Suicidal Behaviour: Assessment of People-At-Risk

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Suicidal Behaviour

ii

Suicidal Behaviour Assessment of People-at-Risk

Edited by

Updesh Kumar Manas K. Mandal

Copyright © Updesh Kumar and Manas K. Mandal, 2010 All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage or retrieval system, without permission in writing from the publisher. First published in 2010 by Sage Publications India Pvt Ltd B 1/I-1 Mohan Cooperative Industrial Area Mathura Road, New Delhi 110 044, India www.sagepub.in Sage Publications Inc 2455 Teller Road Thousand Oaks, California 91320, USA Sage Publications Ltd 1 Oliver’s Yard, 55 City Road London EC1Y 1SP, United Kingdom Sage Publications Asia-Pacific Pte Ltd 33 Pekin Street #02-01 Far East Square Singapore 048763 Published by Vivek Mehra for Sage Publications India Pvt Ltd, typeset in 10/12pt Minion by Star Compugraphics Private Limited, Delhi and printed at Chaman Enterprises, New Delhi. Library of Congress Cataloging-in-Publication Data Suicidal behaviour: assessment of people-at-risk/edited by Updesh Kumar, Manas K. Mandal. â•…â•…â•‡ p. cm. â•… Includes bibliographical references and index. 1. Suicidal behavior—Risk factors—Testing. I. Kumar, Updesh. II. Mandal, Manas K. RC569.S865

616.85′8445—dc22

2010

2009049002

ISBN:â•‡ 978-81-321-0299-1 (HB) The Sage Team:â•‡ Rekha Natarajan, Pranab Jyoti Sarma, Mathew P J and Trinankur Banerjee

Dedicated to Dr (Mrs) Sanjukta Mandal and Mrs Anju Walia

vi

Contents

List of Tables List of Figures List of Abbreviations Foreword Preface

ix xi xiii xvii xix

Section I—Risk Assessment: Theoretical Issues 1. Psychological Perspectives on Suicidal Behaviour Rory C. O’Connor

3

2. Empirically Based Assessment of Suicide Risk Chad E. Morrow, Craig J. Bryan and Kathryn Kanzler Appolonio

20

3. Neurobiological Basis of Suicidal Ideation Jitendra Kumar Trivedi and Sannidhya Varma

42

4. Problem-solving Ability and Repeated Deliberate Self-harm Carmel McAuliffe

65

5. Suicide and Homicide: Theoretical Issues Swati Mukherjee, Updesh Kumar and Manas K. Mandal

91

6. Cultural Issues in Suicide Risk Assessment Erminia Colucci

107

7. Gender Issues in Suicide Risk Factor Assessment Peter Osvath, Viktor Voros and Sandor Fekete

136

8. Developmental Issues in Risk Factor Assessment Kimberly A. Van Orden and Alec L. Miller

152

vii

Suicidal Behaviour

â•‡ 9. Reporting Suicide: Impact on Suicidal Behaviour Farah Kidwai

173

Section II—Assessment: People-at-Risk 10. Suicide: Its Assessment and Prediction Pritha Mukhopadhyay

193

11. Substance Use and Suicidal Behaviour Nishi Misra, Amri Sabharwal and Updesh Kumar

230

12. Suicide Risk in Bipolar Disorder Maurizio Pompili, Marco Innamorati, Enrica De Simoni, Ilaria Falcone, Gaspare Palmieri, Laura Sapienza and Roberto Tatarelli

256

13. Depression and Suicide Eva Schaller and Manfred Wolfersdorf

278

14. The Suicidal Soldier Lars Mehlum and Latha Nrugham

297

15. Suicidal Ideation and Behaviour among Asian Adolescents Angel Nga-man Leung, Cathy Yui-chi Fong and Catherine Alexandra McBride-Chang

324

About the Editors and Contributors Author Index Subject Index

343 355 370

viii

List of Tables

1.1 1.2 2.1

A summary of Baumeister’s (1990) suicide as escape from self model Psychological risk and protective factors associated with suicidal risk

06 11

2.2 2.3

Eight empirically supported areas for suicide risk assessments Categories of suicide risk Suicide risk continuum with indicated responses

28 35 37

4.1

UCL dimensions and Their items

78

7.1 Gender differences of suicide attempters (multivariate logistic regression model) 12.1 Factors contributing to increased suicide risk in cases of comorbid substance abuse disorder and bipolar disorder 12.2 A check-list of risk factors for suicidal behaviour in bipolar disorder 13.1 Psychiatric disorders, especially depressive disorders and suicide in a community-based study using psychological autopsy 13.2 Major depressive disorder and suicide: Comparison of depressive suicide versus depressive non-suicide controls 13.3 Suicidal versus non-suicidal depressed inpatients of the Weissenau Depression Treatment Unit Therapist´s assessment at admission (significantly discriminating variables of a patient’s questionnaire) ix

145 261 263

281 285

287

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13.4 Symptoms significantly differentiating suicides and non-suicides in studies with depressive disorder patients 13.5 The depressed patient with suicide risk—clinical psychopathological picture in the presuicidal situation 15.1 Suicide rates in alternate years among 15- to 24-year-old adolescents per 100,000 of the population in selected Asian countries/regions (1990–2006)

x

289 290

326

List of Figures

1.1 An overarching biopsychosocial model of suicidal behaviour 1.2 Cry of Pain model 1.3 Positive future thinking as a moderator of the SPP–distress relationship

15

2.1 Biopsychosocial model of suicide

24

3.1 A stress-diathesis model of suicide

58

7.1 Suicide rates by age groups in Hungary (per 100,000 inhabitants) 7.2 Suicide attempts by age groups (per 100,000 inhabitants)

xi

5 8

146 146

xii

List of Abbreviations

ACE AMP APA APOE4 ARISE ASIQ AtYS BD BDI BDNF BHS BPD BSSI CAMS CAPS CBT CCK CDC CDI CDRS-R CDS CI COMT CoP CREB CSF

Angiotensin converting enzyme Adenosine monophosphate American Psychiatric Association Apolipoprotein E4 Adaptive regression in service of ego Adult Suicidal Ideation Questionnaire Attitude towards Youth Suicide scale Bipolar disorder Beck Depression Inventory Brain-derived neurotrophic factor Beck Hopelessness Scale Borderline personality disorder Beck Scale for Suicide Ideation Collaborative Assessment and Management of Suicidality Child and Adolescent Perfectionism Scale Cognitive-behavioural therapy Cholecystokinin Centre for Disease Control Children’s Depression Inventory Children’s Depression Rating Scale Collaborative Depression Study Confidence interval Catechol-O-methyltransferase Cry of pain Cyclic AMP response element binding protein Cerebro-spinal Fluid xiii

Suicidal Behaviour

CSF-5HIAA CSPS CSRP DBT DHCR7 DRD2 DSH DSM DZTs EARS EASQ ECA ECT EFA EFA-M EPQ EPS ESEMED

Cerebrospinal fluid 5 hydroxyindoleacetic acid Child Suicide Potential Scale Centre for Suicide Research and Prevention Dialectical Behaviour Therapy 7-Dehydrocholesterol reductase Dopamine D2 receptor Deliberate self-harm Diagnostic and Statistical Manual Dizygotic twins Epigenetic Assessment Rating System Extended Attributional Style Questionnaire Epidemiologic Catchment Area Electroconvulsive therapy Ego Function Test Ego Function Assessment Scale-Modified Eysenck Personality Questionnaire Escape Potential Scale European Study on the Epidemiology of Mental Disorders FACES Family Adaptability and Cohesion Evaluation Scales FAST Firestone Assessment of Self-Destructive Thoughts FDA Food and Drug Administration FTT Future Thinking Task FVT Fluid vulnerability theory GAD Generalised Anxiety Disorder GSK-3 Glycogen synthase kinase-3-b HDRS Hamilton Depression Rating Scale 5-HIAA 5-Hydroxy indole acetic acid HPA axis Hypothalamic-pituitary-adrenal axis HPLS Hopelessness Scale For Children HRSD Hamilton Rating Scale for Depression IASP International Association for Suicide Prevention ICD-10 International Classification of Diseases 10 IES Impact of Events Scale LES Life Experience Survey LHPA Axis Limbic-Hypothalamus-Pituitary-Adrenal Axis LHPT Axis Limbic-Hypothalamus-Pituitary-Thyroid Axis LS Lethality Scales LSI Life Style Index xiv

List of Abbreviations

MAOA MDD MDE MINI MLDA MMPI MPQ MPS MSSI MUP MZTs NIMH NOS NSSI PANAS PANSI PBI PD PET PFC PNQ PROSPECT

Monoamine oxidase A Major Depressive Disorder Major depressive episode Mini International Neuropsychiatric Interview Minimum legal drinking age Minnesota Multiphasic Personality Inventory Motives for Parasuicide Questionnaire Multidimensional Perfectionism Scale Modified Scale for Suicide Ideation Multiple Preanalysis Monozygotic twins National Institute of Mental Health Nitric oxide synthase Non-suicidal self-injurious behaviour Positive and Negative Affect Scale Positive and Negative Suicide Ideation Inventory Parental Bonding Instrument Personality Disorder Positron emission tomography Pre-frontal cortex Psychache Needs Questionnaire Prevention of Suicide in Primary-care Elderly: Collaborative Trial PSI Paykel Suicide Items PST Group Interpersonal Problem-Solving Skills Training programme PTS Post-traumatic stress PTSD Post-traumatic stress disorder RADS-2 Reynolds Adolescent Depression Scale-2 RASQ Reasons for Attempting Suicide Questionnaire RCT Randomised Clinical Trial RFL Reasons for Living Inventory RR Relative risk RRR Risk-Rescue Rating Scale RSIC Rorschach Suicide Index Constellation SAT Separation Anxiety Test SBQ Suicide Behaviours Questionnaire SCIC Suicide Crisis Intervention Centre xv

Suicidal Behaviour

SEESA

Sequential Emotion and Event Form for Suicidal Adolescents SI-IAT Self Injury Implicit Association Test SIS Suicide Ideation Scale SIS Suicide Intent Scale SIS-Q Suicidal Ideation Screening Questionnaire SIISF Self-Inflicted Injury Severity Form SMASI Sudden mass assault by a single individual SMR Standard mortality rate SMSI Self Monitoring Suicide Ideation Scale SNP Single nucleotide polymorphisms SPECT Single Photon Emission Computed Tomography SPP Socially prescribed perfectionism SPRC Suicide Prevention Resource Center SPS Suicide Probability Scale SSF Suicide Status Form SSI Scale for Suicide Ideation SSI-W Scale of Suicide Ideation-Worst SSRI Selective serotonin reuptake inhibitor ST Serotonin transporters TAT Thematic Apperception Test TAU Treatment as usual TEMPS-A-Rome Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire-Rome TH Tyrosine hydroxylase TPH1 Tryptophan hydroxylase 1 TSH Thyroid Stimulating Hormone UCL Utrecht Coping List VNTR Variable number tandem repeats WHO World Health Organization ZDI Zung Depression Scale

xvi

Foreword

T

he problem of suicide is important and intriguing. It is important because it is surprisingly widespread—so widespread, in fact, that it constitutes a legitimate health hazard. It is also important because it often involves talented people in key positions in government and industry, and when it involves these people, key resources disappear forever. The problem is intriguing because it is counter-intuitive from an existential, phenomenological and evolutionary perspective—it is a kind of behaviour that seems to defy the most basic tendencies in human nature, those that concern survival. Properly considered, science is a two-step process which I call prediction and explanation. In the first step, researchers try to detect co-variations in nature, to determine what goes with what, to establish reliable empirical relationships. The second step involves trying to explain why the covariations occur, what the dynamics are that generate the reliable empirical relationships. This is a good description of how science actually develops, but it is a perspective that was badly out of favour among psychologists and philosophers of science for perhaps 50 years; for the behaviourists and the logical positivists, prediction and explanation were identical. They were wrong, and by confusing prediction and explanation, they confused rather than clarified a lot of problems. In psychology, prediction is largely accomplished using assessment— valid psychometric procedures—we use assessment to predict outcomes. Explanation is accomplished by linking the empirical co-variations (the predictions) to underlying biological, physiological and neurological processes. This book has several strengths, perhaps the first of which is the degree to which it implicitly honours the distinction between prediction xvii

Suicidal Behaviour

and explanation. The chapters divide rather neatly into psychometric assessment methods and explanatory models based on a variety of plausible perspectives, including neurophysiology, cognitive processes, and cultural and social influence models. The second strength of the book is its ecumenical focus; the contributors come from different countries, cultures and disciplinary backgrounds. They include psychiatrists, psychologists, sociologists, epidemiologists and suicidologists. The authors include Americans, Germans, Indians, Italians, Australians, Norwegians, Chinese, Irish, Hungarians and English scholars. The book is neither parochial nor partisan. Third, the contributions are sensitive to epidemiological, cultural and gender influences. Suicide is examined from a fully rounded perspective. Finally, the book makes clear that psychological assessment has a crucial role to play in applied psychological and social research. Modern measurement research seems often to have lost its way as it pursues item response theory, structural equations modelling, and latent variable analyses for their own sake. This book makes it abundantly clear that ‘assessment concerns predicting consequential outcomes, not measuring abstract entities’. Assessment remains the most important contribution psychology has so far made to the world of practical affairs. This book is a very useful, balanced and comprehensive introduction to the best modern thinking on the prediction, explanation and potential amelioration of suicide, and the editors and authors are to be congratulated for putting it together. Robert Hogan, PhD Hogan Assessment Systems Amelia Island, Florida

xviii

Preface

T

he increasing suicide rates around the globe have drawn immense attention of psychologists, mental health professionals, policy-makers and researchers towards the dynamics of suicidal behaviour. Suicide constitutes a major public health problem across the world. The United Nations has estimated that between 500,000 and 1.2 million people die by committing suicide each year worldwide. According to the World Health Organization estimates, in the year 2000, approximately 1 million people died by committing suicide, and 10 to 20 times more people attempted suicide worldwide. In most countries, suicide is now one of the leading causes of death among people aged 15–34 years. Indeed, suicide is the most frequently encountered emergency situation in mental health care programmes. Moreover, the trauma of suicide does not end with the individual, but gets reflected in feelings of loss and suffering in the lives of family members and friends for years after the suicide. Innumerable publications are available on the subject of suicidal behaviour, although most of these revolve around the epidemiological or theoretical descriptions of suicide. Utilising empirical evidence in active clinical practice and translating insights gained from clinical experience into empirical data, however, still remains a challenge. Most of the available literature focuses on the clinical symptomatology of suicide and its sociological development and influences. There is a paucity of literature with a strong psychometric basis that explains suicidal behaviour in normal population across lifespan. The present volume attempts to fill this void by following a psychometric approach to outline suicide risk assessment and, in turn, to comprehensively understand the suicidal personality/behaviour. This volume includes 15 chapters from experts in the field encompassing the suicide research carried out globally, and the diverse aspects of this problem in various socio-cultural contexts. xix

Suicidal Behaviour

Suicidal behaviour constitutes a vast area for empirical psychological research. The abundance of research on various aspects of suicide has led to an improved understanding of the behaviour, although accurate assessment still remains a challenge. The chapters of the volume are divided into two sections—‘theoretical issues related to assessment of suicidal behaviour’ and ‘assessment of people at suicide risk’. The first section includes nine chapters on topics related to risk assessment: theoretical issues. The section begins with the chapter by O’Connor that provides an overview of the ‘psychological perspectives on suicidal behaviour’. Suicidal behaviour is described as reaction to a situation that has three components—defeat, no escape and no rescue. The author contextualises the psychological factors implicated in the aetiology of suicidal behaviour with a biopsychosocial model. Clinical implications derived from empirical research are discussed and the need for longitudinal as well as experimental research is emphasised in order to expand the theoretical evidence base on the basis of which effective psychological interventions can be developed. The overview of psychological perspectives on suicidal behaviour is followed by the chapter on ‘empirically based assessment of suicide risk’, which reviews and integrates empirically based strategies for the assessment of suicide risk. The authors, Morrow, Bryan and Appolonio, differentiate between risk assessment and prediction and emphasise the importance of establishing a collaborative relationship with the suicidal patient. A biopsychosocial model of suicide is also presented, along with a continuum of suicidality for risk assessment that addresses both the chronic and acute dimensions of suicide risk. The chapter concludes with recommendations for clinical decision-making and practice that are based on current scientific evidence and standards of care. Trivedi and Varma, in their chapter on ‘neurobiological basis of suicidal ideation’, point out the inadequacy of the standardised assessment and prediction scales available and emphasise the need to better understand and utilise the neurobiological basis of suicidal ideation for prediction purposes. They delineate upon the neurobiological basis of suicide and try to identify the biological markers of suicide. They further support their notions with transmitter non-specific as well as transmitter specific neuroendocrine studies. A detailed discussion is presented regarding the genetic basis of suicidal behaviour and role played by different neurotransmitters. xx

Preface

The chapter on ‘problem-solving ability and repeated deliberate selfharm’ by McAuliffe posits that deliberate self-harm has a strong association with difficulties in problem-solving. Empirical evidence to establish a link between repeated acts of deliberate self-harm with motives of escape and revenge and a passive-avoidant approach to problem-solving is discussed. The chapter also includes a valuable discussion on the efficacy of cognitive-behavioural interventions to reduce suicidal behaviour, including aspects of problem-solving skills training. The chapter ‘Suicide and Homicide: Theoretical Issues’ discusses violence as the common thread underlying both suicide as well as homicide. The authors, Mukherjee, Kumar and Mandal, discuss the evidence in the light of the recent research findings that bring out the cognitive and personality factors placing the two behaviours on a continuum. The chapter highlights the theoretical issues involved and elaborates upon the neurological, sociological and psychological perspectives. Based on the theoretical underpinnings, an attempt is made to draw a profile of individuals likely to engage in such violent behaviours towards self or others. Erminia Colucci delves into ‘cultural issues in suicide risk assessment’ in the next chapter. She emphasises the significance and relevance of culture and ethnicity in promoting our understanding of suicidal behaviour, suicide risk assessment and suicide prevention. The chapter includes an overview of cross-cultural research on youth suicide, and of the role that religion and spirituality may play at each step along the suicidal path. The need to pay more attention to the meaning and interpretation of suicide in suicide risk assessment and the necessity to establish culture-sensitive prevention strategies is also addressed. Gender is a pertinent issue of consideration in the assessment of suicidal risk. Osvath, Voros and Fekete, in their chapter on ‘gender issues in suicide risk factor assessment’, discuss the role of gender in determining various aspects of the suicidal behaviour and summarise epidemiological and socio-cultural research evidence identifying protective and risk factors for suicide in males and females. The higher suicide mortality among males in the Western countries is explained in terms of higher lethality of male suicide methods, the reluctance of men to seek help, the higher rate of substance abuse, and some socio-cultural differences. The authors urge the need for further research in the area of gender differences and point out how the insights gained can be utilised for suicide prevention in both genders. The chapter concludes by highlighting gender-specific treatment possibilities/clinical implications. xxi

Suicidal Behaviour

Suicidal vulnerability and risk factors pertinent to different life stages are discussed by Van Orden and Miller in their chapter on ‘developmental issues in risk factor assessment’. The authors examine the ways in which developmental issues impact clinical decision-making in the process of assessing and managing suicide risk across the lifespan ranging from childhood to late adulthood. They discuss four aspects of suicide risk assessment where developmental issues may play a role: the content of information collected during risk assessments, the process of conducting risk assessments, the context surrounding risk assessments and the decisions generated regarding crisis management. The factors unique to particular developmental stages and the way in which these factors manifest differently at different ages are elaborated upon in a sequential manner. Research has established that the manners of reporting suicide stories have a significant influence on suicidal behaviour and suicide-prevention strategies and policies. Kidwai elaborates upon this emerging area of suicide research in her chapter ‘Reporting Suicide: Impact on Suicidal Behaviour’. She discusses the role of cognitive and arousal processes as mediators that affect suicidal behaviour. The author elaborates upon the contagion and cultivation effects of suicidal behaviour that are probable after media coverage of suicidal acts. It is argued that the portrayal of suicides in the media has an impact on suicidal behaviour, and it is, therefore, essential to educate reporters, editors, film-television producers about suicide contagion and related phenomena. The author conclusively assumes that media’s positive role while reporting suicide stories, based on certain basic guidelines which she proposes in the end, can go a long way in preventing such behaviour. Accurate assessment and prediction of suicidal behaviour is of utmost importance for effective prevention, which is the primary motive of any mental health programme. The lacunae often experienced by clinicians in predicting suicidal behaviour through the use of psychometric assessment tools are filled up by their clinical experience. The second section of the present volume—‘Assessment: People-at-Risk’—includes six chapters. This section opens with Mukhopadhyay’s chapter titled Suicide: Its Assessment and Prediction. In this chapter, the author argues that the psychological and psychosocial risk factors that lead to suicidality require systematic psychological evaluation. She lists and critically reviews the available suicide risk assessment tools for varied parameters ranging from suicidal thoughts to completed suicide and other related psychological xxii

Preface

domains. The tools are evaluated in terms of their psychometric properties and the readers are provided with ample information for choosing the assessment tool that match their requirement. Given multifactor origin of suicide, the author argues the use of battery of tests for the evaluation of direct factors related to suicidal behaviour and indirect potential factors that contribute to it, so as to ensure the understanding of phenomenon in totality. In their chapter on ‘substance use and suicidal behaviour’, Misra, Sabharwal and Kumar present an overview of the research on the incidence of suicidal behaviour in conjunction with substance use. The chapter includes an outline of the possible role of personality, cognitive and neurobiological factors to predict suicidal behaviour among substance users. The comorbidity of substance use with other psychiatric disorders, particularly depression and personality disorders, and the demographic variables and life events that further complicate the assessment of suicide risk among substance users are also discussed. Finally, prevention and intervention measures specific to substance users are listed. Suicide is also the major source of mortality in the patients of bipolar disorder. Bipolar disorder is known to increase suicide vulnerability manifold. Pompili and associates, in their chapter on ‘suicide risk in bipolar disorder’, comprehensively reviews the relevant literature. The authors emphasise the high risk of suicide associated with bipolar disorder and discuss the efficacy of various short and long-term intervention measures for managing suicidality. Schaller and Wolfersdorf extend the issue on similar line in their chapter on ‘depression and suicide’. They elaborate upon the association between depression and suicidal behaviour on the basis of epidemiological data. With adequate support of communitybased and clinically-based updated studies, the authors discuss the prevalence of suicides in depressive disorders focusing on clinical signs, risk factors and symptoms differentiating suicidal and non-suicidal depressed patients. Furthermore, they also discuss about suicide prevention in depressed patients. Discussing the issues involved in suicide prevention, Mehlum and Nrugham describe the emergence, maintenance and prevention of suicidal behaviour in military settings and examine the environmental and individual risk factors, protective factors and assessment issues. Their chapter titled The Suicidal Soldier focuses on the suicidal phenomena in the Norwegian Armed Forces and discusses these in the light of the xxiii

Suicidal Behaviour

research findings and the personal experiences of the authors with the armed forces. The final chapter in this volume focuses on adolescence, a life stage that is marked with maximum suicide vulnerability. The chapter on ‘suicidal ideation and behaviour among Asian adolescents’, by Leung, Fong and McBride-Chang, summarises the trends, risk factors, warning signs and preventive measures for Asian adolescents’ suicidal behaviour. Although majority of the available researches in the area are from Western countries, in this chapter, risk factors for adolescent suicide categorised into psychological, environmental and socio-cultural are discussed in light of sufficient research evidence across major Asian countries. The authors also highlight the warning signs for suicide, and propose preventive measures and treatment options. The theoretical issues elaborated upon in the first part of this volume along with the applied and practical issues of the second part are an effort to put the readers’ insight into the psychometrically sound suicide risk assessment. Varied paradigms of suicidal behaviour along with the suggested prevention strategies are discussed in an effort to provide a scope for widening the horizon of the mental health professionals and researchers working in this area so as to reduce the suicidal behaviour across the world. The issues being raised in the volume are supposed to promote more researches in this area that will certainly prove beneficial in service of humanity. Suicide and suicidal behaviour constitute a vast and varied area of research, and editing a volume on the issue has undoubtedly been a Herculean task. It would not have been possible to come up with the volume in the present form without the help and understanding of the people around us, who provided constant support and encouragement. We extend our gratitude to one and all who facilitated our endeavours in however small manner. We express our gratitude towards our organisation, the Defence Research and Development Organisation for providing us with infrastructural support. We are indebted to our mentors, Shri M. Natarajan (Scientific Advisor to Raksha Mantri, Secretary, Department of Defence Research and Development, and Director General Research and Development) and Dr W. Selvamurthy, Distinguished Scientist, Chief Controller Research and Development (LS & HR) for their encouragement and benevolence.

xxiv

Preface

It has indeed been a rewarding experience to work with researchers who are dedicated to this field of research. Their varied ideas stemming from their diverse professional and cultural backgrounds have not only enhanced our knowledge and understanding of the phenomenon of suicide, but have also made the experience of editing this volume very fascinating. We sincerely thank all the authors for their contributions and look forward to future opportunities to work together. We are also obliged to acknowledge the painstaking efforts put in by the reviewers, Emeritus Prof. (Retd.) Sagar Sharma (Punjab University, Chandigarh) and Prof. (Retd.) G.P. Thakur (Mahatma Gandhi Kashi Vidyapith, Varanasi). Without their involvement it would not have been possible to come up with the volume in its present form. We would also like to extend our gratitude to our colleagues at the Defence Institute of Psychological Research, Defence Research and Development Organisation, for their help and co-operation in our endeavour to bring out this volume on suicidal behaviour. Updesh Kumar Manas K. Mandal

xxv

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xxvi

SecƟon I

Risk Assessment: TheoreƟcal Issues

2

1

Psychological PerspecƟves on Suicidal Behaviour RÊÙù C. O’CÊÄÄÊÙ

I

can’t stop myself thinking, I wish I could turn off, I hate myself, I’m just not good enough, I am tired of life , I’ve had enough—declares a young man, aged 19 years, who took his own life (O’Connor, unpublished). It is generally accepted that suicide is the outcome of a complex interplay of aetiological factors which are psychological, biological and social in origin (e.g., Mann et al., 2005). Indeed, in recent years there has been a growth in biopsychosocial models including the diathesis-stress model of suicidal behaviour (e.g., Mann et al., 1999). Exponents of diathesisstress perspectives argue that the risk of suicide is determined by the interaction of predisposing vulnerabilities and the experience of stress (e.g., Joiner and Rudd, 1995; O’Connor and O’Connor, 2003; Schotte and Clum, 1987). These vulnerabilities take many forms; they can be biological (e.g., increased activity of hypothalamic-pituitary-adrenal [HPA] axis, Mann and Currier, 2007), cognitive (e.g., reduced social problem-solving capacity, Williams, Barnhofer, Crane and Beck, 2005) or personality/ individual differences factors (e.g., perfectionism, O’Connor et al., 2007). For the purposes of the present chapter we will focus on some of the psychological factors and describe how three of the predominant psychological models enhance our understanding of the aetiology and course of suicidal behaviour. 3

Rory C. O’Connor

AN OVERARCHING BIOPSYCHOSOCIAL MODEL OF SUICIDAL BEHAVIOUR In a recent conceptualisation of the role of psychological factors in the aetiology of mental health problems, Kinderman (2005) argues against a simple biological reductionist approach. His conceptualisation calls for greater consideration to be given to the role of psychological processes in the aetiology and treatment of mental disorders. Within suicidology, there has also been increased recognition that we need to move beyond the classic psychiatric diagnostic categories if we are to further understand the aetiology of suicidal behaviour (van Heeringen, 2001). Therein Kinderman (2005) restates Engel’s (1980) original formulation that the biological, psychological and social perspectives which comprise the biopsychosocial model are equal partners in the aetiology of mental health problems. Indeed, he argues cogently that the disruption or dysfunction of psychological processes is a final common pathway in the development of a disorder. He proposes that biological and social factors together with the individual’s life experiences (e.g., negative life events) lead to mental health problems not directly, rather indirectly, to the extent that they disrupt psychological processes, and that it is this disruption or dysfunction of psychological processes which leads to the development of a mental disorder. For example, Kinderman would argue that although there are key biological substrates involved in depression, it is how these substrates (e.g., low levels of serotonin) impact on appraisal mechanisms and information processing which is crucial to the development of depression. From a cognitive perspective, it is the extent to which biological factors change your appraisal of yourself, the world and the future which is central to understanding the aetiology of mental health problems. For the present purposes, I have extended Kinderman’s (2005) model to explain suicidal behaviour (Figure 1.1). Consistent with Kinderman, I see psychological processes as central to understanding this phenomenon. However, I propose two self-destructive pathways. The first leads from psychological processes through mental health disorder to suicidal behaviour. This pathway primarily comprises those individuals who become depressed as a result of disturbed psychological processes characterised by, for example, low self-worth, a sense of entrapment and no rescue. Other factors, which include access to the means of suicide, 4

Psychological Perspectives on Suicidal Behaviour Figure 1.1

An Overarching Biopsychosocial Model of Suicidal Behaviour

Source: Adapted and extended by the author from Kinderman (2005).

cognitive constriction, modelling effects and so on, will determine whether the depressed individual engages in suicidal behaviour. The second pathway is direct, leading from psychological processes to suicidal behaviour and accounts for those suicidal individuals who are not suffering from mental disorder. An impulsive young man who experienced a sudden loss of self-esteem following the loss of his job and subsequently became suicidal would be an example of this second pathway. Studies to understand the psychological processes which lead individuals to take their own lives have grown considerably in recent years. These processes are the focus of the remainder of this chapter. However, any focus on psychological processes would be incomplete without due consideration being given to the key psychological models which have been proffered to explain and treat suicidality. Although Kinderman’s (2005) model acts as a good overarching framework, which parsimoniously describes the relationship between biology, psychology and social factors, a number of other explicitly psychological models have been effective in describing the how, the why and the when of suicidal risk. 5

Rory C. O’Connor

A description of all such models is beyond the scope of the present chapter. However, the predominant ones include escape theory (Baumeister, 1990), the cry of pain model (Williams, 2001), the differential activation model of cognitive reactivity (Williams et al., 2008) and the interpersonalpsychological model of suicidal behaviour (Joiner, 2005). As escape is a commonality in many of these models of suicide, I direct our focus on it now:

ESCAPE AS A CENTRAL SUICIDAL MOTIVE Escape has long been recognised as a central driving force underpinning suicidal motives (Shneidman, 1985). Needless to say, escape-motivated suicides only represent one category of suicides and do not include ritual/altruistic suicides. Indeed, Baumeister (1990) and others (including Leenaars, 2004 and Williams, 2001) have developed models and therapeutic interventions of suicidal behaviour with escape as a key component. In his seminal paper, Roy Baumeister (1990) extended the clinical and sociological models by proposing a psychological model of suicide derived from social and personality psychology. His main argument was that suicide is the endpoint of a complex series of causal steps which are driven by an attempt to escape from painful self-awareness (Table 1.1). Table 1.1

A summary of Baumeister’s (1990) Suicide as Escape from Self Model

Step

Description of step and characteristics

Step 1

During stressful times we fall short of our expectations and standards resulting from either unrealistic expectations or major setbacks. We attribute the blame (for this shortfall) internally; this leads to blame and negative implications of the self. These negative self-implications lead to elevated and unpleasant negative self-awareness such as inadequacy, incompetence or guilt. The negative self-awareness leads to negative affect. To escape this painful self-awareness we engage in cognitive deconstruction (the removal of meaning from awareness). If deconstruction is not effective, other means of terminating thoughts/feelings are required. Because we are disinhibited, we see suicide as more acceptable as the moral/social ‘norms’ (internal barriers to action) are removed.

Step 2 Step 3 Step 4 Step 5

Step 6

Source: Compiled by the author from Baumeister (1990). 6

Psychological Perspectives on Suicidal Behaviour

In short, Baumeister’s (1990) model suggests that a negative experience (or change in severity of existing or chronic negative experiences) is the catalyst for self and social comparison processes whereby we try to make sense of why something happened or why circumstances have changed. If the resultant negative attributions are internal, they lead to blame and negative self-implications, which in turn lead to negative self-awareness (feelings of inadequacy and guilt) and negative affect. In an attempt to escape these painful cognitions and feelings we engage in cognitive deconstruction, which has been described as lower level awareness/thinking that results in ‘the removal of higher meanings from awareness’ (Baumeister, 1990: 92). In addition to numbing aversive thoughts, cognitive deconstruction is also thought to increase disinhibitions such that the social or moral norms (internal barriers to action) are also attenuated or removed rendering suicide more likely. A range of other factors, including access to means, will influence whether suicide is subsequently enacted. A number of studies with clinical and non-clinical samples have yielded evidence consistent with escape theory (Dean and Range, 1999; Dean et al., 1996; Flamenbaum and Holden, 2007; O’Connor and O’Connor, 2003; Tassava and Ruderman, 1999).

ENTRAPMENT AND THE CRY OF PAIN Although escape theory is a useful explanatory framework, recent research has extended this model to improve the prediction of suicidal behaviour—to better identify the circumstances when escape is especially pernicious. Drawing from the animal behaviour literature and the idea of ‘arrested flight’ Gilbert (2006), Gilbert and Allan (1998), MacLean (1990) and Williams and colleagues (Williams, 2001; Williams and Pollock, 2000; Williams, Crane, Barnhofer and Duggan, 2005) have put forward the cry of pain (CoP) or entrapment model of suicide (Figure 1.2). In essence, Williams argues that stressful experiences which result in feelings of defeat and loss can be suicidogenic but that these appraisals are particularly toxic when we cannot escape from the defeating situation. Escape is determined, in part, by failure in social problem-solving. In turn, it is this state of entrapment combined with no opportunities for rescue which Williams posits to be associated with elevated risk of suicide via the activation of 7

Rory C. O’Connor Figure 1.2

Cry of Pain Model

Source: Adapted from Williams and Pollock (2001).

the learned helplessness script. Put simply, the latter is the realisation that there is no relationship between individual action and outcome; in other words, no matter what I do, I cannot change myself, my future or my circumstances. Similar to escape theory, whether we engage in suicidal behaviour is determined by a number of additional factors including whether we are modelling others’ behaviour or we have access to the means of suicide. In short, therefore, Williams and Pollock (2001) proposed that suicidal behaviour is reactive, the response (‘the cry’) to a situation that has three components: defeat, no escape and no rescue. The CoP model is garnering empirical and conceptual support and is attractive not only because it is parsimonious and intuitive but also because it suggests specific, testable, moderating and mediating pathways/hypotheses. To this end, we have completed two clinical case-control type studies which have yielded empirical support for the cry of pain model, specifically demonstrating the power of the CoP variables in discriminating between self-harm patients 8


and controls, and between first-time and repeat self-harm patients (O’Connor, 2003; Rasmussen et al., in press). In addition, these latter studies have found direct evidence for the hypothesised mediating (defeat–entrapment–suicidality relationship) and moderating pathways (escape/entrapment–low rescue factors–suicidality relationship) specified in the CoP model. In the present context, mediating pathways are particularly important theoretically and clinically as they help to identify the mechanisms by which psychological factors are translated into suicide risk. Moderating relationships, on the other hand, specify the conditions under which suicide risk is high (e.g., when rescue factors are low) or low. The Rasmussen et al. (in press) study also extended O’Connor (2003) by employing pure measures of defeat and entrapment to test the CoP model. The CoP has also received experimental attention (Johnson et al., 2008) and conceptual consideration in the context of understanding suicidality in psychosis (Bolton et al., 2007). It is also worth noting that irrespective of the level of explanation, the CoP is a diathesis-stress model of suicidality.

‘CRIES OF PAIN’: SOME PERSONAL COMMUNICATIONS The CoP constructs are not ethereal psychological constructs; they are present in the spoken communications of those who attempt suicide. What follows are selected quotations from suicidal patients within 24 hours of a suicidal episode who took part in one of our recent studies (O’Connor, 2003). They illuminate the human tragedy behind each suicidal episode. The first example is taken from a 20-year-old woman who had an overdose history. Her words illustrate the spiral of despair and ‘overdose-as-problem-solving’ motivation which characterises many suicidal individuals: I take them [tablets] just to block everything off but once it’s finished (the suicidal episode) it’s just there again, so [it’s] a vicious circle, take them again to take the problems away…take them to take the depression away but because [I] am taking them [I] get more and more depressed. (O’Connor, Unpublished)

9

Rory C. O’Connor

Defeat, failure and entrapment were communicated explicitly by many of the suicidal patients. One of the participants, a school pupil, was having difficulties at school. The last line of her communication is important; the young person is not able to do what she wanted, she feels trapped: I was stressed, couldn’t cope with all at school, too much work, too much pressure…Got results back and [I] failed most of them, just felt depressed. Not allowed to just sit three of them. (O’Connor, Unpublished)

A 20-year-old unemployed woman reports feeling hopeless and trapped with no prospect of rescue: On the day before the overdose I’d been to the GP [doctor] for tests. That night [I] had nightmares…Feeling fairly down yesterday, hopeless, felt trapped, very alone, scared of being and feeling alone. Just so much going on I feel I can’t cope with it all. (O’Connor, Unpublished)

Finally, escape as a motivation for a suicidal episode was succinctly described by a 38-year-old married woman: I just wanted to escape. [I] didn’t want to see him. [He] makes me feel depressed.’ (O’Connor, Unpublished)

Although there is growing qualitative and quantitative evidence for the CoP constructs, the evidence base requires expansion. It is not yet clear to what extent these variables predict suicidal behaviour over time, and to what extent these constructs are modifiable within high risk groups. Perhaps unsurprisingly, escape/entrapment and defeat are overlapping constructs (as feelings of defeat may also characterise thoughts of entrapment). Therefore, it would be helpful to further refine these two constructs to better specify the distinct active components of defeat and entrapment, respectively. A key strength of the CoP model is that it allows for two levels of explanation of suicide risk. At a macro-level (first order), it posits three sets of judgements concerning defeat, escape and rescue which account for suicide risk. As noted earlier, these constructs are useful, they seem to be better proximal discriminators of self-harm than clinical variables and past behaviour (O’Connor, 2003). In addition, work by Williams and colleagues have shown that these feelings of defeat and entrapment can be 10


reactivated by negative mood (e.g., Williams et al., 2008). Drawing from the differential activation literature (e.g., Goldstein and Willner, 2002), Williams suggests that patterns of cognition and behaviour (including suicidal ideation and behaviour) become associated when, say, mood is low and these associations become more closely connected if there is a reoccurrence of the lower mood. Consequently, in the future, small changes in mood can give rise to these associations and if suicidal ideation was part of the network of associations when mood was low, it is likely to emerge again during a depressive episode. It is the ease with which these changes in mood reactivate the defeating, entrapping and suicidal thoughts which is crucial to risk assessment. The CoP model also suggests a more fine-grained level of explanation (second order), where biases in information processing, memory deficits, and other individual differences and vulnerabilities affect the decisions concerning defeat, escape and rescue. This level of explanation complements the macro-level model by identifying specific fundamental processes (e.g., future thinking and interpersonal problem-solving) and individual characteristics (e.g., perfectionism) which should be targeted for intervention to reduce suicide risk. A large number of psychological variables have been implicated in the suicidal process (see Table 1.2 for a list of such variables). However, as space is limited, I focus our attention on two factors which we have examined explicitly within the CoP framework: positive future thinking and socially prescribed perfectionism. Table 1.2

Psychological Risk and ProtecƟve Factors Associated with Suicidal Risk

Autobiographical memory biases Interpersonal problem-solving Cognitive rigidity Impulsivity Group/social influences Goal re-engagement Attributional/cognitive style Resilience Attitudes Neuroticism Shame Source: Compiled by the author.

Hopelessness Future thinking Perfectionism Self-criticism Rumination Self-esteem Coping Optimism/pessimism Attentional biases Thought suppression Hardiness

11

Rory C. O’Connor

THOUGHTS OF THE FUTURE AND SUICIDE RISK In the 1990s, MacLeod and colleagues (1993) were keen to determine whether different operationalisations of hopelessness (a key proximal predictor of suicidal behaviour) were functionally equivalent or differentially associated with suicide risk. In a series of studies (MacLeod et al., 1993, 1997, 1998), they determined that suicidal participants consistently reported significantly fewer positive future thoughts compared to controls but showed no difference in negative future expectations. Positive future thinking is usually assessed via the Future Thinking Task (FTT; MacLeod et al., 1997) which asks participants what they are worried about (negative future thoughts) and looking forward to (positive future thoughts) over different future time frames—it generates idiographic, specific positive future expectancies. In short, future expectations of a positive valence are particularly associated with suicide risk (MacLeod et al., 1997) and this finding has been replicated independently (Hunter and O’Connor, 2003; O’Connor et al., 2000, 2004, 2008; Williams et al., 2008). This deficit in positive cognitions is even more striking as it cannot be explained in terms of higher levels of depression among suicidal patients (e.g., MacLeod et al., 1997) nor can the effect be explained by negative cognitive style (O’Connor et al., 2000). Moreover, we recently showed that specific positive future expectancies (as assessed via FTT) were better predictors of suicidal ideation two and a half months following a suicide attempt than global hopelessness (measured via the Beck Hopelessness Scale; Beck et al., 1974; O’Connor et al., 2008). In terms of the CoP model, the deficit in positive future thinking fits well: if one finds oneself in a state of entrapment, the model suggests that the pathway from entrapment to suicidal behaviour is strengthened or attenuated by the presence or absence of rescue factors. In this case, rescue factors are operationalised as the relative paucity in positive future thinking. Therefore, the CoP posits a strengthening of the entrapment–suicidal behaviour relationship, and this is what we have found previously (see Rasmussen et al., in press, for empirical support for this path). Moreover, as positive thinking is thought to be associated with resilience (Ciarrochi et al., 2007), the negative impact of its absence on well-being is understandable. It is encouraging to note that in a pilot Randomised Clinical Trial (RCT) (brief manual-assisted cognitive behaviour therapy versus treatment as usual), self-harm patients in the active arm of the trial showed a significant

12


improvement in positive future thinking over the course of the followup period (MacLeod et al., 1998). However, interpretation of the findings is problematic as the control group also improved their positive future thinking. Needless to say, future research should be directed at such interventions.

SOCIALLY PRESCRIBED PERFECTIONISM AND SUICIDE RISK Given the importance of impaired positive future thinking in the suicidal process, it is important to investigate individual differences/personality factors which may be implicated in the development of this impairment. One such variable which has been of interest in this regard is socially prescribed perfectionism (SPP). Socially prescribed perfectionism—a recognised personality trait—taps beliefs about the excessive expectations we perceive that our significant others have of us (Hewitt and Flett, 1991) and it is independently associated with suicide risk (Hewitt et al., 1997, 1998; O’Connor and O’Connor, 2003). Socially prescribed perfectionism was high up the list of candidate personality variables given that it is consistent with escape theory and the CoP model. Indeed, the first step of the causal chain to suicide in escape theory implicates perfectionistic comparison processes: in stressful times we fall short of our expectations and standards. Similarly, in the CoP, the process by which one appraises stressful situations as leading to defeat and/or entrapment suggests perfectionistic beliefs. It is important to highlight, though, that the perfectionism literature consistently points to the specific effects of perceived excessive/high expectations ‘set by others’ (i.e., SPP) as being more pernicious than those set by oneself (O’Connor, 2007; Shafran and Mansell, 2001), hence the focus on SPP here. We believe that the potency of SPP is due, in part, to the fact that the ‘perceived’ excessive standards set by others are outside one’s personal control, and loss of control has long been associated with poor psychological adjustment (O’Connor and Sheehy, 2000). It would also be theoretically and clinically useful to determine whether SPP increases the ease with which CoP cognitions are reactivated.

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In a series of studies we have shown not only that SPP is associated with positive future thinking (e.g., Hunter and O’Connor, 2003) but that positive future thinking moderates the relationship between SPP and suicide risk in clinical (O’Connor et al., 2007) and non-clinical populations (O’Connor et al., 2004). In the latter study, 206 healthy participants completed the future thinking task contemporaneously with a measure of SPP and hopelessness. Although SPP was independently associated with hopelessness, the relationship was significantly stronger when considered concomitantly with positive future thinking. In other words, those individuals with high SPP and low levels of positive future thinking reported significantly higher levels of hopelessness—a proximal predictor of suicidal behaviour—than those high on positive future thinking. In the former study (O’Connor et al., 2007), we followed up 126 suicide attempters two months following a suicide attempt and found that outcome (i.e., suicidal ideation and hopelessness) was better for those high on positive future thoughts and low on perfectionism (Figure 1.3). Our interpretation of these data is that higher levels of positive future thinking result in (or are akin to) more reasons for living, thereby reducing the sense of entrapment and suicide risk (O’Connor et al., 2007). Future research should experimentally test whether higher levels of positive future thinking decrease perceptions of entrapment.

CLINICAL IMPLICATIONS There are a number of clinical implications from the research summarised here. First, the overarching biopsychosocial model recognises the complex interplay between biology, psychology and social factors in suicidal aetiology but it proposes that psychological processes are a common pathway to mental disorder and suicidal behaviour. Whereas the biopsychosocial model is a generic ‘black box’ model of suicide risk, the escape theory, CoP, and the differential activation model offer specific details of mechanisms and processes. Second, it provides a framework on which to develop treatment interventions and it highlights a number of psychological processes which ought to be considered when a clinician is assessing suicide risk. Taking the CoP and the differential activation models together, it is clear that thoughts of defeat and entrapment are central to the aetiology of suicidal behaviour but that their impact may be latent until these thoughts 14

Source: O’Connor et al. (2007).

