of suicide risk, depression, impulsivity, and drug abuse. After controlling for depression, impulsivity and drug abuse remained significantly associated with suicide risk scores in the juvenile detention group, but did not in the psychiatric contrast group. For depressed female inpatients, hopelessness added significantly to the prediction of suicide risk scores. CONCLUSIONS: Correlates of risk for suicidal behavior in juvenile detainees may differ from those in other high-risk groups. Results suggest that it may be helpful to examine impulsivity and history of drug abuse when assessing suicide risk for detained adolescents. Further study of juvenile detainees as a separate high-risk group is warranted to better determine the nature and extent of risk.     

Eating disorder psychopathology as a marker of psychosocial distress and suicide risk in female and male adolescent psychiatric inpatients

Objective

The aim of this study was to examine psychosocial correlates of specific aspects of eating disorder (ED) psychopathology (ie, dietary restriction, body dissatisfaction, binge eating, and self-induced vomiting) in psychiatrically hospitalized adolescent girls and boys.

Method

A total of 492 psychiatric inpatients (286 adolescent girls and 206 adolescent boys), aged 12 to 19 years, completed self-report measures of psychosocial and behavioral functioning, including measures of suicide risk and ED psychopathology. Associations between ED psychopathology and psychosocial functioning were examined separately by sex and after controlling for depressive/negative affect using Beck Depression Inventory scores.

Results

Among the adolescent boys and girls, after controlling for depressive/negative affect, ED psychopathology was significantly associated with anxiety, low self-esteem, and current distress regarding childhood abuse. Among adolescent girls, after controlling for depressive/negative affect, ED psychopathology was significantly related to hopelessness and suicidality. Among adolescent boys, after controlling for depressive/negative affect, ED psychopathology was positively related to self-reported history of sexual abuse and various externalizing problems (drug abuse, violence, and impulsivity).

Conclusion

In psychiatrically hospitalized adolescents, ED psychopathology may be an important marker of broad psychosocial distress and behavioral problems among girls and boys, although the nature of the specific associations differs by sex.     

Sexual abuse and suicidal behavior: a model constructed from a large community sample of adolescents

OBJECTIVE: To investigate relationships between self-reported sexual abuse, depression, hopelessness, and suicidality in a community sample of adolescents. METHOD: In 1995, students (mean age 13 years) from 27 high schools in Australia (n = 2,603) completed a questionnaire including measures of depressive symptoms (Center for Epidemiologic Studies Depression Scale), hopelessness, sexual abuse, and suicidality. Data analysis included logistic regression. RESULTS: Sexual abuse is associated with suicidality, both directly and indirectly through hopelessness and depressive symptoms in the model developed. High suicide risk (behavior exceeding thoughts such as plans and threats, or deliberate self-injury) is strongly correlated with suicide attempts (odds ratio 28.8, 95% CI 16-52, p <.001). Hopelessness is associated with high suicide risk only, whereas depressive symptoms are associated with high suicide risk and attempts. Hopelessness is more strongly associated with sexual abuse in boys than girls. Depressive symptoms are more strongly associated with high suicide risk in girls than boys. Controlling for other variables, sexual abuse is independently associated with suicide attempts in girls but not boys. CONCLUSIONS: Clinical assessment should consider gender differences in relationships between sexual abuse, depressive symptoms, hopelessness, and suicidality. Sexually abused girls may be at increased risk of attempting suicide, independent of other psychopathology.     

Correlates of suicide risk in adolescent inpatients who report a history of childhood abuse

The study objective was to examine correlates of suicide risk in psychiatrically hospitalized adolescents with a reported history of childhood abuse. Predictors of suicide risk were examined in 74 subjects who reported a history of childhood abuse and 53 depressed subjects who did not report a history of childhood abuse. Subjects completed a battery of psychometrically well-established self-report instruments to assess childhood abuse, suicide risk, and internalizing and externalizing psychopathology. Correlational analyses showed that higher levels of depression, self-criticism, and hopelessness were significantly associated with suicide risk in both study groups and violence was significantly associated with suicide risk in the childhood abuse group. For the childhood abuse group, multiple regression analyses with seven predictor variables accounted for 54% of the variance in suicide risk; depression and alcohol problems made significant independent contributions, while violence and self-criticism were independent predictors at the trend level. For the depressed/nonabused group, multiple regression analyses with the seven predictor variables accounted for 60% of the variance in suicide risk; depression, hopelessness, and self-criticism were independent predictors. Our findings suggest that both internalizing (i.e., depression or self-criticism) and externalizing (i.e., violence or alcohol) factors predict suicide risk in adolescent inpatients who report childhood abuse. This profile appears different from the more internalizing pattern (i.e., depression, self-criticism, and hopelessness) observed for the depressed adolescent inpatients who reported no history of childhood abuse.     

