Differences between adolescent suicide attempters and depressed adolescents.

Most of the characteristics differentiating between adolescent attempters and nonattempters do not have discriminative power in comparing 48 adolescents who recently attempted suicide with 66 depressed adolescents. These characteristics may probably be attributed to an affective disorder that is present in most of the suicide attempters. However, suicide attempters, compared with the depressed group, live in more problematic circumstances (such as family disruption or sexual abuse) and have a cognitive style that promotes a more negative evaluation of events and situations. Their depressive symptoms are distinguished from the depressed group by withdrawal and isolation, besides maintaining a hopeless and negative expectation of the future. Furthermore, there are reasons to accept the idea that suicidal behavior is a serious alternative within their behavioral repertoire. Based on these findings, a psychological interpretation is given concerning the dynamics leading to a suicide attempt. Also, intervention strategies are discussed.     

Protective factors against suicidal acts in major depression: reasons for living

OBJECTIVE: Over 30,000 people a year commit suicide in the United States. Prior attempted suicide and hopelessness are the most powerful clinical predictors of future completed suicide. The authors hypothesized that "reasons for living" might protect or restrain patients with major depression from making a suicide attempt.METHOD: Inpatients with DSM-III-R major depression were assessed for depression, general psychopathology, suicide history, reasons for living, and hopelessness. Of the 84 patients, 45 had attempted suicide and 39 had not.RESULTS: The depressed patients who had not attempted suicide expressed more feelings of responsibility toward family, more fear of social disapproval, more moral objections to suicide, greater survival and coping skills, and a greater fear of suicide than the depressed patients who had attempted suicide. Scores for hopelessness, subjective depression, and suicidal ideation were significantly higher for the suicide attempters. Reasons for living correlated inversely with the combined score on these measures, considered an indicator of "clinical suicidality." Neither objective severity of depression nor quantity of recent life events differed between the two groups. CONCLUSIONS: During a depressive episode, the subjective perception of stressful life events may be more germane to suicidal expression than the objective quantity of such events. A more optimistic perceptual set, despite equivalent objective severity of depression, may modify hopelessness and may protect against suicidal behavior during periods of risk, such as major depression. Assessment of reasons for living should be included in the evaluation of suicidal patients.     

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.     

Suicide attempts and life events 5-9 years after referral for emergency psychiatric outpatient treatment

The aim of this naturalistic and retrospective follow-up study was to identify putative predictors of suicide attempts among young adults at high risk with a particular view on adverse life events. One hundred young adults who had been given emergency treatment for mental health problems in child and adolescent outpatient clinics in Norway were assessed 5-9 years after referral. Suicide and suicide attempts in the follow-up period were registered as well as suicide attempts at referral and previous suicide attempts unrelated to the treatment referral. In addition, adverse life events during childhood and adolescence and social background factors were registered. Only one subject committed suicide during the follow-up period. However, suicide attempts were frequent (29/100) and equally distributed among those referred for suicidal or other reasons. Those who had attempted suicide experienced more adverse life events during adolescence, were more likely to be male, to have incomplete schooling and a record of psychiatric hospitalizations. Clinicians need to address the risk of future suicide attempts also among young emergency patients not referred for suicidal reasons.     

Suicide attempts and life events 5–9 years after referral for emergency psychiatric outpatient treatment

The aim of this naturalistic and retrospective follow-up study was to identify putative predictors of suicide attempts among young adults at high risk with a particular view on adverse life events. One hundred young adults who had been given emergency treatment for mental health problems in child and adolescent outpatient clinics in Norway were assessed 5–9?years after referral. Suicide and suicide attempts in the follow-up period were registered as well as suicide attempts at referral and previous suicide attempts unrelated to the treatment referral. In addition, adverse life events during childhood and adolescence and social background factors were registered. Only one subject committed suicide during the follow-up period. However, suicide attempts were frequent (29/100) and equally distributed among those referred for suicidal or other reasons. Those who had attempted suicide experienced more adverse life events during adolescence, were more likely to be male, to have incomplete schooling and a record of psychiatric hospitalizations. Clinicians need to address the risk of future suicide attempts also among young emergency patients not referred for suicidal reasons.     

Are children and adolescents who have suicidal thoughts different from those who attempt suicide?

In this study we inquire whether children and adolescents with suicidal ideation can be differentiated from children who attempt suicide on the basis of clinical symptoms or social grounds. From a total of 2181 consecutive outpatient referrals to a child and adolescent psychiatry service, 258 young persons who exhibited suicidal ideation are compared with 82 who had actually attempted suicide. We were unable to differentiate children with suicidal thoughts from those who attempted suicide on the basis of clinical symptoms alone. Both groups had similar high levels of symptoms of depression, anxiety, sleep disorder, and irritability. Conduct disorders were less common in both groups but 22% of the attempters abused illicit drugs or alcohol. Suicide attempts were more likely to be associated with chronic family discord and substance abuse. For boys, the odds of suicidal attempts were substantially increased if the subject had experienced loss. Results are discussed with reference to antecedents that may increase the odds of suicidal attempt and suggestions for future research are outlined.     