Figure 1.3 PosiƟve Future Thinking as a Moderator of the SPP–Distress RelaƟonship


15

Rory C. O’Connor

are reactivated by a negative mood or the occurrence of a negative life event and escalate into a suicidal episode over time. So it is important to look at the conjoint effects of these latent characteristics (e.g., entrapment), trait factors (including perfectionism) which confer psychological vulnerability, rescue factors which can act as buffers of psychosocial stressors, as well as the occurrence of negative life events. Third, the work on positive future thinking and social perfectionism highlights specific cognitions and individual characteristics which may influence risk. Further, it highlights precise cognitive-behavioural mechanisms (e.g., entrapment–positive future thinking–suicidal behaviour) which could be targeted directly through therapy. Specific positive cognitions embedded in different future-oriented time frames could also be modified to reduce risk (O’Connor et al., 2008). Indeed, the assessment of positive future thoughts could be incorporated into treatment protocols, with their increase/decrease serving as an indicator of risk. A similar approach with reasons for living has been used successfully by Jobes in his Collaborative Assessment and Management of Suicidality programme (CAMS; Jobes, 2006). Our data also add to the growing body of evidence highlighting the importance of positive cognitions to adaptive selfregulation and adjustment (e.g., Fredrickson and Losada, 2005). Fourth, we need to understand further the means by which the presence of positive future thoughts may buffer against suicide risk. Do they, as I suspect, reduce entrapment and/or do they impact on our defeat and rejection appraisals? Finally, relatively little attention has been directed at conducting and evaluating evidence-based interventions to modify perfectionism. Consequently, we need to tease out the mechanisms which are involved in the development and maintenance of perfectionism. In short, within suicidology, longitudinal and experimental research is urgently required to extend the theoretical evidence base which will hopefully inform the development of effective psychological interventions.

REFERENCES Baumeister, R.F. (1990). Suicide as escape from self. Psychological Review, 97(1), 90–113. Beck, A.T., A. Weissman, D. Lester and L. Trexler (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42(6), 861–65. 16


Bolton, C., P. Gooding, N. Kapur, C. Barrowclough and N. Tarrier (2007). Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why? Clinical Psychology Review, 27(4), 511–36. Ciarrochi, J., P.C.L. Heaven and F. Davies (2007). The impact of hope, self-esteem and attributional style on adolescents’ school grades and emotional well-being: A longitudinal study. Journal of Research in Personality, 41(6), 1161–78. Dean, P.J. and L.M. Range (1999). Testing the escape theory of suicide in an outpatient clinical population. Cognitive Therapy and Research, 23(6), 561–72. Dean, P.J., L.M. Range and W.C. Goggin (1996). The escape theory of suicide in college students: Testing a model that includes perfectionism. Suicide and Life-Threatening Behavior, 26(2), 181–86. Engel, G.L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137(5), 535–44. Flamenbaum, R. and R.R. Holden (2007). Psychache as a mediator in the relationship between perfectionism and suicidality. Journal of Counseling Psychology, 54(1), 51–61. Fredrickson, B.L. and M.F. Losada (2005). Positive affect and the complex dynamics of human flourishing. American Psychologist, 60(7), 678–86. Gilbert, P. (2006). Evolution and depression: Issues and implications. Psychological Medicine, 36(3), 287–97. Gilbert, P. and S. Allan (1998). The role of defeat and entrapment (arrested flight) in depression: An exploration of an evolutionary view. Psychological Medicine, 28(3), 585–98. Goldstein, R.C. and P. Willner (2002). Self-report measures of defeat and entrapment during a brief depressive mood induction. Cognition and Emotion, 16(5), 629–42. Hewitt, P.L. and G.L. Flett (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60(3), 456–70. Hewitt, P.L., J. Newton, G.L. Flett and L. Callander (1997). Perfectionism and suicide ideation in adolescent psychiatric populations. Journal of Abnormal Child Psychology, 25(2), 95–101. Hewitt, P.L., G.R. Norton, G.L. Flett, L. Callander and T. Cowan (1998). Dimensions of perfectionism hopelessness, and attempted suicide in a sample of alcoholics. Suicide and Life-Threatening Behavior, 28, 395–406. Hunter, E.C. and R.C. O’Connor (2003). Hopelessness and future thinking in parasuicide: the role of perfectionism. British Journal of Clinical Psychology, 42(4), 355–65. Jobes, D.A. (2006). Managing Suicide Risk: A Collaborative Approach. New York: Guilford Press. Johnson, J., N. Tarrier and P. Gooding (2008). An investigation of aspects of the cry of pain model of suicide risk: The role of defeat in impairing memory. Behaviour Research and Therapy, 46(8), 968–75. 17

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Joiner, T. (2005). Why people die by suicide. Massachusetts, US: Harvard University Press. Joiner, T.E. and M.D. Rudd (1995). Negative attributional style for interpersonal events and the occurrence of severe interpersonal disruptions as predictors of self-reported ideation. Suicide and Life-Threatening Behavior, 25(2), 297–304. Kinderman, P. (2005). A psychological model of mental disorder. Harvard Review of Psychiatry, 13(4), 206–17. Leenaars, A.A. (2004). Psychotherapy with suicidal people. Chichester: John Wiley & Sons. MacLean, P.D. (1990). The Triune brain in evolution. New York: Plenum Press. MacLeod, A.K., B. Pankhania, M. Lee and D. Mitchell (1997). Parasuicide, depression and anticipation of positive and negative future experiences. Psychological Medicine, 27(4), 973–77. MacLeod, A.K., G.S. Rose and J.M.G. Williams (1993). Components of hopelessness about the future in parasuicide. Cognitive Therapy and Research, 17(5), 441–55. MacLeod, A.K., P. Tata, K. Evans, P. Tyrer, U. Schmidt, K. Davidson, et al. (1998). Recovery of positive future thinking within a high-risk parasuicide group: Results from a pilot randomized controlled trial. British Journal of Clinical Psychology, 37(5), 371–79. Mann, J.J. and D. Currier (2007). A review of prospective studies of biologic predictors of suicidal behavior in mood disorders. Archives of Suicide Research, 11(1), 3–16. Mann, J.J., A. Apter, J. Bertolote, A. Beautrais, D. Currier, A. Haas et al. (2005). Suicide prevention strategies: A systematic review. Journal of American Medical Association, 294(16), 2064–74. Mann, J.J., C. Waternaux, G.L. Haas and K.M. Malone (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2), 181–89. O’Connor, R. C. and N.P. Sheehy (2000). Understanding suicidal behaviour. Chichester: Wiley Blackwell. O’Connor, R.C. (2003). Suicidal behaviour as a cry of pain: Test of a psychological model. Archives of Suicide Research, 7(4), 297–308. O’Connor, R.C. (2007). The relations between perfectionism and suicidality: A systematic review. Suicide and Life-Threatening Behavior, 37(6), 698–714. O’Connor, R.C. (Unpublished). General hospital self-harm: Motives and reasons. O’Connor, R.C. and D.B. O’Connor (2003). Predicting hopelessness and psychological distress: The role of perfectionism and coping. Journal of Counseling Psychology, 50(3), 362–72. O’Connor, R.C., D.B. O’Connor, S.M. O’Connor, J. Smallwood and J. Miles (2004). Hopelessness, stress and perfectionism: the moderating effects of future thinking. Cognition and Emotion, 18(8), 1099–120. O’Connor, R.C., H. Connery and W. Cheyne (2000). Hopelessness: The role of depression, future directed thinking and cognitive vulnerability. Psychology, Health and Medicine, 5, 155–61. O’Connor, R.C., L. Fraser, M.C. Whyte, S. MacHale and G.Masterton (2008). A comparison of specific positive future expectancies and global hopelessness as predictors 18


of suicidal ideation in a prospective study of repeat self-harmers. Journal of Affective Disorders, 110(3), 207–14. O’Connor, R.C., L. Fraser, M.C. Whyte, S. MacHale and G. Masterton (in press). Selfregulation of unattainable goals in suicide attempters: the relationship between goal disengagement, goal reengagement and suicidal ideation. Behaviour Research and Therapy. O’Connor, R.C., M.C. Whyte, L. Fraser, G. Masterton, J. Miles and S. MacHale (2007). Predicting short-term outcome in well-being following suicidal behaviour: The conjoint effects of social perfectionism and positive future thinking. Behaviour Research and Therapy, 45(7), 1543–55. Rasmussen, S., L. Fraser, M. Gotz, S. MacHale, R. Mackie, G. Masterton, S. McConachie and R.C. O’Connor (in press). Elaborating the Cry of Pain model of suicidality: Testing a psychological model in a sample of first-time and repeat self-harm patients. British Journal of Clinical Psychology. Schotte, D. and G. Clum (1987). Problem-solving skills in suicidal psychiatric patients. Journal of Consulting and Clinical Psychology, 55(1), 49–54. Shafran, R. and W. Mansell (2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879–906. Shneidman, E.S. (1985). Definition of suicide. New York: John Wiley & Sons. Tassava, S.H. and A.J. Ruderman (1999). Application of escape theory to binge eating and suicidality in college women. Journal of Social and Clinical Psychology, 18(4), 450–66. van Heeringen, K. (2001). Towards a psychobiological model of the suicidal process. In K. van Heeringen (ed.) Understanding Suicidal Behaviour (pp. 136–59). Chichester: John Wiley & Sons. Williams, J.M.G. (2001). The cry of pain. London: Penguin. Williams, J.M.G. and L.R. Pollock (2000). The psychology of suicidal behaviour. In K. Hawton and K. van Heeringen (Eds), The international Handbook of Suicide and Attempted Suicide (pp. 79–93). Chichester: John Wiley & Sons. Williams, J.M.G. and L.R. Pollock (2001). Psychological aspects of the suicidal process. In K. van Heeringen (Ed.), Understanding Suicidal Behaviour (pp. 76–93). Chichester: John Wiley & Sons. Williams, J.M.G., A.J.W. van der Does, T. Barnhofer, C. Crane and Z.S. Segal (2008). Cognitive reactivity, suicidal ideation and future fluency: Preliminary investigation of a differential activation theory of hopelessness/suicidality. Cognitive Therapy and Research, 32(1), 83–104. Williams, J.M.G., C. Crane, T. Barnhofer and D. Duggan (2005). Psychology and suicidal behaviour: Elaborating the entrapment model. In K. Hawton (Ed.) Prevention and Treatment of Suicidal Behaviour: From Science to Practice (pp. 71–90). Oxford: Oxford University Press. Williams, J.M.G., T. Barnhofer, C. Crane and A.T. Beck (2005). Problem solving deteriorates following mood challenge in formerly depressed patients with a history of suicidal ideation. Journal of Abnormal Psychology, 114(3), 421–31. 19

2

Empirically Based Assessment of Suicide Risk* C AD E. M KA

,C A KA

J. B A A D A

I

t is almost a certainty that mental health professionals will, at some point, be required to evaluate a patient having some form of suicidality (i.e., suicidal thoughts, following a suicide attempt or someone with a history of multiple attempts). Suicidality is the most frequently encountered emergency situation in mental health settings (Buzan and Weissberg, 1992) and is the most anxiety-provoking clinical scenario for practitioners (Pope and Tabachnick, 1993; Rudd, 2006). Approximately one-quarter of all psychologists will experience suicide by a patient at some point in their careers (Chemtob et al., 1988a; Pope and Tabachnick, 1993), as will nearly 50 percent of psychiatrists (Chemtob et al., 1988b) and 23 percent of counsellors (McAdams and Foster, 2000). Fawcett (1999) has estimated that up to half of the suicides are by individuals ‘currently in treatment’. The impact of suicidal behaviour, emotionally and professionally, on those providing clinical care is profound, with clinicians reporting shock, self-blame, guilt and shame (Kleespies et al., 1993), which is often ∗ The views expressed in this chapter are those of the authors and do not necessarily reflect the official policy or position of the Department of Defence, the Department of the Air Force or the US government. 20

Empirically Based Assessment of Suicide Risk

compounded by the legal expectation that clinicians can predict a patient’s suicidal behaviour (i.e., the legal concept of ‘foreseeability’). The notion of suicide prediction is problematic, however, given that it is not possible to reasonably predict such a low base-rate phenomenon as suicide. In fact, because death by suicide occurs so infrequently, a clinician would actually be correct more often if he or she predicted that a patient would not die by committing suicide, regardless of clinical presentation. Despite the inherent limitations in predicting suicidal behaviour reliably, this legal expectation to predict patients’ actions has nonetheless influenced existing standards of care. The inability to reliably predict suicidal behaviour does not suggest, however, that important risk factors associated with increased risk for suicide have not been identified through research. It is critical for the clinician to recognise that their task is not to ‘predict’ suicide per se, but rather to recognise when a patient has entered into a heightened state of risk (i.e., risk assessment), and to respond appropriately. When conducted competently, risk assessment both estimates and explains the risk of suicidal behaviour when used in a consistent manner across all patients, and provides a template for clinical crisis management, including shortand long-term treatment targets (Bryan and Rudd, 2006). The recent publication of core competencies in the assessment and management of suicide risk (Suicide Prevention Resource Center [SPRC], 2006), and the American Psychiatric Association’s (APA, 2003) practice guidelines have clear implications for the nature and process of clinical care. It is important for clinicians to be familiar with available standards and empirically supported approaches for managing suicidal risk. Suicide assessment is a core clinical competency that outpatient mental health clinicians must have. Unfortunately, less than half of mental health professionals receive formal training in suicide risk assessment (Bongar and Harmatz, 1991; Burstein et al., 1973; Feldman and Freedenthal, 2006; Guy et al., 1990), although suicidality is a clinical scenario frequently, if not uniformly, encountered in most clinical settings. In this chapter, suicide risk assessment will be approached from a clinically balanced and scientifically informed standpoint, translating empirical research into clinical practice. Our risk assessment model is based on the SPRC’s (2006) core competencies for managing suicidality, and provides guidelines for assessing suicidal symptoms, directing clinical decision-making, and adopting a best-practices perspective. We have 21

Chad E. Morrow et al.

organised this discussion into three primary areas: understanding suicide, managing emotional reactions to suicide and conducting the suicide risk assessment.

AREA I: UNDERSTANDING SUICIDE A core area for clinician competency is basic knowledge of suicidal behaviours, which includes familiarity with various terms related to suicide, and statistics and facts about suicide. In particular, it is important that clinicians are able to effectively differentiate between various suiciderelated behaviours (e.g., suicide threats, self-harm, suicide attempts with and without injuries), and to articulate an understandable biopsychosocial model of suicidality that can be related in simple and straightforward terms to patients, as well as lend itself to clear and straightforward treatment goals. Perhaps most important, though, is the need for clinicians to have a solid grounding in, and understanding of, those risk and protective factors that have demonstrated the strongest empirical associate with suicidal behaviours. Competency in these areas will increase the effectiveness of assessing and managing risk, improve communication between clinicians, and increase the clinician’s ability to clearly document clinical care.

A Biopsychosocial Model of Suicidality Inherent in any biopsychosocial model of suicide is the recognition of the relative contributions of biological and genetic (e.g., family history, inheritability of psychiatric disorders), psychological (e.g., mood states, impaired problem-solving, hopelessness) and social (e.g., supportive relationships, access to resources) factors. Unfortunately, the relative lack of formal training in suicide assessment and intervention among mental health professionals lends itself to considerable misunderstandings and misconceptions about suicide, and a general inability to explain suicidal behaviours to either patients or medical providers. From a clinical perspective, this is of grave concern since suicidal patients are often confused and distressed about their suicidal experience, and look to the clinician to understand what is happening to them. Clinicians who cannot succinctly 22


explain suicidal behaviours to patients are unlikely to establish the collaborative alliance necessary to positively influence clinical outcomes. An effective clinician must therefore have a clear and straightforward model of suicidal behaviour. One particularly simple and empirically supported biopsychosocial model of suicidality is ‘fluid vulnerability theory’ (FVT; Rudd, 2006), which posits that suicide risk exists on two dimensions: baseline risk and acute risk. According to FVT, baseline risk for suicide varies from individual to individual and is determined by static variables and personal history (e.g., multiple attempts, psychiatric diagnoses, biological and genetic predispositions, history of abuse). Multiple attempters (i.e., individuals who have attempted suicide twice or more) are more vulnerable to suicide and are therefore at chronically elevated risk. In the presence of an environmental stressor, usually a perceived loss of some kind (e.g., relationship problem, job loss, financial stress), an acute suicidal episode becomes activated. The active suicidal episode—what Rudd (2006) has termed the ‘suicidal mode’—consists of cognitive, affective, behavioural, physiological and motivational systems that interact with each other and sustain the suicidal state (Figure 2.1). Also central to FVT is the tenant that suicide risk is inherently dynamic, with fluctuations in intensity and severity from moment to moment. Acute periods of suicidal crises are therefore by their very nature time-limited, since most patients cannot maintain the high level of activation and arousal needed to sustain a suicidal crisis for more than a few hours or, at most, a few days (Rudd, 2006). A primary task of the clinician’s risk assessment is to understand how these various systems interact with each other to sustain the suicidal episode, and to deliver interventions that serve to ‘deactivate’ the systems that maintain the suicidal crisis, with the goal being to return the patient to ‘baseline’ functioning.

The Importance of Accurate Language The language clinicians use when talking about suicidality not only enhances communication with other clinicians, but also with suicidal patients themselves. The issue of inconsistent terminology and language relating to suicidality has received considerable attention and discussion within the professional literature, with several groups calling for the adoption of a 23

Chad E. Morrow et al. Figure 2.1

Biopsychosocial Model of Suicide

Source: Author.

standardised terminology (e.g., O’Carroll et al., 1996; Silverman et al., 2007). The advantages of using standard terminology include (a) improved clarity, precision and consistency of a clinician’s practice both over time and across patients; (b) improved consistency of communication between clinicians; (c) improved clarity in documentation; (d) elimination of 24


inaccurate and potentially damaging language from our vocabulary; and (e) elimination of the unrealistic goal to ‘predict’ suicide (as opposed to assessing risk) through recognition of the complexity and variability of suicidal intent in determining ultimate clinical outcome. We, therefore, recommend that clinicians implement the following terms proposed by Silverman and colleagues (2007): z

z

z

z

z

z

Suicide threat: Any interpersonal action, verbal or non-verbal, without a direct self-injurious component, that a reasonable person would interpret as communicating or suggesting that suicidal behaviour might occur in the near future. Suicide plan: A proposed method of carrying out a design that will lead to a potentially self-injurious outcome. Self-harm: A self-inflicted, potentially injurious behaviour for which there is evidence (either explicit or implicit) that the person did not intend to kill himself/herself (i.e., had no intent to die). Self-harm may result in no injuries, non-fatal injuries or death (i.e., self-inflicted unintentional death). Suicide attempt: A self-inflicted, potentially injurious behaviour with a non-fatal outcome for which there is evidence (either explicit or implicit) of intent to die. Suicide attempts may result in no injuries or non-fatal injuries. Suicide attempts that result in death are classified as ‘suicide’. Suicide: A self-inflicted death for which there is evidence (either explicit or implicit) of intent to die. Undetermined suicide-related behaviour: A self-inflicted, potentially injurious behaviour for which there is an unknown or undetermined degree of suicidal intent. Undetermined suicide-related behaviours may result in no injuries, non-fatal injuries or death.

These terms are more thoroughly outlined and described by Silverman and colleagues (2007), and the reader is encouraged to review these two articles for additional information about the issue of standardised terminology. We highly recommend clinicians be well-versed in these terms to improve consistency in care over time, enhance communication with clinicians and patients, and clarify documentation, especially in clinical settings with multiple clinicians working together. 25


AREA II: MANAGING EMOTIONAL REACTIONS TO SUICIDAL INDIVIDUALS The importance of establishing a strong relationship with the suicidal patient cannot be overstated, since even the best therapeutic techniques are unlikely to be adequately received and implemented by the patient in the absence of a strong patient–clinician relationship. The literature is replete with discussions of the central importance of the quality of the patient–clinician relationship in assessing risk and managing suicidal patients (e.g., Bongar et al., 1989). Some have even argued that a solid therapeutic relationship is not just preferable, but rather ‘essential’ to successful work with suicidal patients (Maltsberger, 1986; Shneidman, 1981, 1984). Perhaps the best-known work on the topic of relationship issues in the treatment of suicidal patients is that of Linehan (1993), who has identified several strategies for approaching the relationship with a suicidal patient, including the targeting of what she calls ‘therapy interfering behaviours’—problematic interpersonal emotional reactions and behaviours of the patient ‘or the clinician’, such as fear, malice, aversion, hate, anxiety, worry, ending appointments prematurely, being late for appointments and rescheduling appointments frequently—which serve to directly interfere with the successful course of treatment. Clinicians must be alert to these behaviours both within their patients and within themselves, and possess adequate skills to appropriately respond to them in the context of the therapeutic relationship. A relationship dynamic central to clinical work with suicidal patients is the potential for a conflict between the goals of the patient and the goals of the clinician. Specifically, the patient’s goal to reduce psychological suffering through suicide can come into direct conflict with the clinician’s goal to prevent death by suicide. This conflict must be resolved in order for the clinician and patient to establish the working relationship necessary for clinical improvement. Resolution can be accomplished with a straightforward and simple defining of a common goal: to reduce the patient’s suffering and emotional pain. Consistent with a functional model of suicide, as the patient’s pain and suffering resolves, it decreases their risk for suicide. Defining a common goal of pain remediation therefore lays the groundwork for the development of a non-adversarial, collaborative therapeutic stance that facilitates establishing and maintaining a good 26


working alliance with the patient. Within a collaborative stance, the patient and clinician work together as a team to target the problem of suicide. Adopting a collaborative stance in which responsibility for the suicidal patient’s outcome is shared can help the clinician to manage common emotional reactions to suicidal patients, including fear, anxiety or anger. These emotional responses can cloud clinician’s judgement and contribute to suboptimal clinical decision-making. A hierarchical approach to questioning suicidal patients is therefore recommended, in which the clinician moves from identifying the precipitant of the suicidal crisis (e.g., ‘How have things been going for you recently? Can you tell me about anything in particular that has been stressful for you?’), to the patient’s symptomatic presentation (e.g., ‘From what you have shared so far, it sounds like you have been feeling depressed. Have you been feeling anxious, nervous or panicky lately?’), to hopelessness (e.g., ‘It is not uncommon when depressed to feel that things won’t improve and won’t get any better, do you ever feel this way?’), and finally, to the nature of the patient’s suicidal thinking (e.g., ‘People feeling depressed and hopeless sometimes think about death and dying; do you ever have thoughts about death and dying? Have you ever thought about killing yourself?’). By gradually progressing in the intensity of the interview, clinicians can manage their own reactions to the suicidal patients while potentially reducing the patients’ anxiety or agitation at the same time, which improves rapport and strengthens the therapeutic relationship. Likewise, by normalising the patient’s hopelessness and suicidal thinking within the context of a depressive episode (or other mental disorder), the clinician can further reduce in-session anxiety, thereby enhancing the likelihood of honest and more detailed self-disclosure on the part of the patient, providing a more accurate risk assessment.

AREA III: CONDUCTING THE RISK ASSESSMENT The following section will provide a brief overview of the most salient empirical findings that directly affect suicide risk, and are therefore central to accurate and effective risk assessment and management. The reader is encouraged to review the APA’s (2003) guidelines for a more thorough review of the scientific literature regarding assessment and management 27


of suicidality. Several key areas have garnered considerable empirical support, and are therefore considered to be essential to risk assessment: predispositions to suicidal behaviour; identifiable precipitants or stressors; symptomatic presentation; presence of hopelessness; nature of suicidal thinking; previous suicidal behaviour; impulsivity and self-control; and protective factors. These areas are listed in Table 2.1. Although this list is certainly not exhaustive, and other areas could arguably be included, the literature significantly supports these areas as having the most sound empirical support, and therefore emerge as clinically meaningful and critical to the assessment process. As previously discussed, suicide risk should be considered from two dimensions: baseline risk and acute risk. Baseline risk is the level of risk when the patient is not in a state of acute crisis, or in general is at his or her Table 2.1

Eight Empirically-supported Areas for Suicide Risk Assessments

Static Variables Contributing to Baseline Risk 1. Predispositions to suicide

2. Previous suicide attempts

3. Impulsivity

Family history of suicide; history of physical, emotional or sexual abuse; marital status; previous psychiatric diagnoses; same-sex orientation; recent discharge from inpatient hospitalisation Frequency and context of previous suicidal behaviours; perceived lethality and outcome; opportunity for rescue and help-seeking; preparatory or rehearsal behaviours; reaction to survival Subjective reports of self-control (verbiage); objective reports of self-control behaviours

Aggravating Variables Contributing to Acute Risk 4. Precipitants or stressors 5. Symptomatic presentation 6. Hopelessness 7. Nature of suicidal thinking

8. Protective factors

Significant loss; social isolation; relationship problems; health problems; legal problems Depression; anxiety or panic; anger; agitation and restlessness; psychosis Severity and duration Frequency, intensity and duration of suicidal ideation; presence and specificity of suicide plan; access to means; preparatory or rehearsal behaviours; sense of courage or fearlessness Reasons for living; presence of children in the home; positive social support; intact reality-testing; problemsolving; religious or moral beliefs against suicide

Source: Modified from Rudd (2006), Bryan and Rudd (2006). 28


relative best. All suicidal individuals have a baseline risk that they return to during periods of relative calm and remissions of psychopathology, but baseline risk is not comparable across groups. However, for some patients (such as multiple attempters), baseline risk level is high and indicates chronic risk, regardless of any acute crisis. Acute risk, by contrast, is the level of risk presented during an acute suicidal crisis, when the patient is symptomatic and at his or her worst. Severity of risk is ‘always’ relative. Accordingly, the variable nature of suicide risk—even among those at chronic high risk—can be acknowledged by adding the descriptor ‘acute exacerbation’ when necessary (e.g., chronic high risk with acute exacerbation).

Baseline Risk Baseline risk is affected by predispositions to suicidality and historical factors such as previous suicidal behaviours. These risk factors contribute to an individual’s overall likelihood to experience or manifest symptoms of suicidality. Because they are static by nature, they typically cannot be directly modified through clinical intervention. PredisposiƟons to suicidality Predispositions to suicidality include genetic, biological and historical factors associated with increased suicide risk. Compelling research points to the role of genetic factors in suicidal behaviours. For example, twin studies have found that 13–19 percent of monozygotic twin pairs were concordant for death by suicide as compared to less than 1 percent of dizygotic twin pairs (Roy, 1992). Likewise, family studies suggest that suicides ‘cluster’ in particular families above and beyond psychiatric conditions (Egeland and Sussex, 1985), which might be due in part to specific chromosomal configurations that have been linked to suicidal behaviours (Joiner et al., 2002). As such, assessing for family history of suicide can provide information about a patient’s baseline risk for suicide. Early life events such as a history of verbal, physical or sexual abuse (Brown et al., 1999), or emotionally invalidating environments (Linehan, 1993) also confer vulnerabilities to suicide. A history of psychiatric disorders is associated with increased risk, especially conditions that are chronic in nature, such as recurrent depression, bipolar disorders or borderline personality disorder. It is important to note, however, that 29


almost all psychiatric disorders have been shown to increase risk for suicide as measured by standardised mortality ratios (Harris and Barraclough, 1998). Clinicians should therefore assess the patient’s psychiatric history when considering baseline risk. Previous suicidal behaviours The clinician should also assess the patient’s history of suicidal thinking, self-injurious behaviours and suicide attempts. Although a history of self-injurious behaviours of any type raises an individual’s baseline risk for suicide above and beyond any other risk factor for suicide (Joiner et al., 2005), previous suicide attempts, in particular, are associated with substantially increased baseline risk for suicide. A history of two or more suicide attempts (i.e., ‘multiple attempter’ status) therefore indicates chronically elevated risk for suicide (Rudd et al., 1996; Wingate et al., 2004). The relatively higher risk for suicide associated with multiple suicide attempts, when compared to selfharm, reflects the importance of differentiating between previous suicide attempts and non-suicidal self-harm. While it is imperative to assess the history of multiple suicide attempts, the absence of these behaviours does not indicate reduced risk. For example, suicide attempters with a history of recurrent self-harm have a higher level of depression, anxiety, hopelessness and impulsivity, and tend to underestimate the lethality of their actions (Stanley et al., 2001), which places them at higher risk for unintended death by suicide. Given that a history of suicidal behaviours is the singlemost robust predictor of future suicidal behaviours (Joiner et al., 2005), it is critical that clinicians obtain this information as a central part of the risk assessment. When assessing the history of suicidal behaviours, the clinician should also attempt to identify behavioural patterns in several dimensions: the frequency and context of the suicidal behaviour (e.g., ‘How often have you attempted to kill yourself or hurt yourself in the past? What was going on at this time in your life?’), perceived lethality (e.g., ‘Why did you choose that particular method? Did you think it would be enough to successfully complete suicide?’), opportunity for rescue (e.g., ‘Did you know your spouse would come home to find you?’), the amount of identifiable preparations for death (e.g., ‘Had you been putting your will in order in case of your death? Had you been giving away your possessions?’) and reaction to survival (e.g., ‘Were you glad to be alive or did you wish you

30


had died afterwards?’). This should be accomplished for ‘each and every’ episode, with the goal to understand the trajectory of risk over time, and to identify clues for treatment interventions. It is recommended that clinicians sequence their questions about past suicidal behaviours by starting with most distant episodes first and progressing forward chronologically towards the current situation. Such an approach can alleviate some of the distress the patient might be experiencing while discussing sensitive and upsetting events, since it can be easier to talk about distal, historical events than it can be to talk about more proximal stressors. Sequencing not only provides structure and order to the clinical interview, but also serves to reduce the likelihood that important clinical data will be missed. Impulsivity The clinician should also assess the patient’s subjective sense of self-control (e.g., ‘Do you consider yourself to be impulsive? Have you recently felt out of control?’) and compare it with objective identifiers of self-control including a history of aggression or violence, or engagement in painful or provocative experiences in life such as high risk activities and risky behaviours (Van Orden et al., 2008). Use of alcohol and drugs has consistently been found to be associated with elevated suicide risk (APA, 2003), and can increase suicidality through a variety of ways: impaired judgement, reduced inhibitions and increased depression. Substance also correlates with social isolation, and is more likely to be co-morbid with personality disorders, both of which are independent risk factors for suicide. Because impulsivity is a fairly stable trait associated with multipleattempt status, impulsive multiple attempters should be considered a chronic suicide risk. In general, a personality style marked by pronounced impulsivity and aggression describes individuals at risk of suicide attempts regardless of psychiatric diagnosis (Mann et al., 1999).

Acute Risk Acute risk involves the level of risk present during an active suicidal crisis, and is often associated with psychiatric symptom exacerbation. Because these precipitating risk factors are more dynamic in nature and fluctuate over time, they are common targets for clinical intervention.

31


Precipitants and stressors As mentioned previously, patients often choose to kill themselves following an environmental event or stressor. When considering what has triggered a suicidal crisis, the clinician should consider significant stressor, such as a financial, interpersonal or employment loss (Fu et al., 2002), acute or chronic health problems (Maris et al., 2000) and family instability (Rubenowitz et al., 2001). Almost always, the patient has experienced some sort of acute stressor that has directly contributed to increased symptomatology and distress. A patient who presents in a suicidal crisis is very likely experiencing one of these stressors, or may be experiencing an acute escalation of multiple chronic stressors. One goal of the clinician is to identify the stressor and to assist the patient in resolving the problem. SymptomaƟc presentaƟon Clinicians should determine the patient’s symptomatic picture, along with the severity of these symptoms, including both Axis I and Axis II comorbidity, and symptom clusters such as depression, anxiety, agitation, anger or agitation (APA, 2003). Psychosis should be assessed and appropriately referred to for evaluation and treatment, whether on an inpatient or outpatient basis, due to the increased risk for suicide associated with this condition (Harris and Barraclough, 1998), especially during periods of acute symptomatology (Kaplan and Harrow, 1999). Shame, guilt, anger, anxiety and depression are particularly powerful and frequently occurring emotions that can drive and maintain suicidal episodes. A growing body of research has found that agitation, restlessness and racing thoughts seem to be a particularly pernicious symptom cluster, especially when they occur in the presence of a depressive episode (Akiskal and Benazzi, 2005; Benazzi, 2005). A simple strategy for assessing the intensity or severity of various psychiatric symptoms is to use a 1-to-10 scale (e.g., 1 being the best the patient has ever felt and 10 being the worst), which can help to improve clarity in communication between patient and clinician, as well as offering a simple method for tracking symptom change over time (cf. Rudd, 2006). Being able to demonstrate improvement in scores, for example, across clinical care is a very powerful method for providing the patient with a sense of control by quantifying his or her emotional experience. Clinicians who can accurately understand the

32


patient’s unique experience and gear interventions towards the reduction of psychological distress will be more successful at reducing suicide risk. Hopelessness A clinician should assess for the presence, severity and duration of hopelessness with any patient who endorses suicidal behaviours. Hopelessness is a well-supported and highly robust predictor of suicidal behaviour (e.g., Beck et al., 1990; Brown et al., 2004), with many suicidal patients reporting the presence of severe hopelessness. Consistent with the functional model of suicidality, relief from the distress associated with hopelessness is a common motivator driving suicidal behaviours. Hopelessness is determined by both state (fluctuating) and trait (static) variables and is greater in suicide attempters than in non-attempters despite similar rates of objective severity of depression or psychosis (Mann et al., 1999). The goal of the clinician is not only to ascertain the patient’s degree of hopelessness, but also to directly target this thought process by instilling a sense of hope for recovery and problem resolution. Nature of suicidal thinking When considering the nature of suicidal ideation, the clinician should assess frequency (e.g., ‘How often do you think about suicide?’), intensity (e.g., ‘Could you rate the intensity of your suicidal thoughts on a scale of 0 to 10?’) and duration (e.g., ‘How long do these thoughts typically last?’) of suicidal thoughts. Intensity and duration of suicidal ideation are more strongly associated with suicidal behaviours than frequency of ideation (Joiner et al., 1997), and should therefore be emphasised in suicide risk assessments. Other dimensions for assessment include specificity of planning (e.g., ‘Have you thought about how, when and where you would kill yourself?’), availability of means (e.g., ‘Do you have access to the means?’), preparatory behaviours (e.g., ‘Have you taken steps to prepare for suicide such as writing a note, getting financial affairs in order, giving away possessions?’), explicit intent (e.g., ‘What do you hope will happen as a result of this behaviour?’) and deterrents to suicide (e.g., ‘What stops you from killing yourself?’). The most robust predictors of suicidal behaviours are suicidal thinking, rehearsing and preparing for suicide—for example, developing a specific suicide plan, acquiring the means for suicide, counting pills, holding a gun to one’s head, and

33


other such ‘practice’ activities—and should therefore be carefully assessed by clinicians (Joiner, 2005; Joiner et al., 1997; Minnix et al., 2007; Pettit et al., 2004).

Protective Factors Protective factors, in contrast to risk factors, serve to decrease risk for suicide. Identifying those variables that serve to mitigate risk is a useful strategy for developing management plans and interventions to target suicide risk (e.g., ‘What keeps you alive right now? What reasons do you have to live?’). Examples of protective factors include the presence of reasons for living (Linehan et al., 1983; Malone et al., 2000), which might convey a sense of optimism or hope for the future, and strong relationships with family or friends (Stravynski and Boyer, 2001; Turvey et al., 2002), including the presence of children in the home (Clark and Fawcett, 1994), each of which supports the proposition that perceived belongingness to a social group serves as a buffer to suicide (Joiner, 2005). Even though risk factors seem to have a stronger empirical relationship with suicidality than protective factors, suicide interventions that focus on increasing or strengthening protective factors while simultaneously reducing risk factors are more effective than focusing on risk factors alone (Bryan and Rudd, 2006). By determining which variables are serving to keep the patient alive, the clinician can begin to build interventions and strategies that serve to reduce risk for suicide.

A Word on Access to Lethal Means Many clinicians spend a considerable amount of time attempting to gauge the severity of suicidal intent when assessing risk, but overlook the importance of availability of means. Research on the relationship between intent and death by suicide has demonstrated conflicting results, arguably due to the confounding variable of availability of means. Intent has been found to bear little relationship to the lethality of a suicide attempt method (Brown et al., 2004; Plutchik et al., 1988; Swahn and Potter, 2001), but availability of means has consistently demonstrated an association with methodology (Eddleston et al., 2006; Peterson et al., 1985). It is therefore 34


recommended that clinicians routinely ask about methods and access to lethal means of suicide. Regular questioning is paramount because suicide attempts almost always occur during short-term peaks in distress. For example, among patients who survived life-threatening suicide attempts, 24 percent made the decision within five minutes preceding the attempt and 70 percent made the decision within the preceding hour (Simon et al., 2001). Further, when suicide rates by firearms are examined, suicide rates have been found to be highest immediately following the purchase of the firearm, with declining risk occurring as time passes: 57 times higher during the first week following firearm purchase, declining to 30 times higher during the first month and seven times higher after one year (Wintemute et al., 1999). Because suicide attempts and death by suicide are commonly impulsive reactions to acute distress, the removal or limitation of access to lethal means can significantly reduce the probability for a suicide attempt.

Risk Categories and a Continuum of Risk We recommend clinicians differentiate between four categories of suicide risk, which are outlined in Table 2.2. Using these four categories will assist clinicians in recognising and considering suicidality from both dimensions of risk. After distinguishing which risk category a suicidal patient falls in, clinicians should next assess the severity of suicide risk in order to direct the most appropriate clinical response. A continuum of suicide risk based Table 2.2

Categories of Suicide Risk

Risk category

Criteria

Baseline

No significant stressors or prominent symptoms; only appropriate for ideators and single attempters Significant stressors and/or prominent symptoms; only appropriate for ideators and single attempters Baseline risk for multiple attempters; no significant stressors or prominent symptoms Acute risk category for multiple attempters; presence of significant stressor or prominent symptoms

Acute Chronic High Risk Chronic High Risk With Acute Exacerbation

Source: Modified from Rudd (2006), Bryan and Rudd (2006). 35


on a synthesis of risk factors and protective factors is presented in Table 2.3 (cf. Bryan and Rudd, 2006; Somers-Flanagan and Somers-Flanagan, 1995), along with implicated clinical response. It is important to highlight that suicide risk assessment is complicated by temporal factors in at least two ways. First, identifiable risk periods are inconsistently defined in the literature, such that there is no reliable way to determine how long an acute suicidal episode will endure. Second, chronic suicidality complicates risk estimates in that multiple attempters have a higher baseline risk for suicide to begin with. In every risk assessment, the clinician should first ask the question, ‘Is this person a multiple attempter?’ If not, the clinician will be considering acute risk only. If the patient is a multiple attempter and in acute distress, however, the clinician should factor in the chronic nature of the patient’s suicidality, and should automatically consider them to be at least a moderate risk (Wingate et al., 2004). We recommend, therefore, that risk assessment be a continuous and routine task throughout the course of treatment.

Translating Risk Assessment into Effective Management and Intervention A distinct risk assessment scheme will ideally translate into straightforward, clinically informed and effective decisions. Table 2.3 provides a summary of risk levels with indicated clinical responses or options. Those determined to be at mild or very low risk require no particular change in treatment aside from continuous evaluation of ideation and risk factors. For those at moderate to severe risk, outpatient management can be accomplished effectively with increases in the intensity of clinical management strategies. For patients at extreme risk for suicide, there is no room for debate about the standard of care, which demands for immediate evaluation for inpatient hospitalisation. In summary, expectations for assessing suicidal risk have significantly changed for outpatient mental health clinicians. Although potentially anxiety-producing for many clinicians at first, clinical decision-making and management of suicidality are surprisingly straightforward when an accurate, empirically based risk assessment is completed competently. Contrary to persistent myths about working with suicidal patients, outpatient care can be accomplished in a safe and effective manner when informed by scientific evidence and competency-based practice. 36

No particular changes in ongoing treatment evaluation of any expressed suicidal ideation to monitor change in risk

Source: Modified from Rudd (2006), Bryan and Rudd (2006).

Extreme

Severe

1. Recurrent evaluation of need for hospitalisation 2. Increase in frequency or duration of outpatient visits 3. Active involvement of the family 4. Frequent re-evaluation of treatment plan goals 5. 24-hour availability of emergency or crisis services for patient 6. Frequent re-evaluation of suicide risk, noting specific changes that reduce or elevate risk 7. Consideration of medication if symptomatology worsens or persists 8. Use of telephone contacts for monitoring 9. Frequent input from family members with respect to indicators 10. Professional consultation as indicated Frequent, intense and enduring suicidal ideation, specific plans, no Immediate evaluation for inpatient hospitalisation (voluntary or subjective intent but some objective markers of intent (e.g., choice involuntary, depending on situation) of lethal method(s), the method is available/accessible, some limited preparatory behaviour), evidence of impaired selfcontrol, severe dysphoria/symptomatology, multiple risk factors present, and few if any protective factors Frequent, intense and enduring suicidal ideation, specific plans, clear subjective and objective intent, impaired self-control, severe dysphoria/symptomatology, many risk factors, and no protective factors

Suicidal ideation of limited frequency, intensity and duration, no identifiable plans, no intent, mild dysphoria/symptomatology, good self-control, few risk factors, and identifiable protective factors Moderate Frequent suicidal ideation with limited intensity and duration, some specific plans, no intent, good self-control, limited dysphoria/symptomatology, some risk factors present, and identifiable protective factors

No identifiable suicidal ideation

Very low

Mild

Indicated Response

Suicide Risk Continuum with Indicated Responses

Risk Level Description

Table 2.3


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Mann, J.J, C. Waternaux, G.L. Haas and K.M. Malone (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2), 181–89. Maris, R.W., S.S. Canetto, J.L. McIntosh and M.M. Silverman (Eds). (2000). Review of suicidology. NY: Guilford Press. McAdams, C.R. and V.A. Foster (2000). Client suicide: Its frequency and impact on counselors. Journal of Mental Health Counseling, 22(2), 107–21. Minnix, J.A., C. Romero, T.E. Joiner and E.F. Weinberg (2007). Change in ‘resolved plans’ and ‘suicidal ideation’ factors of suicidality after participation in an intensive outpatient treatment program. Journal of Affective Disorders, 103(1), 63–68. O’Carroll, P.W., A. Berman, R.W. Maris and E. K. Moscicki (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237–252. Peterson, L., M. Peterson, G. O’Shanick and A. Swann (1985). Self-inflicted gunshot wounds: Lethality of method versus intent. American Journal of Psychiatry, 142(2), 228–31. Pettit, J.W., T.E. Joiner and M.D. Rudd (2004). Kindling and behavioral sensitization: Are they relevant to recurrent suicide attempts? Journal of Affective Disorders, 83(2–3), 249–52. Plutchik, R., H.M. van Praag, S. Picard, H.R. Conte and M. Korn (1988). Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt? Psychiatry Research, 27(1), 71–79. Pope, K.S. and B.G. Tabachnick (1993). Therapists’ anger, hate, fear, and sexual feelings: National survey of therapist responses, client characteristics, critical events, formal complaints, and training. Professional Psychology: Research and Practice, 24(2), 142–52. Roy, A. (1992). Suicide in schizophrenia. International Review of Psychiatry, 4(2), 205–209. Rubenowitz, E., M. Waern, K. Wilhelmson and P. Allebeck (2001). Life events and psychosocial factors in elderly suicides—A case-control study. Psychological Medicine, 31(7), 1193–202. Rudd, M.D. (2006). The assessment and management of suicidality. Sarasota, FL: Professional Resource Press. Rudd, M.D., T.E. Joiner and M.H. Rajab (1996). Relationships among suicide ideators, attempters, and multiple attempters in a young-adult sample. Journal of Abnormal Psychology, 105(4), 541–50. Shneidman, E.S. (1981). Psychotherapy with suicidal patients. Suicide and LifeThreatening Behavior, 11(4), 341–48. Shneidman, E. S. (1984). Aphorisms of suicide and some implications for psychotherapy. American Journal of Psychotherapy, 38(3), 319–28. Silverman, M.M., A.L. Berman, N.D. Sanddal, P.W. O’Carroll and T.E. Joiner (2007). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors part 2: Suicide-related ideations, communications, and behaviors. Suicide and Life-Threatening Behavior, 37(3), 264–77. 40


Simon, T.R., A.C. Swann, K.E. Powell, L.B. Potter, M. Kresnow and P.W. O’Carroll (2001). Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior, 32(Supplement), 49–59. Somers-Flanagan, J. and R. Somers-Flanagan (1995). Intake interviewing with suicidal patients: A systematic approach. Professional Psychology: Research and Practice, 26(1), 41–47. Stanley, B., M.J. Gameroff, V. Michalson and J.J. Mann (2001). Are suicide attempters who self-mutilate a unique population? American Journal of Psychiatry, 158(3), 427–32. Stravynski, A. and R. Boyer (2001). Loneliness in relation to suicide ideation and parasuicide: A population-wide study. Suicide and Life-Threatening Behavior, 31(1), 32–40. Suicide Prevention Resource Center (2006). Core competencies in the assessment and management of suicidality. Newton, MA: SPRC. Swahn, M.H. and L.B. Potter (2001). Factors associated with the medical severity of suicide attempts in youths and young adults. Suicide and Life-Threatening Behavior, 32(1), 21–29. Turvey, C.L., Y. Conwell, M.P. Jones, C. Phillips, E. Simonsick, J.L. Pearson and R. Wallace (2002). Risk factors for late-life suicide: A prospective, community-based study. American Journal of Geriatric Psychiatry, 10(4), 398–406. Van Orden, K.A., T.K. Witte, K.H. Gordon, T.W. Bender and T.E. Joiner (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76(1), 72–83. Wingate, L.R., T.E. Joiner, R.L. Walker, M.D. Rudd and D.A. Jobes (2004). Empirically informed approaches to topics in suicide risk assessment. Behavioral Sciences and the Law, 22(5), 651–65. Wintemute, G.J., M.A. Wright, C.A. Parham, C.M. Drake and J.J. Beaumont (1999). Denial of handgun purchase: A description of the affected population and a controlled study of their handgun preferences. Journal of Criminal Justice, 27(1), 21–31.