Development of a Checklist for Predicting Suicidality Based on Risk and Protective Factors: The Gwangju Checklist for Evaluation of Suicidality

Objective The aim of the study was to develop a checklist for mental health clinicians to predict and manage suicidality. Methods A literature review of the risk and protective factors for suicide was conducted to develop a checklist for evaluating suicidality. Results The fixed risk factors included sex (male), age (older individuals), history of childhood adversity, and a family history of suicide. Changeable risk factors included marital status (single), economic status (poverty), physical illness, history of psychiatric hospitalization, and history of suicide attempts. Recent discharge from a mental hospital and a recent history of suicide attempts were also included. Manageable risk factors included depression (history and current), alcohol problems (frequent drinking and alcohol abuse), hopelessness, agitation, impulsivity, impaired reality testing, and command hallucinations. Protective factors included responsibility to family, social support, moral objections to suicide, religiosity, motivation to get treatment, ability to cope with stress, and a healthy lifestyle. A final score was assigned based on the sum of the risk and protective factor scores. Conclusion We believe that the development of this checklist will help mental health clinicians to better assess those at risk for suicidal behavior. Further studies are necessary to validate the checklist.     

Low serum cholesterol in violent but not in non-violent suicide attempters

Many previous studies have suggested that low or lowered serum cholesterol levels may increase the risk of mortality not due to somatic disease: principally, suicide and violent death. Because violent death is rare, some studies have investigated afterwards the relation between cholesterol levels and either suicide attempts in psychiatric populations or violence in criminally violent populations. However, none of these studies have compared cholesterol levels in violent and non-violent suicide attempters. The blood of 25 consecutive drug-free patients following a violent suicide attempt and of 27 patients following a non-violent suicide attempt by drug overdose was drawn in the 24 h following admission. Patients with a diagnosis of alcohol abuse and with cholesterol-lowering therapy were excluded. Age, sex, body mass index, psychiatric diagnosis and the physical conditions of the suicide attempt were investigated. Thirty-two healthy subjects were used as a control group. There were no differences between the groups in age, frequency of psychiatric diagnoses or body mass index. There was more women in the group of non-violent suicide attempters than in that of violent suicide attempters (P<0.001). In analyses controlling for sex and age, the serum cholesterol concentration was 30% lower (F(2,82)=15.8; P<0.0001) in the group of violent suicide attempters (147+/-54 mg/dl) than in the group of non-violent suicide attempters (209+/-38 mg/dl) or control subjects (213+/-46 mg/dl). Our results showed that low serum cholesterol level is associated with the violence of the suicide attempt and not with the suicide attempt itself. Further investigations are necessary to determine the usefulness of this easily accessible parameter as a potential risk indicator for violent acts such as violent suicidal behavior in susceptible individuals.     

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.     

Anxiety,impulsivity and depressed mood in relation to suicidal and violent behavior

Many different variables have been associated with suicidal behavior as well as with violent behavior. This study was designed to test a model that attempts to relate such variables to violence and suicide risk. Sixty psychiatric patients were evaluated and divided into suicidal and nonsuicidal groups and then into violent and nonviolent groups. Scores on suicide risk, violence risk, anxiety, anger, impulsivity and mood were then compared between these groups. In a second analysis, scores on suicide risk and violence risk were correlated with all the other variables. Anxiety and impulsivity were found to strongly correlate with suicide risk. Angry and resentful mood correlated with violence risk; trait anxiety correlated negatively with violence risk. The results contribute further insight into the authors' two-stage model of countervailing forces.     