Clinical characteristics of adolescent psychiatric inpatients who have attempted suicide

 The clinical characteristics of 191 adolescent inpatients were examined in relation to frequency of previous suicide attempts, predictors of suicide attempts prior to hospitalization, and lifetime suicide attempts. Overall, more than 50% of the adolescent inpatients had attempted suicide during their lifetime, and of these more than half (58%) had made more than one attempt. Approximately half of the suicide attempters had made a serious attempt prior to hospitalization. Girls reported higher levels of depressive symptoms and suicidal ideation than boys, in addition to having attempted suicide prior to hospitalization (33%) or during lifetime (37%) more often than the boys (13% and 26%, respectively). Although about two thirds of the adolescent inpatients reported that they had received some help after a suicide attempt, approximately half of the repeaters had not received any help. The results of multivariate analyses showed that suicide attempts made prior to hospitalization were predicted by depressive symptom levels and a clinical diagnosis of depressive disorder, whereas frequency of lifetime suicide attempts was predicted by suicidal ideation levels and having a family member or a friend who had attempted (or committed) suicide. The high prevalence of lifetime and repeated suicide attempts among the psychiatric inpatients underscores the importance of identifying risk factors in the clinical evaluation of adolescent suicide attempters. Accepted: 1 April 1998     

Suicidal behavior in depression: relationship to platelet serotonin transporter

OBJECTIVE: Suicidal behavior in depressed patients is associated with low central serotonin. Thus, platelet serotonin uptake in relation to suicidal behavior in depression was examined. METHODS: Depressed patients who had never attempted suicide (n = 23) were compared with depressed patients who had never attempted suicide (n = 26) and normal controls (n = 71) for platelet serotonin uptake. RESULTS: Depressed patients who had a lifetime history of a suicide attempt had a significantly greater apparent Michaelis constant (Km) of platelet serotonin uptake than either depressed patients who had never attempted suicide or controls. Patients rated high for current suicidal ideation at the index admission had significantly higher Km values than patients rated low. Also, patients who reattempted or committed suicide during a 5-year follow-up period had significantly higher Km values than controls. Among women patients who had attempted suicide there was a significant correlation between extrapunitive hostility scores and Km values. CONCLUSION: The serotonin transporter warrants further study in relation to suicidal behavior in depression.     

Peripubertal suicide attempts in offspring of suicide attempters with siblings concordant for suicidal behavior

OBJECTIVE: The authors sought to determine 1) whether the risk for familial transmission of suicidal behavior is greater with increased family loading for suicide attempts, and 2) whether the transmission of suicidal behavior is mediated by impulsive aggression. METHOD: A reanalysis of a high-risk study compared the offspring of three mood disorder proband groups: suicide attempters with a sibling who also attempted suicide (N=19), suicide attempters whose siblings never made a suicide attempt (N=73), and nonsuicidal probands whose siblings also never engaged in suicidal behavior (N=73). Probands and offspring were assessed with respect to psychopathology, suicide attempt history, impulsive aggression, and exposure to familial adversity. RESULTS: Offspring of suicide attempters with siblings concordant for suicidal behavior showed a higher risk of suicide attempt than did offspring of nonsuicidal probands and had an earlier age at onset of suicidal behavior than offspring of suicide attempters with siblings discordant for suicidal behavior. Probands from sibling pairs concordant for suicidal behavior and their offspring reported greater lifetime impulsive aggression compared with each of the other two proband/offspring groups. In the offspring, impulsive aggression was the most powerful predictor of early age at first suicide attempt. CONCLUSIONS: Familial loading for suicide attempts may affect rates of transmission as well as age at onset of suicidal behavior, and its effect may be mediated by the familial transmission of impulsive aggression.     

Characteristics of HIV patients who attempt suicide

OBJECTIVE: To examine the risk factors for suicidal behaviour in human immunodeficiency virus (HIV) positive patients. METHOD: HIV substance dependent positive patients who had attempted suicide were compared with HIV substance dependent positive patients who had never attempted suicide for suicide risk factors. RESULTS: Among the 149 HIV positive patients examined almost half had attempted suicide. Significantly more HIV positive patients who had attempted suicide were female. Attempters were significantly younger than non-attempters. Significantly more of the attempters had a family history of suicidal behaviour. Attempters also reported significantly more childhood trauma, scored significantly higher for neuroticism, had experienced significantly more comorbidity with depression, and more of them had received antidepressant medication. CONCLUSION: These data suggest that both distal and proximal risk factors are involved in suicidal behaviour in HIV positive substance dependent patients.     