41

3

Neurobiological Basis of Suicidal IdeaƟon J®ãÄÙ KçÃÙ TÙ®ò® Ä SÄÄ®«ù VÙÃ

A

ccording to the World Health Report 2002, published by WHO (UC Atlas of Global Inequality, 2002), suicide was amongst the top 10 leading causes of death across all age groups in the developed nations in the year 2001. In India, over one lakh lives are lost every year as a result of suicide and this figure does not take into account the gross underreporting (Joseph et al., 2003). According to the National Crime Bureau, Ministry of Home Affairs, Government of India, Accidental Deaths and Suicides in India, 2007 (National Crime Bureau, 2007), youths (15–29 years) and lower middle-aged people (30–44 years) were the prime groups taking recourse to the path of suicides. Around 35.2 percent suicide victims were youths in the age group of 15–29 years and 34.1 percent were middle-aged persons in the age group 30–44 years, adversely affecting not just the family of the victim but also the economic productivity of the nation at large. Reliable methods of predicting suicide which may enable its prevention by effective management are therefore energetically being sought after. In the past it was thought that suicide was related more to defects in the mind (psychological) than in the brain (neurobiological). Recent advances in neurosciences are challenging this notion. There is a growing support for a theory of human emotions that implicates increasingly well-defined brain regions (Stuss et al., 2001), of which, the frontal lobes 42

Neurobiological Basis of Suicidal Ideation

seem to have the greatest significance due to the central role that they play in social cognition, aggression and impulse control. This also strengthens the hypothesis that suicidal behaviour may be due to underlying neurobiological factors. Suicide is not an entity of its own but associated with many other disorders: about 90 percent of the people who commit suicide have a known psychiatric illness such as: 1. major depressive disorder (15 percent of depressives who are admitted in a hospital eventually commit suicide) (McIntosh, 2001); 2. schizophrenia (especially in post-psychotic period); 3. bipolar affective disorder (especially bipolar disorder type I); 4. borderline personality disorder and sociopathic personality disorder in adolescents and young adults; 5. alcohol or other substance abuse are also predictive of suicide (up to 50 percent of the people who commit suicide are intoxicated at the time of death) (Tanney, 2000); and 6. comorbidity of depressive-mood disorder and substance abuse greatly raises risk of suicide—70–80 percent of people who commit suicide have co-morbid diagnoses (Moscicki, 2001). However, numerous studies controlling for the presence of psychiatric conditions have indicated that the liability for suicide is independent from (but conditional on) the genetic factors mediating susceptibility for major psychiatric disorders (Klempan and Turecki, 2005). The underlying neurobiological factors for suicide and the associated psychiatric disorders therefore may be different. In the past 30 years, a comprehensive and multi-faceted approach to study has been undertaken to find more accurate methods for predicting suicide. Even with standardised assessment and prediction scales such as the Hamilton or Beck depression inventories, it has been difficult to predict suicide accurately. Finding the neurological basis of suicide will help not only to better understand this behaviour, but it may also provide us with a reliable means of predicting suicide accurately. The focus has now shifted from suicidal ideation being seen as primarily related to depression to focusing on suicidal acts as primarily being related to biology of aggression and impulsivity. The following discussion deals with the neurobiological basis of suicide. 43

Jitendra Kumar Trivedi and Sannidhya Varma

BIOLOGICAL FACTORS The search for biological markers or aetiology of suicidal behaviour was spurred by the inability of psychologically oriented studies to adequately explain and predict suicidal behaviour. The biological changes may be of two types: (a) structural and (b) neurobiological. There is little evidence in support of structural changes that may be specifically linked to suicidal behaviour. Most of the present work is on the underlying neurobiological factors which are associated with suicide. On the basis of the pharmaco-challenge studies the ‘neurobiological changes’ were further divided into the following two types: 1. Transmitter Non-specific Neuro-endocrine studies 2. Transmitter Specific Neuro-endocrine studies

Transmi er Non-specific Neuro-endocrine Studies Limbic-Hypothalamus-Pituitary-Adrenal Axis (LHPA Axis) A few of the early studies (Bunney and Fawcett, 1965; Krieger, 1974) showed a link between suicidality and LPHA axis over-activity with increased serum levels of cortisol and 17-hydroxycorticosteroids in urine. However, this finding could not be confirmed in other studies. The frontal cortex has fewer binding sites for corticotrophin-releasing hormone and reduced plasma adrenocorticotropin and cortisol responsiveness (Pfennig et al., 2005). Preliminary studies using central corticotrophin-releasing factor binding (Nemeroff et al., 1988) and preopiomelanacortin mRNA (Lopez et al., 1990) as markers of LHPA axis activity are showing more definitive results regarding correlation between axis hyperactivity and suicide. Limbic-Hypothalamus-Pituitary-Thyroid Axis (LHPT Axis) Studies have not revealed any conclusive proof of association between LHPT axis activity and suicide. One group, studying a population with various diagnoses, even has reported enhanced Thyroid Stimulating Hormone (TSH) response in patients with suicidal behaviour (Banki and Arato, 1983).

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Transmi er Specific Neuro-endocrine Studies Serotonin The concept that suicide or suicidal behaviour may arise from some specific anomaly in the biological system arose from early attempts to study the role of neurotransmitter serotonin (5-HT) in depression. In a classic series of papers, Asberg (1997) showed that the Cerebro-spinal Fluid (CSF) concentration of 5-hydroxy indole acetic acid (5-HIAA) was reduced in patients with depression. It was observed that a high proportion of individuals with low CSF 5-HIAA subsequently went on to make suicide attempts and to kill themselves. Later studies reported that measures of low 5-HT function were associated with suicidal behaviour, not only in depression but in schizophrenia and other diagnosis as well (Arango and Underwood, 1997). Brain serotonin levels as a predictor of suicide has been the subject of intense research scrutiny over the past several years, with scientists trying to find easily accessible markers so that the neurotransmitter’s levels might someday be readily measured in clinical settings. The reasons for this approach are: 1. Most effective antidepressant drugs directly/indirectly enhance 5-HT function. 2. Brown and his colleagues (1992) describe a serotonergic trait which includes sleep difficulties, impulsivity, disinhibition, headaches, proneness to pain, glucosteroid abnormalities, mood volatility, disorder of conduct, poor peer relationships and suicidal behaviours. Patients with highest aggression have been found to have lowest serotonin activity. Serotonergic neurons in brain arise from the raphe nuclei in the brain stem and from there project to different parts of the brain including the frontal lobes which are responsible for the integration of sensations, perceptions, consciousness and memory into organised and planned behaviours (Fuster, 1997), and the prefrontal cortex which also mediates prospective cognitive processes. The primary finding in most of the studies of neurological basis of suicide is decreased amount of metabolite of serotonin 5-HIAA in the

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CSF of suicide attempters/victims than in controls. Low levels of 5-HIAA in CSF suggests decreased synthesis of serotonin which may be due to reduced availability of tryptophan or decreased activity of tryptophan hydroxylase (rate limiting enzyme in the synthesis of serotonin). The tryptophan hydroxylase has functional genetic polymorphism in the population and some studies reveal that the less active forms occur more commonly among people who attempt to commit suicide recurrently and impulsively. According to Mann (1998), the extent of the reduction of the metabolite 5-HIAA correlates with the lethality of the attempt of suicide. The association of serotonergic dysfunction is particularly strong for violent and impulsive suicide, but it is not specific to any psychiatric diagnosis. Similar findings have been reported for other forms of violent and impulsive behaviour, such as fire-setting (Linnoila and Virkkunen, 1992). It has been found that the number of serotonergic neurons in the brain of subjects who attempt suicide is increased or remains almost the same when compared to controls. However, the functional capacity of the said neurons is less as compared to the controls (Arango et al., 1997). A more stable index of measuring the serotonin function in the brain is through the receptor protein. Serotonin transporters (ST) mediate uptake of serotonin out of the synaptic cleft (pre-synaptic); they are present in areas of serotonergic activity and low serotonergic activity results in fewer STs. Ligands like [3H] imipramine, [3H] partoxetine and [3H] cyanoimipramine are used to study these receptors in vivo. Most studies show a decreased ST concentration in frontal cortex of suicide victims (Arango et al., 1995; Mann et al., 1996). However, some studies have contradicted these findings, which may be explained as a result of binding of the ligands to non-transporter sites (Mann et al., 1999), the function of which is not known as yet. Depressed patients have a ST deficiency in the pre-frontal cortex (PFC), but suicidal patients have a distinctive localised ST deficiency in the ventral or orbital PFC (Mann et al., 2000). A number of studies found an increase in radioligand binding ([3H] spiroperidol) to the 5-HT2A receptors in post-mortem brains of suicide victims (Kamali et al., 2001). In contrast, reduced in vivo radioligand binding to the 5-HT2A receptors using Single Photon Emission Computed Tomography (SPECT) has been reported in patients with depression who were not suicidal (D’Haenan, 2001). The degree of difference between the suicides and the controls appears to be greater in prefrontal cortex 46


(PFC) than in temporal cortex, suggesting regional specificity of the suicide effect. In vivo positron emission tomography (PET) imaging studies report significant reduction in cortical 5-HT1A receptors binding sites in depression (Sargent et al., 2000). However, numbers are small because of the expense of the technique and there is no reported link with suicidal behaviour or thoughts. Reduced 5-HT1A receptor binding in brains from depressed suicides has been reported in two studies (Deakin and Ben, 2003). Other serotonin receptor subtypes have barely begun to be investigated, and studies are ongoing for 5-HT1C, 5-HT1B and 5-HT1D receptors in suicide victims. Studies have suggested an abnormality in the signal transduction mechanism of the above-mentioned receptors in neurobiology of suicide and mood disorders in general, like defect in protein kinase B or phosphatidylinositol-3-kinase (Akt/PI3) and glycogen synthase kinase-3-β (GSK-3). In suicide victims, the PI3-K/Akt signalling pathway has been shown to be blunted in the occipital cortex with a significant decrease in protein kinase B activity and other upstream effectors (Hsiung et al., 2003). Glycogen synthase kinase-3-β plays a role in the control of many regulatory enzymes concerned with cellular processes like cell survival, apoptosis and embryogenesis. It has been demonstrated that 5-HT activity regulates the phosphorylation of GSK-3 in mammalian brains in vivo, a mechanism thought to be achieved by a balance between opposing actions of 5-HT receptors subtypes (Li et al., 2004). The interest in GSK-3 in psychiatry has been highlighted by the discovery of its inhibition by lithium, which has further been found to inhibit both forms of GSK-3 (Klein and Melton, 1996; Stambolic et al., 1996). The studies have suggested that activity, rather than quantity of these enzymes is defective. However, these alterations have so far been shown to be associated with mood disorders rather than suicide per se (Karege et al., 2007).

5-HT2A Receptors in Platelets and their Connection with Suicide Platelets contain a 5-HT2A receptor that is genetically, pharmacologically and mechanistically the same as the 5-HT2A receptor in the central nervous system. Pandey (1997) found that receptor density was increased 47


in suicidal subjects independent of their psychiatric diagnosis and that increased 5-HT2A density was significantly higher in subjects with a recent attempt compared with those with past suicide attempts. Biegon and colleagues (1989) reported normalisation of platelet 5-HT2A receptors after effective anti-depressant activity which leads to the conclusion that platelet 5-HT2A receptor number might be a state-dependent marker of suicidality. It was also found that the functioning of platelet 5-HT receptors (platelet aggregation in response to serotonin) was also decreased in patients with history of high lethality suicide attempts.

Role of Lipids in Serotonergic System and Suicidal Behaviour Another interesting lead that, in spite of much controversy, is supported by several lines of evidence concerns the relationship between low cholesterol levels and suicidal behaviour (Kaplan et al., 1997). This is an intriguing association with unclear mediating mechanisms to explain how serum cholesterol levels may have an effect on behaviour. In any case, the investigation of components of the lipid metabolisms in the neurobiology of suicide and related behaviours has gained renewed interest in light of the growing evidence demonstrating essential roles for cholesterol in brain synaptogenesis, as well as evidence suggesting that alterations in brain sterol composition may mediate this association (Lalovic et al., 2004). It has been proposed that low cholesterol levels result in reduced serotonin functioning which predisposes individuals towards impulsive behaviour like suicide and aggression.

Fenfluramine Challenge Test Fenfluramine acts on serotonin transporter (ST) and causes serotonin release, which causes an increase in serotonin concentration in the synaptic cleft. Amongst factors like oestrogens, thyrotropin-releasing hormone and others, serotonin also causes a release of prolactin from the anterior pituitary. An increase in serotonin after giving fenfluramine is reflected by an increase in serum prolactin levels. Coccaro and Kavoussi (1994) showed a direct correlation between history of suicide attempt and 48


diminished prolactin response to fenfluramine in patients with different diagnosis (mood disorder and personality disorder); correlation was more with suicidal behaviour than depression. Strickland and colleagues (2002) also showed a correlation between lowered prolactin response to fenfluramine and particularly lethal suicidal attempt. There was no correlation between time difference of suicide attempt, sampling and response to fenfluramine.

Norepinephrine Studies have shown that people with higher propensity of suicide have a higher concentration of norepinephrine, tyrosine hydroxylase, α2adrenergic receptors, and decreased concentration of post-synaptic β-adrenergic receptors and norepinephrine transporters (Maris, 2002). This pattern is similar to that of an excessive stress response that leads to norepinephrine depletion, perhaps because fewer neurons in locus coeruleus (in contrast to serotonergic system where the number of neurons remains intact but function is reduced) could mean reduced functional reserve (Maris, 2002). The findings in studies of norepinephrine have not been as robust as those of serotonergic system and it has been more difficult to correlate different behaviours with the neurochemistry. The findings in these studies point towards the presence of chronic stress response, which emphasises its relation with depression, suicide and hypothalamic-pituitary-adrenal axis. Further studies are warranted along these lines.

GENETICS OF SUICIDE Over the past 30 years, indirect evidence for the existence of a genetic component in the suicidal diathesis has come largely from family, twin and adoption studies. An adjusted meta-analysis of 21 family studies (Baldessarini and Hennen, 2004) estimated that close relatives of suicidal probands have a three times higher risk for engaging in suicidal acts compared with controls, irrespective of psychiatric history. A substantial familial component was confirmed by Kim et al. (2005) who compared 49


suicidal behaviours in relatives of suicide completers with community controls. After making adjustments for psychopathology, they found that relatives of people who have committed suicide have about 10 times higher risk of attempting suicide and an even greater incidence of suicidal ideation than controls. Family history of suicide was strongly associated with earlier onset suicide attempts and male gender (Mittendorfer-Rutz et al., 2007). Overall, family studies have indicated that heritability may be lowest for suicidal ideation, somewhat higher for suicide attempts, and highest for suicide completions (Brent et al., 1996; Maris, 2002). Unlike family-based designs, twin studies allow for a better control of the influences of the shared environment. After pooling published twin studies, Baldessarini and Hennen (2004) found a 175 times higher relative risk among monozygotic twins (MZTs) than dizygotic twins (DZTs). However, these results must be interpreted cautiously, keeping in mind the low incidence of suicidal behaviours in twins and lack of control of post-natal environmental influences. Adoption studies have been scarce and based primarily on Danish public health records. These investigations suggested a 7 to 13 times higher risk for suicidality among biological relatives of adoptees than among adopted relatives, and stronger heritability for suicide completions than attempts (Schulsinger et al., 1979; Wender et al., 1986). These estimates must be considered in light of several limitations, including low number of adoption studies, poor control of psychiatric confounders, lack of more recent adoption data and shortage of data from other countries. Studies for search of genetic markers of suicide have given precedence to the following neurotransmitter systems: 1. 2. 3. 4.

Serotonergic system. Noradrenergic and dopaminergic systems. Hypothalamic-pituitary-adrenal axis. Neurotrophic, GABAergic and glutaminergic systems.

Serotonergic System—Genetic Component Various components of the serotonergic system have been the subject of the various studies:

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1. 2. 3. 4.

Transport (serotonin transporter). Transmission (receptor genes). Anabolism (tryptophan hydroxylase). Catabolism (mono-amine oxidase A).

Serotonin transporter (SLC6A4) The serotonin transporter is responsible for determining the duration of serotonergic signal. Genetic studies focused exclusively on two of its variants, the 44-base promoter deletion/ insertion (LPR) and its associated S/L alleles, respectively, and a variable number tandem repeats (VNTR) polymorphism in intron 2. Of the 44 studies, approximately 20 have linked the former variant to predisposition to suicide attempts, finding S allele carriers to have an elevation in risk ranging between 1.7 and 6.5 times. An early meta-analysis of 12 studies confirmed the association between this promoter variant and suicide attempts but not completions (Anguelova et al., 2003). A subsequent meta-analysis found an overrepresentation of S genotypes in suicide attempters (P = .004) and violent suicides (P = .0001) relative to controls (Li and He, 2007). Only a few studies have reported statistically significant association of VNTR-2 and suicide (de Lara et al., 2006; De Luca et al., 2006). Serotonin receptor genes Genes of serotonin receptors have been studied less often than those of serotonin transporter. Only limited support was found for the involvement of receptor 5-HT1A (Nishiguchi et al., 2002; Ohtani et al., 2004; Serretti et al., 2007). Similarly, only one small study showed an association with 5-HT1B; the remaining investigations found no association with either suicide or suicide attempts (Hong et al., 2004; Nishiguchi et al., 2002; Tsai et al., 2004; Videtic et al., 2006). Variants in other receptors from this class (5-HT1D, 5-HT1E and 5-HT1F) were not associated with suicide completions in French Canadian (Turecki et al., 2003) and Slovenian study samples (Videtic et al., 2006). The 5-HT2A receptor gene may be the most promising serotonergic receptor gene. Genetic association studies in 5-HT2A implicated primarily the T102C polymorphism. However, subsequent meta-analyses based on nine, and more recently 25 studies failed to confirm its involvement (Anguelova et al., 2003; Li et al., 2006). The latter study suggested

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a significant role for the allele A of the A1438G variant, however. Newer studies are being carried out to find out the role of genetic imprinting in 5-HT2A gene variation. Tryptophan hydroxylase Tryptophan hydroxylase 1 (TPH1) was the first gene to be studied for suspected association with suicide. Mutations of this gene have been found to be associated with repeated attempts, impulsive and violent suicide in about half of the studies carried out so far. Recent meta-analysis has shown increased risk (about 60 percent) in carriers of allele A218C in suicidal behaviour (Bellivier et al., 2004). These positive findings have, however, been criticised because TPH1 is primarily expressed in the periphery, its significantly associated single nucleotide polymorphisms (SNP) are intronic and unrelated to splicing or exon skipping, and it exhibits high exonic homology with TPH2 (Shaltiel et al., 2005). TPH2 is a recently identified gene, found to be preferentially expressed in the brain stem and relevant to several psychiatric phenotypes through its involvement in amygdala-mediated responses to emotional stimuli (Canli et al., 2005). This gene also seems to have significant allelic, genotypic and haplotypic relationships with suicidal acts. T and G alleles of TPH2 have been found to be associated with five-fold increase of risk of suicide. Similar to other candidate genes, attempts to replicate TPH1 and TPH2 associations have been unsuccessful, encompassing study populations with different psychiatric diagnoses, such as mood disorders (Ho et al., 2000), schizophrenia (De Luca et al., 2005), and alcohol dependence (Zill et al., 2007), and ethnic membership. Monoamine oxidase A Monoamine oxidase A (MAOA) is an X-linked gene (Xp11.23) responsible for oxidative deamination of bioamines, such as central and peripheral serotonin and noradrenaline. Of the nine studies examining MAOA variation, six focused exclusively on a promoter VNTR. This variant was linked to suicide and violent suicide attempts in men and violent suicide attempts in depressed patients. A recent study investigated Fnu4I, finding its I/I genotypes of relevance in women who had depression (Nishiguchi et al., 2002).

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Noradrenergic and Dopaminergic Genes—Genetic Component Tyrosine hydroxylase (TH) is the rate limiting enzyme in the synthesis of noradrenaline and dopamine. Genetic evidence shows that the TH-K3 allele of the TH gene may be related to the risk for suicide attempts in a Swedish Caucasian sample with adjustment disorders. Dopamine D2 receptor (DRD2) is the only dopaminergic gene which has been linked to suicidal behaviour, with its 141Cdel allele conferring a 30 percent and its E8 allele a 70 percent increased risk in patients who had alcohol dependence (Brezo et al., 2008). The most studied supporting enzyme in adrenergic and dopaminergic systems has been the catechol-O-methyltransferase (COMT), responsible for metabolising the breakdown of levodopa into 3-O-methyldopa. Val158Met single nucleotide polymorphism of COMT has been found to be associated with violent suicide.

Hypothalamic-Pituitary-Adrenal Axis Variation in only one hypothalamic-pituitary-adrenal (HPA) axis gene has been studied for association with suicide: the CRCH2 gene’s haplotype 5–2–3 has been found to be positively associated with severity of suicidal behaviour (De Luca et al., 2007).

Neurotrophic Genes Brain-derived neurotrophic factor (BDNF), the most abundant neurotrophin in the brain, may be lower in the plasma of patients who are suicidal than in those who are non-suicidal and depressed, although it seems to be unrelated to the lethality of suicide attempts (Dwivedi et al., 2003). Its mRNA was, however, reduced in the hippocampus and PFC of individuals who committed suicide. Three neurotrophic genes have been studied so far:

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1. NOTCH4 2. NGFR 3. BDNF None of them was found to be associated with major effect on suicidal behaviour. BDNF gene, when considered in context of the environmental factors, was found to be significantly associated with suicide. Val/ Val genotype of BDNF gene was found to be associated with violent suicide attempts in people who had suffered from childhood sexual abuse.

GABA and Glutaminergic Genes Although expression data suggests changes in GABA and glutaminergic systems, very few studies have been carried out so far to examine their genetic variation. None of the four published studies investigating GABAergic and glutamatergic gene variation showed support for its relevance to suicidal behaviours. Genes examined include glutamate decarboxylase 1 and 2 (De Luca et al., 2004) and GABA receptor alpha-3 (Baca-Garcia et al., 2004) and alpha-5 genes (Wasserman et al., 2007), each subject of one study.

Other Candidate Genes In the last 30 years, about 20 genes outside the major systems have been put under the scanner for association with suicidal behaviour. Most of these candidates are involved in signalling and transport, with a few participating in lipid metabolism, deoxidation and gene transcription (Brezo et al., 2008). Cyclic adenosine monophosphate (AMP) and phoshpoinositide signalling systems and their components have been implicated in suicidal behaviour. The cyclic AMP response element binding protein (CREB) is a transcription factor which is associated with both of the foregoing systems and an important part of the genes expressed in the neurons

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(Dwivedi et al., 2004). Its mRNA was found to be decreased in PFC of adolescents who committed suicide (Pandey et al., 2007). HPA axis dysfunction in suicidal behaviour may be associated with abnormalities in the renin-angiotensin system by way of corticotrophinreleasing hormone (Saavedra et al., 2004). Angiotensin converting enzyme (ACE) gene is one of its chief components. Mutation in intron 16 of ACE gene is associated with increased suicide risk. Mutations in nitric oxide synthase (NOS) 1 and 3 are found to be associated with an increased risk of attempted and completed suicide respectively. Genes governing lipid and cholesterol metabolism are now being investigated as candidates for suicidal behaviour. Deficiency in the 7dehydrocholesterol reductase (DHCR7) enzyme involved in cholesterol biosynthesis may be responsible for a fourfold increase in suicidal acts as compared with controls (Lalovic et al., 2007). Apolipoprotein E4 (APOE4) and cholecystokinin (CCK) genes are associated with suicide in geriatric patients with depression and suicide in Japanese men respectively. Biological sciences have come a long way in deciphering the mysteries of mind behind behaviours such as aggression, impulsivity and suicide; however, most of the studies cited have certain shortcomings which must be kept in mind before conclusions are drawn. First, many post-mortem studies have been conducted which have a high number of variables associated with them, namely, the time after death when the studies were conducted, the chemicals which have been used to preserve and process the tissue sample and the manner of suicide (whether by ingestion of poisonous substances or slashing wrists) as it may have an impact on process of decomposition of the body, etc. Second, not many studies have tried to take into account the multiple factors that are contributing to cause suicidal behaviour at one particular moment of time. They usually focus on one factor which prevents us from developing a multi-dimensional theory regarding the cause of suicide. Although a lot of information has been accumulated in the last 30 years or so which will help in our understanding of suicidal behaviour, how it will lead to better patient care in the near future still remains to be seen. A laboratory test to accurately predict suicide in psychiatric patients could be a vital tool in prevention of suicides but so far it remains elusive.

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NEUROBIOLOGICAL MODELS OF SUICIDE Requirements of a biological model are that it should be: 1. clinically explanatory, 2. biologically correlated and 3. testable in biological and clinical studies (Mann et al., 1999). A model meeting the foregoing criteria was proposed by Mann and his colleagues (1999), based on the following key observations: 1. About 90 percent of the suicide victims are known to have a psychiatric disorder. 2. Most of the patients with psychiatric disorders do not make any attempts to commit suicide. 3. The objective severity of symptoms is not predictive of suicidal behaviour. 4. In a factor analysis, a combination of aggression and impulsivity appear to be the most important predicting factors of suicide. 5. Family studies have shown that the inheritance of suicidal behaviour is independent of the inheritance of any psychiatric disorder. It has also been found that the people who have attempted or died of suicide show abnormalities of the (a) PFC which is involved with control of impulse and aggression, and (b) serotonergic system of the brain which is also found in aggressive and violent subjects. Based on the aforementioned findings, the model postulates two independent components working together in suicidal behaviour: 1. Stressor: The calamity which makes life an ordeal (acute psychiatric illness, drugs, alcohol, medical illness, family or social stress). 2. Diathesis: Vulnerability to stressor. With regard to sensitivity to life events, early studies focused on the hypothesis that a generalised cognitive rigidity (characterised by perseveration, an inability to tolerate uncertainties, difficulty with changes, restricted interests, poor judgement and difficulty in taking other persons

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point of view) mediates the relationship between stressful life events and suicidal behaviour (Brent et al., 1996). However, more recent findings are consistent with the possibility that among people with depression those who attempt suicide differ from those who do not on some but not all neuropsychological tests (King et al., 2000). Using a modified Stroop task, Becker, Strohbach and Rinck (1999) found that the level of suicidal ideation in people with depression correlated particularly with biases in the selective attention (a cognitive process through which a part of the vast amount of information that we are receiving at a given time is selected for processing). Another study could not demonstrate any difference in attention measures between suicide attempters and non-attempters in a group of people with depression (Becker et al., 1999). Although clearly much more research is needed, these findings suggest a role of attentional bias in the development of suicidal ideation—but not suicidal behaviour— in people with depression. This diathesis is necessary for suicide but not sufficient to produce it all by itself. Many patients with increased vulnerability to stress do not commit suicide. This diathesis can be considered a tendency to take a decisive action in response to a stressor; an action which is more often than not aggressive and impulsive, due to a lowered threshold for motor activation, decreased inhibitory circuits, or an aggressive style of decisionmaking towards self or others. In spite of this, all psychiatric patients and those having suffered a loss do not attempt suicide. There probably are powerful protective mechanisms that prevent most of us from taking such a step even when we are faced with great stressors in life. Shakespeare describes this protective mechanism in his literary work Hamlet where the main character hesitates in attempting suicide even though he had the stressor of discovering his father murdered and his succession to the throne of the kingdom challenged, as follows: Thus conscience makes cowards of us all; And thus the native hue of resolution Is sicklied o’er with the pale cast of thought, And enterprises of great pith and moment With this regard their currents turn away And lose the name of action (Hamlet, Act-III, Scene 1)

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In this example from Hamlet, there was a stressor but probably an absence of diathesis, which prevented Hamlet from attempting suicide. Suicide tends to occur in circumstances where both the stressor and diathesis are present (see Figure 3.1). Figure 3.1 A Stress-diathesis Model of Suicide

Source: Amsel and Mann, 2000; Courtesy of New Oxford Textbook of Psychiatry, p.1045. (By permission of Oxford University Press.)

CONCLUSION Finding the biological markers is vital for better detection of at-risk patients and their subsequent appropriate management. There is some evidence that indicates that neurobiological factors especially may be associated with suicide. However, there is as yet nothing concrete in the findings of the extensive studies that have been carried out till date, which would allow us to detect and manage people at risk of suicide. Same is true for a large part of psychiatry, where there is no clear line of demarcation between different disorders in terms of biology even though their symptoms might be different. In the end, it can be concluded that though the path to finding reliable biological markers of suicide is a tortuous one, we must make an endeavour to tread it as best as we can.

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ACKNOWLEDGEMENTS The authors would like to thank Dr Mohan Dhyani, MD, Senior Resident, Department of Psychiatry, Lady Hardinge Medical College, New Delhi, and Dr Himanshu Sareen, Junior Resident, Department of Psychiatry for their invaluable inputs.

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4

Problem-solving Ability and Repeated Deliberate Self-harm C RM

S

M A

uicidal behaviour including deliberate self-harm (DSH) can be conceptualised as a maladaptive coping response (Sakinofsky, 2000) in which the person’s overarching motive is to escape from a problem situation (Baumeister, 1990; Williams and Pollock, 2001) to solve a problem (Applebaum, 1963; Chiles and Strosahl, 2004), or to avoid or relieve unpleasant emotions (Bancroft et al., 1976, 1979; Chapman et al., 2006; McAuliffe et al., 2007). Deliberate self-harm and its repetition pose a major challenge to mental health and social services internationally (Madge et al., 2008; Sakinofsky, 2000). Repetition accounts for a significant proportion of hospital-treated DSH episodes and is regarded as the central characteristic of self-harm (Kerkhof, 2000). More recent evidence shows that repetition is also common among adolescents who do not present to medical services following a DSH episode (Madge et al., 2008). Repeated DSH increases the risk of subsequent suicide (Hawton and Fagg, 1988; Maris, 1992; Nordentoft et al., 1993; Zahl and Hawton, 2004) and there is evidence that rates of repetition are increasing (Hawton, Harris, Hall, Simkin, Bale and Bond, 2003; Henriques et al., 2004; National Suicide Research Foundation, 2008; Schmidtke et al., 2004). A pragmatic response to this problem has been to identify the characteristics of individuals who engage in repeated suicidal behaviour in order to better inform the development of effective 65

Carmel McAuliffe

interventions for its prevention and treatment. Although the association between problem-solving difficulties and repeated self-harm is poorly understood (Pollock and Williams, 1998; Sakinofsky, 2000) there is increasing evidence that treatment interventions which incorporate problem-solving skills training are effective in the prevention of repeated self-harm (Arensman et al., 2001; Brown et al., 2005; Hawton et al., 1998; McLeavey et al., 1994; Salkovskis et al., 1990; Slee et al., 2008). The current chapter will review the existent research evidence of the role of problemsolving difficulties in self-harming behaviour and its repetition and describe a randomised controlled trial of group problem-solving skills training which was designed to prevent repeated DSH. In order to understand the association between problem-solving difficulties and repetition of DSH it is important to first consider the problemsolving process and how problem-solving ability acts as a vulnerability factor for DSH. Given the considerable variation in terminology used to describe different forms of suicidal behaviour in the scientific literature (O’Carroll et al., 1996), in this chapter the terms ‘deliberate self-harm’ (DSH) and ‘self-harm’ will be used to reflect the diversity of motives associated with this behaviour, without making any assumptions about suicide intent.

THE PROBLEMͳSOLVING PROCESS What role does problem-solving ability play in vulnerability to DSH? The following early definition of the problem-solving process (D’Zurilla and Goldfried, 1971: 108) gives some clues: ‘… a behavioural process, whether overt or cognitive in nature, which a) makes available a variety of potentially effective response alternatives for dealing with the problematic situation and b) increases the probability of selecting the most effective response from among these various alternatives.’ This process enables people to respond appropriately in situations they have not previously experienced or to problems where no immediate solutions are apparent. D’Zurilla and colleagues (D’Zurilla, 1986; D’Zurilla and Goldfried, 1971; D’Zurilla and Nezu, 1990) in their stage sequential model of social problem solving distinguish two main processes: (a) problem orientation and (b) problem solving. Problem orientation refers to a set of relatively stable schemata 66

Deliberate Self-harm

governing how people relate to problems in living and their thoughts and feelings with regard to their own problem solving ability. Problemsolving relates to a person’s application of problem-solving skills aimed at finding the ‘best’ or most appropriate solution for a specific problem (D’Zurilla and Chang, 1995). The five stage model outlined by D’Zurilla and Nezu (1990) includes problem orientation, generation of alternative solutions, decision-making, solution implementation and solution verification. As Pollock and Williams (1998) explain, these stages do not necessarily illustrate how healthy people engage in problem solving but they do provide an explanation for the particular parts of this process that can fail. People who engage in DSH have cognitive characteristics which undermine this process, including greater cognitive rigidity (McLeavey et al., 1987; Neuringer, 1964; Patsiokas et al., 1979), greater dichotomous thinking (Neuringer and Lettieri, 1971) and field dependence (Patsiokas et al., 1979); overgeneral autobiographical memory (Evans et al., 1992; Pollock and Williams, 2001); poorer performance on means–ends thinking (Dieserud et al., 2001; Linehan et al., 1987; McLeavey et al., 1987; Pollock and Williams, 2004) and lower self-appraised problem-solving ability (Dieserud et al., 2001; McLeavey et al., 1987).

PROBLEMͳSOLVING ABILITY AS A VULNERABILITY FACTOR FOR SUICIDAL BEHAVIOUR Clearly, not all individuals with poor problem-solving ability engage in DSH. As Williams and Pollock (2001) point out, problem-solving difficulties in and of themselves are not important, but when they signify to the person that there is ‘no escape’ they become important. There is substantial evidence that problem-solving ability mediates the relationship between stress and DSH, whereby individuals with poor problem-solving ability under chronic stress are more likely to become hopeless and/or suicidal (Sandin et al., 1998; Schotte and Clum, 1982, 1987). There is also evidence that good problem solving—as a stable trait characteristic— protects against DSH, independently of depression or hopelessness levels (Dieserud et al., 2001). Problem-solving ability is important in the association between environmental factors—for example, poor parenting and early exposure to stressful life events—and subsequent suicidal 67

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behaviour, as it helps to distinguish those who are more likely to engage in DSH. Furthermore, early exposure to chronic stress may adversely affect the development of problem-solving ability (Carriss et al., 1998; Clum et al., 1979; Yang and Clum, 2000). A number of models based on the original interactional model of suicidal behaviour by Braucht (1979), incorporating both individual and environmental factors, outline how problem-solving ability influences other associated risk factors for DSH in setting the context in which DSH can occur. For example, Schotte and Clum (1982, 1987) developed their seminal diathesis-stress-hopelessness model of suicidal behaviour in which cognitive rigidity mediates the relationship between stress and suicidal ideation, based on the finding that college students who reported high levels of negative life stress and were poor interpersonal problem-solvers also had the highest levels of hopelessness and suicidal ideation. They retested this model with a sample of suicidal psychiatric patients (Schotte and Clum, 1987) and found that they generated fewer than half as many potential solutions to interpersonal problems as matched controls. Levels of stress were positively correlated with levels of hopelessness and suicide ideation. Some interactional models emphasise the formative influence of early life experiences including parenting and adverse childhood experiences on problem-solving ability. Clum and colleagues (1979) focused on the interactions between early learning, the development of certain response sets conducive to DSH and precipitating environmental stressors. They described a developmental path analysis model based on a review of the empirical evidence, outlining multiple paths to DSH. One of their examples includes a parental role model for suicidal behaviour and a period of stress during adolescence leading to DSH. Another path they describe involves reward of avoidant behaviour combined with low reinforcement of problem solving, leading to cognitive rigidity, which—they argue—in the face of chronic or accumulated stress combined with an environment lacking in supports, increases the likelihood of DSH. Clum and colleagues point out that these paths are overlapping rather than mutually exclusive. Yang and Clum (2000) found that the impact of early negative life events on suicidal behaviour in adulthood was considerably stronger when examined through their impact on an individual’s cognitive functioning (including self-esteem, locus of control, hopelessness and problemsolving difficulties) than through their direct impact on suicidal behaviour. 68


They also found that early negative life events affected cognitive difficulties, whereas current life events did not. They hypothesised that high levels of stress early in life may interfere with the development of effective problemsolving skills, leading to an internalised model of lower perceived personal efficacy and increased helplessness and hopelessness. Sandin and colleagues (1998) describe a stress process model, outlining the impact of psychosocial stress (major life events, daily hassles and chronic stressors) on suicidal behaviour by integrating mediating variables (including negative appraisal, coping, problem solving and hopelessness) and moderating variables (including social supports and individual characteristics). They suggest that coping, which includes problem solving along with emotion-focussed and appraisal-focussed strategies, and hopelessness are critical end points of a causal mechanism leading to suicidal behaviour. Carriss and colleagues (1998) tested a mediational model of family rigidity, adolescent problemsolving difficulties and suicidal ideation. They found that family rigidity affects adolescent suicidal ideation indirectly through its effect on adolescent problem-solving ability as measured by the problem-solving inventory (Heppner, 1988). However, the study was cross-sectional, and family rigidity, adolescent problem solving and adolescent suicidal ideation were assessed concurrently. Problem-solving ability appears to be an important mediator of the relationship between psychosocial stress and suicidal behaviour. However, the effect of low mood on problem-solving ability is an important consideration and we now turn our attention to the possible effects of hopelessness on problem solving among those who engage in suicidal behaviour.

HOPELESSNESS One explanation for the observed problem-solving difficulties among self-harm patients is that they are brought about by low mood at the time of a self-harm episode. However, hopelessness seems to operate independently of problem-solving difficulties. For example, Dieserud and colleagues (2001) found evidence that hopelessness and problem-solving ability are part of two separate processes in a two-path model of DSH in a clinical sample. The first path was one of depression/hopelessness, 69

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in which low self-esteem, loneliness and divorce collectively increased vulnerability to the development of depression which was further mediated by hopelessness and suicidal ideation in its relationship with DSH. The second path was one of problem-solving difficulties, separate from the path mediated by depression, hopelessness and suicidal ideation. This cognitive path was based on low self-esteem and a low sense of self-efficacy. In this second separate path they found that negative self-appraisal of problem-solving ability and poor interpersonal problem-solving skills mediates the relationship between low self-esteem/low self-efficacy and DSH. There were no significant associations between the problem-solving variables and the depression/hopelessness variables when the distal variables (low self-esteem, low self-efficacy, loneliness and separation/divorce) were controlled for. Earlier studies have also found that correlations between hopelessness and interpersonal problem-solving skills are mainly nonsignificant (MacLeod and Williams, 1992; Schotte and Clum, 1987). Another study (Pollock and Williams, 2004) comparing a group who had engaged in DSH with a non-suicidal psychiatric control group found poorer social problem-solving ability among the DSH group; and this difference persisted while levels of depression, hopelessness and suicide ideation reduced following an episode of DSH. Hopelessness may be more important for problem orientation—the aspect of problem solving governing how people approach problems rather than problem-solving performance. When hopelessness is high, the range of alternatives that the individual perceives to be available to him or her may be restricted. In one study, depressed patients suffering from severe hopelessness—compared with those who had lower hopelessness scores—indicated that more life areas were presenting as problems to them (Nekanda-Trepka et al., 1973). They were also inclined to hold more negative expectations of the prospect of solving their problems, and of a poorer outcome if preoccupying problems did not improve. They also felt less competent about effecting an improvement (poorer self-efficacy) than did those who scored lower on hopelessness. Rudd, Rajab and Dahm (1994) report that suicide ideators similarly tend to focus on potentially negative consequences of implementing alternative solutions. Hopelessness may therefore influence problem orientation in such a way that the person not only tends to perceive more life issues as problematic but also feels unable to alleviate them and predicts negative consequences of their attempts to solve problems. Psychosocial treatment interventions that use problem-solving skills training need to address hopelessness by getting 70


clients to set realistic goals and by reinforcing clients’ efforts to solve their problems. To summarise, hopelessness may influence problem orientation among those engaging in DSH as distinct from problem-solving performance. This is important because it suggests that poor problem-solving ability is a stable cognitive characteristic among those engaging in DSH as opposed to compromised coping due to high levels of hopelessness. However, there is evidence that suicide ideators with a history of depression are vulnerable to deterioration in problem-solving performance as a result of low mood (Williams et al., 2005) while in a separate study (Schotte et al., 1990) a sample of suicide ideators and attempters showed significant improvements between time of admission and one week later in levels of depression, anxiety, hopelessness and suicide intent, which were associated with improvements in problem-solving skills in one week post admission. Based on these studies it appears that those with a history of depression and suicidal ideation are a sub-group for whom mood may influence problemsolving performance. In both studies, however, a large proportion of the samples examined were suicide ideators without a history of DSH.

PROBLEMͳSOLVING ABILITY AS A MAINTENANCE FACTOR FOR SUICIDAL BEHAVIOUR Early exposure to adverse life events and specific styles of parenting, as previously stated, are important in the development of problem-solving skills (Carriss et al., 1998; Clum et al., 1979; Yang and Clum, 2000). This is all the more relevant given the evidence that compared with first evers, repeaters suffer greater psychosocial disadvantage from early in life and chronic in nature (Arensman and Kerkhof, 2004b). Repeaters also have a greater range of psychiatric disorders (Rudd et al., 1996) including comorbid psychiatric disorders (Hawton, Houston, Haw, Townsend and Harriss, 2003) and more severe symptoms of depression (Rudd et al., 1996), hopelessness (Arensman and Kerkhof, 2004a) and suicidal ideation (Rudd et al., 1996). The risk factors related to repeated DSH therefore comprise a heterogeneous set, of which the only common factor may be the inclination to respond to a wide variety of stressful experiences with a repeated act of self-harm (Clum et al., 1979; Sakinofsky, 2000). 71

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More recent work has shown that among female self-poisoners in contrast to those presenting with a first DSH episode, repeated episodes of selfharm are more autonomous and are less determined by the occurrence of a specific stressful event (Crane et al., 2007). While previous self-harm was included in the model tested by Dieserud and colleagues (2001) the interactional models generally do not offer explanations for repeated self-harm and have not tested the association between problem-solving ability and DSH prospectively. One of the few prospective studies of problem-solving difficulty in repeated DSH found that repeaters view their problems as more insurmountable or overwhelming and themselves as relatively powerless over their lives. A tendency to perceive problems as more severe was the factor most predictive of repetition at three months in one prospective study of 228 consecutive DSH patients who were treated in hospitals (Sakinofsky and Roberts, 1990). Based on a separate analysis from the same study, nonrepeaters reported a significantly greater number of improvements in terms of personal change, financial situation, marriage, family and work, but had no fewer reports of experiencing new stressful events (Sakinofsky et al., 1990). Taken together these findings suggest that orientation to problems—rather than the specific problem or event—is particularly important in the case of repeaters of DSH and that a positive approach to problems is likely to buffer against the effects of new emerging problems in the aftermath of a self-harm episode.

EFFICACY OF PROBLEMͳSOLVING THERAPY IN TREATING PEOPLE WHO SELFͳHARM In one review of cognitive-behavioural therapy (CBT) interventions to reduce suicidal behaviour, Tarrier and colleagues (2008) report that 14 of the 28 CBT studies reviewed included some aspect of problemsolving training. Five of these trials focused uniquely on problem-solving therapy. Early trials using problem-solving skills training (McLeavey et al., 1994; Salkovskis et al., 1990) found promising results in reducing repetition of DSH (Arensman et al., 2001; Hawton et al., 1998). However, these early studies suffered from the limitations of a small sample size, making it impossible to detect any significant treatment effects 72


on repetition. Townsend and colleagues (2001) reported on outcomes other than repetition from a meta-analysis of six trials that tested problem-solving therapy for those engaging in DSH. They found that in comparison with control treatments, problem-solving therapy showed a significantly better effect in lowering levels of depression and hopelessness and significantly more of those assigned to problem-solving therapy reported an improvement in problems. Trials of Dialectical Behaviour Therapy for patients with Borderline Personality Disorder, which incorporates elements of interpersonal problem-solving skills training, have reported a significant reduction in rates of repeated DSH (Linehan et al., 1991, 1993, 2006). In many of the more recent larger trials, problemsolving interventions have more often been delivered as part of a broader treatment package of CBT. One trial comparing usual care with cognitive therapy based on 10 outpatient cognitive-therapy sessions that included a problem-solving component reported a significantly lower re-attempt rate in the cognitive-therapy group (Brown et al., 2005). The investigators also reported a significant improvement in self-reported levels of depression and hopelessness. There was no difference between treatment groups on rates of suicidal ideation. Overall, 96.7 percent of participants received at least one treatment session. In a separate study, Slee and colleagues (2008) examined a 12-session CBT programme. The programme was based on a model of maintenance factors of DSH including negative thinking and problem-solving difficulties to be modified by CBT. The authors reported a significant reduction in the number of repeated DSH episodes in the CBT group. There was full compliance with treatment sessions by all participants assigned to the CBT treatment arm. The failure of an earlier trial using a manual-assisted cognitive-therapeutic approach to demonstrate a reduction in repeat episodes (Tyrer et al., 2003), in which over one-third of the active treatment sample received a treatment manual alone without any treatment sessions, suggests that reliance purely on a self-help approach among repeaters of DSH is ineffective in reducing repetition, in particular among DSH patients with a history of previous DSH episodes (Arensman et al., 2004). Overall, despite promising findings from trials that incorporate problemsolving skills training, the number of studies focussing uniquely on a problem-solving approach remains small. In studies where significant effects have been found for CBT in reducing repeated suicidal behaviour, there is still uncertainty regarding the therapeutic processes within CBT that may be effective. 73

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METHODOLOGICAL ISSUES A major methodological problem hindering research into the identification of risk factors for repeated DSH is the use of heterogeneous samples, combining for example, suicide ideators with deliberate self-harmers, or repeaters with first evers (Rudd et al., 1996). Most studies that examine the association between problem solving and repeated DSH use ‘process’ measures—which assess attitudes and skills in problem solving—as opposed to ‘outcome’ measures of problem-solving ability (Rudd et al., 1996) which assess problem-solving performance based on solution efficacy. The use of a retrospective design makes it difficult to establish if ‘risk’ factors are causal or consequential. In terms of the evidence base for the efficacy of problem-solving therapy, large randomised controlled trials of problem-solving therapy are lacking. For these reasons we now turn our attention to three studies in which we have investigated the association between problem-solving ability and repeated DSH. A fourth study, examining the efficacy of a programme of problem-solving therapy in preventing repeat episodes of DSH is also described. These studies were carried out to address the following four research questions: 1. Motives for repeated DSH: Do repeaters have distinct motives for engaging in DSH; and a greater number of motives, indicative of greater problem-solving difficulties, when compared with first evers? 2. Problem-solving orientation of repeaters of DSH: Do repeaters of DSH have a different orientation to problems when compared with non-repeaters and is their problem-solving style characterised by a more negative problem-solving orientation generally? 3. Optional thinking ability: Can deliberate self-harmers who subsequently repeat be identified prospectively on the basis of their performance in problem solving? 4. Problem-solving skills training: Can a treatment programme based specifically on problem-solving skills training in addition to standard care significantly reduce repeated DSH compared with standard care alone? In all four studies ‘deliberate self-harm’ was defined according to the definition of parasuicide/attempted suicide devised by the World Health 74


Organization (WHO) Working Group of the WHO/EURO Multicentre Study on Suicidal Behaviour: …an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause self-harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic dosage, and which is aimed at realizing changes which the subject desired via the actual or expected physical consequences. (Platt et al., 1992)

This definition includes acts that are interrupted before DSH is inflicted, for example, a person removed from a bridge before jumping off, but excludes episodes by individuals who do not understand the meaning or the outcome of their act, for example, due to a learning disability or severe mental disorder (Bille-Brahe et al., 1994). The terms ‘parasuicide’, ‘attempted suicide’ and ‘deliberate self-harm’ were used interchangeably by the WHO/EURO Multicentre Study on Suicidal Behaviour.