Correlates of risk of suicide in violent and nonviolent psychiatric patients

OBJECTIVE: This study was designed to identify variables that correlate with the risk of suicide in two patient groups that differ mainly in their level of expressed aggression. METHOD: Twenty-eight psychiatric patients with a history of violent behavior who were in a forensic psychiatric facility were tested and compared to 28 psychiatric inpatients without a history of violence who were admitted to a large municipal hospital. Measures used included a battery of self-report questionnaires, with acceptable reliability and validity, that provided indices of risk of suicide, risk of violence, impulsivity, anger, anxiety, and various mood states. RESULTS: The two groups, matched on demographic variables and overall risk of suicide, differed significantly on the measured risk of violence. The two groups showed similar patterns of correlations between risk of suicide and such variables as risk of violence, anger, fear, state and trait anxiety, lack of impulse control, suspiciousness, and rebelliousness. They differed in the correlation between suicide risk and depression. In the nonviolent patients there was a high correlation between risk of suicide and sadness; in the violent patients there was no correlation between these variables. CONCLUSIONS: The low correlation between sadness and risk of suicide in the violent patients, and the low prevalence of affective disorder diagnoses in these patients compared to other patients, suggests that suicidal risk should be managed differently in highly violent patients than in others.     

A theoretical model of adolescent suicide risk

A theoretical model of adolescent suicidal behavior was examined separately for 192 male and 329 female (N = 521) students of a suburban junior high school in the southwest. The model consisted of five constructs: the predictor variables of depression, hopelessness, self-esteem, and substance use and the criterion variable, suicide risk. A theoretical model consisting of five research hypotheses was proposed based on the suicide literature and was examined by path analysis using a structural equations statistical package, SAS PROC CALIS (Version 6.10). Results revealed that all relationships were in the predicted direction. The final model reasonably accounted for the data in spite of some gender differences. Males progressed from depression to substance use and then to suicide risk, while females progressed directly from depression to suicide risk. Depression was a stronger predictor of low self-esteem for females than for males. While hopelessness was a viable predictor of substance use for both males and females, it was not a viable predictor of suicide risk.     

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.     

Sex differences in risk factors for suicidality among Japanese substance use disorder patients: Association with age, types of abused substances, and depression

Aim: The aim of this study was to identify risk factors for suicide in Japanese substance use disorder (SUD) patients, adjusting for age and sex, and to examine sex differences in suicide risk among these patients. Methods: A self-reporting questionnaire on age, sex, types of abused substances, current depression, and suicidality was administered to 1420 SUD patients who consecutively visited seven hospitals specializing in SUD treatment during the month of December 2009. Unadjusted/adjusted odds ratios of factors associated with suicidality were calculated for each sex. Results: The multivariate analysis using the total sample identified younger age, female sex, and current depression as risk factors for severe suicidality in SUD patients. The multivariate analysis by each sex demonstrated that younger age and current depression were associated with severe suicidality in male SUD patients. Only current depression was associated with severe suicidality in female patients. Conclusion: Current depression is a risk factor for suicide in SUD patients common in both Western countries and Japan, although in Japanese SUD patients both younger age and female sex were more closely associated with severe suicidality than aspects of SUD. Additionally, young male SUD patients are speculated to have psychosocial features associated with suicidality in common with female SUD patients.     

Electrodermal reactivity in male and female depressive patients who later died by suicide

On the basis of earlier studies on electrodermal responsiveness in patients with suicide attempts, an investigation on electrodermal activity (EDA) in former depressive inpatients was carried out. Male and female depressive inpatients who died of suicide later and participated in an habituation experiment during their inpatient treatment were identified retrospectively and compared (strictly matched by age and sex) to depressive suicide attempters with violent or nonviolent methods, suicide ideators and a nonsuicidal depressive group. In the first part of the study only male depressives (n= 12) who had committed suicide after or during inpatient treatment were compared with their controls. The hypothesis of a expected low electrodermal responsiveness and a fast habituation as an peripheral expression of a central impulse or violence control disturbance could not be confirmed. This was done in the second part of this study. We came to the following results: 1) a tendency to a faster habituation in the violent suicides compared with nonsuicidal depressives and violent suicide attempters plus violent suicide group in male depressives compared to suicide attempters (SA), nonviolent suicide ideators and nonsuicidal depressives. 2) A significant difference with faster habituation rates in a male and female violent suicide group compared with nonsuicidal depressives and again comparing a group of male and female violent suicides and SA with nonviolent SA, suicide ideator and nonsuicidal depressive controls. These results may reflect a dysregulation of violence and impulsivity control mechanism as an underlying disorder or personality trait.     