Suicide attempts in a cohort of drug abusers: a 5-year follow-up study

A group of 125 drug abusers admitted consecutively for detoxification and short-term rehabilitation were followed up 5 years after discharge. They were asked about possible suicide attempts in a semi-structured face-to-face interview. Nearly half of the group (45%) reported having attempted suicide at some point in their life. The most common reasons given were the loss of a person whom they loved, and feelings of loneliness. Only three respondents reported using their drug of choice in the attempt(s). The suicide attempters were more often found to have been in child psychiatric treatment earlier, and to have experienced loss of significant others in childhood, than those who did not report attempting suicide. At follow-up the suicide attempters indicated that they experienced more depressive moods and more severe psychological problems than those who had never made a suicide attempt. The importance of assessing the risk of suicide attempts among drug addicts in order to be able to take measures to prevent future suicidal behaviour is emphasized.     

Parental loss and reported childhood stress in young women who attempt suicide

For young women aged 18 to 30 years who attempted suicide, and whose suicide attempts were of widely differing physical threat to life, the experience of parental death and separation or divorce, and of reported childhood stress, was similar, irrespective of the lethality of the suicide attempt. Taken as a group, the suicide attempters reported significantly greater childhood stress and more often had experienced parental loss through separation or divorce than young women in a control group. The association between parental loss and suicidal behaviour did not appear to be an artefact of a primary relationship between parental loss and depression. Five of eight reported childhood stress factors significantly distinguished the suicidal and control subjects. Those who attempted suicide were more likely to report a childhood broken home, that their parents quarrelled often, that they had frequent disagreements with their parents, that they had poor physical health, and that they perceived their parents' character negatively.     

Effect of gender on suicide attempters versus nonattempters in an adolescent inpatient unit

BACKGROUND: Although gender differences have been noted in the risk factors for suicide and attempted suicide, comparative studies to date have used only 2 groups and a limited number of measures. The present study compared the effect of gender on suicide among 4 groups of psychiatrically hospitalized adolescents using a cross-sectional design. METHODS: The study sample consisted of 404 patients, aged between 12 and 21, who were divided into 4 groups: 76 male suicide attempters, 103 male nonattempters, 143 female suicide attempters, and 82 female nonattempters. Patients were tested for life events, affective disorders, aggression, impulsivity, ego defense mechanisms, and death perception with the Child Suicide Potential Scale, Beck Depression Inventory, State-Trait Anxiety Inventory, Overt Aggression Scale, Multidimensional Anger Inventory, Impulsivity Control Scale, and Life Style Index. Findings were analyzed by multivariate regression with stepwise logistic models. RESULTS: Depression and anxiety were more prevalent in female nonattempters than in male nonattempters; there were no such gender differences among the attempters. Antisocial behavior was more prevalent in male attempters than in female attempters; there were no gender differences on this aspect among the nonattempters. There were gender differences for defense mechanisms in the attempters. Logistic regression models for men and women separately revealed that antisocial behavior and anxiety were common predictors of suicide attempt, that destructiveness was a predictor in women only, and that depression was associated with suicide attempt in men only. CONCLUSIONS: Suicide-prone female and male adolescent inpatients show distinct differences in psychopathology, ego defense mechanisms, and life events compared to psychiatrically hospitalized adolescents without any history of suicide attempt. Any deviation from a gender-specific behavior must raise suspicion of a risk of attempted suicide.     

Comparisons of Prisoners Who Make or Do Not Make Suicide Attempts and Further Who Make One or Multiple Attempts

Suicidal behavior among prisoners is a major problem. The objective of this study was to compare prisoners who have made an attempt at suicide vs non-attempters and further to compare single vs multiple suicide attempts. Among 1,537 prisoners, 200 (13%) had a lifetime history of attempting suicide and 92 (6%) had made multiple attempts. Those who had made multiple or single attempts were compared on socio-demographic, developmental, personality, forensic, and psychiatric variables. In a re-analysis we also compared non-attempters with attempters in this larger sample. The comparison showed that prisoners who had made multiple attempts had experienced significantly more childhood trauma, were more introverted, less resilient, had a history of self-mutilation, and had more suicidal ideation. Anger and hostility scores and criminal and violence histories significantly differentiated prisoners who had attempted from those who had never attempted but they did not differentiate multiple from single attempters. Having a history of multiple attempts may be indicative of more severe psychopathology in prisoners, as found in other populations. These findings may be helpful in predicting which prisoner is at increased risk of exhibiting suicidal behavior while incarcerated and after release.     