MoƟves for Repeated Deliberate Self-harm We examined the motives reported for engaging in DSH by medically treated DSH patients interviewed at one centre participating in the Repetition-Prediction part of the WHO/EURO Multicentre Study on Suicidal Behaviour (McAuliffe et al., 2007). Previous history of DSH was established on the basis of specific questions asked during the initial interview. Repeaters were identified as those who engaged in more than one episode of self-harm before their initial interview—whether treated in hospitals or not. First evers were defined as patients whose index episode was their only known act of DSH at the time of the EPSIS I interview (European Parasuicide Study Interview Schedule). The first objective of this study was to establish if repeaters of DSH have a greater number of motives for engaging in DSH compared with first ever patients, as measured by the motives for parasuicide questionnaire (MPQ; Kerkhof et al., 1993) administered at index episode. A greater number of motives would be indicative of greater problem-solving difficulties in a range of areas. As expected, compared with first ever patients, repeaters reported significantly more motives at the time of the index DSH episode, suggesting 75

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a wider range of difficulties than first evers. This is consistent with Sakinofsky’s (2000) observation that what may be the only factor common to all repeaters is a tendency to repeat acts of DSH in response to a wide variety of non-specific stresses. The second objective was to establish whether repeaters have distinct motives for engaging in DSH compared with first ever patients. We found this to be the case. There were important differences in the reported motives for DSH according to the repeater status of DSH patients at index episode. Repeaters significantly more often reported motives aimed at escape from an unbearable mental state or an unbearable situation, by death or in order to make things easier for others. Repeaters were more likely to report motives of revenge against others—to make others pay and to make others feel guilty—and an appeal motive to show someone how much they loved them, to get help from someone, to know if someone cared or to change someone’s mind. Self-harm patients with high scores on the ‘escape’, ‘appeal’ and ‘revenge’ motive factors were at significantly increased risk of being a repeater. Controlling for the effects of the other motives, high scores on ‘escape’ and ‘revenge’ motives remained significantly associated with previous DSH. Clinical implicaƟons A large number of motives were reported by DSH patients generally and by repeaters in particular, indicating coping difficulties for the group as a whole, but with an even wider range of coping difficulties among those who repeat. Routine risk assessment of DSH patients should include specific questions regarding a broad range of motives for the DSH episode to effectively assess the extent of problemsolving difficulties. Psychotherapeutic interventions should address selfharm patients’ underlying problems across a broad range of areas. As an escape motive reflecting an inability to tolerate distressing thoughts or situations is independently associated with a history of DSH, therapeutic approaches with repeaters should include problem-solving skills training. Acceptance-based behavioural therapy or mindfulness-based cognitive therapy may be useful for improving emotion regulation and distress tolerance and for offering alternatives to avoiding or escaping difficult situations. The importance of the revenge motive for repeaters indicates considerable communication and interpersonal difficulties which also need to be focused on in treatment programmes. 76


Problem-solving OrientaƟon of Repeaters of Deliberate Self-harm We investigated problem-solving orientation among medically treated DSH patients (McAuliffe, Corcoran, Keeley et al. 2006) based on responses to the Utrecht Coping List (UCL; Schreurs et al., 1988), a process measure of problem-solving ability administered as part of the WHO/EURO Multicentre Repetition-Prediction study. The main objectives of the study were: 1. to examine the association between problem-solving orientation and previous history of DSH and 2. to establish if those reporting previous DSH are characterised by a more negative problem-solving orientation (a negative approach to problem solving—most typically a pessimistic attitude and a passive response to problems). Previous history of DSH was established on the basis of specific questions asked during the initial and follow-up interviews (EPSIS I and II). Repeaters were identified as patients who engaged in more than one episode of DSH before their follow-up interview—whether treated in hospital or not. Analysis of responses to the UCL was carried out from follow-up EPSIS II interviews at 12 participating centres of the WHO/EURO Multicentre study to explore the association between problem-solving orientation and previous history of DSH. Greater passivity was independently associated with increased risk of a previous history of DSH, when considered alongside gender and age. In addition, greater avoidance was independently associated with a previous history of DSH. The problem-solving style represented by this new factor, passive-avoidance (Table 4.1) is best described as a negative problem-solving orientation in which the individual entertains negative feelings, gets caught up in problems, worries about the past, and feels hopeless and helpless. In terms of behavioural response, there is a greater likelihood of giving in so as to avoid further difficult situations, a greater tendency to resign oneself to the situation and to try to avoid problems. For the repeater, the effect of this approach to problem solving is that he or she stops trying to solve problems. 77

Carmel McAuliffe Table 4.1 Problem-solving dimension

UCL Dimensions and Their Items

N items Items

Passive-Avoidance

7

Active Handling

7

Being totally pre-occupied with the problems Feeling unable to do anything Worrying about the past Taking a gloomy view of the situation Giving in—in order to avoid difficult situations Resigning oneself to the situation Trying to avoid difficult situations as much as possible Finding out all about the problem Making several alternative plans for handling a problem Considering different solutions to the problem Making a direct intervention when problems occur Using a direct approach in order to solve the problem Considering problems as a challenge Realising every cloud has a silver lining

Source: McAuliffe, McLeavey, Corcoran, et al. (2006); originally compiled by the author.

The association between passive-avoidance and previous history of DSH was no longer significant when the remaining four problem-solving dimensions along with general health, problem drinking and self-esteem were included in a regression. It was principally the inclusion of self-esteem that weakened the association between passive-avoidance and previous DSH. Self-esteem has elsewhere been described as a moderating individual characteristic of the relationship between psychosocial stress and suicidal behaviour. Low self-esteem can prime the individual to appraise problems negatively in situations of high stress (Sandin et al., 1998), whereas at high levels, self-esteem may protect against repeated self-harm (Petrie et al., 1988) by exerting a positive impact on the attitudes of people who do self-harm to their ability to deal with problems. High scores on the active handling dimension (Table 4.1) were significantly associated with reduced likelihood of previous DSH, when considered alongside age and gender. However, the association was weaker than that of passive-avoidance. Male repeaters were significantly more inclined to engage in negative emotional expression (showing anger or annoyance). Males were also significantly less inclined to share problems, 78


particularly male non-repeaters. However, while these differences were statistically significant, their magnitude in real terms was relatively small. Clinical implicaƟons Psychotherapeutic interventions for those who repeatedly self-harm should directly address passive and avoidant problem orientations. The characteristic negative thoughts and feelings evoked in DSH patients (e.g., hopelessness, helplessness) when confronted with problems should be explored in order to increase awareness of the impact of negative cognitions in responding to problems. Training in mindfulness-based cognitive therapy or acceptance-based behavioural therapies to enhance tolerance of negative cognitions, together with training a more active approach to problem-solving are key components of these interventions. The characteristic problem-solving style of repeaters of DSH is a combination of a passive and an avoidant orientation to problems. Level of self-esteem is a negative confounder of the association between passiveavoidance and repeated self-harm. This means that preventing repetition of DSH in repeaters is unlikely to be achieved by addressing a passive and avoidant problem-solving orientation without addressing low self-esteem. This indicates the need for intensive therapeutic input and follow-up for patients with repeated self-harm to develop a positive approach to problems through a structured problem-solving skills training programme; and to involve clients in practicing skills with their own personal problems as opportunities to increase self-efficacy and self-esteem.

OpƟonal Thinking Ability and Repeated Deliberate Self-harm A recent study examined the association between optional thinking ability—one of the principal difficulties in problem-solving performance among those who deliberately self-harm (McLeavey et al., 1987; Neuringer, 1964; Patsiokas et al., 1979)—and prospective repetition of DSH within 12 months (McAuliffe et al., 2008). The main objective was to identify DSH patients who subsequently repeat within one year on the basis of an outcome measure of problem-solving ability (the optional thinking test) administered at index episode, controlling for previous DSH, and 79

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other relevant sociodemograhic and clinical variables including level of education, levels of suicide intent and hopelessness. Poorer optional thinking ability on interpersonal problems was associated with an increased risk of repeated DSH within one year among patients medically treated for a first DSH episode. This means that, the first ever patients who had difficulty in generating alternative solutions to interpersonal problems were more likely to repeat DSH within one year of their index episode. The association between optional thinking ability and further self-harm was not significant for those who were repeaters at index episode, as they were significantly more likely to have repeated again by 12-month follow-up, independently of their optional thinking ability. In fact, the association between history of self-harm and a further repeat episode within 12 months was independent of the effects of all the other variables. Taken together these results suggest that optional thinking difficulties increase the risk of a first repeat DSH episode but for those who have two or more previous episodes, a history of repeated self-harm is more important than optional thinking in identifying those most likely to repeat again. Clinical implicaƟons For patients presenting with a first DSH episode, problem-solving skills training to enhance optional thinking ability may help to prevent a first repeat episode of DSH. For DSH repeaters, optional thinking ability may be less important as a single factor in determining outcome compared with first ever patients. As a corollary, problem-solving interventions for first episode self-harmers should be delivered as soon as possible following the DSH episode as this is the optimal time to interrupt the development of DSH as an automatic stress response.

Problem-solving Skills Training to Prevent Repeated Deliberate Self-harm A large randomised controlled trial was carried out to determine the efficacy of a structured Group Interpersonal Problem-Solving Skills Training programme (PST) as an intervention approach to DSH in addition to treatment as usual (TAU) as offered by the mental health

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services, compared with TAU alone (McAuliffe, McLeavey, Corcoran et al., 2006; McLeavey et al., in press. The PST consisted of six two-hour sessions, held weekly, of structured group interpersonal problem-solving skills training, facilitated by a trained therapist and a cotherapist. A manualised skills training programme (McLeavey et al., 2001) based on the original five-stage model of problem solving (D’Zurilla and Goldfried, 1971; D’Zurilla and Nezu, 1990) was strictly adhered to. Participants were encouraged to carry out homework assignments on a structured practice journal between sessions using their own interpersonal problems. During the recruitment phase patients aged between 18 and 64 years with a recent episode of DSH were screened for the trial. Just under twothirds of those recruited had a previous history of DSH at index episode. A total of 221 patients were randomised to group interpersonal problemsolving therapy, while a further 222 were randomised to treatment as usual. Over half of the patients screened were ineligible for the trial, the most common reason for ineligibility being alcohol dependence, followed by age outside trial range, followed by a diagnosis of psychosis and living outside the trial area. Outcome measures at baseline and follow-up With the exception of impulsivity, which was lower among participants in PST, there were no significant differences between treatment conditions on any of the outcome measures at baseline. Comparing baseline to six weeks followup, a significant reduction was observed for suicidal ideation, level of depression, hopelessness and anxiety; while a significant increase was observed for self-efficacy and self-rated problem-solving ability, in both treatment conditions. A significant improvement was also observed on perceived problem-solving ability. At six months follow-up these gains were maintained, with no further changes on these outcome measures. Compared to those in the TAU condition, DSH patients who had completed PST did not show a significantly greater change on any of the outcome measures at either follow-up stage with the exception of the practical support subscale from the social life scale on which they showed significant improvement at six weeks. The practical support subscale is a measure of the extent to which a person both needs and receives practical help from the person closest to them.

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Similar proportions of repeaters (hospital treated and non-hospital treated episodes) were identified in each treatment condition at all three follow-up periods (6 weeks, 6 months and 12 months). A similar number of repeat episodes was reported by participants in both treatment conditions at six weeks and at six months follow-up. There were no significant differences between treatment conditions in terms of the number of repeat hospital treated episodes at 12 months follow-up based on manual checks of hospital records. Compared to those who received standard care alone, participants assigned to PST evaluated the treatment programme significantly more positively in terms of: satisfaction with the treatment programme, relevance of the treatment programme to their problems, usefulness of the treatment programme for coping with problems, their understanding of the content of sessions and application of skills to their own problems. Furthermore the level of compliance with PST was high. The experimental treatment (PST) condition targeted the development of improved interpersonal problem-solving skills in participants. However, no significant differences were found between those in PST and those in TAU on any of the outcome measures of problem solving. Both treatment groups improved to a similar extent on these outcomes between baseline and follow-up, which suggests that the experimental treatment programme was not sufficiently long to effect a significantly greater change in the problem-solving skills of those in PST. Clinical implicaƟons No significant differences were found at follow-up between DSH patients in the problem-solving therapy (PST) and TAU conditions on any of the outcome measures examined, with the exception of needing and receiving practical support from a significant other, on which participants in the PST condition showed a significantly greater improvement. Although there was a significantly higher level of satisfaction with the PST treatment programme among the patients assigned, it is likely that it was too short to effect significantly greater changes in problem-solving ability than TAU, particularly in light of the fact that the majority were already repeaters at intake. The use of a group-based format alone in the PST intervention may not have sufficiently addressed the needs of DSH patients with a history of previous DSH episodes.

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INTEGRATING THE FINDINGS: KEY CONCLUSIONS WITH REGARD TO PROBLEM SOLVING There is a dearth of studies investigating the association between problemsolving ability and repeated DSH. Based on the studies described earlier, it was possible to distinguish repeaters of DSH as a sub-group of the selfharming population on the basis of their problem-solving characteristics. The following conclusions can be drawn: 1. Important associations exist between the problem-solving characteristics of DSH patients and repetition. 2. Repeaters’ acts of DSH are motivated by a wider range of factors, which implies a self-harm response that is more indiscriminate and generalised. 3. Escape and revenge motives are significantly associated with increased risk of repeated DSH. 4. Repeaters suffer greater impairment both in terms of how they approach problems and how they perform in problem solving. Their passive-avoidant orientation to problems locks them into a cycle of repeated failure to solve problems, which is likely to be one of the factors contributing to their lower self-esteem. 5. Different aspects of problem-solving ability may be relevant at different stages of the suicidal career: Poor optional thinking ability is particularly important in the transition from a first to a repeat DSH episode but once a first repeat episode occurs previous DSH history has a more important association with repetition than does optional thinking ability. These findings could be thought to provide an evidence base for the use of structured interpersonal problem-solving skills training programmes to reduce the likelihood of repetition in DSH patients. However, in the randomised controlled trial of structured group interpersonal problemsolving skills training described earlier, no differences in outcomes were observed between the PST experimental treatment condition and standard care. This leads us to conclude that brief programmes of structured group interpersonal problem-solving skills training probably do not

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allow sufficient time for the acquisition of skills and the development of higher levels of self-efficacy, particularly where individuals have already established a pattern of self-harming behaviour in response to the problems they encounter. A longer treatment intervention based on structured problem-solving skills training should be tested: 1. A six-session programme of structured group interpersonal problem-solving skills training probably does not allow sufficient time for the acquisition of skills and the development of higher levels of self-efficacy, particularly in a sample of self-harmers where the majority have already established a pattern of self-harming behaviour in response to the problems they encounter. 2. A longer treatment intervention based on structured problemsolving skills training should be tested in a large randomised controlled trial to allow adequate time for acquisition of problem-solving skills, including emotion regulation skills, and opportunities to increase levels of self-esteem in their successful application to the problems encountered by this client group. This longer programme of problem-solving therapy should incorporate initial individual sessions followed by group therapy sessions.

ACKNOWLEDGEMENT The author wishes to acknowledge the important contribution of Dr Ella Arensman, Director of Research at the National Suicide Research Foundation, Cork, Ireland.

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5

Suicide and Homicide: TheoreƟcal Issues Sóã® Mç»«Ù¹, UÖÝ« KçÃÙ Ä MÄÝ K. MÄ½

T

he twentieth century has been termed as the century of violence. It is not uncommon to talk about the ‘culture of violence’ prevailing in almost all the societies and across cultures. Based on the resolution adopted at the Forty-ninth World Health Assembly (WHO, 1996) about violence prevention, Krug, Dahlberg, Mercy, Zwi and Lozano (2002: 5) define violence as ‘the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation’. According to World Health Organization (WHO, 2002), each year more than a million people lose their lives as a result of self-inflicted, interpersonal or collective violence. Almost half of these are attributed to suicide and almost onethird to homicide. Violence is a major public health problem in most countries that incurs a huge cost not only in terms of the financial loss and infrastructural requirements for its prevention and management, but also in terms of the pain, suffering and trauma faced by the victims. The word suicide was coined by Sir Thomas Browne in his Religio Medici in the year 1642 based on Latin sui (of oneself) and caedere (to kill) intending to distinguish between the homicide of oneself and the killing of another. Freud (1915/1957) had hypothesised suicide as an expression of anger towards a love object that the individual turns back on the self.

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Menninger (1938) described suicide as the gratification of self-destructive tendencies, which include a wish to kill, a wish to be killed and a wish to die. The distinction between suicidal tendencies and violence directed towards the other has often been emphasised by researchers (e.g., Breed, 1963; Henry and Short, 1954; Smith and Parker, 1980) based on epidemiological, aetiological and socio-cultural data. Recent studies, however, have highlighted the commonality between the two types of violence, though there is a very small epidemiological overlap reported between the two. van Praag, Plutchik and Apter (1990) have reported that nearly 30 percent of violent individuals also have a history of self-destructive behaviour, conversely 10–20 percent of those who are suicidal also have a history of violence.

HOMICIDE: FATAL VIOLENCE TURNED TO THE OTHER The word homicide originates from the Latin homicidium, composed of homo, meaning ‘man’, and cidium derived from the verb caedo, meaning ‘to cut’ or ‘to kill’. Homicide is a complex phenomenon constituting ‘a complex set of behaviours with distinct and varying aetiologies, clinical courses, and prognoses’ (Schlesinger, 2007: 708). As it is true for suicide, each homicide is unique, defined by specific characteristics of the perpetrator, the victim and the circumstances. Despite the dynamic and interdisciplinary nature of homicidal behaviour, most research in the area of homicide studies has been carried out with a criminological perspective. The complexity of the phenomenon makes it difficult to explain a homicide solely on the basis of a psychopathology, except in the cases where psychosis (usually paranoid) or brain pathology leading to aggression is involved (Schlesinger, 2007). A dynamic approach to explain homicidal behaviour, involving biological, psychiatric and socio-cultural factors is warranted. Attempts have been made to classify homicides using various criteria, such as on the basis of the relationship between perpetrator and victim, like uxoricide (killing the spouse or consort), filicide (killing one’s children), familicide (killing one’s family members), siblicide (killing one’s sibling) or fratricide (killing one’s brother, which has acquired a wider connotation in the military context, and is used to denote killing of one’s own companions). Certain other classifications use motive as the 92

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criteria and provide categories such as gang-related homicide, homicide in retaliation to prior homicide and family-intimate partner homicide (Loeber et al., 2005). Heide (2003) has offered a classification based on the circumstances leading to homicide, for example, psychotic episodes, conflicts and crime leading to homicide. However, such classifications are limited in the sense that these add very little to the understanding of the aetiology of violence and homicidal behaviour (Loeber et al., 2005). Another approach to classifying homicides depends on the characteristics of the perpetrators, specifically on their ‘developmental pathways’ (Loeber et al., 2005). The developmental approach takes into account the past history of the individual for aggression and involvement in violent acts other than homicide. However, based on a review of homicide offenders, Heide (2003) has found mixed evidence to support the fact that homicide offenders have had a lengthy history of violence and aggression. This implies definite difficulties involved in predicting homicidal behaviour based on developmental indicators. Loeber et al. (2005) provide a brief overview of the theories explaining the origin of violent behaviour at the individual level, and classify these into ontogenic, sociogenic and mixed theories. The ontogenic theories propose that violent behaviour can be explained by the initial proneness of an individual (determined by factors like neurobiological deficits, personality, temperament and parenting) that stays fairly stable over time. The sociogenic theories postulate that life events have a dynamic impact on the individual, increasing or decreasing the probability of occurrence of violent behaviours. The mixed theories resolve the seemingly oppositional propositions made by the ontogenic and sociogenic theories, by combining the impact of early individual differences model with adulthood life circumstances. Lober and colleagues (2005) propose the mixed model as being useful for explaining and predicting homicidal behaviours.

Understanding the Overlap with suicide Psychiatric studies One common way of exploring the overlap between suicide and violence has been to study the occurrence of these behaviours among psychiatric patients. It has been noted that an underlying psychiatric illness might be the root cause of both the destructive behaviours (Nock and Marzuk, 2000). The psychiatric illnesses most often 93


associated with suicidal behaviours are mood disorders, substance abuse, schizophrenia and personality disorders. There is a plethora of research available exploring these associations that have been discussed elsewhere in the present book. Most of these disorders have also been found to be associated with violence. Alcohol and substance abuse have been reported to increase the prevalence of violence in psychiatric inpatients as well as community samples (Steadman et al., 1998). Schizophrenia is long known to be associated with violence, self directed or directed at others (Eronen et al., 1996; Link et al., 1992; Swanson et al., 1990). Violent individuals have often been diagnosed with personality disorders, especially antisocial and borderline personality disorder (Eronen et al., 1996; Volavka, 1995). Prevalence of mood disorders among the violent individuals has been reported to be three times higher than the non-violent individuals (Swanson et al., 1990). Diagnostic and Statistical Manual-IV (DSM-IV) categories that include violence and aggression have been reported by Lion (1995). These include substance abuse disorders, personality disorders, conduct disorder, dementia, post-traumatic stress disorder, mental retardation, sexual disorders and schizophrenia. The psychiatric disorder most intensively studied in association with aggression and violence is intermittent explosive disorder (Lion, 1995), which is characterised by aggressive impulses out of proportion to any precipitating psychological stressor (Burt, 1995). Evidence from jail and prison data Another opportunity to understand the overlap between suicidal and homicidal behaviours is given by the research exploring suicidal tendencies among criminals, especially among those convicted of homicide (Nock and Marzuk, 2000). Many studies have reported unusually high rates of suicide among prison and jail inmates (Joukamaa, 1997; Kerkhof and Bernasco, 1990). It has also been reported that being charged with murder/manslaughter significantly raises the risk for suicidal behaviours (DuRand et al., 1995; Kerkhof and Bernasco, 1990). However, both kinds of research studies have limited applicability as both focus on inmate population and not on general community samples. Moreover, the labels of prison inmate or psychiatric inmate might be superficial, as the labeling usually depends on which system the individual encounters first—legal or psychiatric (Nock and Marzuk, 2000). Though an overview of such studies suggests the underlying psychopathology in both the behaviours (increased impulsiveness, affective lability, 94


disinhibition, problems with reasoning and decision-making leading to increased aggressiveness; Nock and Marzuk, 2000), it also highlights the need for further exploring the dynamics of violent behaviours among the general population. The dynamic nature of violence has been emphasised by the ecological model (Bronfenbrenner, 1979; Garbarino and Crouter, 1978). The ecological model explores the relationship between individual and contextual factors, and considers violence as the product of multiple levels of influence on behaviour. It seeks to understand, predict and prevent violence on the basis of individual, relationship, community and societal level factors. Extending the ecological model, the research studies exploring the link between different types of violence can be utilised to further the knowledge of the overlap between suicidal and homicidal behaviours. It is accepted that exposure to violence in home during childhood is associated with being a victim or perpetrator of violence in adolescence and adulthood (Maxfield and Widom, 1996). Associations have been reported between suicidal behaviour and different types of violent behaviours. Paolucci, Genuis and Violato (2001) have reported associations of childhood maltreatment, the experience of being rejected and abused with violent and suicidal behaviours during adulthood. Intimate-partner violence (Stark and Flitcraft, 1995), sexual assault (Paolucci et al., 2001) and abuse of the elderly (Bristowe and Collins, 1989; Pillemer and Prescott, 1989) have also been found to be associated with suicidal behaviours. Homicide–suicide An extreme manifestation of the link between homicidal and suicidal behaviours (Nock and Marzuk, 2000) is the occurrence of both the destructive acts in close succession involving the same individual. Homicide–suicide is a relatively rare phenomenon in which the perpetrator kills another individual, usually an intimate partner, and commits suicide shortly thereafter, usually within minutes or hours (Cohen, 2000). The defining aspect of homicide–suicide is considered to be the intrinsic link between the two acts (Nock and Marzuk, 1999). Both homicide and suicide are seen as ‘antagonistic expressions of human aggression’ (Liem et al., 2007), and the occurrence of homicide–suicide poses a unique opportunity to understand the dynamics of both. Though most of the studies in the area do not focus on the clinical aspects of the phenomenon, researchers have shown the uniqueness of homicide–suicide based on epidemiological data, demographic characteristics of the victims and perpetrators, and the 95


modus operandi of the act (Liem et al., 2007). The typical psychological profile of the perpetrator in cases of homicide–suicide appears to be ‘that of a passive–aggressive, young adult, with poor self-esteem, insecure, and socially inadequate, who occasionally uses drugs and alcohol and exhibits proneness to explosive behaviour. The background frequently includes a dysfunctional family, including sexual abuse as a child’ (Palermo, 2007: 10). Liem and her colleagues (2007) have distinguished three subtypes of homicide–suicide and have described the dynamics involved. According to her an incidence of homicide–suicide can be distinguished by the underlying motive, either primarily suicidal or primarily homicidal. She has proposed a model that describes suicide, homicide and homicide–suicide as the culmination of aggressive intent, directed either against the self or the other, depending upon the attribution made by the individual for his/her frustrations, and emotional dependence on the victim. Based on a review of statistical data regarding the phenomenon and placing these in the context of sociological, psychiatric and psychoanalytic theories, Palermo (1994) prefers to rename homicide–suicide as ‘extended suicide’. He profiles the perpetrator as a fragile, dependent, ambivalent and aggressive individual who hides behind a facade of self-assertion. Unable to withstand the rejection by an intimate partner, on whom he is dependent, he kills himself after killing his ‘extended self’. Though most homicides involve a single victim, it is not uncommon to find multiple homicides in most societies. Palermo (2007) has described three types of multiple homicides—spree killings, mass killings and serial murders. Various similar behaviours occurring in different cultures, involving a violent outburst have been described by Cooper (1934), such as ‘amok’ in Malaysia, ‘Wihtico psychosis’ among the Cree Indians, ‘jumping Frenchman’ in Canada and ‘imu’ in Japan. Most of these are culture-bound syndromes that involve inappropriate and grossly exaggerated response to sudden or loud stimuli, high suggestibility, echolalia, echopraxia and violent behaviour that results in causing injuries/fatalities to others and subsequently to the individual himself (Colman, 2001). These disorders, despite the probability of a similar aetiology and underlying pathology, are manifested in culture-specific ways. Determined by larger socio-cultural environment and opportunities for expressing the aggression, these unique manifestations seem to highlight the role of sociogenic factors. However, Hempel and colleagues (2000) found more similarities than differences between oriental and occidental cases of running amok. They compared a nonrandom sample of North American cases of sudden mass assault by 96


a single individual (SMASI, n = 30) with a nonrandom sample of Laotian amok cases (n = 18) and other amok studies, and reported perpetrators showing evidence of social isolation, loss, depression, anger, pathological narcissism and paranoia, across the cultures.

CULTURE SPECIFICITY OF HOMICIDAL BEHAVIOUR It is an accepted fact that homicide rates vary in different countries and across societies. In the United States, homicide rate varies from 12 to 140 per million depending on the social group involved and the area studied (Cordess, 1995). European rates are generally lower, with rates in England and Wales being 12 per million (Home Office, 1993). According to the WHO report (Krug et al., 2002) the region-wise rates of violent deaths (both homicidal as well as suicidal deaths) based on Global Burden of Disease project for 2000, Version 1 show wide disparity across regions. According to WHO, the rates of violent death vary according to country income levels. In 2000, the rate of violent death in low- to middle-income countries was 32.1 per 100,000 population, more than twice the rate in high-income countries (14.4 per 100,000). Large differences in suicidal and homicidal rates are also reported among different countries within a region, between urban and rural populations, between rich and poor groups, and between different racial and ethnic groups. This clearly shows that much more is involved in homicidal occurrences than mere economic disparities. Daly and Wilson (2003) provide a provoking discussion on the involvement of cultural issues in homicide, and debate the proposition of attributing high prevalence of violence and consequent high rates of homicides in certain groups to a ‘subculture of violence’. Seeking more ‘utilitarian explanations’ than mere transmission of values that legitimise violence they call for exploring the possible role played by the current economic, demographic and social circumstances of the individuals involved.

TheoreƟcal Underpinnings Each homicide is a complex conglomeration of factors at varying levels, and cannot be explained by resorting to psychogenic factors or sociogenic 97


factors in isolation. Scholars have propagated different theoretical propositions in an attempt to elaborate upon the phenomenon. Neurobiological perspecƟve Neurobiological evidence has shown the involvement of amygdale, hippocampus, hypothalamic nuclei and prefrontal lobes in violent behaviour (Weiger and Bear, 1988). The limbic system and mid-temporal zones, which are the sites of emotional trigger zones, are also reported as having involvement in homicidal syndrome (Palermo, 2007). Impulsivity, lack of control, poor objectivity, poor discriminating capacity and improper situational appraisal are some of the manifestations of prefrontal lobe dysfunction found in majority of homicidal individuals (Palermo, 2007). Studies exploring neuro-chemical basis of violence have found abnormalities in the metabolism of inhibitory neurotransmitters (e.g., serotonin and cerebro-spinal fluid 5 hydroxyindoleacetic acid [CSF5HIAA]), as well as the metabolism of excitatory neurotransmitters (e.g., norepinephrine) (Lion, 1995). The knowledge gained through animal experimentation applied to human studies has led to enhanced understanding of both suicidal and homicidal behaviours. Diminished CSF5HIAA levels have been reported to be associated with impulsivity and aggressive dyscontrol. Lion (1995) reports significantly lower CSF-5HIAA levels in suicide survivors who had used violent methods as compared to those who had used less violent methods. The proposition that suicide and homicide are variants of the same underlying aggressive intent seems to be supported by neurological evidence. Sociological perspecƟve Sociological explanations for violence, specifically homicide, assert that the violent tendencies manifest because of a subculture of violence (Wolfgang and Ferracuti, 1967). Certain others attribute violence to presence of social vacuum (Palermo, 2004). Societal factors that have been reported to enhance the probability of homicidal behaviours are disinhibition due to drugs or alcohol, socially dysfunctional family structure, substandard economic conditions and social emargination (Palermo, 2004; Wolfgang and Ferracuti, 1967). Poor achievement, lack of specific skills and lack of steady employment have also been associated with homicidal behaviour (Palermo, 2007). The sociological theories of violence resort to the macro-level socio-cultural and economic dynamics for explaining individual and interpersonal behavioural phenomena. 98


Durkheim (1897/1951) has elaborated upon the influence of sociogenic factors upon individual behaviour. Construing homicide and suicide as interconnected and interdependent phenomena, he asserted that occurrence of both these violent behaviours is determined by the degree of integration or cohesion in a society and the degree of social regulation. According to him impulsivity increases in individuals as a result of social disorganisation, especially in times of rapid social change. The social anomie in such societies causes ‘a state of irritated weariness’ (p. 257) at the individual level that is either turned towards self (resulting in suicide), or towards the other (resulting in homicide). Within the typology of suicide (egoistic, altruistic, anomic and fatalistic) developed by Durkheim (1897/1951), fatalism has often been used to explain suicide as well as homicide (e.g., Cavan, 1928; Peck, 1979). Cavan provides an explanation for homicide-suicide describing it as an act of fatal resignation, where the individual finds no solution to his problem than suicide, but also blames the other for his unhappiness and kills that person in anger, revenge or jealousy. Durkheim’s (1897/1951) propositions provide a theoretical framework to explore the sociological and socio-psychological roots of violent behaviours. Summarily, the factors contributing to the homicidal profile from sociological perspective are proposed as relative deprivation (ascribed and illegitimate economic disparity), oppression (injustice, real or perceived, by government/other group), social learning (violence follows observation) and cultural dissociation (in-group, out-group). Psychological perspecƟve A review of the available research suggests that the homicidal behaviour, ‘short of those cases in which there is premeditation, organisation, and clear planning, is viewed today as the outcome of an individual’s disorganisation and his or her incapacity to control basic dangerous impulses, internal or external’ (Palermo, 2007: 6). Freud (1920/1961) viewed both suicide and homicide as expressions of aggression, as alternative responses to common cause. According to him, suicide represents an impulse to kill another turned inward on the self, and it has two roots, the death wish (Thanatos instinct), and sexual frustration or repression. Homicide occurs when the life instinct (Eros) counters the Thanatos and turns its impulse to kill one self to the other. Conversely, suicide happens when frustration is coupled with a blocked desire to commit murder. Freud (1920/1961) attributed all goal-directed behaviour to libidinal force and opined that as libido drives an individual 99


to achieve good goals, it may also direct one to destructive aggression, including homicide. Disinhibited aggressive behaviour, according to Freud, results due to instinctual forces overcoming the control imposed by ego and superego and allowing for an uninhibited expression of basic negative emotions. One of the most influential theories based on Freudian propositions is the frustration–aggression hypothesis, proposed by Miller (1941) in association with Robert R. Sears, O.H. Mowrer, Leonard W. Doob and John Dollard. The original propositions of the frustration–aggression hypothesis (Dollard et al., 1939) presuppose existence of frustration in all cases of aggression, and conversely construe aggression as the only consequence of frustration. Dollard and colleagues (1939) also said that absence of overt aggression subsequent to frustration was only due to inhibition caused by threat of punishment to self or to loved ones. Over the years the theory has generated much research and debates. Many modifications have been incorporated beginning with Miller (1941) and colleagues, who accepted that frustrations (i.e., the inability to attain desired goal due to external thwarting) can have non-aggressive behavioural consequences as well, though, they said that if the thwarting to goal-directed behaviour continue, the aggressive responses would eventually become dominant over nonaggressive responses. Another relevant proposition is of the distinction between hostile aggresion and instrumental aggression (Feshbach, 1964). Aggression is defined as a behaviour that is aimed at causing harm or injury to the target (Dollard et al., 1939). Hostile aggression is primarily aimed at causing harm whereas instrumental aggression is primarily oriented at attainment of some other objective, like money, status or power. The frustration– aggression hypothesis has relevance in the context of understanding the genesis of hostile aggression, manifested in violence towards self or towards others. The frustration–aggression hypothesis also proposes that the aggression generated by the frustration is directed at the agent perceived to be the source of frustration (Dollard et al., 1939: 39), or its displacement to substitute targets having appropriate stimulus characteristics. On the basis of empirical evidence, Berkowitz (1989) concluded that attributional interpretation of the aggression-provoking situation (the intentionality and perceived legitimacy of the thwarting) is significant in determining the emotional reaction of the individual. Berkowitz (1989) also concluded 100


that aggression facilitating cue do not generate aggression, but play an important role in reinforcing or intensifying the aggressive reaction generated by goal thwarting. The role of social rules and inhibitions against aggressive reactions (Cohen, 1955), role of prior learning (Bandura, 1973), individual differences like ego-strength (Block and Martin, 1955), or personality type (Strube et al., 1984), and cognitive processes like thoughts about the goal (Folger, 1986; Thibaut and Kelly, 1959), or thoughts about the reasons for frustration (Averill, 1982; Zillmann, 1978) have been shown to determine the emotional reactions to frustrations.

CONCLUDING REMARKS The evidence from neurological, sociological and psychological perspectives points towards negating the dichotomy of suicide and homicide. It is suggested, therefore, to view both behaviours as variations of the same underlying aggressive intent. Heightened aggressiveness has been reported among suicidal individuals, and the research involving individuals with a history of violent behaviours shows high incidence of suicidal behaviours. The causal factors for suicidal and homicidal behaviours seem to be involved in a complex dynamic pattern. Though, impulsivity and heightened aggressiveness form the core of both behaviours, the dynamics of specific manifestations are not adequately explained by the theoretical perspectives or the empirical evidence gathered so far. The directionality (inward bound or outward bound) and strength of the aggressive intent are key issues in explaining the suicidal and homicidal behaviours. Current body of knowledge does not provide an adequate explanation to the question why or how the same aggressive intent causes two different manifestations. An understanding of the theoretical perspectives is undoubtedly helpful in gaining a deeper knowledge of the dynamics involved in destructive behavioural manifestations at the individual, interpersonal and group levels. However, an overview of the various perspectives reveals the limitations of each to adequately explain the destructive behavioural phenomena. The neurological perspective provides an explanation that is idiosyncratic in nature and looks for roots of violence in genetic, neuro-chemical and 101


neurobiological anomalies. It elaborates upon the biological processes that create behavioural dispositions and potential for aggressive behavioural manifestations. These potential behavioural dispositions are manifested in various specific manners mediated by social and cultural facilitations or reinforcements. The neurological perspective, thus, provides an answer to the ‘what’ of destructive behaviours, and seeks the aid of socio-cultural perspectives to explicate upon the ‘how’ and ‘why’ of specific behavioural manifestations. Keeping the caution to guard against regarding the biological dispositions as deterministic, the neurobiological perspective proves its worth by providing with an important criterion to identify the people-at-risk, that is, individuals with known genetic, hormonal or neuro-chemical anomalies that make them vulnerable to violent behaviour. A closely related position is taken by psycho-pathological perspective that predicts aggressive behaviour based on the known psychopathology of the individual. Research has shown that certain psychiatric disorders are specifically linked to aggressive behaviours. Lion (1995) has provided a summary of these disorders with known aggressive manifestations. Though, it is known and accepted that lowered inhibitions and heightened aggressiveness due to excitatory dyscontrol are at the base of violent behaviours, establishing a specific aetiology still remains. Moreover, the dynamics of the process leading from anger to aggression, aggression to violence, and ultimately to homicidal violence are yet to be explored. Though, major mental disorders have been associated with an increased probability of homicidal behaviour (Schamda et al., 2004), it usually occurs when the individual is under the influence of delusions or hallucinations (Palermo, 2007). Frustration, fear and general behavioural immaturity have been associated with homicidal behaviour (Palermo, 2007), but the threshold that turns the ‘normal’ individuals into ‘time bombs’ that ‘suddenly explode, and their destructive fury kills both those known and unknown to them’ (Palermo, 2007: 8) remains to be defined in operational terms for assessment and prediction purposes. The socio-cultural perspective provides the larger canvas on which the homicidal behaviour unfolds. The facilitations, reinforcements and learning opportunities provided by the socio-cultural environmental context, not only influence the manifestations of aggressive behaviour, but also decide the social acceptability of particular behaviour patterns. The cultural variations reported in the literature underline the need to validate 102


the theories and models developed to explain destructive behaviours across cultures and develop predictive criteria based on a profile of the people-at-risk.

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Dollard, J., L. Doob, N. Miller, O. H. Mowrer and R. Sears (1939). Frustration and aggression. New Haven, CT: Yale University Press. DuRand, C.J., G.J. Burtka, E.J. Federman, J.A. Haycox and J.W. Smith (1995). A quarter century of suicide in a major urban jail: Implications for community psychiatry. American Journal of Psychiatry, 153(7), 1077–80. Durkheim, E. (1951). Suicide: A study in sociology (J.A. Spaulding and G. Simpson, Trans.). New York, NY: Free Press. (Original work published 1897). Eronen, M., P. Hakola and J. Tiihonen (1996). Mental disorders and homicidal behaviour in Finland. Archives of General Psychiatry, 53(6), 497–501. Feshbach, S. (1964). The function of aggression and the regulation of aggressive drive. Psychological Review, 71(4), 257–72. Folger, R. (1986). A referent cognitions theory of relative deprivation. In J.M. Olson, C.P. Herman and M.P. Zanna (Eds), Relative deprivation and social comparison (pp. 33–55). Hillsdale, NJ: Earlbaum. Freud, S. (1957). Mourning and melancholoia. In J. Strachey (Trans. and Ed.). The standard edition of the complete psychological works of Sigmund Freud (pp. 243–58). London: Hogarth. (Original work published 1915.) Freud, S. (1961). Beyond the pleasure principle. In J. Strachey (Trans. and Ed.). The standard edition of the complete psychological works of Sigmund Freud: Vol. 18 (pp. 7–64). London: Hogarth. (Original work published 1920.) Garbarino J. and A. Crouter (1978). Defining the community context for parent– child relations: The correlates of child maltreatment. Child Development, 49(3), 604–16. Heide, K.M. (2003). Youth Homicide: A review of the literature and blueprint for action. International Journal of Offender Therapy and Comparitive Criminology, 47(1), 6–36. Hempel, A.G., R.E. Levine, J.R. Meloy and J. Westermeyer (2000). A cross-cultural review of sudden mass assault by a single individual in the oriental and occidental cultures. Journal of Forensic Sciences, 45(3), 582–88. Henry, A. and J. Short (1954). Suicide and homicide: Some economic, sociological and psychological aspects of aggression. Glencoe, IL: Free Press. Home Office (1993). Criminal statistics England and Wales. London: HMSO. Joukamaa, M. (1997). Prison suicide in Finland, 1969–1992. Forensic Science International, 89(3), 167–74. Kerkhof, J.F.M. and W. Bernasco (1990). Suicidal behaviour in jails and prisons in The Netherlands: Incidence, characteristics, and prevention. Suicide and LifeThreatening Behaviour, 20(2), 123–37. Krug, E.G., L.L. Dahlberg, J.A. Mercy, A.B. Zwi and R. Lozano (Eds) (2002). World report on violence and health. Geneva: World Health Organization. Liem, M., I. Deerenberg and P. Nieuwbeerta (2007). Homicide followed by Suicide: A comparison with both homicide and suicide. Presented at the 8th Annual Conference of the European Society of Criminology, Edinburgh, September 2008. Retrieved 9 March 2009 from http://www.aic.gov.an/conferences/ 2008-homicide/ liem.pdf 104


Link, B.G., H. Andrews and F.T. Cullen (1992). The violent and illegal behaviour of mental patients reconsidered. American Sociological Review, 57(3), 275–92. Lion, J.R. (1995). Aggression. In H.I. Kaplan and B.J. Sadock (Eds), Comprehensive textbook of psychiatry VI, Vol. 2. (pp. 310–17). Baltimore, Maryland: Williams & Wilkins. Loeber, R., E. Lacourse and D.L. Homish ( 2005). Homicide, violence, and developmental trajectories. In R.E. Tremblay, W.W. Hartrup and J. Archer (Eds), Developmental Origins of Aggression. (pp. 202–22). New York, NY: The Guilford Press. Maxfield M.G. and C.S. Widom (1996). The cycle of violence: Revisited 6 years later. Archives of Pediatrics and Adolescent Medicine, 150(4), 390–95. Menninger, K. (1938). Man against himself. New York: Harvest. Miller, N.E. (1941). The frustration-aggression hypothesis. Psychological Review, 48(4), 337–42. Nock, M.K. and P.M. Marzuk (1999). Murder-suicide: Phenomenology and clinical implications. In D.G. Jacobs (Ed.), Harvard Medical School guide to suicide assessment and intervention. (pp. 188–209). San Francisco: Jossey Bass. Nock, M.K. and P.M. Marzuk (2000). Suicide and violence. In K. Hawton and K. van Heeringen (Eds), The International Handbook of Suicide and Attempted Suicide (pp. 437–56). Chichester, England: John Wiley & Sons. Palermo, G.B. (1994). Murder-suicide: An extended suicide. International Journal of Offender Therapy and Comparative Criminology, 38(3), 205–16. Palermo, G.B. (2004). The faces of violence. Springfield, IL: Charles C. Thomas. Palermo, G.B. (2007). Homicidal syndromes: A clinical psychiatric perspective. In Richard N. Kocsis (Ed.), Criminal profiling: International theory, research, and practice (pp. 3–26). Totowa, NJ: Humana Press. Paolucci, E.O., M.L. Genuis and C. Violato (2001). A meta-analysis of the published research on the effects of child sexual abuse. Journal of Psychology, 135(1), 17–36. Peck, D.L. (1979). Fatalistic suicide. Palo Alto, CA: R and E Research Associates. Pillemer, K.A. and D. Prescott (1989). Psychological effects of elder abuse: a research note. Journal of Elder Abuse and Neglect, 1(1), 65–74. Schamda, G., G. Knecht, D. Schreinzer, T. Stompe, G. Ortwein-Swoboda and T. Waldhoer (2004). Homicide and major mental disorders: A 25-year study. Acta Psychiatrica Scandinavica, 110(2), 98–107. Schlesinger, L.B. (2007). Psychopathology of homicide. In A.M. Goldstein (Ed.). Forensic Psychology: Emerging topics and expanding roles (pp. 708–33). Hoboken, New Jersey: John Wiley & Sons, Inc. Smith, M.D. and R.N. Parker (1980). Type of homicide and variation in regional rates. Social Forces, 59(1), 136–47. Stark, E. and A. Flitcraft (1995). Killing the beast within: Woman battering and female suicidality. International Journal of Health Services, 25(1), 43–64. Steadman, H.J., E.P. Mulvey, J. Monahan, P.C. Robbins, P.S. Applebaum, T. Grisso et al. (1998). Violence by people discharged from acute psychiatric inpatient facilities and others in the same neighbourhoods. Archives of General Psychiatry, 55(5), 393–401. 105


Strube, M.J., C.W. Turner, D. Cerro, J. Stevens and F. Hinchey (1984). Interpersonal aggression and the Type A coronary-prone behaviour pattern: A theoretical distinction and practical implications. Journal of Personality and Social Psychology, 47(4), 839–47. Swanson, J.W., C.E. Holzer, V.K. Ganju and R.T. Jano (1990). Violence and psychiatric disorders in community: Evidence from the Epidemiologic Catchment Area Survey. Hospital and Community Psychiatry, 41(7), 761–70. Thibaut, J.W. and H.H. Kelly (1959). The social psychology of groups. New York: Wiley. van Praag, H.M., R. Plutchik and A. Apter (Eds) (1990). Violence and suicidality: Perspectives in clinical and psychobiological research. New York: Brunner Mazel. Volavka, J. (1995). Neurobiology of violence. Washington, DC: American Psychiatric Press. Weiger, W.A. and D.M. Bear (1988). An approach to the neurology of aggression. Journal of Psychiatric Research, 22(2), 85–98. WHO Global Consultation on Violence and Health. (1996).Violence: a public health priority. Geneva, World Health Organization, (document WHO/EHA/ SPI.POA.2). WHO (2002). World report on violence and health. Geneva: World Health Organization. Wolfgang, M. and F. Ferracuti (1967). The subculture of violence. London: Social Science Paperbacks. Zillmann, D. (1978). Attribution and misattribution of excitatory reactions. In J.H. Harvey, W.J. Ickes and R.F. Kidd (Eds), New directions in attribution research: Vol. 2. Hillsdale, NJ: Erlbaum.