Suicidality in schizophrenia: a review of the evidence for risk factors and treatment options

Suicide is a major contributor to the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in these patients. The known risk factors for suicide in schizophrenia include prior suicide attempts, substance abuse, male sex, onset during first decade of illness, social isolation, depression, and feelings of hopelessness. There is significant evidence suggesting that clozapine reduces the suicide rate in patients with schizophrenia and schizoaffective disorder. Possible factors that lead to a decrease in suicidality with clozapine include the following: a direct antidepressant action, improved cognitive function and insight, diminished negative symptoms, reduced substance abuse, and improved compliance. These effects may converge or lessen feelings of hopelessness and more of its converse optimism. The International Suicide Prevention Trial (InterSePT) is a large prospective, 2-year randomized trial of the comparative effects of clozapine and olanzapine involving 980 patients at high risk for suicide in 11 countries in 56 sites. The study included complete freedom to augment these treatments if needed, blinded ratings, a blinded Suicide Monitoring Board, and equivalent clinical contact. The results support the superiority of clozapine over olanzapine to reduce the risk of suicidality and suggest its use should be considered for all patients with schizophrenia with high risk for suicide.     

Correlates of suicide and violence risk: III. A two-stage model of countervailing forces

Questionnaires and self-report scales were administered to 100 psychiatric inpatients. The scales measured such variables as depression, hopelessness, impulsivity, mental and life problems, family violence, personality characteristics, and dyscontrol tendencies. These were correlated with indices of suicide risk and violence risk. Most variables were found to correlate significantly with both suicide and violence risk. Partial correlation analyses revealed that 10 variables correlated significantly with suicide risk but not violence risk, while four variables correlated significantly with violence risk but not suicide risk. A two-stage model of countervailing forces, incorporating concepts from both psychoanalysis and ethology, is presented as a way of interpreting the results.     

A theoretical model of adolescent suicide risk

Abstract

A theoretical model of adolescent suicidal behavior was examined separately for 192 male and 329 female (N = 521) students of a suburban junior high school in the southwest. The model consisted of five constructs: the predictor variables of depression, hopelessness, self-esteem, and substance use and the criterion variable, suicide risk. A theoretical model consisting of five research hypotheses was proposed based on the suicide literature and was examined by path analysis using a structural equations statistical package, SAS PROC CALIS (Version 6.10). Results revealed that all relationships were in the predicted direction. The final model reasonably accounted for the data in spite of some gender differences. Males progressed from depression to substance use and then to suicide risk, while females progressed directly from depression to suicide risk. Depression was a stronger predictor of low self-esteem for females than for males. While hopelessness was a viable predictor of substance use for both males and females, it was not a viable predictor of suicide risk.     

Is violent method of suicide a behavioral marker of lifetime aggression?

OBJECTIVE: The main purpose of this study was to investigate whether the method of suicide is a valid behavioral marker of a lifetime history of aggression. METHOD: The authors applied the psychological autopsy method to investigate 310 individuals who committed suicide. They used structured clinical assessments and personality trait scales in interviews with family members of the deceased. RESULTS: Violent method was associated with a higher level of lifetime aggression and a higher level of impulsivity. In addition, violent method was associated with lifetime substance abuse or dependence and psychotic disorders. Controlling for age, sex, substance disorders, and other major psychopathology, the authors found that lifetime aggression and the interaction between impulsivity and aggressive behavior remained associated with violent method. CONCLUSIONS: These results support the use of violent method of suicide as a behavioral marker of a higher level of lifetime impulsive-aggressive behaviors.     

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.     

Life events and psychopathology in a group of suicide attempters

Researchers examined the incidence of negative life events and associated these events with psychological scales (depression, hopelessness, self-esteem and state-trait anger) in a group of suicide attempters (n = 101) within the framework of the WHO/EURO Multicenter Study on Suicidal Behavior. Certain negative life events (especially relationship problems and physical/mental abuse in childhood) turned out to be the main indicators of severe mental problems in the family of the attempters (e.g. addiction, self-destructive behavior or psychiatric hospitalization). Significant positive correlations were found between the number of events and some psychopathological symptoms like depression, hopelessness, anger and lack of self-esteem. The role of stressful life events in suicidal behavior is emphasized. Particularly traumatic events (e.g. abuse in childhood) may be involved in the development of psychological and/or biological vulnerability (stress-diathesis model) and cognitive dysfunction. Therefore, in the psychotherapy of suicide attempters, it is essential to explore and discuss negative life events.