Adolescent/Adult Differences in Suicidal Behavior and Outcome

A comprehensive literature review compared the patterns of suicide and suicidal behavior for adolescents and adults to identify age-related similarities and differences. Particular attention was given to follow-up rates of suicide by psychiatrically treated persons in these age groups. The major findings were that (1) adults and adolescent suicide completers were similar with respect to their gender ratio, use of guns in the attempt, completion of the initial attempt, and serious psychopathology; (2) adolescents differed from adults in suicidal behavior in their greater attempt rate, higher attempt/completion ratio, and lower rates of short and intermediate completion following psychiatric treatment; (3) the suicide outcome following psychiatric hospitalization is eightfold greater in adults than in youths during the first 3.5 years post-discharge; and (4) the 5:1 male/female ratio is the same for both adolescent attempters who later suicide and for all U.S. 15–19-year-old suicide completers. The frequent practice of combining adult and adolescent suicide and suicide behavior findings can result in misleading conclusions.     

Family history of suicidal behavior and earlier onset of suicidal behavior

The study examined whether having a family history of suicidal behavior is associated with an earlier age of first attempting suicide. Interviews were conducted with 545 patients who had attempted suicide about their family history of suicidal behavior and about their age of first suicide attempt. The results showed that attempters with a family history of suicidal behavior, particularly attempters with two or more such family members, had first attempted suicide at an earlier age than attempters who did not have a family history of suicidal behavior. These results suggest that a family history of suicide, which is known to increase the risk of suicidal behavior, may also be associated with an earlier age of first attempting suicide.     

Treatment for adolescents following a suicide attempt: results of a pilot trial

OBJECTIVE: To compare the efficacy of a skills-based treatment protocol to a supportive relationship therapy for adolescents after a suicide attempt. METHOD: Thirty-nine adolescents (12-17 years old) and parents who presented to a general pediatric emergency department or inpatient unit of a child psychiatric hospital after a suicide attempt were randomized to either a skills-based or a supportive relationship treatment condition. Follow-up assessments were conducted at intake and 3 and 6 months post-attempt. RESULTS: In contrast to the low rates of treatment received by adolescent suicide attempters in the community, approximately 60% of this sample completed the entire treatment protocol. Significant decreases in suicidal ideation and depressed mood at 3- and 6-month follow-ups were obtained, but there were no differences between treatment groups. There were six reattempts in the follow-up period. CONCLUSIONS: When adolescents who attempt suicide are maintained in treatment, significant improvements in functioning can be realized for the majority of patients.     

Completed versus attempted suicide in psychiatric patients: a psychological autopsy study

The aims of this study were to identify specific risk factors associated with completed suicide in a sample of suicide victims diagnosed with mental illness and to discriminate completed suicides from attempted suicide in individuals who did not kill themselves for at least the next 2 years after the index attempt. Ninety-four adults (34 women; 60 men; mean age = 50.81 [SD = 18.08]) admitted to the Division of Psychiatry of the Department of Neurosciences of the University of Parma who died by suicide between 1994-2004 were matched for sex and age (+/- 2 years) with 94 outpatients (mean age = 50.70 [SD = 18.08]) who made at least one suicide attempt during the years of the study. Data were gathered by proxy-based interviews with referring psychiatrists and general practitioners and from examination of medical records. Suicide victims were more likely to be not married, have poor social support (OR = 5.28), and have more voluntary and compulsory admissions to hospitals (1 admission: OR = 5.44; > 1 admissions: OR= 8.84) than suicide attempters. Suicide victims were also less likely to have had stressful life events during their childhood and adolescence (OR = 0.09) and to be divorced or widowed than were the attempters.     

A neuropsychological comparison of depressed suicide attempters and nonattempters

The neuropsychological performance of 18 older inpatients with major depression who were admitted following a suicide attempt was compared with that of 29 older depressed inpatients who had never attempted suicide. There was an interactive effect of age and group on the Trail Making Test, part B, such that attempters showed greater performance declines with age. No other differences were detected between groups on a range of neuropsychological tasks. These findings are discussed in the context of the methodological limitations of previous studies and the need for future research to better elucidate the nature of the relationships between age, cognitive functioning, and suicidal behavior.     

Hypothalamic-pituitary-adrenal axis function and suicidal behavior in depression.

Hypothalamic-pituitary-adrenal (HPA) axis function was examined in relation to suicidal behavior in depression. There were no significant differences between depressed patients who had or had not attempted suicide for either cerebrospinal fluid concentrations of corticotropin-releasing hormone, plasma cortisol levels predexamethasone or postdexamethasone, or for urinary-free cortisol outputs. However, depressed patients who had made a violent suicide attempt had significantly higher 4 PM and maximum postdexamethasone plasma cortisol levels, and significantly more of them were cortisol nonsuppressors than patients who had made nonviolent suicide attempts. A 5-year follow-up was carried out. There were no significant differences on indices of HPA function between depressed patients who did or did not reattempt suicide during the follow-up or who had never attempted suicide. These results suggest the possibility that dysregulation of the HPA axis may be a determinant of violent suicidal behavior in depression.