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6

Cultural Issues in Suicide Risk Assessment* EÙM®Ä® CÊ½ç®

… no one who commits suicide does so without reference to the prevailing normative standards and attitudes of the cultural community. Therefore, cause of suicide can be understood only with reference to the socio-cultural norms and attitudes that govern suicide in each cultural community. (Boldt, 1988: 106)

THE IMPACT OF CULTURE ON SUICIDAL BEHAVIOUR

O

verall, suicide rates of different countries tend to be relatively stable over time and very different from one another. For example, Lester (1987, cited in Zonda and Lester, 1990) found that suicide rates of European countries in 1975 were strongly associated with the suicide rates of 100 years earlier. The different suicide rates persist when immigrants ∗ Acknowledgements: Thanks to Anne O’Hanlon for granting permission to reproduce parts of Colucci (2006). Parts of this chapter were previously published in Colucci, E. (2006). The cultural facet of suicidal behaviour: Its importance and neglect. Australian e-Journal for the Advancement of Mental Health, 5(3), 1–13. Retrieved December 25, 2006, from www.auseinet.com/journal/vol5iss3/colucci.pdf. Permission of reproduction has been granted. 107

Erminia Colucci

from these countries are examined in the United States, Canada and Australia (De Leo, 2002; Dusevic et al., 2002; Lester, 1994). Similar considerations led to Zonda and Lester’s (1990: 381) conclusion that ‘these national and regional variations in suicide rates point to the possible role of cultural factors’. In addition, De Leo (2002), interpreting the World Health Organization (WHO) rates of suicide in different countries, noted that epidemiological studies provide evidence that social and cultural dimensions amplify any biological and psychological aspect. In particular, the male/female ratio appears to be particularly influenced by the cultural context (De Leo, 2002). Similarly, other researchers have noticed cultural differences in the epidemiology of suicidal behaviour among a range of countries. For example, Mayer and Ziaian (2002) and Vijayakumar (2005) pointed out different suicide patterns in Asian compared to Western countries. For instance, the age distribution and male to female ratio are different: rates are highest in the elderly in Western countries, but in young people in Asia. In the former, the male to female ratio is greater at 3 (or more):1 whereas in the latter the ratio is smaller at 2:1, with some countries like India showing a very similar ratio (1.4:1) and China showing higher suicide in women (Vijayakumar, 2005). Emphasising further the presence of important socio-cultural differences among countries, the selective review of Vijayakumar, John, Pirkis and Whiteford (2005) pointed out that in some developing countries (e.g., India) being female, living in a rural area and holding religious beliefs that sanction suicide, may be of more relevance to suicide risk than the same factors in developed countries. On the other hand, being single or having a history of mental illness may be of less significance. Similar findings and reflections indicate how important it is for researchers to identify which findings have cross-cultural generality and which are culturally specific (Lester, 1992–93; Mishara, 2006). Considerations of this kind led various scholars to recognise that suicide is a phenomenon that needs to be studied and understood in its social and cultural milieu. For instance, Tseng (2001: 392) stated that ‘suicide, even though it is a personal act, is very much socio-culturally shaped and susceptible to socio-cultural factors’ and Kazarian and Persad (2001) affirmed that the embrace of culture and life-enhancing perspective to research and practice are likely to contribute to better understanding of suicidal behaviour and to improved individual, family and community well-being. Range and colleagues (1999), after examining suicide among African Americans, Hispanic Americans, Native Americans and Asian 108

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Americans, declared that suicide must be studied from all angles, and ethnic origin is one of the characteristics that must be recognised and considered in assessing risk and designing interventions. In spite of the well-established and long-term interest in sociocultural aspects of suicidal behaviour, the research in this area is still in an embryonic stage and, as Kral (1998: 225) underlined, ‘we are only beginning to look seriously at the power of cultural ideas like suicide’. Furthermore, as pointed out by Lester (1992–93), although culture may influence the incidence of suicide, the circumstances and the methods, the reasons and meanings of suicide, most researchers have focused on the association between culture and incidence of suicide. This was also underlined by Marsella (2000). This partially finds its reason in the fact that, even though some researchers attempted to study the way in which culture influences suicidal behaviour, the conceptual consideration (i.e., theorisation) of the interface between culture and suicide has been, with few exceptions (e.g., Durkheim, 1897/1997), an overall recent phenomenon (Kazarian and Persad, 2001). As an example of a theoretical explanation, Cohen, Spirito, Apter and Saini (1997) hypothesised that culture affects the development of psychopathology which, in turn, affects suicide rates. Similarly, Tseng (2001) applied his theorisation of the effects of culture on psychopathology to suicidal behaviour, indicating various effects of culture on suicide, although suggesting an arguable application of the pathological frame to suicidal behaviour: 1. Culture contributes to the nature and severity of the distress that people may suffer (e.g., China and Korea prohibit the union of certain couples), which may then contribute to the occurrence of their suicidal behaviour (pathogenetic effects of culture). 2. Culture demonstrates pathoselective effects in a person’s choice of suicide over other possible solutions to problems (e.g., facing bankruptcy). 3. The pathoplastic effects of culture on suicide are well illustrated by the manifestation of special forms of suicidal behaviour in addition to individual personal suicide, such as family suicide, group suicide and mass suicide or seppuku (traditionally observed in Japan) and suttee (practised in India in the recent past). 109

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4. A pathoelaborating effect may be shown in various terminologies that have evolved to recognise and distinguish different forms of suicide, such as Japan, where laypersons use many terms to refer to different kinds of suicide. 5. The pathofacilitative effects are well proven by the variation in frequencies and rates of suicide among different societies. 6. Many societies have a very negative attitude towards suicidal behaviour: Muslims see it as an unforgivable sin and Indians still see it as crime, whereas Japanese have a more sympathetic view. Attitudes and stigmas show the pathoreactive effects of culture on suicidal behaviour. The impact that culture has on suicide has been the focus of research by a number of scholars although, as mentioned before, compared with other aspects of suicidal behaviour, this has been a rather neglected area of study, considering its importance, as observed also by other scholars (e.g., Eskin, 1999; Kral, 1998; Leenaars et al., 2003; Shiang, 2000; Tortolero and Roberts, 2001; Trovato, 1986). Watt and Sharp (2002) noted that there are relatively few available cross-cultural studies of suicide, and they are mainly on adults; usually young people are not examined separately. Captivated by this observation, Colucci and Martin (2007a, 2007b) reviewed all the trans/cross-cultural studies on youth suicide. The findings from the 82 references matching the review criteria were published in two papers: one on suicide rates and methods (Colucci and Martin, 2007a) and the other on risk and precipitating factors, and attitudes towards suicide (Colucci and Martin, 2007b). The main findings and considerations from this review will be summarised in the following section (readers are referred to Colucci and Martin [2007a, 2007b] for a more detailed review and to Leach [2006] for a review of the literature also on other age groups).

ETHNOͳCULTURAL ASPECTS OF YOUTH SUICIDE Roberts, Chen and Roberts (1997: 209) pointed out: ‘In general, ethnicity has been little studied in relation to suicidal behaviours; results from the few studies that have examined ethnic differences have been equivocal.’ Also the results of the first part of the literature review (Colucci and Martin, 110


2007a) were not homogenous and many studies seemed to provide discordant results on the epidemiology of suicide among youth belonging to different ethnic groups. However, some trends can be traced: for instance, the increase of suicide for young African Americans, particularly in young males (which are levelling the White versus Black suicide rates; see McIntosh, 1989), a pattern of extremely high peaks of suicide in young Pacific Islanders (Tseng et al., 1982) and aboriginal peoples (e.g., Kirmayer, 1994), and more frequent suicide attempts among Asian females compared to females of other ethnic groups (e.g., Bhugra et al., 1999). Suicide rates seem to be particularly high (Raleigh, 1996) and increasing (Bhugra et al., 1999) in young people from the Indian subcontinent. Hispanics appear to have higher rates of self-harmful behaviour than Whites (e.g., Gutierrez et al., 2001). The effect of migration on suicide statistics was the focus of a few studies but the data are ambiguous. For instance, Sorenson and Shen (1996) showed that, in California in the period 1970–92, foreign-born Whites were at higher suicide risk, foreign-born Blacks and Asian/Others were at similar risk, but foreign-born Hispanics were at lower risk. Like the prevalence of suicidal behaviour, the method chosen for suicide is also (at least partially) culturally determined (e.g., Colucci, 2008a; Sorenson and Shen, 1996). The second part of the review (Colucci and Martin, 2007b) covered the cross-cultural literature regarding youth suicide risk and precipitating factors, and attitudes towards suicide (it also provided suggestions for future research on cultural aspects of suicide). Overall, cross-cultural studies in young people have demonstrated many of the same risk factors for suicidal behaviour as found in more general research; for instance, depression, exposure to suicide, previous suicidal behaviour and interpersonal problems. However, some differences between ethnic groups emerged as well. For instance, while the cross-cultural literature showed that previous suicidal behaviour is a strong predictor of future suicidal behaviour, Heisel and Fusé (1999) found higher levels of suicidality over time in Japanese previous suicide attempter students but not in Canadians. Exposure to suicidal attempts and suicides of relatives, parents and friends is also known to promote the same kind of behaviour, but few publications have analysed the impact of exposure on different ethnic groups. Although this research is sparse, it does appear that exposure to suicidal behaviour may be a universal risk factor across cultures. 111

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With regards to interpersonal factors, cross-cultural research showed the impact of low family support, unsatisfying parental relations, or parental derogation on suicidal ideation and behaviour (e.g., Perkins and Hartless, 2002). However, here ethnicity also seems to play a role. For instance, of adolescents presenting to a UK accident and emergency department for self-poisoning (Biswas, 1990), significantly more White than Asian boys reported parental conflict with possibility of divorce. Also Handy and colleagues’ (1991) study showed that more self-poisoned English youth came from a disrupted family than did young Asian people. On the other side, in a similar UK emergency department study, Kingsbury (1994) showed that Asian adolescents, with lower suicidal intent but higher rates for suicide risk factors, experienced parents as more controlling than their Caucasian counterparts. In a study by Vega, Gil, Zimmerman and Warheit (1993) parent derogation was an important risk factor for African American and Nicaraguans but not for White boys. Another important suicide risk factor is a relational problem with peers and friends, although here also there are some cultural (and gender) differences (Colucci and Martin, 2007b). School connectedness emerged as a significant protective factor for suicide thinking (Resnick et al., 1997). This has also been shown in cross-cultural studies of suicide attempts in Hispanic and White students but not in Blacks by Borowsky and colleagues (2001), whereas Rew and colleagues (2001) demonstrated protection in all three ethnic groups. Physical and sexual abuse are risk factors for suicidal behaviour among young people has been demonstrated among the Black, Hispanic and White representative US sample investigated by Borowsky et al. (2001) and Rew et al. (2001). However, in a sample of White and Black students (Thatcher et al., 2002), sexual and physical abuse were associated with increased risk of attempted suicide in White males and females but not in Blacks. A few studies have examined personality aspects, such as coping style, locus of control, anxiety and hopelessness (Colucci and Martin, 2007b). Eshun (1999) demonstrated a similar significant positive correlation between suicidal ideation and hopelessness in both Americans and Ghanaians. A number of comparative studies have demonstrated relationships between depression and suicidal thinking or suicide attempts across samples comprising Indian, Chinese, Malaysian, Kuwaiti, Turkish, 112


Mexican American, Filipinos, and in Northern Plains and Pueblo Indian tribes (Colucci and Martin, 2007b). However, in the model developed by Gutierrez and colleagues (2001), depression had an impact on suicidal ideation in all groups (White, Black and Hispanic students), but the influence of depressive symptoms on history of suicide attempts was higher in Blacks than Whites. Another area extensively studied is alcohol and drug use and abuse in suicidal people, but these risk factors are also influenced by cultural determinants (e.g., Vega, Gil, Warheit, Apospori and Zimmerman, 1993). As observed in Colucci and Martin (2007b), suicide-precipitating factors are also culturally dependant. Besides risk and protective factors outlined earlier, Colucci and Martin (2007b) reported the findings on several studies examining attitudes towards suicide in different ethnic groups. In summary, young Americans showed more positive attitudes towards suicide than Ghanaian, New Zealander, Nigerian and Mexican American youth, but Canadians and Japanese were more accepting of suicide than Americans. Indian students manifested more negative attitudes towards suicide than both Dutch and Austrian students, and Singaporeans more than Australians. Other groups that have been compared on this aspect are Zambians, Swedish, Chinese and Turkish. More positive attitudes seem to be correlated with suicidal ideation (Domino et al., 2001–02; Eshun, 2003; Zhang and Jin, 1996), but more studies are needed to clarify this relationship. Basically, as shown by the review, there are some risk factors that might be generalisable to almost all ethnic groups, and others more specific to a given culture or ethnic group. Furthermore, the same factors may influence but to a greater or lesser degree, as demonstrated by Perkins and Hartless (2002) in European American and African American students. For example, hopelessness was a significant predictor for African Americans and European Americans but the association was significantly greater for European Americans, as was also physical abuse. Hard drug use was a stronger predictor for European Americans. Also in Vega, Gil, Zimmerman and Warheit (1993), the same risk factors had different importance for suicide attempts across the ethnic group: for African American and Hispanic boys, low self-esteem as well as negative parent and teacher perception were more important, while for White boys personal deviancy and delinquent behaviour were more important in predicting suicide attempts. To date, however, little research has been conducted examining whether the extent of risk factors in typically increasing suicide risk differs based 113

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on cultural groups, as also observed by Leach (2006). Beyond the specific variable importance in the determination of suicidal behaviour, risk factors interact in different ways depending on the specific culture examined. For example, Yuen, Nahulu, Hishinuma and Miyamoto (2000) estimated that suicide attempts were best predicted for Hawaiian students by depression, substance abuse, grade level, Hawaiian culture affiliation and the main wage earner’s education, compared to substance abuse, depression and aggression for non-Hawaiians. Concluding, both parts of the literature review underlined (also in light of often discordant results) the urgent need to extend and deepen the crosscultural research on suicide, to more exhaustively understand the influence of cultural dimensions on the personal choice to end life (Colucci and Martin, 2007a).1 Following this understanding, more culturally adequate suicide risk assessments and prevention strategies may be possible. While the literature review mainly explored epidemiological studies, other scholars reflected on the way culture affects the particular meaning attributed to suicidal behaviour in various cultures. This will be briefly examined in the following section (for further discussion, see Colucci, 2006).

THE CULTURAL MEANINGS OF SUICIDE As argued by Leenaars, Maris and Takahashi (1997: 2): Individuals live in a meaningful world. Culture may give us meaning in the world. It may well give the world its theories/perspectives. This is true about suicidology. Western theories of suicide, as one quickly learns from a cultural perspective, may not be shared. Suicide has different meanings for different cultures.

1 It must be noted that, at the end of the review, I was critical of the current cross-cultural literature on youth suicide for different reasons (see Colucci and Martin (2007a, 2008), for more details). In particular, I criticised the fact that the majority of the studies have been conducted in Western developed countries, especially in the United States. Furthermore, the majority of youth suicide cross-cultural research is epidemiological (at the time of the review, I could not find any qualitative cross-cultural study on youth suicide) and crossnational instead of cross-cultural.

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Shneidman cautioned us, when making cross-cultural comparisons, to not make the error of assuming that ‘a suicide is a suicide’ (1985, cited in Leenaars et al., 1997). Lester (1997) too recognised that suicidal behaviour may be quite differently determined and have different meanings in different cultures. In Suicide in Different Cultures, Farberow (1975) also affirmed that suicide is viewed very differently by different cultural groups and that culture influences form, meaning and frequency of suicide. Of the same opinion are Maris and Lazerwitz (1981) and Hendin (1964, cited in Boldt, 1988) who made the point that suicide varies culturally and that differences in meaning may have an influence on suicide. Also Durkheim, as Boldt (1988) revealed, explicitly recognised the potential influence of cultural meanings on suicide rates, but excluded meanings from his analysis because he believed the Protestants and Catholics, comprising his sample, espoused the same meanings. Discourses on meaning of suicide may be confused with discussion on the description of the word ‘suicide’ but the ‘meaning’ of suicide, as Boldt (1988) pointed out, must be differentiated from the ‘definition’ of suicide. He stated that meaning goes beyond universal criteria for certifying and classifying self-destructive deaths, to how suicide is conceptualised in terms of cultural normative values. He then listed some examples of peculiar socio-cultural conceptualisations of suicide: suicide as an unforgivable sin, a psychotic act, a human right, a ritual obligation, an unthinkable act. Despite the number of scholars who have underlined the relevance of what suicide means to people belonging to different socio-cultural backgrounds, the study of meaning is an unjustifiably missing area in suicide research. To date studies analysing this aspect are very rare and Meng’s (2002) paper on suicide as a symbolic act of rebellion and revenge for some Chinese women is one of very few exceptions. Everall (2000), in her study about the meaning of suicide in young people, noted that despite the amount of research conducted in suicidology, surprisingly little is known about the experience of being suicidal and argued that ‘while demographic variables may be useful in identifying at-risk groups, they provide little in the way of meaningful understanding of the suicidal individual’ (p. 111). In a similar way, Boldt (1988: 95) showed concern about the scarce consideration manifested for the study of the meaning of suicide: ‘Suicidologists use the term “suicide” as though there is no need to understand its meaning. This neglects the fact that meaning precedes ideation and action, and that individuals who commit suicide do so with reference to cultural-normative specific values and attitudes.’ 115

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Boldt (1988) and Douglas (1967) tried to find some reasons for this neglect and both of them concluded that perhaps the main reason resides in the scholars’ tendency to not pay attention to fundamental (but taken for granted, obvious) things. Another reason for the few studies to date on the cultural meaning of suicide might be linked also to the arduousness of this kind of study, for the difficulty to get in contact with meanings— not only for the researcher but for the subject under study as well—as stated by both Boldt and Douglas. But, of course, the difficulty of fully understanding the meaning of suicide should not become a justification to not dedicate as much effort and resources as possible to this important topic. On the contrary, the recognition and study of cultural relativity in the meaning of suicide is an urgent need in the present phase of social scientific suicide research. Only by differentiating as precisely as possible the culture-dependant meanings of suicide, and by systematically bringing these into the research paradigm, can the development of valid theories of ‘cause’, prevention and treatment begin. Trying to amplify this field of knowledge, I explored the cultural meanings of youth suicide among university students of 18–24 years of age in three different countries—Italy, India and Australia—using a combination of qualitative and quantitative methods (Colucci, 2008a). Some of the findings from this study are presented in the next section, as an exemplification of the way culture may influence several aspects of suicidal behaviour.

THE CULTURAL MEANINGS OF SUICIDE: A COMPARISON BETWEEN ITALIAN, INDIAN AND AUSTRALIAN YOUTHS In this study (Colucci, 2008a), data was collected through a multi-method approach, using a questionnaire with structured and semi-structured questions (such as case scenarios, word association, attitude scale, openended questions) and tape-recorded focus groups2 (research methods are partially described in Colucci, 2007, 2008b). 2 Quantitative data was analysed using SPSS 13.0. Qualitative data was analysed separately and then discussed by two bilingual psychologists and myself. The categories so developed were compared with those of a third psychologist, to create a final list of codes. The coding process was supported by the software for qualitative analysis ATLAS.ti 5.0.

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Almost 700 students across countries took part in the first phase of the study (i.e., survey) and 96 participated in the following focus groups (two sessions for each group for a total of 24 sessions). The comparisons highlighted differences and similarities across cultures in meanings and social representations of suicide. First, there were differences on prevalence: more than half of the total sample reported suicide ideation but this was higher among Italian and Australian participants, compared to Indians. In contrast, the latter reported more suicide attempts, followed by Australians and then Italians. Other questions investigated reasons for young people to attempt suicide or to indeed suicide. There were statistically significant differences on almost all suicide attempt reasons between cultures. For example, Indians showed higher agreement that youth at times attempt suicide to force others to do what they want. Compared with the other two samples, Italian participants showed higher disagreement that youth who attempt suicide are mentally ill. Another question asked to rank a list of 14 reasons for youth suicide. Participants presented statistically significant differences on all of them. For example, financial problems were among the most important reasons for Indians. Mental illness, depression and anxiety were more important for Australians and loneliness or interpersonal problems were so for Italians. The questionnaire also included a 21-item attitudes scale. Both mean scores on the single items and subscales scores showed cultural differences. For example, Indians, followed by Australians, had more negative attitudes towards youth suicide compared to Italians. The open-ended section of the questionnaire was composed of various parts investigating participants’ mental associations with the word ‘suicide’ and interpretations of both this word and ‘attempted suicide’, feelings about death, stereotypes of the ‘kind of’ youth who attempt suicide or kill themselves, reasons for living and suicide prevention strategies. For instance, when asked for which reasons they would not suicide, participants from the three countries wrote similar motivations, referring to the value and love for life, loved ones and the belief that difficulties are part of life and can be overcome. But there were also differences. In India, for example, participants more frequently mentioned God as a deterrent against suicide compared to participants in Italy and Australia. Italians rarely expressed negative judgements towards suicide (e.g., suicide is selfish) to justify the choice not to suicide, whereas this was quite frequent in Indians, followed by Australians. Furthermore, Australians more often expressed 117

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the hope that they would get some help and support compared with the other groups. In relation to help-seeking, overall the majority of students reported that, if they were thinking about killing themselves, they would talk to no one or talk to friends, followed by someone in the family. Some students, especially in Australia, referred to professional help. Focus group transcripts helped to further understand questionnaire answers and pointed out issues such as altruistic suicide (i.e., suicide to not be a burden on the family) and expected/forced suicide in India, the pressure to be ‘macho’ thus not expressing emotions and sharing problems and the conflict of expectations between friends and adults in Australian men, and the ‘involvement’ in other people’s life in Italian youth. Although gender issues were not the specific aim of the study, the crosscultural comparison revealed several differences based on participants’ sexes (e.g., Indian females thought, planned and attempted suicide significantly more than Indian males). Most importantly, it was evident that gender issues were central in several participants’ beliefs and narratives about youth suicide, particularly among Indians, followed by Australians. For example, there was generally a slightly more accepting attitude in females compared to males and more negative attitude in males, especially Indian males. In each country, a lower propensity to ask for help was reported by males, and this was amplified in the Australian sample where it was also stressed a greater social pressure towards males to conform to the ‘male image’ (i.e., macho-man) repressing emotions and feelings. These sort of findings highlights that it is also critical to consider gender differences when exploring the cultural meanings of suicidal behaviour.3 In summary, a number of culture-related issues emerged in this study which emphasise the importance of developing culturally sensitive suicide risk assessments and prevention strategies. 3

For example, Counts (1988, cited in Lester, 1992–93) illustrated the ways in which a culture can determine the meaning of the individual suicidal act in her account of suicide among females in Papua New Guinea, where female suicide is a culturally recognised way of imposing social sanctions, with political implications for the kin and for those held responsible for the events leading to the act. A similar study of accounts of suicidal behaviour showed that Sri Lankan participants associated essentialist accounts with women’s suicides and contextual accounts with men’s suicides (Marecek, 1998). Canetto and Lester (1998) also suggested that narratives of suicidal behaviours can be examined through the lens of gender-specific cultural scripts. 118


As part of understanding the cultural aspects of suicide, I also investigated participants’ spiritual beliefs, which later became one of my main research interests. The inner experience of spiritual and religious feelings is an integral part of the everyday lives of many individuals. Therefore, when considering ethno-cultural issues in the suicide risk assessment, we certainly cannot avoid (or should not) investigating our client’s (religious and/or not religious) spiritual beliefs. In this regard, Bhugra and Osbourne (2004: 6) recommended that the role of religion/spirituality ‘in individual’s cultural identity must be taken into account when ascertaining mental state and formulating management strategies’. Shafranske and Malony (1996, cited in Johnson and Hayes, 2003) suggested that religion/spirituality needs to be considered like any other client’s cultural characteristic and mental health professionals have an ethical obligation to consider spirituality a part of a standard assessment. At the opposite, to date mental health sciences have ‘excluded spirituality apart from seeing it as a form of pathology or pathological response’ (Dein, 2005: 538). For over 100 years scholars from several disciplines have contributed to the study of the role of religion as a deterrent to suicidal behaviour. The following section offers a synthesis of existing literature investigating the relationship between religion/spirituality and suicide keeping the ‘suicide continuum’ as a reference: from suicidal ideation to non-lethal suicidal behaviour to lethal suicidal behaviour. Studies giving indications of religious beliefs that might lead to suicide and spiritually oriented intervention strategies for suicidal patients and suicide survivors are also discussed. Particular emphasis is given to the importance of routinely taking spiritual issues into account when assessing people at risk of suicide and placing a more significant emphasis on spirituality in suicide prevention and intervention strategies: ‘[S]uicidology cannot continue to turn a blind eye to the central role that spirituality often plays in the experience of and recovery from suicidality’ (Webb, 2003: 5).

RELIGION AND SPIRITUALITY IN SUICIDE RISK ASSESSMENT Scholars and clinicians might have their own beliefs regarding the impact of spirituality/religion on suicidal behaviour and its role in suicide 119

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prevention and intervention. However, if they desire to provide evidence (pros or cons) for their ideas, they might find it difficult to ‘disentangle’ themselves from the literature which, in one way or the other, addressed this subject. For this reason, I attempted to give an aid for this difficult task by systematising the existing literature investigating the relationship between religion/spirituality and suicide (Colucci and Martin, 2008). This article began with an overview of the attitudes of the main religions (e.g., Catholicism, Islam and Buddhism) towards suicide, followed by the mainstream theories developed to ‘explain’ the link between religion and suicide. The core of the article was the description of the main findings from studies on religion/spirituality distributed in three parts of the ‘suicidal path’: suicidal attitudes and ideation, non-lethal suicidal behaviour and lethal suicidal behaviour. In the article, attention was also given to the (few) studies presenting indications of religious beliefs as a risk factor for suicidal behaviour, studies on suicidal behaviour prevention and treatment and on survivors. In this chapter, I summarise the main findings from the cited literature review but readers are referred to Colucci and Martin (2008) for the complete review. When the literature was analysed along the suicidal path, the main findings were as follows:4

Spirituality in Thought: Suicidal IdeaƟon and Aƫtudes Overall, studies have shown that religious factors are associated with lower suicidal ideation/plan and with more negative attitudes towards suicide. For instance, in the study mentioned earlier (Colucci, 2008a), I showed that Indian students who defined themselves as religious/spiritual reported lower suicidal ideation compared to those who were non-religious/ spiritual. Furthermore, participants’ specific religious preference was

4

Inconsistent findings are present in the literature investigating the spiritual/religious variables and suicide (Colucci and Martin, 2008). A possible reason for the disparity in results is the plethora of indicators used to study the impact of religion on suicidal behaviour. Another issue that must be taken into consideration is that the impact of religion/spirituality changes in different cultural and socio-political contexts and during historical periods.

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associated with presence of suicidal thoughts. There was an association also between students’ self-reported religiosity/spirituality and attitudes towards youth suicide as measured by the 21-items Attitude towards Youth Suicide scale (AtYS; Colucci, 2008a). In particular, whilst there were no statistically significant differences in India between religious/ spiritual and non-religious/spiritual students, in Italy religious/spiritual students believed more that suicide is preventable and agreed less that it is acceptable. In Australia, religious/spiritual students manifested more negative attitudes and less acceptability. Scores on the subscales were also analysed looking at the specific religious affiliations, which significantly impacted the scores on each of the four attitudes subscales. However, other scholars have shown that religiosity is only weakly associated (Lester and Francis, 1993) or not associated (Dervic et al., 2004; Eshun, 2003; Kamal and Loewenthal, 2002; Loewenthal et al., 2003) with suicidal ideation. On the other hand, participants with distress and strain related to religious or spiritual concerns reported more suicidal ideation (Exline et al., 2000; Johnson and Hayes, 2003). In the former study, it was the belief of having committed a sin too big to be forgiven which was primarily associated with suicidal thoughts. An observation from this first part of the review (Colucci and Martin, 2008) was that research has rarely focused on non-religious forms of spirituality and meaning in life or has put religion/spirituality in relation to the ethno-cultural context.

Spirituality in Non-lethal Suicidal Behaviour First of all, of the three, this was the part of the suicide path least investigated by scholars. Although a few studies have shown that religious/spiritual persons have lower rates of suicide attempts, a few others did not find any association between religiosity and suicidal behaviour. For instance, whilst in Italy and Australia a similar percentage of religious/spiritual and non-religious/spiritual students attempted suicide, Indian students who recognised themselves as non-religious/spiritual attempted suicide more often than religious/spiritual participants; the specific religion was also associated with suicide attempts (Colucci, 2008a). At the opposite, Loewenthal et al. (2003) found no association between participants’

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religiosity and suicide attempts. On the other side, a couple of studies suggested that in some circumstances religion might be a risk factor for such behaviour (e.g., Grossoehme and Springer, 1999). It is important to note that research suggested that only some aspects of religiosity (e.g., importance of religion) or some spiritual variables (e.g., sense of connectedness or coherence) might be associated with suicidal behaviour (Colucci and Martin, 2008).

Spirituality in Lethal Suicidal Behaviour The majority of research on lethal suicidal behaviour has focused on mortality statistics and indicated that variables such as religious affiliation and church attendance offer some protection against suicide. Breault and Barkey (1982) not only found an association between religious integration (as measured by religious book and newspapers production), but that this relationship was exponential: past a certain point or threshold, even a small decrease in integration was associated with a sharp increase in suicide rates. However, some studies have shown that the association between religion and suicide is mediated or influenced by other variables underlining an overall weak association between religion and suicide, for instance, level of urbanisation (Faupel et al., 1987), whereas others have reported an overall absence of a significant association (e.g., Wasserman and Stack, 1993). The epidemiological data have been questioned and Sorri, Henriksson and Lonnqvist’s study (1996) showed that in some cases religiosity can support a suicide decision. Also in this ‘path section’, research on nonreligious spirituality or on essential aspects of religiosity/spirituality (i.e., meaning/purpose in life) is scarce.

HOW CAN CLINICIANS CONSIDER CULTURAL ISSUES IN SUICIDE RISK ASSESSMENT? Leach (2006: VII), like previous scholars, argued that ‘understanding cultural nuances can assist with typical suicide assessment procedure to 122


offer greater breath and depth to the evaluation, thus assisting clinicians with their decision-making processes and interventions’. But how can we consider cultural issues in the assessment? When considering the client’s ethno-cultural background and spiritual beliefs while assessing their risk for suicide, we might assume that there will be a scale or similar psychometric measure readily available for this task. This would be a wrong assumption because there is no tool developed for a particular ethnic/racial/cultural group and no instrument might ever be able to measure such multi-faceted and complex constructs. We can find scales measuring concepts such as ethnic identity (see, for instance, Yamada et al., 2002) but ‘understanding’ cultural aspects of suicide is a life-long task, which requires much more than a list of items. Familiarising oneself with the major faith traditions and cultural groups at least in the district where the clinician works is a first step, but above all it is important to ask clients’ explanations for things we cannot make sense of within our own culture (even if sometimes clients might be surprised that we ask questions for taken-for-granted facts) and to learn to listen ‘for understanding’. Rumbold (2007: 61) stated that ‘spiritual assessment must be a process, not merely an event’ and this applies, in a broader sense, to any cultural assessment. Having said this, some countries (e.g., India) have developed their own suicide risk scales and clinicians might want to consider using them, although these are generally published in local literature and only those familiar with the language of publication might be able to use them. If we look specifically at spiritual issues, in Kehoe and Gutheil’s (1994) evaluation of suicide assessment instruments, the authors noted that, although the psychiatric literature suggests that religion and spirituality are significant and meaningful forces in suicidal patients, the number of religious items included on assessment scales approaches zero. For this reason, they criticise designers of suicide scales, which appear to seek factors that may help to identify people at risk of suicide but ignore the possible impact of what ‘a person, on the brink of life itself, believes about life and about life after death’ (p. 368). As concluded by these authors, front-line clinicians do not regularly investigate the religious area of a person’s life as a factor in assessing suicidal risk. But, for those mental health professionals sensitive to patients’ spiritual needs, scales are available

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which could potentially become part of the clinical assessment of a suicidal person.5 A few also measure non-strictly religious aspects of spirituality (e.g., Paloutzian and Ellison, 1982 cited in Ellison, 1983; Underwood and Teresi, 2002; WHOQOL SPRB Group, 2002). Although rare, some scales (e.g., Crumbaugh, 1977; Ryff and Keyes, 1995) address meaning or a sense of life’s purpose, a primary component of spirituality which has been neglected by the suicide literature (Colucci, 2008c). However, like Swinton (2001), I am very critical of the use of quantitative methods to study religion and spirituality and any reductionistic and simplistic approaches to the investigation of these constructs. In the cross-cultural journals reviewed by Tarakeshwar, Stanton and Pargament (2003), these authors criticised that religious dimension is assessed through a few global indicators (such as church affiliation, church attendance and prayer) which do not reflect the multi-dimensional nature of religion. The point, which was made also by Oldnall (1996), is that spirituality does not lend itself to measurement in a natural science sense. On the contrary, as postulated also by Burkhardt (1989), spirituality lends itself more to qualitative measures, where the subjectivity of response is valued. Therefore clinicians who prefer to use a psychometric measure to investigate the cultural milieu in which their client’s life is embedded should not delimit their assessment to these kind of tools. Talking specifically about religion, clinicians should consider that it might be more important to ask ‘how’ a person is religious rather than ‘whether’ a person is religious (Allport, 1950, in Hill and Pargament, 2003). Regardless of the method used, clinicians should investigate if their client’s spiritual/religious beliefs changed over time or if they are different from the spiritual/religious beliefs held by the people around them. Assessing clients’ beliefs about the afterlife is an 5 Readers interested in such scales might find it useful to consult the book Measures of Religiosity by Hill and Hood (1999), which classifies more than one hundred scales on religious development, beliefs, values, attitudes, attribution, orientation, practices, coping and problem-solving, commitment and fundamentalism. Scales on spirituality, mysticism, God concept, views of death/after life, forgiveness and others are represented in the book as well. Furthermore, the Fetzer Institute and the National Institute of Aging (1999) convened a panel of scholars with expertise in religiousness/spirituality and health/well-being to develop items in order to assess health-relevant domains of religiousness and spirituality. The resulting instrument ‘Multidimensional Measurement of Religiousness/Spirituality’ is composed of various scales representing different domains of religiousness and spirituality (e.g., meaning, values, beliefs, private religious practice, religious/spiritual coping).

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important part of suicide risk assessment, as it was also observed by Leach (2006). However, clinicians must also bear in mind that, although religion is generally regarded as a protective factor against suicide, a person who defines him/herself as strongly religious might still be at risk of suicide. They should also note that a few studies have suggested that religious beliefs may expose individuals or groups of believers to a greater risk of suicidal behaviour (e.g., Mancinelli et al., 2002; Zhang and Jin, 1996). Furthermore, clinicians should not ask only about a specific religious affiliation but need to be aware that people might hold multi-faith beliefs or might express a non-religious form of spirituality. In particular, the spiritual dimension of ‘meanings and purpose in life’ must be investigated as part of the suicide risk assessment (see Colucci, 2008c, for further discussion on spirituality and meanings, and instruments). Lastly, when undertaking suicide risk assessment, mental health professionals need to be aware that more research is required to define which aspects of religiosity and spirituality are protective against suicide, because religious affiliation or simply attending church are not ‘necessary and sufficient’ conditions to prevent suicidal behaviour (Colucci, 2008c).

CONCLUSIONS Range and Leach (1998) remarked that research methodology in Suicidology has historically developed from philosophical roots in logical positivism and structural determinism. This had led to research based on assumptions of cause–effect relationships, reductionistic analysis and focus on the individual as the primary unit under study, which might explain why relatively little research has addressed socio-cultural aspects of suicide. On the other side, some mental health experts recognise that culture functions as a lens through which we construct, define and interpret reality (Marsella and Kaplan, 2002) and a growing number of scholars have underlined the need to consider culture during suicide risk assessment and in planning suicide prevention/intervention strategies. But the path to inclusion of ethno-cultural considerations in mainstream mental health sciences and Suicidology is still a lengthy and arduous one. Kral (1998: 230) concluded his essay posing the question: ‘Is it time to ask different questions in Suicidology?’ My answer is ‘definitely yes’ and 125

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my hope is that this chapter will act as an invitation for a larger number of researchers, clinicians and policy makers to consider the socio-cultural milieu of their participants, clients and communities when assessing and treating suicidal ideation and behaviour. In order to improve our ability to assess the risk of suicide it is not enough to know what the principal suicide risk factors are. As observed by Leach (2006: 3), ‘[I]t is through culture that we begin to understand personal meaning, because culture offers the lens through which suicide factors such as coping styles, buffers, emotional expressions, family structures, and identity can be viewed.’ As it has been highlighted in this chapter, we need to understand the prevailing norms, meanings, social representations and attitudes regarding suicide in the many cultural (and subcultural) communities of the world, even though this is a difficult task, where no ‘true’ answer should be expected and no ‘right’ instrument should be assumed. All people involved in suicide prevention—health professionals, policy makers, spiritual guides, suicide survivors and so on—are required to understand what the act of suicide symbolises and represents for that person and that cultural group if we really want to help them find a different way—constructive and not destructive—to express and manifest those meanings. In conclusion, the following are a few points that clinicians should bear in mind during suicide risk assessment: 1. Although the literature on cultural influences on suicide is sparse at best, we have some evidence to suggest that a number of suicide risk and protective factors seem to be shared across cultural groups whereas others are more relevant or unique to a cultural group. However, the same risk and protective factors might have a different impact or act differently in different cultures and between genders in the same cultural group. For example, as reported by Leach (2006), previous suicidal attempts is a stronger predictor of suicide completion among European Americans than among African Americans, and depression seems to be a stronger predictor of suicide completion among African American females than among African American males. Thus, when assessing the risk of suicide, we should be aware that even the best-known risk factors for suicide, such as previous suicide attempts and depression, might show differences among cultural groups and genders and should 126


not assume cultural invariability or universality for anything. This also includes suicide warning signs.6 2. As there is the risk of mistakenly assuming universality, there is always the risk, when considering suicidal behaviour in its cultural milieu, to discount similarities in favour of dissimilarities whereas— as shown by Marshall and Yazdani’s (1999) research on construals of self-harm amongst Asian young women—it is important to recognise the commonalities across ethno-cultural groups rather that starting with the expectation of cultural differences. This was criticised also by Mishara (2006: 3) who pointed out that ‘Suicidology research tends to either ignore cultural differences entirely or focus upon a specific culture without examining possible commonalities across cultures’. Therefore, the author further stated, it is important to explore and understand the frontier between universal aspects of suicide and its cultural specificity. Leach (2006: IX) also commented that there is overlap among cultural groups, for example ‘hopelessness leading to suicide manifests itself similarly regardless of culture’ and this was also partially confirmed by the literature review earlier summarised (Colucci and Martin, 2007a, 2007b). However, as also argued by Leach, the nuances of culture need to be examined further with regard to many suicide factors, such as risk and protective factors, cultural views on illness and treatments and so on. As it is important to consider the similarities between cultures in suicide risk assessment the existence of within-group differences cannot be overlooked. 3. The relationship between religiosity and suicide has been scientifically investigated extensively since Durkheim (1897/1997) formulated the concept of religious integration. Still, the topic needs further and deeper examination, because data is inconsistent. Nevertheless, the majority of the studies seem to suggest that religiosity exercises a certain degree of protection against suicide. However, more research is needed that addresses the spiritual dimension

6 Suicide First Aid guidelines for Japan, India and Philippines, and the mental health professionals involved in the Delphi study reported some cultural variations also on suicide warning signs (Colucci et al., in press).

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of human beings, not only spirituality in its religious form—as it has been the tendency until now—but also in non-religious forms, as also observed by Swinton (2001). Scholars (e.g., Greening and Stoppelbein, 2002; Leach, 2006; Marion and Range, 2003) have suggested taking religious and spiritual issues into account routinely when assessing people at risk of suicide. I also invite scholars and clinicians to place a more important role on spirituality in suicide risk assessment and suicide prevention/intervention strategies, as discussed in Colucci (2008c). In this regard, Sexson (2004: 45) commented, ‘Integrating questions about spiritual and religious beliefs into the routine history taking and assessment … demystifies the subject and establishes its importance along with other aspects of the social history.’ While doing this, clinicians must note that, although less frequently found, there is some clinically important evidence of harmful consequences of religiosity, thus religious beliefs may expose individuals or groups of believers to a greater risk of suicidal behaviour. Furthermore, holding religious beliefs might decrease but not necessarily eliminate such risk. 4. Knowing risk and protective factors is not enough for suicide risk assessment but it is also necessary to understand the cultural meanings of suicide: mental health professionals must not take for granted that the meanings, interpretations and mental representations of suicidal behaviour remain the same in different (sub)cultures. 5. Discussing cultural issues of suicide prevention strategies is beyond the scope of this chapter (other scholars in this book have written about this topic). Nonetheless, I would like to conclude this chapter by arguing that suicide prevention strategies need to be developed from within the cultural milieu, rather than merely be adapted, that is making use of what has been done elsewhere. This point has also been made by the present International Association for Suicide Prevention (IASP) president (Mishara, 2006) while addressing current challenges for the association. He wrote that, to date, the emphasis in IASP has been upon commonalities in suicide, with adaptations to specific cultures and settings, and that the association’s activities—while allowing for cultural diversity— have usually assumed a universal perspective. Some steps in this 128


direction have been taken but the cultural perspective of suicide intervention continues to be in an embryonic stage and more needs to be done.

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7

Gender Issues in Suicide Risk Factor Assessment PTÙ OÝòT«, V®»TÊÙ VÊÙÊÝ Ä SÄÊÙ F»T

I

n the developed Western countries the number of men committing suicide is three times more than that of women. However, women are more likely to attempt suicide than men (Kaplan and Sadock, 2003). This is not a recent phenomenon, as in the nineteenth century Durkheim (1897) pointed out a similar gap in suicide mortality among men and women; but the difference became more apparent in the last decades of the twentieth century. There are many ways to explain why completed suicides are more prevalent in men; however, they do not explain the relatively low female suicide rates all over the world. Two approaches arise about gender differences in suicide: ‘why suicide rates are so high among males?’ or ‘why they are significantly lower in females?’ The answer to these questions lies within the multi-dimensional quality of suicidal behaviour, namely that completed and attempted suicides are not different phenomena, and many times often the reasons, the mechanisms and the methods are the same in both cases, only the outcome differs. Since gender is one of the most frequently replicated predictors for suicide, gender differences in suicidal behaviour have been analysed in a number of recent studies (Canetto and Sakinofsky, 1998; Hawton, 2000; Moscicki, 1994). Identifying variables which indicate greater risk of suicidal

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behaviour and investigating whether risk factors associated with suicide differ by gender are among the principal tasks of the epidemiological and socio-cultural research. According to these studies numerous socioeconomic, demographic, psychiatric, familial and help-seeking differences can be recognised in the various protective and risk factors between males and females (Mortensen et al., 2000; Qin et al., 2000). The explanations for the higher suicidal mortality of males remain insufficient, which may be caused by the complexity of factors involved in suicidal behaviour. The main hypotheses—aimed to explain the higher suicide mortality in men—are the following: the higher lethality of male suicide methods; the reluctance of men to seek help, the higher rate of substance (especially alcohol) abuse; and some socio-cultural differences. There has been a significant rise in the number of suicide rates among young males and a decline in rates among—especially elderly—females in numerous Western countries in recent years (Hawton, 1998).

DIFFERENCES IN EPIDEMIOLOGY In most countries, more men die because of suicide than women (male/ female ratio: 2–4/1); however, China is one of the few but most important countries of the exceptions (Cheng and Lee, 2000). According to the ‘gender paradox’ (Canetto and Sakinofsky, 1998), suicide attempts are more common among females compared to males (female/male ratio: 4–6/1), which lead the researchers to believe that male gender can be classified as a special, tertiary risk factor for suicide in the hierarchical classification of suicide risk factors characterised by Rihmer (Rihmer et al., 2002). Paradoxically, the higher number of suicide attempts tend to lower the risk of fatal outcome among women. In the past couple of years most countries have experienced a significant decrease in their overall suicide rates (mainly in older females), despite slight increase in the rates of younger age groups, particularly among males. Social factors—mostly linked to changes in gender roles—and the fact that men respond more strongly to the changes in social and economic conditions, seem to be the two most likely explanations for this phenomenon (Hawton, 1998).

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DIFFERENCES IN SOCIO ECONOMIC RISK FACTORS Many studies indicated that socio-economic risk factors for suicide also differ among males and females (Canetto and Sakinofsky, 1998). Concerning socio-economic factors, unemployment, retirement, single lifestyle and absence from work due to sickness are the most significant risk factors for suicide, mainly among younger males (Qin et al., 2000). Economic stressors, such as employment status, income and wealth, work as more significant triggers for suicide among males than in females. This fact supports the hypothesis that men respond more strongly to changes in social and economic conditions than women (Varnik et al., 1998). Occupational factors are also particularly important for males. Increased occupational instability has been proposed as one factor behind the recent increase in young male suicides (Hawton, 1998). Absence from work due to illness was significantly associated with a higher suicide risk, but only for males. This indicates that physical weakness might more easily lead to lack of self-esteem and confidence (Qin et al., 2000). Given the occupational content of male gender role stereotypes, it seems likely that unemployment and uncertainties at work would have a stronger impact on the male population’s self-esteem and mental stability, while women have more possibilities to retain other status and domestic and caring responsibilities (Payne et al., 2008). Male status is more often dependent on success at the workplace and control over their work and financial background, so they may be more sensitive to deprivation and more vulnerable to the basic gender-role distress. We can observe quite a similar situation in the case of European (especially males) adolescents’ suicides, who are more vulnerable to social changes (e.g., unemployment), so suicide may be a response to their problems with work, which in many countries is considered a ‘masculine’ response and behaviour (Mittendorfer-Rutz, 2006). From a socio-biological viewpoint there are some age-dependent gender differences, which might be in connection with the diminished capacity to reproduce and to get social support. In many countries (e.g., United States, Hungary) suicide rates in women tend to peak around middle age (the years of the menopause and the ‘middle life crisis’), while male suicide rates are much more higher among the elderly (Fekete et al., 2005). In old age, men become less fit physically and the reproductive capacity diminishes with isolation and deteriorated social support (Maris, 2002). The region of living also has a special gender-specific effect on suicide risk. Urban living 138


is linked to a higher rate of female suicide, mostly because women living in cities feel more alienated and socially isolated (Murphy, 1998).

DIFFERENCES IN CHOICE OF METHODS Concerning the differences between various methods, males tend to use more violent methods both in completed and attempted suicide, while women are more likely to choose self-poisoning (Kaplan and Sadock, 2003). A recent European multicentre study on youth suicide showed that males have a significantly higher risk for using firearms, hanging and poisoning by other means in their suicide attempts and lower risk of poisoning by drugs and jumping (Varnik et al., 2008). The difference between the rates of suicide attempts and completed suicides among women may reflect a lesser degree of intent, but it also shows a tendency among women not to use highly violent or particularly lethal methods. There is, however, an important exception, because in China—where selfpoisoning with pesticides is a common lethal method (Zhang et al., 2008)—the rate of suicide is equal in males and females (or higher in the rural female population). Greater suicidal intent, aggression, knowledge regarding violent means, less concern about bodily disfigurement are all likely explanations for the excess of violent suicide in males (Hawton, 2000). Strong cultural beliefs of suicide considered as ‘masculine’ and surviving a suicide as being culturally unacceptable might influence young males to use more violent or lethal methods (Mittendorfer-Rutz, 2006). This hypothesis is supported by the fact that men are more likely to attempt suicide through violent methods. For men surviving the suicidal act is perceived as inappropriate, and—from the viewpoint of traditional masculinity—death by suicide among men is viewed as ‘less wrong’ than in women (Canetto, 1997). Lethal suicide among men may be seen as an act of masculine expression or as an attempt to escape the negative consequence of surviving a suicide attempt. According to another explanation, the gender difference in choosing the method also relates to the communicative aspect of suicidal behaviour. By using a less violent method women might seek to protect others. So they tend to choose methods without regarding their attractiveness (Payne et al., 2008). 139

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DIFFERENCES IN MENTAL DISORDERS Mental illnesses are the most replicated predictors for suicides among both genders but especially for women (Rihmer et al., 2002). Psychological autopsy studies clearly demonstrate that affective disorders carry the highest risk—both to males and females—often comorbidly with personality-disorders and with other mental disorders (Hawton, 2000). Rates of schizophrenia and addictions are higher among males, while eating disorders—especially anorexia nervosa—are more common among female suicide victims (Harris and Barraclough, 1997; Mortensen et al., 2000). In a longitudinal study, hospitalised mental illness (particularly recent discharge from a psychiatric hospital) appeared to be the most prominent risk factor for suicide with both genders (Qin et al., 2000). These differences may be viewed as artifacts of men’s lower likelihood to seek help or because the symptoms of male depression are different from women’s. If the symptoms of a mental disorder are perceived as inconsistent with masculinity, men try to hide such symptoms (as signs of weakness) and do not ask for treatment (Payne et al., 2008). Men in line with norm-congruent behaviour drink more and more alcohol to combat depression instead of seeking professional help. Furthermore, alcohol and substance abuse, in its own right, has positive associations with suicide, especially among women (Payne et al., 2008).

DIFFERENCES IN PROTECTIVE FACTORS In spite of the fact that little research attention has been paid to factors which protect against suicide, there are some differences even among the protective factors. According to a Danish study, parenthood appears to explain an apparent protective effect of marriage for women, rather than the marriage itself per se, whereas among men marriage appears to be a protective factor in its own right (and single status is a risk factor) (Qin et al., 2000). According to another study, pregnancy has been found to be a protective factor for women (Appleby, 1996). Single men have higher risk for suicide than single women, and divorce is a significant risk factor for men, but not with women (Louma and Pearson, 2002; Qin et al., 2003). Interestingly, marital status seems to be more of a 140


protective factor for men rather than for women which can be explained with the socially constructed gender role. Marriage offers emotional and social integration, which are particularly important for men because they have fewer alternatives to having closer human relationships, and the gender role stereotypes (particularly of the need to be independent) diminish the capacity of males to develop social networks. Divorce or the death of a spouse can cause significantly more stress for males and might lead them to suicidal behaviour, while women are more likely to have extended and rooted social networks which might help them to cope with interpersonal losses (Payne et al., 2008). For women, the social construction of femininity includes family roles and the caring for children which offer them benefits to fulfil the sociocultural stereotypes based on traditional gender roles (Payne et al., 2008). There is another protective factor for women, namely to hold religious beliefs and negative attitudes towards suicide (Steen and Mayer, 2004).

DIFFERENCES IN HELP SEEKING BEHAVIOUR While being a male is an important risk factor for suicide, the presentation of suicidal behaviour is generally more common among women. Females are also more likely to seek help from general practitioners for their mental health problems (Osvath, Michel and Fekete, 2003). There are also special gender differences in various cultures; men often view help-seeking as a sign of weakness (Murphy, 1998). Men rarely ask for professional help and they are also more reluctant to ask for support from family and friends (Biddle et al., 2004). This reluctance and the special features of male depression may contribute to the fact that depression is more often undetected and untreated among men (Rihmer et al., 2002). This may—at least partially—explain the striking paradox: major depression (which has the strongest association with suicide among mental disorders) is about twice as common among women than men, but men are four times more likely to commit suicide than women. In the Gotland study the decrease in depressive suicide has almost entirely been the result of a decrease in female depressive suicides, while male suicidal rate has not changed. This probably explains why the apparent benefits of the educational programme in detection and treatment of 141

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depression for general practitioners on the Swedish island of Gotland were confined to females who were treated for depression (Rutz, 2001). Several studies and summarised clinical impressions suggest that the compliance for the therapy and prevention of male patients is significantly poorer than for females, and there is also some indication from treatment studies that fewer male attempters actually benefit from the treatments offered to them (Hawton, 1998, 2000). While this may reflect differences in the overall attitude towards help, it could also result from the available therapy type. Gender differences in verbal abilities and the reluctance of many males to share emotional problems may make some of the usual talking therapies less attractive to some males, at least initially (Hawton, 2000). These data suggest that gender-specific suicide prevention could be further improved by diagnosing and treating the male patients’ mental problems in a more effective manner, since they often mask their problems with impulsive, aggressive behaviour or alcohol abuse and their behaviour is frequently characterised by a lack of help-seeking attitude and noncompliance (Rihmer et al., 2002).

SOCIO CULTURAL ASPECTS OF GENDER DIFFERENCES IN SUICIDAL BEHAVIOUR Despite the mentioned main differences in suicidal behaviour, gender is mostly treated as a descriptive and causal factor in suicidal behaviour. But gender is not one of an array of individual, social and demographic characteristics (e.g., household composition, employment status, education). It is rather an inter-dependent variable that connects with, and impacts on, other influences and it also has special effects on suicidal behaviour (Payne et al., 2008). These effects could be explained with a complex socio-cultural theory about socially constructed masculinities and femininities, which may impact on a suicide-related behaviour and help explain the gender difference. We emphasised the fact that suicide is a result of a very complex interaction of a number of precipitating factors and that the socio-cultural theories focus on the social determinants of suicidal behaviour.

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In the complex socio-cultural model the traditional gender roles have a close relationship with suicide-related behaviour and the socio-cultural factors impact and reinforce these. Male gender role (characterised by dominance, aggressiveness, invulnerability) can help to explain the reason why men tend to choose more lethal methods, why they are struggling with asking for help and support for psychological problems and mental disorders, and why they tend to misuse alcohol and other substances as inappropriate self-medication. In contrast, traditional female role typically includes fragility, emotionality, expressiveness and family orientation, which may explain women’s help-seeking behaviour and their tendency to use less lethal methods. Additionally women have more opportunities to cope with negative life-events in a more effective manner (Payne et al., 2008). Houle, Mishara and Chagnon (2008) found some empirical evidence of a mediation model, in which the masculine gender role increased the suicide risk indirectly while being exercised through various mediator variables. In this model the most important variables were of negative influence on the mental state, social support and help-seeking. According to the model, men with traditional roles often experience a greater feeling of shame because of their problems which can diminish their self-esteem and undermine their mental stability. The masculine gender role deprives men from important sources of social support (due to the higher demands of autonomy). Some forms of emotional expression are less valued or denied (especially emotionality and weakness), while others, such as anger and aggression are accepted. The traditional masculine gender role may result in increasing the risk of suicide indirectly via mediator factors, since it tends to undermine the stability of mental state and inhibit the protective effect of help-seeking and social support. An interesting socio-cultural explanation to gender differences had been found in China. Researchers found a significantly higher rate of suicide among young females living in the rural areas. The findings are mostly due to the fact that women hold quite a low status in the Chinese society which can cause their deeply frustrating constraints. For young Chinese women the suicide act is therefore a form of protest and an escape from social distress, maltreatment and their lack of freedom (Mitra and Shroff, 2008).

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GENDER DIFFERENCES IN SUICIDE ATTEMPTERS The excess rate of suicide attempts in females, and the stronger association between attempted and completed suicide in males (Hawton, 1998) refer to the fact that attempts by females are more often based on nonsuicidal, but communicative motivation, while in males the attempts are often associated with greater suicidal intent. In a cross-national survey, the risk of suicidal behaviour (suicidal ideation, plan and attempt) was found significantly related to women compared to men (OR: 1,4 for suicide ideation, 1,4 for suicide plan and 1,7 for attempt) (Nock et al., 2008). Since gender is one of the most significant risk factors for suicide, and in a great number of completed suicides there are preceding suicide attempts in the medical history of suicide victims, it is important to study suicide attempters in relation to gender differences. Additionally, numerous reliable data are available on the characteristics of suicide victims, but the proportion of studies on attempted suicide is relatively low. Therefore, a collaborative study was conducted to detect differences in the suicidal behaviour between males and females by examining a large sample of medically treated suicide attempters in Hungary, a country with one of the highest suicide rates in the world. This analysis was performed within the frameworks of the WHO/Euro Multicentre Study on Suicidal Behavior (Osvath, Kelemen, Erdõs, Vörös and Fekete, 2003; Schmidtke et al., 1996). The aim of the European collaborative study was to identify epidemiological, socio-demographic features of suicide attempters, to find protective and risk factors of suicide behaviour. Registration of attempted suicides was carried out on consecutive episodes at university clinics in Pecs. In the data collection a standardised monitoring form developed for this multicentre study was used (Schmidtke et al., 1996). Out of 1158 medically treated suicide attempters, 63 percent (n = 728) were females. The highest rates of suicide attempts belonged to the adolescent and middle-aged population in both genders. More than half of the attempts were repeated suicide attempts, both in males (53.3 percent) and in females (52.1 percent). The statistical analysis (logistic regression model) separated male and female attempters quite sharply (Table 7.1). A ‘typical’ female suicide attempter can be characterised as follows: retirement or economical inactivity, widowhood, divorce and depression in personal history. Female attempters were mainly repeaters, using the method of self-poisoning, mostly with benzodiazepines. Among males 144

Gender Issues in Suicide Table 7.1 Gender Differences of Suicide A empters (Mul variate Logis c Regression Model)

Employment status Marital status and household composition Mental disorder Method of attempt Medication type in selfpoisoning Other

Male

Female

Economical inactivity (unemployment) Living alone, never married

Economical inactivity (retirement) Divorced or widowed

Alcohol abuse Violent (cutting, jumping) Meprobamate, carbamazepine

Depression Self-poisoning Benzodiazepines

—

Repeated attempts

Source: Fekete, Voros and Osvath (2005).

‘unemployment, living alone, never been married, addictive problems and the use of violent methods’ were the main characteristics. In case of selfpoisoning, males are more likely to take meprobamate or carbamazepine (Fekete et al., 2005). A couple of years prior to this study, Hungary had the highest suicide rate in the world. Nevertheless, it is peculiar that in spite of the more than 30 percent decrease (from 45/100,000 to under 27/100,000) of suicides in the last two decades, the number of suicide attempts of both genders stayed fairly stable. While comparing rates of suicide (Figure 7.1) and attempted suicide (Figure 7.2)—according to gender and age groups—it is well recognised that suicides show almost a linear increase in both genders. The number of attempts does not a show a continuous decline—as indicated from some previous data—but it has three different peaks parallel in both sexes. The first peak is the young-aged group (around the twenties), at the time of adolescent crisis; the second is the middle-aged group (around the forties), in the years of the mid-life crisis; and the third peak is the oldaged group (around the eighties), at the time of life-end period. The association of significant life periods of the psychosocial developmental crisis (Erikson, 1950) and the age curve of suicide attempts emphasise the importance of psycho-socio-cultural origin of suicidal behaviour. Suicide attempts are very high in the groups of young males, and young and middle-aged females, thus indicating a more important communicative aspect (asking for protection from others in the crisis situation) of these acts. Another possibility is the inadequate knowledge of methods, 145

Peter Osvath et al. Figure 7.1

Suicide Rates by Age Groups in Hungary (per 100,000 inhabitants)

Source: Hungarian Central Statistical Office (2002). Figure 7.2

Suicide A empts by Age Groups (per 100,000 inhabitants)

Source: Data from Pecs Center of WHO/Euro Multicenter Study on Suicidal Behaviour 2001 (Fekete et al. 2005). 146


or it also might be the case that these people are physically more resistant. There were no significant differences in mental illnesses between males and females, except for the rates of affective disorders and addiction. The former was almost twice as much in females than in males, while the latter was much higher among males, which may support the theory (similar to the suicide victims) that alcohol abuse among men might be a symptom of an affective disorder, or rather alcohol abuse in men marks latent or masked depression and it might be an inadequate method of self-medication. From another perspective, it is also possible to suggest that females ‘resort to’ depression instead of turning to alcohol. Significant differences were found concerning methods of selfpoisoning according to age, gender and repeated attempters. Regarding self-intoxication, benzodiazepines were the most chosen drugs; besides, men tended to use meprobamate and carbamazepine as well, which in fact might be linked to the high prevalence of alcohol-related disorders in Hungary (Osvath, Kelemen, Erdõs, Voros and Fekete, 2003). Among repeated attempters, a higher rate of taking an antidepressant, carbamazepine or antipsychotic medicine was found compared to benzodiazepines, which might indicate a higher prevalence of mental illnesses, or a disappointment of the therapy among repeaters. In the group of first attempters using a benzodiazepine rather than an antidepressant might indicate that many attempters only get symptomatic therapy for anxiety and sleeping disturbances, and the depressive disorders remain concealed (Osvath, Michel and Fekete, 2003). This phenomenon is mainly characteristic to men, whose help-seeking behaviour and compliance for therapy is poorer. The importance of the study lies in the fact that—by studying a great sample group—significant gender differences were found in suicide attempters, in line of former results on suicide victims. The results supported the significance of socio-cultural factors in association with the gender roles and suicide attempts, considering age, marital status, choice of method and mental disorders.

GENDER SPECIFIC TREATMENT POSSIBILITIES: CLINICAL IMPLICATIONS Since suicide is a phenomenon with multiple causes, its therapy and prevention should be complex and gender differences should be taken 147

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into consideration while building up helping strategies. Investigations of genetic and biological factors and epidemiological studies related to risk of suicidal behaviour are in their infancy but should be conducted from a gender perspective. Improved detection and management of psychiatric disorders are undoubtedly key factors in the prevention of suicidal behaviour among men as well as among women (Rihmer et al., 2002). Therefore, the awareness of gender differences in the clinical manifestation of depression is important in successful suicide prevention in depressed patients. We emphasise the significance of preventive efforts such as adequate diagnosing of mental disorders (especially affective disorders, alcohol abuse/dependency and personality disorders) and the effective treatment of these disturbances (rather antidepressants, instead of sedatohypnotics), both of which are crucial factors—particularly among men—in the prevention of suicide attemps in both genders (Osvath, Michel and Fekete, 2003). There is increasing evidence that alterations in socio-economic and socio-cultural conditions are also relevant to suicide prevention in males. Suicide prevention strategies reinforced that clinicians and other health care professionals should have adequate risk factor assessment skills. Although the predictive power of these risk factors is not clear (Goldney, 2000), some studies suggest that separate risk-assessment schedules are required for the two genders, meaning that based on gender differences initiatives to develop gender-specific approaches may be indicated. It is important to train health care professionals for a better understanding of the psychological characteristics of males, based on traditional masculine role, to improve their competencies for adequate and effective intervention in the mental problems of males (Houle et al., 2008). Investigating the socio-economic status, finding the risk and protective factors according to gender, and a marked concern for the high-risk groups, for example repeaters, elderly, chronically (physically or mentally) ill, could also help to prevent suicidal acts in everyday practice (Rihmer et al., 2002). Based on socio-cultural models it would be important from a primary prevention perspective to encourage prevention programmes for young boys focusing on the development of effective coping mechanism and on learning to express their emotions and to seek help without a feeling of shame. By doing this they can get a chance to solve difficult or stressful situations more successfully, without feeling shame or experiencing a decrease in self-esteem and efficiency (Houle et al., 2008). 148


Little research attention has been paid to possible gender differences in response to treatment in people at risk of suicidal acts. Studies on gender differences suggest that treatment programmes—which have more of a practical emphasis on problem-solving—can prove more successful in engaging males-at-risk. Gender differences in suicidal behaviour clearly merit more research attention to generate information that can guide clinical practice and prevention strategies in ways that will prove most effective for preventing suicidal behaviour in both genders.

REFERENCES Appleby, L. (1996). Suicidal behaviour in childbearing women. International Review of Psychiatry, 8(1), 107–15. Biddle, L., D. Gunnel, D. Sharp and J.L. Donovan (2004). Factors influencing help seeking in mentally distressed young adults: A cross sectional survey. British Journal General Practice, 54(501), 248–53. Canetto, S.S. (1997). Meanings of gender and suicidal behavior during adolescence. Suicide and Life-Threatening Behavior, 27(4), 339–51. Canetto, S.S. and L. Sakinofsky (1998). The gender paradox in suicide. Suicide and Life-Threatening Behavior, 28(1), 1–23. Cheng, A.T.A. and C.S. Lee (2000). Suicide in Asia and the Far East. In K. Hawton and K. Van Heeringen (Eds), The International Handbook of Suicide and Attempted Suicide (pp. 121–35). Chicester: John Wiley and Sons. Durkheim, E. (1897). Le Suicide. Etude de Sociologie. Paris: Alcan. Erikson, E. (1950). Childhood and society. New York: WW Norton. Fekete, S., V. Voros and P. Osvath (2005). Gender differences in suicide attempters in Hungary: Retrospective epidemiological study. Croatian Medical Journal, 46(2), 288–93. Goldney, R.D. (2000). The privilege and responsibility of suicide prevention. Crisis, 21(1), 8–15. Harris, E.C. and B. Barraclough (1997). Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry, 170 (3), 205–28. Hawton, K. (1998). Why has suicide increased in young males? Crisis, 19(3), 119–24. Hawton, K. (2000). Sex and suicide: Gender differences in suicidal behaviour. British Journal of Psychiatry, 177 (6), 484–85. Houle, J., B.L. Mishara and F. Chagnon (2008). An empirical test of a mediation model of the impact of the traditional male gender role on suicidal behavior in men. Journal of Affective Disorders, 107(1–3), 37–43. Hungarian Central Statistical Office (2002). Hungarian Statistical Bulletin, 2001. Hungarian Central Statistical Office, Budapest, Hungary. 149

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Kaplan, H.I. and B.J. Sadock (2003). Kaplan & Sadock’s synopsis of psychiatry: Behavioural sciences/clinical psychiatry. Philadelphia, USA: Lippincott Williams & Wilkins. Louma, J.B. and J.L. Pearson (2002). Suicide and marital status in the United States, 1991–1996: Is widowhood a risk-factor? American Journal of Public Health, 92(9), 1518–22. Maris, R.W. (2002). Suicide. Lancet, 360 (9329), 319–26. Mitra, S. and S. Shroff (2008). What suicides reveal about gender bias. Journal of SocioEconomics, 37(5), 1713–23. Mittendorfer-Rutz, E. (2006). Trends of youth suicide in Europe during the 1980s and 1990s – Gender differences and implications for prevention. Journal of Mental Health, 3(3), 250–57. Mortensen, P.B., E. Agerbo, T. Erikson, P. Qin and N. Westergaard-Nielsen (2000). Psychiatric illness and risk factors for suicide in Denmark. Lancet, 355(9197), 9–12. Moscicki, E.K. (1994). Gender differences in completed and attempted suicides. Annuals of Epidemiology, 4(2), 152–58. Murphy, G.E. (1998). Why women are less likely than men to commit suicide. Comprehensive of Psychiatry, 39(4), 165–75. Nock, M.K., G. Borges, E.J. Bromet, J. Alonso, M. Angermeyer, A. Beautrais et al. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192(2), 98–105. Osvath, P., G. Kelemen, B.M. Erdõs, V. Voros and S. Fekete (2003). The main factors of repetition. Review of some results of the Pecs Center in the WHO/EURO Multicentre Study on Suicidal Behaviour. Crisis, 24(4), 151–54. Osvath, P., K. Michel and S. Fekete (2003). Contacts of suicide attempters with healthcare services in Pecs and Bern in the WHO/EURO Multicentre Study on Parasuicide. International Journal of Psychiatry in Clinical Practice, 7(1), 3–8. Payne, S., V. Swami and D.L. Stanistreet (2008). The social construction of gender and its influence on suicide. A review of the literature. Journal of Men’s Health, 5(1), 23–35. Qin, P., P.B. Mortensen, E. Agerbo, N. Westergaard-Nielsen and T. Eriksson (2000). Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry, 177(6), 546–50. Qin, P., E. Agerbo and P.B. Mortensen (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric and familial factors: A national register-based study of all suicides in Denmark, 1981–1997. American Journal of Psychiatry, 160(4), 765–72. Rihmer, Z., N. Belsõ and K. Kiss (2002). Strategies for suicide prevention. Current Opinion in Psychiatry, 15(1), 83–87. Rutz, W. (2001). Preventing suicide and premature death by education and treatment. Journal of Affective Disorders, 62(1–2), 123–29. Schmidtke, A., U. Bille Brahe, D. De Leo, A. Kerkhof, T. Bjerke, P. Crepet et al. (1996). Attempted suicide in Europe: Rates and sociodemographic characteristics of suicide 150


attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 93(5), 327–38. Steen, M.D. and P. Mayer (2004). Modernization and the male-female suicide ration in India 1967–1997: Divergence or convergence? Suicide and Life-Threatening Behavior, 34(2), 147–58. Varnik, A., D. Wasserman, M. Dankowicz and G. Eklund (1998). Age specific suicide rates in the Slavic and Baltic regions of the former USSR during perestroika, in comparison with 22 European countries. Acta Psychiatrica Scandinavica, 394(Supplement), 20–25. Varnik, A., K. Kolves, J. Allik, E. Arensman, E. Aromaa, C. van Audenhove et al. (2008). Gender issues in suicide rates, trends and methods among youths aged 15–24 in 15 European countries. Journal of Affective Disorders, doi: 10.1016/ j.jad.2008.06.004. Zhang, X., H.S. Li, Q.H. Zhu, J. Zhou, S. Zhang, L. Zhang et al. (2008). Trends in suicide by poisoning in China 2000–2006: Age, gender, method, and geography. Biomedical and Enviromental Sciences, 21(3), 253–56.

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Developmental Issues in Risk Factor Assessment KIM

A. V

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ndividual biology, cognitions, emotions, social interactions and life stressors impact risk for suicidal behaviour (Maris et al., 1992). Individuals at different points in human development differ across these five domains suggesting that adopting a developmental perspective—and attending to developmental issues—may help to explain and prevent suicidal behaviour across the lifespan (Lester, 1991). An examination of US suicide rates across the lifespan (Gould et al., 2003) indicates the following characteristics: first, suicide is uncommon in children and early adolescents (i.e., up to age 14); second, the incidence of suicide increases at a high rate starting in later adolescence (i.e., ages 15–18) and continuing through early adulthood (i.e., early twenties); suicide rates remain at a relatively stable level from the early twenties through the fifties; suicide rates are markedly elevated among the elderly (i.e., 60 years and older; in the United States elevated rates among the elderly are accounted for by White men). The current chapter considers developmental issues in risk assessment; we focus our discussion on four broad ‘developmental stages’, each of which corresponds to one of the age-related patterns delineated earlier: childhood, adolescence and early adulthood, middle adulthood, late adulthood. We examine the ways in which developmental issues impact 152

Risk Factor Assessment

clinical decision-making in the process of assessing and managing suicide risk across the lifespan. Our discussion is organised around four aspects of suicide risk assessment where developmental issues may play a role: the ‘content’ of information collected during risk assessments, the ‘process’ of conducting risk assessments, the ‘context’ surrounding risk assessments and the ‘decisions’ generated regarding crisis management.

CONTENT OF RISK ASSESSMENTS In the following section, we examine how the content of risk assessments— the risk and protective factors assessed by clinicians—can be informed by a consideration of developmental issues. A useful distinction is between long-standing risk factors (i.e., distal factors that may predispose individuals to suicidal behaviour) and more proximal risk factors and warning signs (e.g., acutely stressful life events; Rudd et al., 2006). First, we consider distal risk factors that are common across the lifespan, including those that evidence differential predictive power at different ages. Next, we consider the same for proximal risk factors. Subsequently, we consider risk factors and warning signs that are common across the lifespan but manifest differently at different ages. Finally, we consider factors unique to particular developmental stages.

Risk Factors Common across the Lifespan Across the lifespan, the presence of a prior history of suicidal behaviour1 is one of the strongest distal risk factors for future suicidal behaviour (Brown et al., 2000; Joiner et al., 2005; Maser et al., 2002; Pfeffer et al., 1993). Suicidal ideation and suicide attempts in childhood elevate risk for suicide attempts in adolescence (Pfeffer et al., 1993). A previous suicide 1

The definition of suicidal behaviour varies across suicidologists. We consider suicidal behaviour to include suicidal ideation, suicide attempts and completed suicide. Non-suicidal self-injurious behaviour (NSSI; any acute deliberate destruction of body tissue without intent to die) is an independent risk factor for suicide; however, we reference this behaviour (NSSI) separately. 153

Kimberly A. Van Orden and Alec L. Miller

attempt is one of the strongest predictors of death by suicide in adolescents (Brent et al., 1999; Shaffer et al., 1996), adults (Harris and Barraclough, 1997; Mann et al., 1999) and the elderly (Beautrais, 2002; Conwell et al., 2002). The presence of ‘multiple past attempts’ is an especially pernicious predictor of future suicidal behaviour in both adolescents (Kotila and Lonnqvist, 1987) and adults (Rudd et al., 1996). Although the presence of past attempts is a potent predictor of suicidal behaviour, most individuals who die by suicide will do so on their first attempt (Brown et al., 2000; Simon, 2006). This finding is stronger for elders, as the lethality of suicide attempts is higher among the elderly: a greater proportion of suicide attempts result in death among elders compared to younger individuals (Crosby et al., 1999; McIntosh et al., 1994). ‘Nonsuicidal self-injury’ also confers risk for non-lethal and lethal attempts in adolescents and adults (Lipschitz et al., 1999; Stanley et al., 2001). ‘Family history of suicide’ has also been found to increase risk for death by suicide in youth (Agerbo et al., 2002) and adults (Runeson and Asberg, 2003). Other distal risk factors include ‘impulsivity and aggression’, which show a documented relationship with suicidal behaviour among children (Dervic et al., 2008), adolescents (Witte et al., 2008) and adults (BacaGarcia et al., 2005). ‘Problem-solving deficits’ are a feature among suicidal children (Cohen-Sandler et al., 1982; Orbach et al., 1987), adolescents (Klimes-Dougan et al., 1999) and adults (Wingate et al., 2005). Targeting these deficits has been found to be helpful in reducing suicidal ideation in younger adults (Wingate et al., 2005) and in increasing quality of life for older adults (Gellis et al., 2007). Several forms of stressful life events, considered proximal risk factors, have also been found to increase risk for suicide across the lifespan. ‘Bereavement’ is one such risk factor: maternal death in youth elevates risk (Agerbo et al., 2002) and loss of a spouse elevates risk for adults, though the effect is stronger for younger compared to older adults (i.e., at a time when such losses are less expected; Duberstein et al., 1998). ‘Incarceration’ in jail or prison also elevates risk for suicide in adolescents (Penn et al., 2003; Sanislow et al., 2003) and adults (Metzner and Hayes, 2006). Certain ‘physical illnesses’—acquired immune deficiency syndrome (AIDS), brain cancer and multiple sclerosis—elevate risk for suicide and this relationship is moderated by age, with older adults having greater risk (for a review, see Hughes and Kleespies, 2001). 154


Finally, limiting ‘access to lethal means’ is one of the few interventions that has been demonstrated to have a population-level impact on suicide rates (Kreitman and Platt, 1984; Ludwig and Cook, 2000), indicating that access to lethal means is a powerful risk factor for death by suicide. Data from the United States suggests that limiting access to handguns may be a particularly effective strategy for suicide prevention in the elderly: initiation of the ‘Brady Act’ was associated with lowered suicide rates only among individuals over age 55 (Ludwig and Cook, 2000). Limiting access to handguns may also be particularly indicated for the youth given the data that the availability of a handgun in the home is associated with a four-fold increase in adolescents’ risk for suicide (Brent et al., 1993).

Warning Signs Common across the Lifespan Indicators of (the likely presence of) current suicidal crises are termed warning signs. The American Association of Suicidology created an evidence-based list of suicide warning signs (Rudd et al., 2006), which can be remembered with the mnemonic IS PATH WARM?—‘I’ is for ideation (as in suicidal ideation); ‘S’ is for substance abuse; ‘P’ is for purposelessness; ‘A’ is for anxiety and agitation; ‘T’ is for ‘trapped’ (as in feeling trapped); ‘H’ is for hopelessness; ‘W’ is for withdrawal; ‘A’ is for anger; ‘R’ is for recklessness; and ‘M’ is for mood fluctuations. We focus our discussion of these warning signs on five of the most potent predictors of suicidal crises across the lifespan—suicidal intent, hopelessness, social isolation (listed as withdrawal), agitation and sleep disturbances (not included in the list). ‘Intent to die’ at the time of self-injury (i.e., the degree to which an individual wishes to die when engaging in self-injurious behaviours) is a warning sign for suicidal crises and has been shown to predict death by suicide in adults (Harriss et al., 2005). Current intent for suicide is a key component of suicide risk assessment protocols for adolescents (Reynolds, 1991) and adults (Jobes, 2006; Joiner et al., 1999; Linehan et al., 2000; Shea, 1999; Simon, 2006). Pfeffer (2003) indicates that assessing intent for suicide in children is difficult because children may not be able to verbalise intent or may deny intent even when significant risk for suicide exists. Children as young as three years have concepts of death and even though these conceptions may be inaccurate (e.g., to die is to go to sleep), self-destructive behaviour has been observed in children with intent to achieve their 155


idiosyncratic conceptualisations of death (Pfeffer, 2003). To address these complications, Pfeffer advises clinicians to gather collateral information from parents, teachers and others in a child’s life, and to consider both the outcome the child expects and the likely objective outcome when ascertaining the degree of dangerousness inherent in a child’s level of intent to engage in self-harm behaviours. The relation between ‘hopelessness’ and suicidality is one of the most consistent and robust findings in the suicidality literature. Hopelessness predicts future suicidal behaviour in children (Nock and Kazdin, 2002) and adolescents (Huth-Bocks et al., 2007). In adult samples, hopelessness has been shown to prospectively predict death by suicide one year later (Brown et al., 2000) and over a 13 years follow-up (Wen-Hung et al., 2004). Less research has been conducted on hopelessness in the elderly, but available data indicates that hopelessness predicts higher levels of suicidal ideation in elders (Heisel and Flett, 2005). In contrast, the ability to identify ‘reasons for living’ is a strong protective factor against suicidal behaviour in both youth (Osman et al., 1998) and adults (Strosahl et al., 1992). ‘Social isolation’ is a strong risk factor for suicide across the lifespan. Loneliness predicts suicidal ideation and behaviour among adolescents (Roberts et al., 1998), adults (Dieserud et al., 2001; Koivumaa-Honkanen et al., 2001) and the elderly (Waern et al., 2003). Social isolation was one of the most frequently cited problems among a sample of children and younger adolescents (ages 8–15) who died by suicide (Hawton et al., 1996). Among adults, rates of suicide are lower among those who are married (Stack, 2000) and those who have children (Hoyer and Lund, 1993; Qin and Nordentoft, 2005), suggesting a protective effect of social connections. Social isolation has also been found to be a pernicious risk factor for suicide among the elderly (Conwell and Heisel, 2006). Having a greater number of friends and family members to confide in is protective against suicide in the elderly (Duberstein et al., 2004; Turvey et al., 2002), while living alone is a risk factor for suicidal behaviour among the elderly (Conner et al., 1999; De Leo et al., 2001). ‘Severe anxiety/agitation’ is a strong predictor of imminent risk for suicide. In a study of inpatients ranging in age from 16 to 72 who died by suicide, 79 percent demonstrated severe anxiety/agitation within one week of death (Busch et al., 2003). In addition, agitation has been posited as a potential mechanism whereby antidepressant side effects may increase risk for suicidal behaviours in youth (Smith, forthcoming). 156


‘Sleep disturbances’ are a warning sign for suicidal ideation and behaviours across the lifespan. In a sample of depressed children and adolescents, the presence of insomnia was found to differentiate between those youth who presented with current (or past) suicidal ideation with a plan from non-suicidal youth (Barbe et al., 2005). Dysregulated sleep differentiated between a group of adolescents who died by suicide and healthy controls even when controlling for mood disorders (Goldstein et al., 2008). Finally, reduced sleep quality was found to predict suicide in a prospective study of older adults (Turvey et al., 2002).

Differen al Manifesta ons of Risk across the Lifespan In this section, we review several risk factors common to all ages that present differently across the lifespan. One such risk factor is the ‘experience of physical and sexual abuse’. Childhood physical and sexual abuse are risk factors for suicidal behaviour among young children (Rosenthal and Rosenthal, 1984), death by suicide in childhood and adolescence (Dervic et al., 2008; Wagner, 1997), suicide attempts in adolescence (Martin et al., 2004), a greater number of lifetime suicide attempts as an adult (Brown et al., 1999; Joiner et al., 2007). The experience of sexual violence as an adult increases risk for suicidal ideation and suicide attempts as an adult (Stepakoff, 1998). Relatedly, the experience of intimate partner violence as an adult has been found to predict suicidal ideation in a sample of African American females (Leiner et al., 2008), history of suicide attempts in female psychiatric inpatients (Sansone et al., 2007), and death by suicide in a psychological autopsy study in Sri Lanka (a country with a markedly elevated suicide rate; Samaraweera et al., 2008). Finally, although definitive data are needed, elder abuse has been posited as a risk factor for suicidal behaviour among the elderly (Conwell, 1995). The vast majority of individuals of all ages who die by suicide (i.e., approximately 95 percent) suffer from ‘mental disorders’ (Cavanagh et al., 2003; Gould et al., 2003), and it is quite possible that the remaining 5 percent suffer from subclinical variants of mental disorders. However, it is also the case that the vast majority of individuals of all ages who suffer from mental disorders do not die by committing suicide (Conner et al., 2001), indicating that the presence of psychopathology in itself does not confer a high degree of specificity with regards to an individual’s level of risk for suicide. 157


An increase in specificity can be achieved by focusing on mental disorders that confer the greatest risk for different age groups. Among children who die by committing suicide, mood disorders and disruptive behaviour disorders are the most common diagnoses (Dervic et al., 2008). Major depression, bipolar mixed state, substance abuse and conduct disorder are the forms of psychopathology most common among adolescents who die by suicide (Brent et al., 1993; Moskos et al., 2005; Shaffer et al., 1996). Among adults, the mental disorders that confer the greatest risk for suicide are major depressive disorder, bipolar disorder, anorexia nervosa, schizophrenia and borderline personality disorder (Joiner et al., 2009). Among older adults, depression stands out as the mental disorder with the strongest relation with suicide (Conwell et al., 2002). Although research on the relationship between dementia and suicide has been mixed (Conwell et al., 2002), it appears that when dementia is diagnosed during hospitalisation it is a strong predictor of suicide among elders (Erlangsen et al., 2008). Finally, personality traits that involve rigidity and low openness to experience have been found to predict suicide risk in the elderly (Duberstein, 2001). This personality style may increase elders’ risk for suicide by decreasing capabilities to adapt to aging in healthy ways and by making psychological distress more difficult for others to notice (Duberstein, 2001). Life stressors that involve ‘interpersonal conflict’ are also robust precipitants of suicidal behaviour across the lifespan. Adolescents report 70 percent of their suicidal behaviour is precipitated by interpersonal conflicts (Miller and Glinski, 2000). For children and adolescents, discord with parents is a predictor of lethal suicidal behaviour (Brent et al., 1994; Dervic et al., 2008), while family cohesion and higher levels of parental involvement function as protective factors against suicidal behaviour in children and adolescents (Flouri and Buchanan, 2002; Rubenstein et al., 1998). Peer conflict predicts suicidal behaviour in adolescents: loss of friends after disclosing sexual orientation is a strong predictor of nonlethal attempts among gay, lesbian and bisexual youth (Hershberger et al., 1997); severe suicidal ideation has been found among adolescents who are bullied and those who bully others (Kaltiala-Heino et al., 1999). Among adults, interpersonal conflict also manifests in romantic relationships: it is a well-replicated finding that suicide rates are elevated among divorced individuals in the United States (Stack, 2000). Finally, family conflict is also a predictor of suicidal behaviour in the elderly (Beautrais, 2002; Rubenowitz et al., 2001). 158


Life stressors that involve ‘perceptions of lowered social competence/ contribution’ are also robust precipitants of suicidal behaviour across the lifespan. Among adults, perceptions of burdensomeness on family members (and other significant others) have been found to predict suicidal ideation (de Catanzaro, 1995; Van Orden et al., 2008) and to differentiate between non-lethal and lethal suicide attempt status (Joiner et al., 2002). In youth, this risk factor may manifest as perceptions of ‘expendability in the family’: Sabbath (1969: 272–73) describes the ‘expendable child’ construct as a ‘parental wish, conscious or unconscious, spoken or unspoken, that the child interprets as [the parents’] desire to be rid of him, for him to die’. Research has borne out this relationship between feelings of expendability and suicidal behaviour in children. In a sample of preschoolers, suicidal children were significantly more likely to be the product of ‘unwanted’ pregnancies (Rosenthal and Rosenthal, 1984). In addition, Woznica and Shapiro (1990) demonstrated that suicidal adolescents scored higher on a measure of perceived expendability than non-suicidal adolescent outpatients. Lowered competence may also manifest in adolescence as academic difficulties, a life stressor that has been shown to predict suicidal behaviour in this age group (Mazza and Eggert, 2001). Finally, functional decline—related to such indices as retirement and physical illness—places elders at increased risk for suicide, but only in the presence of other risk factors (e.g., depression) as all elders experience functional decline, but most do not die by committing suicide (Conwell and Heisel, 2006).

Factors Unique to Developmental Stages The phenomenon of ‘suicide contagion’ involves the interpersonal transmission of elevated risk for suicidal behaviour through mechanisms such as modeling. A related concept is suicide clustering—deaths by suicide occurring in a greater concentration than would be expected by random chance. The preponderance of evidence in support of contagion/modeling effects (including media depictions) has been for youth (Insel and Gould, 2008). In addition, evidence suggests that these effects may be strongest among younger adolescents and lose their potency in young adulthood (Gould et al., 1994). Adolescents with exposure to friends, relatives, classmates or other significant others, who attempt or commit suicide are at elevated risk for engaging in suicidal behaviour. Therefore, it is critically 159


important for family members and school personnel to assess and monitor a teen whose peer from school has committed suicide or when a teen icon (e.g., Kurt Cobain) has killed himself or herself. An additional factor unique to adolescents and children is the possible association between ‘antidepressant prescription’ and increased risk for suicidal behaviour. The ‘black box’ advisory issued by the Food and Drug Administration (FDA) in October 2004 on the potential danger of treating children and adolescents with antidepressants (US Food and Drug Administration Public Health Advisory, 2004) was primarily based on findings from a meta-analysis of 23 randomised trials that found higher rates of suicidality (no lethal attempts occurred) among youth prescribed with selective serotonin reuptake inhibitors (SSRIs; Hammad et al., 2006). Subsequent investigations have raised doubts about the FDA’s conclusion that SSRIs cause suicidality in youth (Kaizar et al., 2006) and some suggest that the risk-to-benefit profile indicates that benefits outweigh risks in the treatment of youth with SSRIs (Bridge et al., 2007). Regarding potential mechanisms for increased risk for suicidality in youth prescribed with SSRIs, Smith (2009) found that increased risk is partially attributable to medication half-life, with shorter half-life medications conveying greater risk, possibly due to greater risk for side effects such as akathisia. Concerning effects of the FDA regulations, data indicate that SSRI prescription rates for children and adolescents decreased subsequent to the advisory, with associated increases in suicide rates (Bridge et al., 2008; Gibbons et al., 2007). These data indicate a need for ongoing assessment of suicide risk in children and adolescents who are prescribed SSRIs, including monitoring of side effects and clear communication with youth and parents that they must make contact with the physician at the first signs of any troublesome changes in mood or behaviour (Brent, 2004).

PROCESS AND CONTEXT OF RISK ASSESSMENTS The majority of elders who commits suicide present for services in primary care settings: these elders do not, in most cases, present to clinics for mental health services (Luoma et al., 2002). In fact, a recent review of studies reported that 77 percent of older adults (across 40 studies) were seen by a primary care physician in the year before their deaths by committing 160


suicide (100 percent of the women, 78 percent of the men; Luoma et al., 2002). These data indicate that risk assessment efforts focused solely in mental health clinics are unlikely to reach most elders, whereas efforts targeting both mental health clinics and primary clinics have the potential to reach the majority of elders at high risk for suicide. Thus, a consideration of the context of risk assessment for elders must include primary care as well as mental health settings. The process of risk assessment in primary care differs from the process used in mental health clinics because of the greater heterogeneity in risk levels. To address this issue, a hierarchical stepped care model of assessment and intervention can be used, with more in-depth assessment and intervention for elders who present with elevated risk on an initial screening. Prevention of Suicide in Primary-care Elderly: Collaborative Trial (PROSPECT) is an evidence-based suicide prevention programme for the elderly, based in primary care settings, that utilises a stepped care model and has demonstrated efficacy for older adults in the reduction of suicidal ideation (Bruce et al., 2004) and in the treatment of residual symptoms of depression (Alexopoulos et al., 2005). Screening for suicide risk outside of mental health clinics is also relevant to suicide prevention in children and adolescents. Estimates suggest that many (if not most) of the adolescents who commit suicide might not have received mental health treatment (Blumenthal, 1990). Gatekeeper training as well as screening for risk factors represent potentially effective methods of suicide prevention (Shaffer and Pfeffer, 2001). Gatekeeper training involves educating laypersons in direct contact with youth (e.g., teachers, parents, clergy and peers) about warning signs for suicide (e.g., IS PATH WARM acronym) so that the ‘gatekeepers’ can refer these youth to mental health professionals. Research has demonstrated that schoolwide screening for suicide risk can be efficacious in the prevention of adolescent suicide (Reynolds, 1991; Shaffer and Craft, 1999) but school officials are often hesitant to do so because they believe that asking about suicide will encourage youth to engage in suicidal behaviour (Miller et al., 1999). A randomised controlled trial of the effect of youth screening for suicide on suicidal behaviour did not find iatrogenic effects of screening (Gould et al., 2005), and the study authors concluded that screening for suicide in youth is a safe component of prevention programmes. Several suicide-risk screening protocols for adolescents have been developed and tested, including the Columbia University Teen Screen Program (Shaffer et al., 2004). 161


The process of risk assessment with children and adolescents differs from the process used with adults because of a stronger emphasis on the role of collateral information from family members. While gathering collateral information from significant others can be valuable when working with adults—an important component of some adult risk assessment protocols (e.g., Shea, 1999)—the process of including family members in risk assessment is especially important when working with children and adolescents because data indicate that youth often minimise their degree of intent for recent suicidal behaviour (Kingsbury, 1993), or often have difficulties expressing suicidal ideas and intent (Pfeffer, 2003), including having differential responses to interviewer-administered versus self-report questions regarding suicide (Velting et al., 1998), and may misjudge the lethality of suicidal methods (Pfeffer, 2003). Ability to consent to treatment and issues of confidentiality surrounding sharing information with parents are additional issues that concern risk assessment with youth. Studies suggest that both suicidal adolescents and elders may demonstrate less willingness to disclose suicidal behaviours compared to adults. Regarding adolescents, Gould and colleagues (2004) reported data indicating that many youth believe they should be able to handle problems on their own and should keep suicidal behaviours a secret—and thus believe they should not seek help for mental health problems. Regarding elders, recall the research described earlier demonstrating that elder adults with personality styles characterised by rigidity and low openness to experience may be less likely to disclose suicidal ideation (Duberstein, 2001). Thus, clinicians working with elders and youth are advised to use interviewing techniques designed to increase willingness to disclose and to obtain collateral information on other relevant risk factors. Clinicians working with adolescents may wish to consider the Evaluation of Suicide Risk Among Adolescents and Imminent Danger Assessment (Rotheram, 1987), a clinician-administered interview that addresses risk factors unique to, or especially relevant for, adolescents, including exposure to suicidal behaviour in family and friends and conduct disorder symptomatology. Clinicians working with elder adults may wish to consider the Chronological Assessment of Suicide Events (Shea, 1999)—a risk assessment framework that emphasizes the use of rapport-building techniques designed to enhance individuals’ willingness to disclose information about suicidal behaviours—or the Collaborative Assessment and Management of Suicidality (Jobes, 2006), a risk assessment framework 162


that emphasises collaboration as well as the importance and value of the therapeutic alliance.

PULLING IT TOGETHER: CLINICAL DECISION MAKING We now turn to the fourth aspect of risk assessment that should be informed by developmental considerations, crisis management—clinical decision-making as how to best manage risk and prevent a suicide attempt. Involvement of family members to promote a safe environment is essential when working with suicidal children and adolescents. For example, clinicians should meet with parents/guardians to ensure that firearms, lethal medications or any means for suicide are removed from the home or, at the very least, inaccessible to the youth (Shaffer and Pfeffer, 2001). Research suggests that an explicit discussion of this precaution with parents is necessary to ensure that it is implemented: parents/guardians do not tend to take these precautions unless explicitly instructed to do so (McManus et al., 1997). Removal of firearms from the home is an action relevant across the lifespan, but may be particularly indicated for youth, given that the presence of a firearm is a strong predictor of suicide in adolescents (Brent et al., 1999) and elders, given that most elders who die by suicide use firearms, and suicidal behaviour in the elderly involves a greater degree of planning and the use of more lethal means (Conwell and Heisel, 2006). Our discussion of developmental considerations relevant to suicide risk assessment has emphasised the commonalities in risk assessment across the lifespan while highlighting unique features when appropriate. A final feature of suicide risk common across the lifespan is the fact that the vast majority of individuals exhibiting the risk factors and warning signs presented in this chapter will (fortunately) not engage in suicidal behaviour. Research has yet to definitively elucidate which factors are necessary and sufficient to result in suicidal behaviour. It is our hope that the material presented in this chapter will serve two inter-related functions: first, to assist clinicians in skillfully assessing and managing suicide risk for individuals of all ages; and second, to assist researchers in identifying commonalities in suicidal behaviour that may provide clues as to those factors most likely to cause suicidal behaviour. 163


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ReporƟng Suicide: Impact on Suicidal Behaviour FÙ« K®ó®

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uicide, widely considered as the most tragic way of ending one’s life, poses a major challenge to civil society. Worldwide, there is an estimated 850,000 deaths due to suicide and well beyond 15 million suicide attempts every year. Suicidal behaviour is now acknowledged as a major global public health problem. It hits particularly the young, and currently worldwide deaths from suicide are among the top three causes of death among people aged 15–35 years, for both males and females. Social scientists have discovered that the majority of people who consider suicide are ambivalent. They are not sure that they want to die. One of the key factors leading a vulnerable individual to suicide could be publicity about suicides. Although suicide accounts for only 1 percent of all deaths, yet, when these occur they frequently attract disproportionate media interest. It has long been thought that widespread coverage of a suicide by the media is capable of triggering copycat suicides in the mass public. According to the social learning theory, the greater the amount of coverage of suicide in the media, the greater is the increase in suicide rate. Research has established that when media, that is newspapers, film and television, report suicidal deaths, additional suicides may result by virtue of contagion or copycat effects (Etzendorfer et al., 1992; Gould, 2001; Stack, 2000a, 2000b, 2003). 173

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It also shows that an increased number of suicides result from media accounts of suicide which romanticise or dramatise the description of suicidal deaths (Cheng, Hawton, Lee and Chen, 2007). The work of David Phillips in the 1970s initiated the systematic scientific investigations on copycat suicide. The suicide of the well-known movie star Marilyn Monroe resulted in the largest possible copycat effects. There were an additional 303 suicides, an increase of 12 percent, during the month of her suicide in August 1962. However, in general, highly publicised stories increase the national suicide rate by only 2.51 percent in the month of media coverage (Stack, 2000b).

SUICIDE CONTAGION In the present era, when suicides involving the young have assumed another dimension of political and global terror, identification and efficient interventions for suicidal behaviour pose a more daunting challenge before societies across the nations. The role of media too has come under closer scrutiny as it was often seen as glorifying or legitimatising suicides for a ‘cause’. There is a paucity of media research on impact of media on suicide in India. However, in Western academic sphere, the existence of ‘suicide contagion’ is ably recognised by all those working in the field of mental health, social sciences and mass media. Suicide contagion refers to a process by which exposure to the suicide or suicidal behaviour of one or more persons influences others to commit or attempt suicide (Davidson and Gould, 1989). It implies the exposure to suicide or suicidal behaviours within one’s family, one’s peer group, or through media reports of suicide and can result in an increase in suicide and suicidal behaviours. Media reports may encourage vulnerable individuals, who may have had some predispositions towards suicide ideation but normally would not have carried out a suicidal attempt, to act on their suicidal impulses. Considerable evidence has been accumulated for imitation effects from suicide reported via newspaper and television (Etzendorfer et al., 1992; Stack, 2000a). Imitation effect tends to be particularly strong when newspaper stories about suicides are featured prominently. Imitation is more likely among audience members who can identify with the suicide victim in some way; for example by age, gender or nationality. 174

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Young people and elderly people appear to be more vulnerable than those in their middle years to media-related suicide contagion. Stack (2000b) has affirmed that such imitation effects are particularly likely to affect young people. Increased numbers of television news reports of suicides have been found associated with a significant increase in suicides for those under the age of 25 (Romer et al., 2006). Greater numbers of newspaper reports on suicide were associated with suicide deaths across age groups. A substantial increase in deaths by suicide has been observed in Hong Kong, following the death of a well-known Hong Kong pop singer who jumped from a high building (Yip et al., 2006). This again underscored the importance of influence of extensive and dramatic media coverage of suicides. Media studies conducted mostly in the United States, the United Kingdom, etc., have documented that the risk for suicide contagion as a result of media reporting can be minimised by factual and concise media reports of suicide (Hawton and Coulter, 2003). These research findings have shown that reports of suicide should not be repetitive, as prolonged exposure can increase the likelihood of suicide contagion. However, suicide risk can be minimised by having family members, friends, peers and colleagues of the victim evaluated by a mental health professional. Alarmed by a high rate of suicide in its ranks, the United States’ army has prepared a unique prevention tool—an interactive video ‘Beyond the Front’ (2008) which is set to be mandatory viewing army-wide, in which soldiers play the role of an anguished infantryman and make virtual choices that lead the character to get help or, in the worst case, shoot himself in the head. In an article in Washington Post, Scott (2008) analysed a video ‘Beyond the Front’ which has a specialist Kyle Norton narrating experience of a 19-year-old after a bomb-clearing mission in Iraq. ‘Beyond the Front’ leads the viewer through a detailed drama in which Norton is hit by relationship troubles, financial problems and scrapes with the law—what US Army research shows are major events that precipitate suicide. Norton is blindsided by an e-mail from his fiancée, who has become pregnant by another man. He is devastated further when one of his best friends is killed in an ambush. Questions pop onto the screen at key moments, prompting the viewer to decide whether to get help by opening up with buddies, the sergeant, clergy or the counsellor. Depending on the choices, Norton edges towards recovery or sinks deeper into suicidal thoughts. The goal of the video preparation is to immerse the viewer into Norton’s life in a 175

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way that makes preventive lessons stick, claimed army officials and the video’s producers. The video is one of several initiatives launched by the US Army to try to stem the suicide rate among active-duty soldiers. That rate increased from 12.4 per 100,000 in 2003, when the Iraq war started, to 18.1 per 100,000. In all of 2007, 115 soldiers committed suicide. Suicide attempts by soldiers have also increased since 2003. Berman (as cited by Scott, 2008), executive director of the American Association of Suicidology, who viewed part of the video, said that ‘it’s obviously done in a much more realistic fashion’ than previous interactive prevention efforts. Nevertheless, he warned that it is risky to widely distribute such a programme without scientific evaluation to determine its impact on a suicidal person. ‘Some media presentations about suicide can increase the likelihood of suicidal behaviour, so there is a potential danger,’ he said. According to this school, the media constantly provides opportunity for transmission of suicide contagion. This means of influence is potentially more far reaching than direct person-to-person propagation. Suicide contagion should be viewed within the larger context of behavioural contagion, which has been described as the situation in which the same behaviour spreads quickly and spontaneously through a group. Behavioural contagion has also been conjectured to influence the transmission of conduct disorder, drug abuse and teenage pregnancy. According to behavioural contagion theory, an individual has a preexisting motivation to perform a particular behaviour, which is offset by an avoidance gradient, so as that an approach-avoidance conflict exists. As media and violence studies have shown, the coverage of suicides in the media may serve to reduce the avoidance gradient—the observer’s internal restraints against performing the behaviour. Evidence clearly establishes that the media may affect methodspecific suicide rates. Ashton and Donnan (1981) revealed that in Britain, an excess of about 60 suicides by burning occurred in the 12 months after the widely publicised political suicide by burning of a woman in Geneva. Bhattacharya (2003) has reported that an ‘alarming escalation’ in people’s use of burning charcoal to commit suicide followed after detailed media accounts of a woman who took her own life by starting a charcoal fire in her cramped apartment and suffocating in the carbon monoxide gas produced. Increase in suicide rates, following the reporting of real life suicide, has been described both in Britain and the United States (Barraclough et al., 176

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1977; Phillips and Cartensen, 1986). Schmidtke and Hafner (1988) have produced more robust evidence by examining suicide rates after two separate broadcasts of the fictional portrayal of a young man’s suicide on a railway line. An imitation effect was observed leading to methods specific and absolute increases in the number of suicides. The imitation effects were greatest in those of the same age and sex as the fictional character, and the numbers of suicides closely corresponded with the audience figures for the two broadcasts. Effects were observed for up to 70 days after the broadcast; an estimated overall excess of 60 suicides occurred (Schmidtke and Hafner, 1988). The effect of a television series, dramatising the work of the Samaritans, on suicide rates has also been studied. Although the series led to a rise in new client referrals, no effect was seen on the number of suicides (Holding, 1975). It is argued that only the choice of method is influenced by publicity but suicides occur only among those who are already suicidal. A century ago Durkheim argued that although media attention may precipitate clusters of suicide, these occur only among those who would commit suicide sooner or later anyway, the publicity merely acting as a precipitant to an inevitable event. Schmidtke and Hafner (1988) observed greatest increases among those most similar to the ‘model’ portrayed, but Ashton and Donnan (1981) did not. It is difficult to disentangle these conflicting hypotheses as suicide is a rare event and the particular methods examined constitute only a small fraction of all suicides. There is an ample amount of evidence in Western academic circles to show that the magnitude of the increase in suicidal behaviour after newspaper coverage is related to the amount of publicity given to the story and the prominence of the placement of the story in the newspaper. Imitation appears more likely when the suicide is covered on the front page, in large headlines, and is heavily publicised, suggesting a ‘dose–response’ relationship. Phillips, Lesyna and Paight (1992) have argued that repetition is a key factor for news stories’ imitative potential. In contrast to the ‘structural’ elements of the story, there is less information on what characteristics of the ‘models or content’ of the story have imitative effects. One characteristic of the model that has been studied is the ‘celebrity status’ of the suicide victim (Cheng, Hawton, Chen et al., 2007). Wasserman (1984) found that a significant rise in the national suicide rate occurred only after celebrity suicides were covered on the front page of the New York Times. Stack (1987) replicated this study, but 177

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upon correcting substantial measurement error, a later analysis found that non-celebrity stories also had a significant impact, although not as great as publicised celebrity stories. Gundlach and Stack (1990) reported that non-celebrity stories yielded imitative suicides if they received enough publicity. In another study, Weimann and Fishman (1995) conducted a content analysis of more than 430 suicide cases published in the two leading daily newspapers in Israel in which suicide report was analysed for the form of its coverage—including space allocation, placement in the paper and inclusion of picture—and for the content of its coverage, including demographic characteristics of the victim, mode of suicide, attribution of responsibility and general attitude towards the act or person. They found that the space devoted to suicide stories and the prominence of the stories increased steadily during the 1980s and 1990s. Newspaper reports focused on the more violent modes of suicide. An economic/financial motive was attributed mainly to males, while romantic motives or problems with a partner were attributed mainly to females. Most of the reports were neutral, but among those that did express an attitude, approximately 18 percent were positive and 8 percent were negative. Positive coverage was more likely when external causes were presented and when suicides were committed during military service (Weimann and Fishman, 1995).

CULTIVATION THEORY In the context of media and suicide, Gerbner and Gross (1976) had proposed a ‘cultivation theory’ which argued that humans cultivate understandings of the world around them through indicators found within television programming. Concerning the relationship between media portrayal of suicide and suicidal behaviour, the evidence has established a causal association between non-fictional media reporting of suicide and suicidal behaviour, and between fictional media portrayal and actual suicide. These studies have been based on social learning theory and emphasised on the effects of television viewing on the attitudes rather than the behaviour of viewers. According to this theory, most human behaviour is learned observationally through modelling. Imitative learning is influenced by a number of factors, including the characteristics of the model and the consequences or rewards associated with the observed 178

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behaviour. Consequences or rewards, such as public attention, may lower behaviour restraints and lead to the disinhibition of otherwise ‘frowned upon’ behaviour (Gerbner and Gross, 1976). Heavy watching of television is seen as ‘cultivating’ attitudes which are more consistent with the world of television programmes than with the everyday world. Watching television may tend to induce a general mindset about violence in the world, quite apart from any effects it might have in inducing violent behaviour. Cultivation theorists (Gerbner and Gross, 1976) distinguish between ‘first order’ effects (i.e., general beliefs about the everyday world) and ‘second order’ effects (i.e., specific attitudes, such as to law and order or to personal safety). Gerbner and Gross (1976) argue that the mass media cultivate attitudes and values which are already present in a culture: the media maintain and propagate these values amongst members of a culture, thus binding it together. They have argued that television tends to cultivate middle-of-the-road political perspectives. They considered that ‘television is a cultural arm of the established industrial order and as such serves primarily to maintain, stabilize and reinforce rather than to alter, threaten or weaken conventional beliefs and behaviours’ (Gerbner and Gross, 1976). Boyd-Barrett and Braham (1987) observed that such a function is conservative, but heavy viewers tend to regard themselves as ‘moderate’. Youth exposed to media, such as television programmes, posters that glorify previous martyrs and Internet websites, are being cultivated into becoming martyrs themselves. Gerbner and Gross (1976: 173) believe that television’s ‘system of messages, with its storytelling functions, makes people perceive as real and normal and right that fits the established social order.’ Moreover, television offers frames of reference and the means to make sense of the world around us. As youth are exposed to messages about their lives, the programmes they watch define the range of possibilities for their lives. The BBC Producers’ Guideline (BBC, 2003) in its chapter on Values, Standards and Principles, has observed, ‘Suicide is a legitimate subject for news reporting but the factual reporting of suicides may encourage others. Reports should avoid glamorizing the story, providing simplistic explanations, or imposing on the grief of those affected. They should also avoid graphic or technical details of a suicide method particularly when the method is unusual. Sensitive use of language is also important.’ 179

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In her landmark film The Making of a Martyr, Goldstein (2006) makes it clear that youth who are persuaded into suicide bombing attacks have limited resources, both symbolic and material, available to them. When traumatised by acts of violence, they look for frameworks to make sense of the chaotic world around them. Explanations such as the demonisation of the enemy or the hope of paradise in life after death become frames that assign meanings to events and to the corresponding actions that a youngster could take. In the case of media images, Goldstein (2006) documents a variety of images that are used to instil a particular view of reality in the youth of ravaged areas. Television, posters and graffiti, all glorify the acts and agents of martyrdom, reinforcing a system of bodily sacrifice that adversely affects the children. These symbolic resources do not provide other avenues for children to broaden their horizons and tend to limit their vision. Goldstein (2006) believes that censorship practices would be one means by which these messages could be combated. In addition to her call, alternative message strategies that promote different possibilities for youth in the Middle East could offer youngsters other options than being enticed into martyrdom. In other words, they need to cultivate other ideas about the importance of their lives. If presented with a variety of images and values, these youngsters may be less likely to believe that martyrdom is an acceptable end to their lives.

IMPACT OF MEDIA ON COGNITIVE AND AROUSAL PROCESSES In psychological terms, it is pertinent to understand the effect of media portrayal of suicide on cognitions, attitude and emotions of an individual. Factors that mediate between viewing media coverage of suicide and suicidal behaviour have also been subject matter of intense debate and discussion among the social scientists. As it is understood, cognitive and arousal processes are the two major types of mediating process that affect the acquisition, maintenance and emission of suicidal behaviour. At cognitive level, reaction to exposure depends on the observer’s interpretations of the witnessed suicidal behaviour and the thought activated by viewing 180

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suicide. In viewing suicidal coverage by media, people form a representation or cognitive structure comprised general social knowledge about the positive value that can be attached to viewing suicide and how it can be committed. The depth and exact content of such a cognitive structure also take in account factors such as attention, comprehension, attitude, moral evaluation and attributions.

Atten on and Comprehension It has been observed that while viewing media, observers form some mental representation. What is gleaned from the media depends on attentional process and processes of comprehension. For example, the salience and complexity of the programme will determine the degree of his or her attention, which will in turn affect the rate and degree of comprehension. In addition, media also affects observer acceptability of the event (i.e., attitude), attribution and moral evaluations. The nature of the mental representation that a person forms in viewing media is partially dependent on attentional process. These processes determine what is selectively observed and extracted from the observed material. Material that is not salient or is too complex is not likely to be remembered. Huston and Wright (1983) have found that certain perceptually salient formal features (e.g., action, high pace and sound effects), which are characteristics of much television fare, attract and hold the attention of observers/viewers. More importantly, these studies have shown that attention is elicited and maintained more by formal features (e.g., pacing, action) than by the content of the films. Huston and Wright (1983) suggested that salient formal characteristics along with the content of programmes would hold a viewer’s attention more, thereby facilitating comprehension and the formation of an enduring mental representation. Research studies concerning comprehension have shown that it is important for understanding the impact of media because of two reasons. First, a person’s comprehension of an event is related to his/her attitude towards the event or character. Second, comprehension is also related to the viewer’s tendency to identify with the characters. Thus, attitude and identification are the two important factors that determine the impact of media on individual’s behaviour. 181

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Attribu ons and Moral Evalua ons Some authors have also suggested that attributions and moral evaluations contribute to the extent to which an unwanted behaviour will be inhibited (Berkowitz, 1984; Ferguson and Rule, 1983; Rule and Ferguson, 1984). Attributions pertain to the perceived causes of, or reasons for, a particular behaviour. For example, an instance of humiliation may have been perceived as having been produced intentionally but for justifiable reasons, or intentionally but for unjustifiable reasons. When an individual perceives that he has been intentionally subjected to humiliation for an unjustified cause, it affects self-esteem and develops a feeling of worthlessness which may lead a person to extreme behaviour. Similarly, moral evaluations pertain to the perceived praiseworthiness or blameworthiness of an action. Thus, an unjustifiably intended action would be seen as more blameworthy than justifiably intended action. As a result there would be less inhibition of unwanted behaviour against expression of justified behaviour than unjustified behaviour.

Attitude The most common source of information about suicide tends to be media. In a study conducted by Beautrais, Horwood and Fergusson (2004), it was observed that young people tend to hold mixed attitudes towards suicide, having both liberal and conservative views. Those with lifetime histories of suicidal ideation or suicide attempt and those with family histories of suicide or suicide attempt tended to hold more liberal attitudes. Attitudes towards suicide were unrelated to gender and to knowledge about suicide. Moreover, the younger generation overestimated the prevalence of youth suicide and the fraction of suicides accounted for by youth deaths, and held both conservative and liberal attitudes towards suicide (Beautrais et al., 2004). Their primary source of information about suicide is the media. These findings raise concerns about the potential for media coverage of youth suicide issues to normalise suicide as a common, and thereby acceptable, response among young people, and suggest the need

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for careful dissemination of accurate information about suicide by knowledgeable, respectable and reputable sources.

Emo onal Arousal Media influences a viewers’ arousal state. There has been considerable interest in the role of arousal as a mediator of the link between exposure to media and a particular behaviour. Arousal refers to an energiser of behaviour. It has been found that media exposure not only elevates excitation, it also maintains a particular level of pre-exposure arousal. Exposure to media violence is assumed to affect suicidal tendency through emotional arousal. Observing suicide may arouse feelings associated with suicidal thoughts, but at the same time it may reduce emotional reactions to the negative consequences of suicide for the self and the people affected by it. Thus, people may get immune to suicide viewing and their tendency to commit suicide may increase. The major factor that determines the impact of media coverage of suicide is emotional habituation.

Emo onal Habitua on/Desensi sa on People who initially experience negative emotional responses while observing suicidal behaviour may respond less emotionally after repeated exposure to its viewing. The reduced negative effect associated with increased exposure to suicidal behaviour may increase the likelihood of committing suicide or toying with its idea. Moreover, such emotional habituation (‘adaptation’, ‘desensitisation’) may reduce concern for others’ suicidal attempts. In two studies of desensitisation conducted by Björkqvist (1985) and Linz, Donnerstein and Penrod (1984), it was found that repeated exposure decreases emotional responsiveness. Various other researches using both correlational and experimental designs show that repeated exposure leads to decline in physiological arousal and also decreases the intensity of self-reported emotion. While there is growing consensus that some types of media reporting and portrayal of suicide increases suicide risk among others, ongoing

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and future research projects are focusing on the need for enhancing safe reporting and portrayal of suicide by the media.

HOW CAN MEDIA BE MORE RESPONSIBLE IN REPORTING SUICIDES? In the context of the substantial evidence for suicide contagion, some societies tried to work out a ‘prevention strategy’ that sought to educate reporters, editors and film and television producers about contagion in order to yield media stories that minimise harm. It also took in account the media’s positive role in educating the public about risks for suicide. In the United States, the Centres for Disease Control published a set of recommendations on reporting of suicide that emerged from a national workshop. The American Association of Suicidology adopted these as their official guidelines for journalists in an attempt to minimise contagious effects from news reports of suicides. Guidelines for media reporting now exist in several countries, including Australia, Austria, Canada, Germany, Japan, New Zealand and Switzerland. Additional guidelines have been developed by the World Health Organization and the American Foundation for Suicide Prevention (2001). Although the media guidelines that were developed have so far not put to any empirical validation, adopting these guidelines certainly seems to be effective in avoiding suicide contagion behaviour. Prior to reporting, media should properly analyse whether any act of suicide is newsworthy or not. Media must avoid misrepresenting suicide as a mysterious act by an otherwise ‘healthy’ or ‘high achieving’ person. It must necessarily be indicated that suicide is most often a fatal complication of different types of mental illness, many of which are treatable. It would be of prime importance to highlight that suicide is not a reasonable way of solving problems. Media must always keep in mind that suicide is not portrayed in a heroic or romantic fashion. Proper care is required to be exercised with publishing pictures of the victim and/or grieving relatives and friends to avoid fostering over identification with the victim and inadvertently glorifying the death. The coverage must be minimised to only necessary content and detailed description of adopted methods must positively be avoided. Media is required to limit the prominence, length and number of stories 184

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about a particular suicide and front-page coverage and sensational and inappropriate headlines must be avoided. Furthermore, local treatment resource information must also be provided. Closer home, in Sri Lanka and Hong Kong, the Hong Kong Journalists Association (2002) have established similar guideline on suicide reporting. According to their manual, professional journalists should prevent reporting suicide in a way that could have potential negative effect on the vulnerable group of suicide or youth readers. Media professionals can play a role in publicising the warning signs and to convey the message of helpseeking. Some of their suggestions include: (a) report news with public interest; (b) minimise harm and (c) appropriate reporting. In specific terms of placement of news and headline, they advise against publishing the suicide news on the front page unless the reporting involves public interest; avoid using large font headline; avoid mentioning the suicide method or suspected cause such as ‘jumping’ or ‘charcoal burning’ in the headline. In contents such as wordings, they suggest that phrases like ‘successful suicide’, ‘unsuccessful suicide’ or ‘suicide-prone person’ should be avoided altogether. As per World Health Organization (WHO, 2000) guidelines, the media worldwide should observe certain amount of restrain and address specific issues that need to be addressed when reporting on suicide. For instance, statistics about suicide should be interpreted carefully and correctly and only authentic and reliable sources should be used. The WHO (2000) wants that media practitioners should avoid making impromptu comments in spite of time pressures and generalisations based on small figures. Expressions such as ‘suicide epidemic’ or ‘the place with the highest suicide rate in the world’ should be avoided under most circumstances. It also calls for reporting on suicidal behaviour as a responsible social behaviour where degradation should be resisted. In what it describes as ‘Do’s and Don’ts, the WHO (2000) urges media to work closely with health authorities in presenting the facts. Media has been suggested to (a) refer to suicide as a completed suicide, not a successful one; (b) highlight alternatives to suicide; (c) publicise risk indicators and warning signs and (d) provide information on help lines and community resources. In addition, WHO (2000) has further suggested media to stick to the following: 1. Do not publish photographs or suicide notes. 2. Do not report specific details of the method used. 185

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3. 4. 5. 6.

Do not give simplistic reasons. Do not glorify or sensationalise suicide. Do not use religious or cultural stereotypes. Do not apportion blame.

The following points (WHO, 2000) should be borne in mind while ‘reporting on a specific suicide’: 1. The coverage of suicides should be minimised to the extent possible. Sensational coverage of suicides should be conscientiously avoided, particularly when a celebrity is involved. Every effort should be made to avoid overstatement. Any mental health problem the celebrity may have had should also be acknowledged. Photographs of the deceased, of the method used and of the scene of the suicide are to be avoided. Front-page headlines are never the ideal location for suicide reports. Research has shown that media coverage of suicide has a greater impact on the method of suicide adopted than the frequency of suicides. Added publicity with certain locations (e.g., bridges, cliffs, tall buildings, railways) that are traditionally associated with suicide increases the risk that more people will use them. Therefore, detailed descriptions of the method used and how the method was procured should be avoided. 2. Suicide is never the result of a single factor or event. It is usually caused by a complex interaction of many factors such as mental and physical illness, substance abuse, family disturbances, interpersonal conflicts and life stressors. Hence, suicide should not be reported as unexplainable mystery or in a simplistic way. Acknowledging that a variety of factors contributes to suicide would be helpful. Furthermore, media coverage reports should take account of the impact of individual’s suicide on families and other survivors in terms of both stigma and psychological suffering. Suicide should not be depicted as a method of coping with personal problems such as bankruptcy, failure to pass an examination or sexual abuse. 3. The emphasis of media report should be on mourning the person’s death. Glorifying suicide victims as martyrs and objects of public adulation may suggest to susceptible persons that their society honours suicidal behaviour. Describing the physical consequences of non-fatal suicide attempts (brain damage, paralysis, probability of being disable/handicapped, etc.) can act as a deterrent. 186

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PROACTIVE ROLE OF MEDIA IN PREVENTION OF SUICIDES Media can play a proactive role in helping to prevent suicide by publishing some necessary information along with news on suicide. Media should list available mental health services and help lines with their up-todate telephone numbers and addresses so that a person can find it easy to approach support services in times of problem. Media should also publicise the warning signs of suicidal behaviour so that the people close to the suicidal person can identify and provide help to him. Media must convey the message that depression, which is often associated with suicidal behaviour, is a treatable condition. A message of sympathy must be offered to the survivors in their hour of grief and they should be provided the telephone numbers of support groups, if available. This increases the likelihood of intervention by mental health professionals, friends and family in suicidal crises. Concentrating on all the discussed issues media can also play an active role in the prevention of suicides.

REFERENCES American Foundation for Suicide Prevention. (2001). Reporting on suicide: Recommendations for the media. American Association of Suicidology and Annenberg Public Policy Centre. Ashton, J.R. and S. Donnan (1981). Suicide by burning as an epidemic phenomenon: An analysis of 82 deaths and inquests in England and Wales in 1978–79. Psychological Medicine, 11(4), 735–39. Barraclough, B., D. Shepherd and C. Jennings (1977). Do newspaper reports of coroners inquests incite people to commit suicide? British Journal of Psychiatry, 131(5), 528–32. BBC (2003). Values, standards and principles: BBC Producers’ Guidelines. London: British Broadcasting Corporation. Beautrais, A.L., L.J. Horwood and D.M. Fergusson (2004). Knowledge and attitudes about suicide in 25-year-olds. Australian and New Zealand Journal of Psychiatry, 38(4), 260–65. Berkowitz, L. (1984). Some effects of thoughts on the anti and prosocial influences of media events: A cognitive neoassociationistic analysis. Psychological Bulletin, 95(3), 410–27. 187

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Bhattacharya, S. (2003). Media coverage boosts ‘charcoal burning’ suicides. British Medical Journal, 326(7400), 498. Björkqvist, K. (1985). Violent films, levels of anxiety, and aggression. 3rd European Isra Conference, 3–7 September, Parma, Italy. Boyd-Barrett, O. and P. Braham (1987). Media, knowledge & power. London: Routledge. Cheng, A.T.A., K. Hawton, T.H.H. Chen, A.M.F. Yen, C.Y. Chen, L.C. Chen et al. (2007). The influence of media coverage of a celebrity suicide on subsequent suicide attempts. Journal of Clinical Psychiatry, 68(6), 862–66. Cheng, A.T.A., K. Hawton, C.T.C. Lee and T.H.H. Chen (2007). The influence of media reporting of the suicide of a celebrity on suicide rates: A population-based study. International Journal of Epidemiology, 36(6), 1229–34. Davidson, L.E. and M.S. Gould (1989). Contagion as a risk factor for youth suicide. In Alcohol, Drug Abuse, and Mental Health Administration. Report of the Secretary’s Task Force on Youth Suicide, Risk factors for youth suicide (pp. 88–109). Washington, DC: US Department of Health and Human Services, Public Health Service. Etzendorfer, E., G. Sonneck and S. Nagel-Kuess (1992). Newspaper reports and suicide. The New England Journal of Medicine, 327(7), 502–03. Ferguson, T.J. and B.G. Rule (1983). An attributional perspective on anger and aggression. In R. Geen and E. Donnerstein (Eds), Aggression: Theoretical and Empirical Reviews (pp. 41–74). New York: Academic Press. Gerbner, G. and L. Gross (1976). Living with television: the violence profile. Journal of Communication, 26(2), 172–99. Goldstein, B. (Producer) and A. Leyland (Director) (2006). The making of a martyr [Film]. Isreal: a2b Film Productions. Gould, M. (2001). Suicide and the media. In H. Hendin and J. Mann (Eds), Suicide Prevention: Clinical and Scientific Aspects (pp. 200–24). New York, NY: Academy of Science. Gundlach, J. and S. Stack (1990). The impact of hyper media coverage on suicide: New York City, 1910–1920. Social Science Quarterly, 71(3), 619–27. Hawton, K. and P. Coulter (2003). Suicide and the Media: Pitfalls and Prevention. Report on a Seminar organised by the Reuters Foundation Programme at Green College and the Oxford University Centre for Suicide Research (CSR). Holding, T.A. (1975). Suicide and “The Befrienders”. British Medical Journal, 3(5986), 751–53. Hong Kong Journalists Association. (2002). Hong Kong Journalists Association guidelines on coverage of suicides. Hong Kong. Huston, A.C. and J.C. Wright (1983). Children’s processing of television: The informative functions of formal features. In J. Bryant and D.R. Anderson (Eds), Children’s Understanding of TV: Research on Attention and Comprehension (pp. 37–68). New York: Academic Press. Linz, D., E. Donnerstein and S. Penrod (1984). The effects of long-term exposure to filmed violence against women. Journal of Communication, Reprinted in Media in Society: Readings in Mass Communication, 34(3), 130–47. 188

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Phillips, D.P., K. Lesyna and D.J. Paight (1992). Suicide and media. In R.W. Maris, A.L. Berman, and J.T. Maltsberger (Eds), Assessment and prediction of suicide (pp. 499–519). New York: Guilford. Phillips, D.P. and L.L. Cartensen (1986). Clustering to teenage suicides after television news stories about suicide. The New England Journal of Medicine, 315(11), 685–89. Romer, D., P.E. Jamieson and K.H. Jamieson (2006). Are news reports of suicide contagious? A stringent test in six U.S. cities. Journal of Communication, 56(2), 253–70. Rule, B.G. and T.J. Ferguson (1984). An overview of the relations among attribution, moral evaluation, anger and aggression. In A. Mummendey (Ed.), Social psychology of aggression: From individual behavior towards social interaction (pp. 41–74). Berlin: Springer-Verlag. Schmidtke, A. and H. Hafner (1988). The Werther effect after television films: new evidence for an old hypothesis. Psychological Medicine, 18(3), 665–76. Scott, T.A. (2008). Army tries to combat soldier suicide, “Beyond the front,” Washington Post, Wednesday, 8 October 2008. Retrieved 8 Oct 2008 from www.washingtonpost. com/wp-dyn/.../AR2008100702780.html Stack, S. (1987). Celebrities and suicide: A taxonomy and analysis, 1948–1983. American Sociological Review, 52(3), 401–12. Stack, S. (2000a). Suicide: A 15-year review of the sociological literature. Part II: Modernization and social integration perspectives. Suicide and Life-Threatening Behavior, 30(2), 145–62. Stack, S. (2000b). Media impacts on suicide: A quantitative review of 293 findings. Social Science Quarterly, 81(44), 957–71. Stack, S. (2003). Media coverage as a risk factor in suicide. Journal of Epidemiology and Community Health, 57(4), 238–40. Wasserman, I.M. (1984). Imitation and suicide: A re-examination of the weather effect. American Social Review, 49, 427–36. Weimann, G. and G. Fishman (1995). Reconstructing suicide: Reporting suicide in the Israeli press. Journal of Mass Communication, 72(3), 551–58. World Health Organization. (2000). Preventing Suicides: A Resource for Media Professionals. Geneva: WHO, Department of Mental Health. Yip, P.S., K.W. Fu, K.C.T. Yang, B.Y.T. Ip, C.L.W. Chan, E.Y.H. Chen et al. (2006). The effect of a celebrity suicide on suicide rates in Hong Kong. Journal of Affective Disorders, 93(1), 245–52.

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190

SecƟon II

Assessment: People-at-Risk

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10

Suicide: Its Assessment and PredicƟon PÙ®ã« Mç»«ÊÖ«ùù

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ulti-faceted problem of suicidal behaviour has been the subject of extensive studies by many researchers (Brown et al., 2000; Goldstein et al., 1991). It has resulted in development of a host of different models, scales of measurement to track and understand the factors responsible for the act of suicide. Although significant risk factors have been identified and models have emerged, no major breakthrough is yet evident to prevent the suicidal behaviour and to help the vulnerable person to cope with suicidal intent and adverse life situations. Perhaps, the root of suicidality is embedded deep in human psyche. This chapter on assessment starts with an introduction and clinical and empirical approaches to assessment and prediction of suicide, which will be followed by the details of the assessment tools and discussion regarding the same with a conclusive note on role of assessment in prevention and prediction. In this chapter an attempt has been made to provide a systematic examination of the measures that assess suicidal ideation and behaviour across the age, from childhood to older adulthood. The assessment tools encompass: (a) suicide ideation and behaviour; (b) cognitive and affective factors underlying suicidal behaviour; (c) lethality of suicide attempts; (d) attitudes and knowledge concerning suicide; and (e) brief screening measures of suicidality. Although some measures do not directly assess suicidal behaviour, the variables closely associated with suicide have been 193

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given due consideration. Some of these factors are potentially modifiable with appropriate timely interventions. The present review mostly includes suicide assessment instruments with adequate reliability and validity. A few tests, which appear to be in their developing phases, have been included as it might be helpful to the interested researchers. Measures concerned with psychopathology have not been prioritised as it is the part of clinical history-taking. Many of the measures of personality have not been considered as these are not of great utility in comprehensive suicide risk evaluations (Johnson et al., 1999). Minnesota Multiphasic Personality Inventory (MMPI), Thematic Apperception Test (TAT) and Rorschach Inkblot Test have not been found to be predictors of suicidality (Beck et al., 1979). Since the factors not identified previously may prove significant in a given person, suicide risk assessment should be based on clinical judgement duly considering the clinical details (Jacobs, 2003). It is deemed desirable that thorough psychiatric examination, identification of risk and protective factors, a distinction between the modifiable and stable risk factors are to be incorporated in case conceptualisation—a prerequisite condition of assessment of suicidal behaviour (Meichenbaum, 2005). Heterogeneity in definition of suicidal behaviour is an additional problem in developing suicide measures and evaluating them from the same platform. The definitions provided by O’Carroll and colleagues (1996) have been considered by the reviewers (Brown, 2008; Goldston, 2003) as useful ones in understanding the domain of suicidality.

CLINICAL AND EMPIRICAL APPROACHES TO ASSESSMENT AND PREDICTION Clinical evaluation is an important part of assessment in suicidal behaviour. Clinical assessment includes a detailed interview that elicits information regarding the person’s life experience, temperament and character and adaptive need structure to enable clinicians to understand the diathesis underlying suicidal behaviour. This would give direction to empirical approach of assessment, which is concerned with the identification of persons at risk based on response of the person on standardised tools. The assessment requires inclusion of both the clinical and empirical approaches together to reach a final decision. Since the assessment tool for 194

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suicidal behaviour is inferential in nature, decision may not go beyond subjectivity. As a matter of fact, even prediction loses its accuracy when it is not anchored on scientific theoretical framework and clinical insight. It may well be the reason to adopt clinical approach to comprehend suicidal behaviour. The development of the tool, Collaborative Assessment and Management of Suicidality (CAMS), has helped clinicians to improve their methods to identify, assess and conceptualise treatment plans and to view suicide-prone individuals in an empathic, matter-of-fact and nonjudgemental fashion (Jobes et al., 2007). Agreement between clinical and empirical evaluation should be achieved for an in-depth understanding of a case that may add significance to the concept of typology and varied nomenclature in suicidal behaviour. Information regarding previous suicidal history, personality constellation, sensitivity to life experiences and vulnerability along with diagnosis of any psychiatric illness, including Axis I and Axis II disorders which could be a comorbid condition with suicidality, are essential in predicting suicidal intent. A comprehensive approach for understanding a case would include precise clinical interview, self-report in conjunction with objective behavioural measures. However, diagnostic diversity and non-specificity of life stressors along with the reports of stressful life events not being a significant predictor (Dogra et al., 2008) suggest the difficulty in prediction of suicidal behaviour. Even a significant biological marker, like low 5-HIAA, has not been reported to serve as a single good predictor of suicidality (Brown et al., 1992). However, review of the current literature (Berk et al., 2007; Dervic et al., 2007; Dhar and Basu, 2006; Haaga et al., 1991; Sil and Basu, 2007; Wilson et al., 2007) suggests the existence of two distinct groups of patients, irrespective of diagnostic category, namely (a) those who are characterised by depression, hopelessness, suicidal ideation and pre-meditation and (b) those with impulsivity and comparatively lower level of depression or hopelessness without any contemplation. This indicates the utility of assessment of psychic constellation through different psychological tools.

VARIOUS MEASURES OF ASSESSMENT Suicidal ideation is the thought serving the means to one’s death. It involves the attitude towards suicide, the intent and the plan to 195

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attempt it. The suicide intent may vary in seriousness depending on the degree of suicide intent and specificity of suicide plans. It may be manifested from transient thoughts with respect to worthlessness of life and death wish, to permanent recurring plans for killing oneself and preoccupation with self-destruction that reflects depressive mood and hopelessness, where suicide is seen as a mode for coping with such a mood. Suicide ideation may be chronic or acute in nature. The measures of suicidal behaviour can be divided broadly in the domains of cognition, affect and behaviour. The various psychological tools used to measure suicidality and associated factors along with its psychometric properties are summarised in the Appendix to this chapter.

EvaluaƟon of the Scales It is quite evident from the table (see Appendix) that a host of measures of suicide-related behaviours are available for assessment of cognitive, affective and behavioural aspects underlying suicidal behaviour in adults and in children. Most of these measures have adequate internal reliability and concurrent validity. However, it is evident that no single instrument and single-time assessment can yield an accurate estimate of the intention and prediction of suicidal behaviour. In terms of prediction, a multigating procedure is deemed essential to overcome the limitation of a single test since suicidal behaviour is the function of interplay of multiple factors that makes its prediction difficult. The same risk factors, when accompanied by a protective factor could have a different implication than when it is not so. Poor predictive validity of the assessment tool may also be ascribed to the rarity of the incidence of suicide (Maris et al., 1992). Perhaps, the assessment would be effective and helpful in suicide prevention and prediction when suicidal behaviour is a cry for help akin to the psyche of deliberate self-harmers and individuals with parasuicidal intent than those with intent of terminating their lives. Questionnaires administered by clinicians to a patient, in a face-to-face situation, in a conducive environment, could enhance the efficacy of the tool, eliciting more genuine response of the patient instead of depending more on self-reporting measures. The research report (Joiner et al., 1999) reveals that the intensity of suicide intent and planning is less on self-report measures than when it is conducted by a clinician. 196


Although different scales of suicide ideation measure current intensity of patient’s specific attitude, behaviours and plan to commit suicide on the day of the interview, Scale of Suicide Ideation-Worst (SSI-W; Beck et al., 1997)—an interviewer-administered rating scale for suicide ideation—yields more accurate estimate of suicide risk. This may be attributable to the better elicitation of response with the ambience of empathy associated with interviewing. Also the demand of the test is to make the respondent recall the approximate date and circumstances when the patient was experiencing most intense desire to commit suicide. The assessment of mental state immediately prior to attempt is definitely useful and enhances knowledge for understanding and prediction of suicidal behaviour, but this retrospective reporting is subject to retrieval falsification unless collected in an emergency set-up just after the incident. However, it has been reported (Beck et al., 1997) that 16 and above score on SSI-W has 14 times more likelihood to predict suicide commitment. Similarly it has six times more likelihood of suicide commitment in case of 2 or more scores on Scale for Suicide Ideation (SSI; Beck et al., 1997). Sequential Emotion and Event Form for Suicidal Adolescents (SEESA; Negron et al., 1997) also makes an attempt to give a detailed cognitive, affective and behaviour status at the time of suicidal episode. A very few tests, like SSI, SSI-W and Adult Suicidal Ideation Questionnaire (ASIQ), claim to have predictive validity, though most of the tests lack predictability. However, the randomised clinical trials have shown the sensitivity of the tests like SSI, Modified Scale for Suicide Ideation (MSSI), Suicide Probability Scale (SPS), Suicide Behaviours Questionnaire (SBQ) and Self Monitoring Suicide Ideation Scale (SMSI) to the changes in suicidal thinking and level of depression and hopelessness which have immense clinical implication and protective value for any subsequent suicidal incidents. Negative correlation between SBQ and Reasons for Living Inventory (RFL) reveals SBQ’s sensitivity to one’s appraisal for reasons to live also. Efficacy of brief screening tools, like Paykel suicide items and suicide ideation screening questionnaire, might have been enhanced because of adopting interview technique. However, the psychometric properties of the screening tool may require improvement. On the other hand, the tests of suicidal behaviour are subject to criticism for its poor sensitivity and specificity. It may be attributable to the inferential nature of these tests. Beck and his co-workers (1990) reported the possibility of false positive and false negative responses on the Beck 197

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Hopelessness Scale (BHS) which may lead to inaccurate prediction, though they claim 9 and above score on BHS has a good predictability for suicidal behaviour. But it is also true that even one with his best intent to answer honestly, may rate himself at the lower end of the response category, subjectively perceiving his intent as not to be so highly scored. Although suicide probability (Cull and Gill, 1988) and suicide status scales (Jobes et al., 1997) measure the probability of suicide risk considering the factors, like negative self perception, negative mood state or external pressure, they do not give due consideration to the protective factors, though suicidal status and probability are outcomes of the interplay of risk factors and associated protective factors as well. Consideration of modifiable risk and protective factors could help to assess the probability of risk over some significant period of time. Even though there exists a good number of scales to assess suicidal behaviour and new assessment tools are in the offing, but the assessmentsoutcome of different scales are not always comparable as they are either standardised on different populations or are developed based on different theoretical constructs. Rather, application of the same tool across the population, culture and different settings could develop huge sets of database and would be helpful to bring out clarity in conceptualising the aetiology of suicidal behaviour (Brown, 2008). Moreover, most of the tests are standardised on the population of one’s own country and have not been always duly tested in other populations. Although suicidal scales are available for children and adolescents (Goldston, 2003), tools addressing the need of old age is also relatively scarce (Brown, 2008). A battery of tests including the evaluation of direct factors related to suicidal behaviour and indirect potential factors that contribute to it is essential for understanding the phenomenon in totality. The indirect tests assess the personality constellation, cognitive and affective appraisals of life events that underlie suicidality having the potency to ignite suicidal desire that culminates in suicidal act. Assessment of depression, on Beck Depression Inventory (BDI) or Hamilton Rating Scale for Depression (HRSD), hopelessness on BHS, or use of Psychache scale that reveals the penetrating value of distress, Psychache Need Questionnaire that indicates the gap between one’s wish and wish fulfilment, Reasons For Living denoting the worth of living cognition of the person, reasons for attempting suicide as assessed on RFL along with sensitivity to life events as measured by Life Event Scales and assessment of ego integrity on Ego Function Test (EFA) test could be considered as a battery for assessment of suicidal 198


disposition in a person. Consequently, the underlying determinants of personality constellation, like family cohesion, interpersonal relationship, attachment with significant persons, become the essential part of suicidal assessment. Several measures, such as SMSI (Clum and Curtin, 1993) or Linehan’s diary card for monitoring suicide ideation and self-harm behaviours (Linehan, 1993), specific items of Beck Depression Inventory-II (BDI-II; Beck et al., 1996), may be applied repeatedly during intervention. Clinicians may provide with adequate intervention to prevent suicide attempt in patients who regularly attend psychotherapy sessions and complete the scales, such as BDI-II and BHS, prior to each visit that indicates hopelessness or suicidal tendency in the patient (Ellis and Newman, 1998). However, it may be suggested that if the test developers aim to correlate the assessment tool of suicidal behaviour with the measures of a few other relevant domains of affect and cognition that underlies suicidal behaviour, the assessment procedure could be made simpler and more precise.

CONCLUSION Consideration of personality constellation factors, namely depression, hopelessness and psychache, on the one hand, and impulsivity, aggression and emotional instability on the other, which are empirically distinct but highly correlated constructs, may yield a more integrated view for understanding and predicting suicide. Perhaps prediction becomes more difficult due to unique psychic constellation of each individual. Any discrepancy between objective and subjective criteria favours subjective criteria to decide suicide risk. This necessitates an idiographic approach to investigate total individual psyche. Moreover, the prediction of suicide potential is not equivalent to prediction of event of suicide and the term prediction loses its significance and may be replaced with the term ‘estimation of risk’ (Motto, 1992). Furthermore, the aim of any assessment is prevention and treatment. The information regarding the intensity of suicide ideation and intent, severity of underlying psychopathology and availability of protective factors are the determinants not only in choosing treatment modality but also in taking decision for indoor or outdoor treatment. The risk assessment, if suggestive, may cause immediate forceful 199

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admission of the patient in hospital—thus maximising the benefit of assessment outcome. From prevention perspective, with increased number of people in the community to come under high risk group, formulation of preventive programme at the community level is also becoming essential. Though imposing restriction onto the accessibility to the method employed in making attempts on suicide seems effective (Gelder et al., 1988), its wide application may prove impracticable. In preventive programme, assessment of vulnerable and resilience factors of each age group, and nature of environmental setting is required as these could be the target to make any intervention programme effective. An important preventive effort may be made, from government as well as non-government levels, for the high-risk adolescent population by organising school-based programmes, wherein the teachers, parents, other mentors and students are psychoeducated about the warning signals of suicide and learn when to refer someone who seems to be in danger (Kalafat and Elias, 1994). A study by Mishara and Daigle as mentioned by Gould and colleagues (2003) further suggests the necessity of development of centres for crisis intervention and online help to provide effective support for the help-seekers. However, although school-based programmes have been acknowledged to improve attitude (Kalafat and Elias, 1994) and help-seeking behaviour (Ciffone, 1993), its efficacy has been questioned including the report of no benefits (Shaffer et al., 1991) and even showing its detrimental effects (Shaffer et al., 1991) on the vulnerable persons. As a result, skill training programme has been devised to immunise suicideprone persons against suicidality (Gould et al., 2003). Moreover, youth at risk usually do not attend the programme though the person with suicide intent usually visit doctors prior to the occurrence of the event (Maris et al., 1992), indicating their desire to seek help in a very personal and one-to-one setting. Although efficacy of primary prevention programme has been proved in Gotland project (Gelder et al., 1988), the suicide rate had come at the baseline level three years after the termination of the project, indicating the necessity of continuation of the programme. Community organisations may come forward with continuous programme and operate in the seeking mode for those who are troubled, and function as paraprofessionals who help bridge the gap between mental health professionals and the sufferers. 200

Constructs

Suicidal ideation Frequency of attempt Degree of intent to kill with two major dimensions of preparation and motivation

Retrospective information of patient’s most intense desire to commit suicide Two important dimensions: preparation and motivation

The Scale for Suicide Ideation (SSI; Beck et al., 1979)

Scale for Suicide Ideation-Worst (SSI-W; Beck et al., 1997)

(Appendix Continued)

Number of items: 21 Interviewer administered Sample studied: Adult psychiatric inpatients and outpatients Validity: CV = Significantly associated with BDI and HDRS PV = Presence of suicidal ideation provides an independent estimates of the risk for suicide Reliability: CC: r = .84 to .89 IR r = .83 to .98 Number of items: 19 Interviewer administered Sample studied: Adult psychiatric inpatients and outpatients Validity: CV = Associated with measures of suicide ideation including SSI, BDI and HDRS

Standardisation details

Suicide Ideation Scales

Details of Assessment Tools with their Psychometric Properties (Abbreviations used in the tables CV = Concurrent Validity; PV = Predictive Validity; CC = Chronbach Coefficient; IR = Interrater Reliability)

Scales and authors

APPENDIX

Desire for death Preparation for suicide Actual suicide desire

Suicidal desire Preparation for attempt Perceived capability of making an attempt

Beck Scale for Suicide Ideation (BSSI; Beck and Steer, 1991)

Modified Scale for Suicide Ideation (MSSI; Miller et al., 1986)

Standardisation details PV = Patients with higher score for high risk category were 14 times more likely to commit suicide than patients who scored in the low risk category Reliability: CC : r = .88 IR Reported High Number of items: 21 Self-report version of SIS Sample studied: Adolescents and adult psychiatric inpatients and outpatients Validity: CV = Highly correlated with SSI .90 to .94 Moderately correlated with BDI suicide item, .58 to .69 Moderately correlated with BDI, .64 to .75 and BHS, .53 to .62 Reliability: CC : r = .87 to .97 Test-retest reliability r = .54 Number of items: 18 Semi-structured interview Sample studied: Adult psychiatric inpatients and outpatients Validity: CV = Moderately high correlation with SSI (r = .74) Moderate correlation with suicide item from BDI (r = .60) Significant correlation with total BDI (r = .34) Zung Depression Scale (ZDI) (r = .45) and BHS (r = .46)


Constructs

Scales and authors


Intensity and duration of ideation and level of control in making a suicide attempt

Suicide ideation Hopelessness Positive outlook Interpersonal closeness Hostility Angry impulsivity

Positive and negative thoughts related to suicide attempts

Self Monitoring Suicide Ideation Scale (SMSI; Clum and Curtin, 1993)

Suicide Probability Scale (SPS; Cull and Gill, 1988)

Positive and Negative Suicide Ideation Inventory (PANSI; Osman et al., 1998)


Reliability: CC: r = .87 to .94 Item total correlation, .41 to .83 Test-retest reliability (r = .65) Number of items: 3 Self-report measure for daily assessment Sample studied: Chronically and severely suicidal college students (18–24 years) Validity: CV = Moderately correlated with SSI and MSSI ranging from .46 to .56 Significantly correlated with BHS and ZDI Number of items: 36 Self-reporting scale Sample studied: Non-clinical adolescents and adults Validity: CV = With following scales of MMPI Positively correlated with depression (r = .44 to .73) Psychopathic deviate (r = .48 to .63) Paranoia (r = .47 to .61) Schizophrenia (r = .56 to .68) Suicide thread scale developed for the MMPI (r = .67 to .71) Reliability: CC: r = .93; IR for subscale r = .62 to .89 Test-retest reliability r = .92 Number of items: 20 Self-report measure Sample studied: Undergraduate college students (mean age = 20 years)

Constructs

Suicide ideation and behaviour in adults

Adult Suicidal Ideation Questionnaire (ASIQ; Reynolds, 1991a, 1991b)

Validity: CV = Moderately and negatively correlated with SPS (r = –.47); SBQ (r = –.21 to –.45) Moderately and positively correlated with SPS (r = .59) and with SBQ (r = .39 to .61) Reliability: IR: r = .80 to .93 Number of items: 25 items Self-report measure Sample studied: Undergraduate college students (mean age 20 years) and clinical population Validity: CV = Highly correlated with HRSD (r = .77); significant correlation with measures of depression (r = .60); anxiety (r = .41) and the history of prior suicide attempts (r = .36) Validity in community sample: Significantly correlated with measures of depression (r = .60); hopelessness (r = .53); anxiety (r = .38); low self-esteem (r = .48); history of prior suicide attempt (r = .33) PV = Baseline ASIQ scores significantly predicated suicide attempt in 3 months follow-up study in a sample of psychiatric inpatients who had previously attempted suicide Reliability: CC: r = .96 to .98 Test-retest reliability: r = .95



Scales and authors


Severity or intensity of suicidal ideation

Beliefs and expectations for not committing suicide subscales include: Survival and coping Beliefs Responsibility to family Child-related concerns Fear of suicide Fear of social disapproval Fear of oral objections

Suicide Ideation Scale (SIS; Rudd, 1989)

Reasons for Living Inventory (RFL; Linehan et al., 1983)


Number of items: 10-items Self-report scale Sample studied: College students (16–30 years) Validity: CV = Moderately correlated with centre for epidemiologic studies depression scale (r = .55) and the BHS (r = .49) Reliability: CC: r = .86 Item–Total Correlation r = .45 to .74 Number of items: 48 Self-report measure Sample studied: General population (mean age, 36 years) Validity: CV = Following subscales of survival and coping, responsibility to family, child-related concerns and moral objections—inversely related to measures of suicide ideation (r = –.13 to –.53) and suicide probability (r = –.28 to –.67). Survival and coping subscale negatively correlated with the Beck Depression Inventory (r = –.68), the Beck Hopelessness Scale (r = – .71) and the Suicide Intent Scale (r = –.42) Moderately and negatively correlated with the Scale for Suicide Ideation (–.64) and the Beck Hopelessness Scale (–.63) in a sample of college students Reliability: CC: r = .72 to .92 for each subscale RFL total scale: r = .89

Motivation for suicide Two scales: Internal perturbation Extrapunitive/manipulative motivation

Suicidal behaviours in youths scales assessing ego functioning and ego defence mechanisms

Reasons for Attempting Suicide Questionnaire (RASQ; Holden and McLeod, 2000)

Child Suicide Potential Scale (CSPS; Pfeffer et al., 1979)

Number of items: 14 Self-reporting questionnaire Sample studied: Clinical and non-clinical adult population Validity: PV = Internal perturbations correlate .41 with previous suicide history Reliability CC: Internal perturbations scale: r = .71 to .87 Extrapunitive/manipulative motivations scale: r = .80 to .86 Comprehensive semi-structured interviews Sample studied: Child and adolescent psychiatric (6–12 years) inpatients and outpatients and corresponding non-clinical population Validity: CV: Perception of death as temporary and use of introjection on CSPS consistently associated with suicidality among child psychiatric inpatients PV = CSPS ratings of suicidal behaviour among adolescent psychiatric inpatients predict CSPS rating of suicidal behaviour one year later With Suicidal Ideation Questionnaire-Junior High School Version (SIQ-Jr) ratings of suicidality



Constructs

Scales and authors


Constructs

Psychological pain External pressures Agitation Hopelessness Low self regard Overall risk of suicide

Emotional, cognitive and behavioural staus of suicidal adolescents before, during and after the suicidal episode

Scales and authors

Suicide Status Form (SSF; Jobes et al., 1997)

Sequential Emotion and Event Form for Suicidal Adolescents (SEESA; Negron et al., 1997)


Number of items: 12 Six self-reporting and six clinician administering items Sample studied: Non-suicidal (18–26 years) and suicidal college students (17–55 years) Validity: CV: Moderately and negatively correlated with Linehan Reasons for Living Scale (r = –.42) Test-retest reliability: r = .35 to .69 Two parallel semi-structured questionnaires Sample studied: Adolescent suicide ideators and attemptors (mean age 12 years)


Suicide Status Scales

6 to 8 months later; child psychiatric inpatients and nonclinical controls Childrens’ three and six times more scores on suicidal ideation and suicide attempts respectively on the Spectrum of Suicidal Behaviour likely to make suicide attempts over the 6- to 8-year follow-up IR Concept of Death Scales: r = .89 to .90 Ego Mechanism Scales: r = .65 to 1.0 Ego Defense Scales: r = .83 to 1.0

Constructs

Psychological needs: Seven subscales: Achievement, affiliation, autonomy, counteraction, order, avoidance and succorance

Scales and authors

Psychache Needs Questionnaire (PNQ; Munchua, 2003)

Domain of Affect

Number of items: 35 Self-reporting questionnaire Sample studied: Adult non-clinical sample Validity: Differentiate between suicide attempters and non-attempters in a university undergraduate sample Reliability: CC: r = .82


Standardisation details Number of items: 15 Interviewer administered Sample studied: Admitted suicidal patient after attempt (18–63 years) Validity: CV = Moderate correlations with measures of depression (r = .17 to .62) and with measures of hopelessness (r = .31 to .41), highly correlated with self-report version of SIS (r = .87); relates to lethality of suicide attempts (r = .38) PV = SIS total scale did not predict completed suicide Reliability: CC: r = .95; IR: r = .81 to .95; lethality of intent: r = 90; planning: r = .74

Constructs

Seriousness of the intent to commit suicide among attempted suicide patients

Scales and authors

Suicide Status Scales

Suicide Intent Scale (SIS; Beck, Schuyler and Herman, 1974; as cited in Brown, 2008)


State Anger, Trait Anger, Angry Temperament, Angry Reaction, Anger turned inwards, Anger turned outwards, Anger Control, Anger Expression

State–Trait Anger Expression Inventory (Speilberger, 1988)

Items: Semi-projective instrument with 20 drawings Sample studied: Adolescents (12–16 years) Validity: Demonstrated by identifying seven different factors Reliability: Reported satisfactory split-half and test-retest reliability Number of items: 44 Self-reporting questionnaire Sample studied: Adolescents and adults Validity: CV-r = Trait Anger: Buss-Durkee Hostility Inventory: Male (M), .71; Female (F), .66; MMPI Hostility Scale: M, .59; F, .43; MMPI Overt Hostility Scale: M, .32; F, .37; Eysenck Personality Questionnaire (EPQ) Neuroticism: M, .50; F, .49; Psychoticism: M, .21; F, .20; Lie Scale: M, –.20; F, –.25 State Anger: with (EPQ) Neuroticism: M, .43; F, .27; Psychoticism: M, .26; F, .27. Reliability: CC: r = .73 to .85

Constructs

Suicide thoughts and behaviour

Scales and Authors

Suicide Behaviours Questionnaire (SBQ; Linehan, 1981)

Number of items: 4 items (abbreviated) Self-reporting questionnaire Sample studied: Female psychiatric outpatients (mean age 32 years) and college students Validity: (Appendix Continued)

Standardisation Details

Domain of Suicide Behaviour

Child’s reaction to separation and loss

Separation Anxiety Test (SAT; Hansburg, 1980)

Five behavioural domains: past suicidal ideation, future suicidal ideation, past suicide threats; future suicide attempts and likelihood of dying in a future suicide attempt

Impulsivity

Suicidal Behaviours Questionnaire (Revised) (SBQ-14; Linehan, 1996)

Impulsivity Control Scale (ICS; Plutchik et al., 1989)

CV = Significantly correlated with SSI r = .69; negatively related with Linehan RLI r = –.34. Items measuring self-harm on SBQ and diagnostic interview for borderline personality disorder (BPD)—moderately to highly correlated (r = .61 to .93) Reliability: CC: r = .75 (clinical sample) r = .80 (non-clinical sample) Test-retest reliability: r = .95 Number of items: 34 Self-reporting questionnaire Sample studied: Non-clinical adult population Validity: CV = Positively correlated with item of SSI and SCI (r = .36 to .51) Positively correlated with SSI, BDI and BHS (r = .55 to .62) Negatively correlated with Linehan RLI r = .46) Reliability: CC: r = .73 to .92 Number of items: 15 Self-reporting scale Sample studied: Adolescents and adults Validity: Correlates with other measures of suicide and violent risk Reliability: IR: r = .77


Domain of Suicide Behaviour

Constructs

Scales and authors


Medical lethality of a suicide attempts Eight separate scales according to the method of attempt

Two aspects (composite score): Escapability Controllability

Degree to which most stressful r ecent life event led to feelings of defeat, rejection, loss and failure

Availability of social support to patients with chronic conditions

Lethality and intent of a suicide attempt

Lethality Scales (LS; Beck et al., 1975)

Escape Potential Scale (EPS; Baumeister, 1990)

Defeat Scale (O’Connor and Leenaars, 2003)

Rescue Scale (Sherbourne and Stewart, 1991)

Risk-Rescue Rating Scale (RRR; Weissman and Worden, 1972)


Interviewer-administered scales Sample studied: Admitted patient with suicide attempt (mean age 29 years) Validity: CV = Correlation between suicide intent and medical lethality was found to be low (r = .19); highly correlated with SIS (r = .73); moderately correlated with RRR measure (r = .60) Reliability: IR: r = .80 Number of items: 2 Sample studied: Parasuiciders and non-clinical adults Reliability: CC: r = .63 Number of items: 4 Sample studied: Parasuiciders and non-clinical adults Reliability: CC : r = .86 Number of items: 18 Multi-dimensional instrument Sample studied: Parasuiciders and non-clinical adults Reliability: CC: r = .83 to .93 Number of items: 10 Interviewer-administered scale Sample studied: Admitted suicide attempters (10–60 years or older) Validity:


Risk and Methods of Lethality

Constructs

Scales and authors

Focuses on the assessment of injury lethality. There are seven methods of injury category rated according to the degree of lethality

Self-Inflicted Injury Severity Form (SIISF; Potter et al., 1998)

CV = Moderately correlated with Beck’s Lethality Scale (r = .60); positively associated with high scores on SIS (r = .38) Reliability: IR: Kappa = .67; IR: Kappa = .59 Number of items: 7 Interviewer-administered scale Sample studied: Admitted patient with self-inflicted wound (13–34 years) Validity: CV: High rate of agreement with RRR (Kappa = .88) Reliability: IR: Kappa = .94; IR: on ‘near fatality’ ratings r = .93


Constructs

Self-destructive thoughts; self-defeating composite; addictions composite, self-annihilating composite suicide intent composite

Scales and authors

Firestone Assessment of SelfDestructive Thoughts (FAST; Firestone and Firestone, 1996)

Number of items: 84 Self-report questionnaire Sample studied: Adult psychiatric inpatients and outpatients and on-clinical college students Validity: CV = The suicide intent composite subscale was highly correlated with suicide ideation subscale of SPS (r = .85) and BSSI (r = .81) Reliability:


Domain of Cognition

Constructs

Risk and Methods of Lethality

Scales and authors


Constructs

Severity of depression

Depressive symptom severity

Scales and authors

Beck Depression Inventory (BDI; Beck and Steer, 1987)

Hamilton Depression Rating Scale (HDRS; Hamilton, 1960)

Number of items: 21 Self-report inventory Sample studied: Adolescents and adults Validity: CV: Average correlation of the BDI with clinical ratings of psychiatric patients (r = .72) and non-psychiatric patients (.60); with Hamilton Rating Scale for Depression (.73), for psychiatric patients and non-psychiatric patients (.74) PV: 2 or higher score indicates 6.9 times (95 percent, CI: 3.7–12.6) more likelihood to commit suicide Reliability: CC: r = .73 to .95 Number of items: 21 Interviewer-administered rating scale Sample studied: Affective disorder of depressive type Validity: CV = Highly correlated with ASIQ, SSI and suicide item of BDI PV = Patients who scored 2 or higher on HRSD suicide item were 4.9 times (95 percent, CI: 2.7–9.0) more likely to commit suicide than patients who scored less than 2 Reliability: IR : r = .92 Test-retest reliability: r = .64 (Appendix Continued)


Depression and Hopelessness

CC: r = .84 to .97 Internal consistency: r = .76 to .91 Test-retest reliability: r = .63 to .94

Current level of an adolescent’s depressive symptomatology Dysphoric mood, anhedonia/ negative affect, negative selfevaluation and somatic complaints

27 sets of items yields a total score and five subscale scores on: mood, interpersonal problems, ineffectiveness, anhedonia and negative self-esteem

Reynolds Adolescent Depression Scale-2 (RADS-2; Reynolds,1987, 1988)

Children’s Depression Inventory (CDI; Kovacs, 1982)

Number of items: 30 Self-reporting scale Sample studied: Adolescents with depressive symptomatology Validity: CV = Correlation with BDI-II (r = .84), correlation with Hamilton interview on retesting was .76 Reliability: CC: r = .91 Test-retest reliability: r = .87 Number of items: 27 sets of item Self-report inventory Sample studied: Children and adolescents (7 to 17 years) Validity: CV: Correlation of CDI suicidal items and remaining total scores in non-clinical group, r = .45; psychiatric sample, r = .52; newly diagnosed diabetic youths, r = .22; second sample of school children, r = .49; sexually abused youth, r = .27. PV: Moderately predictive of suicidal second sample of school children, r = .49; sexually abused youth, r = .27. PV: Moderately predictive of suicidal ideation one year later, r = .39 Reliability: Test-retest reliability: 50 percent of the youths endorsed initial score at the second testing 6 to 9 weeks later



Constructs

Scales and authors


To diagnose severity of 17 symptoms of depression

Extent of negative expectancies about the future

Hope in chronically ill patients

Children’s Depression Rating Scale (CDRS-R; Poznanski et al., 1984)

Beck Hopelessness Scale (BHS; Beck et al., 1974)

Multi-dimensional Hope Scale (Raleigh and Boehm, 1994)

Brief rating scale based on a semi-structured scale Interviewer administered Sample studied: Child (or an adult informant who knows the child well) Validity: Good concordance with diagnosis of depression Corroborates with recovery Correlates with other tests of depression severity Reliability: IR: r = .86 Number of items: 20 true–false statements Sample studied: Psychiatric inpatients and outpatients with suicide ideation and attempt Validity: CV = Correlations with clinical ratings of hopelessness, r = .66 to .74 Correlation coefficients between the BHS and the BDI pessimism item, r = .42 to .64 in clinical samples PV = Scores of 9 and above have accurate prediction of eventual suicide completion in outpatients Sample studied: Inpatients and in non-clinical population— minimum age, 13 years reported Validity: CV = Significant negative correlation with the BHS, r = –.45 Reliability: CC: r = .95 Test-retest reliability: r = .82 (Appendix Continued)

Present status in hope and described as ‘Goal scale for the present’

Hope as disposition, described as ‘the future scale’

Dispositional index of hope Combination of agentic and pathways thinking towards goals, i.e., perceived capability to produce routes to those goals

State Hope Scale (Snyder et al., 1996)

Adult Dispositional (Trait) Hope Scale (Snyder et al., 1991)

Children’s Hope Scale (Snyder et al., 1997)

Number of items: 6 Self administered Sample studied: Non-clinical adults Validity: CV: with Trait Hope Scale, r = .79 With self-esteem, .45 to .75; with negative affect of Positive and Negative Affect Scale (PANAS), –.37 to –.50 Reliability: CC: Agency subscale, .79 to .95 CC: Pathway subscale, .59 to .93 Test-retest: .82 to .93 Number of items: 12 Self-reporting scale Sample studied: Non-clinical college students and individual in psychological treatment Validity: CV: with optimism (test of Life-Orientation) .50 to .60 with hopelessness scale of Becket, r = –.51, and BDI –.42 Discriminant validity with Self-Conscious Scale Reliability: CC: .74 to .84. Test-retest: r = .80 for individual in psychological treatment Number of items: 6 Self-reporting scale Sample studied: Children Validity: CV: r = .38, reported adequate discriminant, and incremental validity



Constructs

Scales and authors


Hopelessness (Modification of the BHS)

Self-oriented Other-oriented Socially prescribed dimensions

Hopelessness Scale for Children (HPLS; Kazdin et al., 1986)

Multidimensional Perfectionism Scale (MPS; Hewitt and Flett, 1991)

Reliability: CC: r = .72 to .86 Item-remainder coefficients = .27 to .68 Test-retest reliability: r = .71 Number of items: 17 Self-reporting scale Sample studied: Adolescents and psychiatric patients Validity: CV = Positive correlation (r = .71) with a five-item questionnaire used by Beck to validate the BHS PV: With severity of depressive symptoms, depressive diagnoses, poor self-esteem, poor self-rated social skills, anxiety and perfectionism in girls, difficult temperament, lower estimated intellectual functioning, suicidal ideation, suicidal tendencies and suicide attempts Moderate stability (r = .57) in HPLS scores over a six-week period of time among child psychiatric inpatients Reliability: Internally consistent (r = .89) among adolescent psychiatric inpatients Number of items: 45 Self-reported scale Sample studied: Clinical and non-clinical adult population Validity: Item-to-subscale total correlations: Self-oriented items: r = .51 and .73 Other-oriented items: .43 and .64 Socially prescribed items: .45 and .71 Reliability: (Appendix Continued)

3 dimensions: Internal–external Stable–unstable Global–specific

Measure social problem skill by generating social scenarios and asking for possible solutions and obstacles Reaction time measure of implicit association between self-injury and oneself to detect suicide ideators and attempters

Extended Attributional Style Questionnaire (EASQ; Joiner and Metalsky,1999)

Means–End Problem-Solving Procedure (Platt and Spivack, 1975)

Self Injury Implicit Association Test (SI-IAT; Nock and Banaji, 2007)

Self-oriented and socially prescribed-oriented perfectionism

Child and Adolescent Perfectionism Scale (CAPS; Flett et al., 1992)

Items: Series of images of self-injury—related or neutral Sample studied: Suicide ideators, suicide attempters and nonsuicidal adolescents (12–19 years) Validity: PV = 74–77 percent accuracy in discriminating randomly selected suicidal individual from non-suicidal ones

CC: Self-oriented perfectionism, r = .86 Other-oriented perfectionism, r = .82 Socially prescribed perfectionism, r = .87 Number of items: 22 Self-reporting scale Sample studied: Adolescent (11–19 years) Reliability: Test-retest reliability (one week), r = .80; CC: r = .85 Items: 12 hypothetical negative events Self-rating scale Sample studied: University undergraduates Reliability: CC: r = .86 (achievement events); .82 (interpersonal events) Validity: Parasuiciders discriminated from normal, generating fewer and less relevant solutions



Constructs

Scales and authors


Separate dimensions for each of the 12 ego functions Reality testing, judgement, sense of reality, drive control, object relation, thought process, adaptive regression in service of ego (ARISE) defensive function, stimulus barrier, autonomic function, synthetic/ integrative function, sense of mastery and competence

Ego defence mechanisms of compensation, denial displacement, intellectualisation, projection, reaction formation, regression, repression

Ego Function Assessment ScaleModified (EFA-M; Basu et al., 1996) (adapted from Bellack, 1989)

Life Style Index (LSI; Plutchik et al., 1979)


Number of items: 120 Self-reporting scale Sample studied: College students (20–23 years) Validity: Internal consistency validity between each item and corresponding subscale (r = .32 to .84); CV = Psychoticism scale, .20 to .36 (excepting ARISE scale) Neuroticism scale, .30 to .55 (excepting ARISE scale) Reliability: Reliability coefficient for each subscale Chronbach, .50 to .79; Split half, .52 to .79 Number of items: 97 Self-reporting questionnaire Sample studied: Non-clinical college students Reliability: Internal consistency for each of the defence mechanisms obtained from a sample of inpatients and college students and test-retest reliability are respectively as follows: Displacement (.69, .62, .76) Intellectualisation (.58, .30, .61) Projection (.86, .75, .75) Reaction formation (.73, .63, .76) Regression (.65, .56, .38) Repression (.55, .38, .48) Compensation (.59, .43, .61) Denial (.54, .52, .55)


Domain of Personality

Constructs

Scales and authors


Rating of narrativised speech sample Sample studied: Adolescents (12–16 years) Validity: Validated demonstrating factorial independence of psychological dimension and arousal at various levels of personality dimensions across the task conditions Reliability: IR: r = .80

Response from 10 cards Sample studied: Clinical and non-clinical adolescents Validity: Four of six of the features on this index selected 64 percent of suicidal subjects PV: Estimated S-CON score of 7 or more predictor of near-lethal suicide attempts

Constructs

Family relationships: evaluate communication styles, family interactions and flexibility

Family Adaptability and Cohesion Evaluation Scales (FACES IV; Olson, Gorall and Tiesel, 2004; as cited in Olson and Gorall, 2006)

Number of items: 20 Self-report survey Sample studied: Adolescents and adults (12 years onwards) Validity: r = .91 to .93 Reliability: CC: Disengaged = .87, Enmeshed = .77, Rigid = .83, Chaotic = .85, Cohesion = .89, Balanced Flexibility = .80

Standardisation Details

Domain of Interpersonal Relationship

Scales and Authors

Epigenetic Assessment Rating System (EARS; Wilson, Passik and Kuras, 1989; as cited in Feldman and Wilson, 1997)

Suicide proneness Affective variables (vista responses, colour-shading blends, colour-dominated responses and morbid content), cognitive distortion (inaccurately perceived human movement responses [M-] and special scores) Describes 10 levels of personality organisation

Rorschach Suicide Index Constellation (RSIC; Exner, 2002)

Domain of Personality

Constructs

Scales and authors


Intrusion Avoidance Degree to which respondents have experienced intrusive and avoidant thoughts relating to a specified event that occurred in the last 6 months Relatively frequently occurring life events

Impact of Events Scale (IES; Horowitz et al., 1979)

Life Experience Survey (LES; Sarason et al., 1978)

Constructs

Scales and authors

Life Event Scales

Two aspects: Care Protection

Parental Bonding Instrument (PBI; Parker et al., 1979)


Number of items: 47 (general), 10 items (students) Self-reporting scale Reported adequate validity Reliability: 6-week test-retest: r = .63

Number of items: 15 items Self-reporting scale Sample studied: Adult parasuicider and non-clinical control Reliability: CC: Intrusion, r = .83; Avoidance, r = .72


Number of items: 25 Self-report questionnaire Sample studied: Adolescents (12–18 years) Validity: Convergent validity with family, corroborative witnesses and twin studies and studies using independent raters on construct of care and protection Reliability: Internal consistency (split half) Care: r = .88; Protection: r = .74

Attraction to life Repulsion to life Attraction to death Repulsion to death

Multi Attitude Suicide Tendency Scale for Adolescents (Orbach et al., 1991)

Number of items: 30 Sample studied: Adolescents, non-clinical high school students, psychiatric inpatients and outpatients Validity: CV: r = with Israelian Index of suicide potential Attraction to life, .66; repulsion to life, .64 Attraction to death, .48; repulsion to death, .28 Reliability: Internal consistency Attraction to life, .83; repulsion to life, .76 Attraction to death, .76; repulsion to death, .83 Total scale = .92


Domain of Attitude

Constructs

Questions with increasing levels of intent to assess suicidality during the past week, month, year or lifetime. On residents of psychiatric catchments area

Scales and authors

Paykel Suicide Items (PSI; Paykel et al., 1974)

Number of items: 5 Interviewer administered Samples studied: Adults between 18 and 60 years and above Validity: CV = with any suicidal feelings during the past year, psychiatric symptoms with social isolation, somatic complaints and had a greater proportion of two or more


Brief Screening Measures

Constructs

Scales and authors

Suicidal Ideation Screening Questionnaire (SIS-Q; Cooper-Patrick et al., 1994)

Disturbance in sleep and mood, guilt and hopelessness during the past year

negative life events in the past year than non-suicidal controls Suicidal subjects with hospital admission for emotional problems or for taking tranquilizers in the past year Number of items: 4 Samples studied: Patients receiving care in general medical setting (18–70 years) Interviewer administered Validity: CV: Correctly identified 84 percent of general medical patients with suicide ideation

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Linehan, M.M. (1981). Suicidal behaviors questionnaire. Unpublished inventory, University of Washington, Seattle, Washington. Linehan, M.M. (1993). Cognitive-behavioral treatment of Borderline Personality Disorder. New York: Guilford. Linehan, M.M. (1996). Suicidal Behaviors Questionnaire (SBQ). Unpublished manuscript, Department of Psychology, University of Washington, Seattle, WA. Maris, R.W., A.L. Berman and J.T. Maltsberger (1992). Summary and conclusions: What have we learned about suicide assessment and prediction? In R.W. Maris, A.L. Berman, J.T. Maltsberger and R.L. Yufit (Eds), Assessment and Prediction of Suicide (pp. 640–72). New York: The Guilford Press. Meichenbaum, D. (2005). 35 years of working with suicidal patients: lessons learned. Canadian Psychologist, 46(2), 64–72. Miller, I.W., W.H. Norman, S.B. Bishop and M.G. Dow (1986). The modified scale for suicide ideation: Reliability and validity. Journal of Consulting and Clinical Psychology, 54(5), 724–25. Motto, J.A. (1992). An integrated approach to estimating suicide risk. In R.W. Maris, A.L. Berman, J.T. Maltsberger and R.L. Yufit (Eds), Assessment and Prediction of Suicide (pp. 625–39). New York, The Guilford press. Munchua, M.M. (2003). The underlying need structure of psychache and its role in the statistical prediction of suicidal manifestations. Unpublished Master’s Thesis, Queen’s University, Kingston, Ontario, Canada. Negron, R., J. Piacentini, G. Flemming, M. Davies and D. Shaffer (1997). Microanalysis of adolescent suicide attempters and ideators during the acute suicidal episode. Journal of American Academy of Child and Adolescent Psychiatry, 36(11), 1512–19. Nock, M.K. and M.R. Banaji (2007). Prediction of suicide ideation and attempts among adolescents using a brief performance based test. Journal of Consulting and Clinical Psychology, 75(5), 707–15. O’Carroll, P.W., A.L. Berman, R.W. Maris, E.K. Moscicki, B.L. Tanney and M.M. Silverman (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237–52. O’Connor, R.C. and A.A. Leenaars (2003). A thematic comparison of suicide notes drawn from Northern Ireland and the United States. Current Psychology, 22(4), 339–47. Olson, D.H. and D.M. Gorall (2006). FACES IV & the Circumplex Model. Retrieved 10 October 2008 from http://www.facesiv.com/pdf/3.innovations.pdf Orbach, I., I. Milstein, D. Har-Even, A. Apter, S. Tiano and A. Elizur (1991). Multi attitude suicide tendency scale for adolescents. Psychological Assessment, 3(3), 398–404. Osman, A., P.M. Gutierrez, B.A. Kopper, F.X. Barrios and C.E. Chiros (1998). The positive and negative suicide ideation inventory: Development and validation. Psychological Reports, 82(3, part 1), 783–93.

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Sherbourne, C.D. and A.L. Stewart (1991). Rescue scale. The Medical Outcomes Study’s (MOS) measure of social support. The MOS Social Support Survey. Social Science and Medicine, 32(6), 705–14. Sil, M. and S. Basu (2007). A study of hope, hopelessness, reasons for living and suicidal ideation in college students. Indian Journal of Clinical Psychology, 34(1), 76–82. Snyder, C.R., B. Hoza, W.E. Pelham, M. Rapoff, L. Ware, M. Danovsky et al. (1997). The development and validation of the children’s hope scale. Journal of Pediatric Psychology, 22(3), 399–421. Snyder, C.R., C. Harris, J.R. Anderson, S.A. Holleran, L.M. Irving, S.T. Sigmon et al. (1991). The will and the ways: Development and validation of an individual differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570–85. Snyder, C.R., S.C. Sympson, F.C. Ybasco, T.F. Borders, M.A. Babyak, Higgins et al. (1996). Development and validation of the state hope scale. Journal of Personality and Social Psychology, 70(2), 321–35. Speilberger, C.D. (1988). State-Trait Anger-Expression Inventory. Odessa, Florida: Psychological Assessment Resources. Weissman, A.D. and J.W. Worden (1972). Risk-rescue rating in suicide assessment. Archives of General Psychiatry, 26(6), 553–60. Wilson, S.T., B. Stanley, M.A. Oquendo, P. Goldberg, G. Zalsman and J.J. Mann (2007). Comparing impulsiveness, hostility, and depression in borderline personality disorder and bipolar II disorder. Journal of Clinical Psychiatry, 68(10), 1533–39.

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Substance Use and Suicidal Behaviour N SH M S , A

W

S H

U

SH K

ith suicide accounting for over 1 million deaths worldwide every year, suicidal behaviour is a pressing global health and social concern (WHO, 2001). Such behaviour commonly occurs as a result of interactions between multiple predisposing factors and current environmental factors that influence its development. These may be neurobiological, genetic, medical, psychological, social, economic or cultural (Beautrais et al., 1996; Norstrom et al., 1995). Particularly influential in suicidal behaviour is the presence of psychiatric disorders. The majority of individuals who commit suicide have a diagnosable mental disorder and, indeed, suicidal behaviour is more frequent among psychiatric patients (Henriksson et al., 1993; Mann, 2002). In their meta-analysis of 3,275 suicides across the world, ArsenaultLapierre, Kim and Turecki (2004) reported that ‘on average, 87.3 % of the subjects who committed suicide had a mental disorder’. Affective, substance-related, personality and psychotic disorders accounted for the majority of these diagnoses. Numerous studies have reported a significant association between substance abuse and suicidal behaviour, especially in young people (Fowler et al., 1986; Neeleman and Farrel, 1997). In fact, substance abuse itself is viewed as a form of self-destructive behaviour by some researchers. Meninger (1938), for example, described substance abuse as ‘chronic 230

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suicide’, suggesting that substance abuse is, perhaps, at least partially motivated by suicidal impulses, either consciously or unconsciously. The San Diego Suicide Study by Rich and colleagues (1986) was one of the first investigations to report an association between substance abuse and suicide. This study also suggested that this association is stronger among individuals aged under 30 as compared to those aged 30 and above. According to a 2004 World Health Organization study, substance-related disorders are involved in 17 percent of completed suicides (Bertolote et al., 2004). Molnar, Berkman and Buka (2001), in their assessment of data from the US National Comorbidity Survey, concluded that alcohol and drug abuse are associated with a suicide risk 6.2 times greater than the average risk. Several studies of suicide among adolescents and young adults in the United States have consistently reported high rates of substance use (60–70 percent; Brent et al., 1988; Shafii et al., 1985), although similar studies in Europe have reported relatively lower rates of substance use associated with suicide (30–47 percent; Appleby et al., 1999; Marttunen et al., 1991). Asian research exploring the association between suicidal behaviour and substance use is unfortunately still scarce. The risk of suicidal behaviour is associated not only with substance abuse, but also with substance use and dependence. Borges, Walters and Kessler (2000) found that current substance use, even in the absence of abuse or dependence is a significant risk factor for unplanned suicides among individuals who have suicidal ideation.

THE CONTINUUM OF SUICIDAL BEHAVIOUR Suicidal behaviour spans a spectrum that, in addition to completed suicide, also encompasses suicidal ideas and thoughts of varying intensity and specificity, and other acts of deliberate self-harm of varying intent and lethality. The tripartite classification system suggested by Beck, Resnik and Lettieri (1973) categorises these behaviours as suicidal ideation, suicide attempt and completed suicide. Completed suicide is defined as self-inflicted death, and suicide attempt as self-destructive act with a non-fatal outcome, both accompanied by evidence (explicit or implicit) that the person intended to die 231

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(American Psychiatric Association, 2003). At the mildest end, suicidal ideation is a preoccupation with intrusive thoughts of ending one’s own life which includes suicide threats, direct expressions of the wish to die, and indirect indicators of suicide planning (Harter et al., 1992). The three forms of suicidal behaviour—completed suicide, suicide attempt and suicidal ideation—can, thus, be understood as a continuum of selfharming behaviours.

TYPES OF STUDIES Studies exploring the association between substance use and suicide can be broadly classified into three categories based on their research design (Hillman et al., 2000): 1. Psychological autopsy studies—which involves the retrospective psychiatric assessment of the deceased by means of a proxy-based interview process with best informants on the deceased (ArsenaultLapierre et al., 2004). 2. Case behaviour (cases) and a representative sample of those who do not (controls), on the risk factors of interest (Breslow and Day, 1980). 3. Longitudinal studies—which involve repeated observations of the same sample for suicidal behaviour, with assessments of exposure to the risk factors, at regular intervals (Beautrais, 2003).

THE SUBSTANCES OF ABUSE Substance use has generally been found to increase the likelihood of a suicide attempt, but the specific association between the different types of substances of abuse (with the exception of alcohol) and suicidal behaviour has not been clearly established (Borges et al., 2000). In many cases of suicidal behaviour abuse of drugs and alcohol are co-occurring, which makes it difficult to distinguish the contributions of each separately (Harris and Barraclough, 1997). Research discussing the role of alcohol 232


in elevating suicide risk is considerably more extensive and robust than similar research on the role of other drugs of abuse in suicidal behaviour. Felts, Chenier and Barnes (1992), in their study on adolescents in North Carolina, found that the use of cocaine/crack was more closely associated with a self-reported incidence of attempted suicide than was the use of alcohol, marijuana or needle drugs. Analysis of data on 7,227 suicides in 2003 (Serpi et al., 2005) indicated that among suicide victims who tested positive for substances, 33.3 percent tested positive for alcohol, 16.4 percent for opiates, 9.4 percent for cocaine, 7.7 percent for marijuana and 3.9 percent for amphetamines.

Alcohol The association between alcohol use and suicidal behaviour, both in alcohol dependent and non-alcohol dependent populations, has long been recognised and documented (Wilcox et al., 2004). According to a metaanalysis of mortality studies by Inskip, Harris and Barraclough (1998), the lifetime risk of suicide is 7 percent for alcohol dependence. Several studies across the world have consistently reported a high prevalence of alcohol use disorders among people who committed suicide (20–56 percent; Caces and Harford, 1998; Pirkola et al., 2000; Vijayakumar and Rajkumar, 1999). Alcohol dependence has also been found to be associated with attempted suicide and suicidal ideation (Borges et al., 2000). An increased risk of suicide attempts in alcoholism has been reported, ranging from 17 (Schuckit, 1986) to 29 percent (Whitters et al., 1985). Certain other variables have been found to be associated with suicidal behaviour among alcoholics. In many studies, suicidal behaviour has been more strongly associated with alcohol use among males than among females (Ohberg et al., 1996; Pirkola et al., 2000). On the other hand, other studies have reported that the risk for suicide among those with alcohol use disorders is higher for females (e.g., Roy et al., 1990). Other demographic variables associated with suicide attempts among alcoholics are younger age, lower socio-economic status and family history of alcohol abuse (Roy et al., 1990). With respect to per capita alcohol consumption, Stack (2000) reported that the greater the alcohol consumption, the higher is the suicide rate, 233

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although the strength of this association varied considerably across countries. Positive and significant associations between per capita alcohol consumption and male suicide rates have been found in a number of countries, for example, Denmark (Skog, 1993), France (Norstrom, 1995), Norway (Rossow, 1993) and Portugal (Skog et al., 1995). This relationship between alcohol consumption and suicide rate has also been evidenced in the former Union of Soviet Socialist Republics (USSR), where, as a part of an anti-alcohol campaign, the prices of alcohol were increased and its availability was reduced. As a result, the consumption of alcohol reduced considerably, as did the suicide rate (Wasserman et al., 1998). The severity of alcoholism has been shown to be associated with suicidal behaviour (Conner and Duberstein, 2004). For example, Kockott and Feuerlein (1968, as cited in Lester and Beck, 1975) reported that individuals suffering from alcohol use disorder, who have a history of delirium tremens, have a higher incidence of suicidal behaviour than those who have not experienced delirium tremens. It has also been found that suicidal behaviour is more common in the later stages of alcoholism than in the earlier stages (Robins and Murphy, 1965). Alcohol intoxication, even without abuse or dependence, has been shown to predict suicidal behaviour. Autopsy studies have found alcohol to be present in 20–50 percent of persons who commit suicide (Ohberg et al., 1996). Suokas and Lonnqvist (1995) reported that 62 percent of suicide attempters had consumed alcohol prior to or at the time of their attempt. In fact, it has been claimed that immediate alcohol intoxication presents a greater risk for suicidal behaviour than the habitual consumption pattern (Borges and Rosovsky, 1996).

Cannabis/Marijuana In a case-control study comparing 302 consecutive hospital admissions of medically serious suicide attempts with 1,028 randomly selected control participants, Beautrais, Joyce and Mulder (1999) reported that 16.2 percent of the attempters met the DSM-III-R criteria for cannabis abuse/ dependence at the time of the attempt, compared to only 1.9 percent of comparison subjects. However, when this association was controlled for socio-demographic factors and psychiatric comorbidity, it fell short of significance. More recently, however, regular or excessive cannabis use 234


has been shown to be significantly associated with suicidal behaviour even after adjusting for socio-demographic factors and comorbidity (Kung et al., 2003). This association between cannabis use and suicidal behaviour is found to be more common among young people. In two recent studies of high school students in France, on the basis of hierarchical multiple regression analysis, Chabrol and colleagues reported that cannabis was a significant predictor of suicidal behaviour including suicidal ideation (Chabrol, Chauchard and Girabet, 2008; Chabrol, Mabila and Chauchard, 2008). A study of 1,265 children for over a 21-year period found that cannabis use, particularly heavy or regular use, was associated with later increases in suicidal thoughts and suicide attempts (Fergusson et al., 2002). Heavy cannabis use has also been associated with a relative risk for suicide four times that of non-users in a prospective study of Swedish conscripts (Andreasson and Allebeck, 1990). Lesser/casual use, however, was not associated with an increased risk. A cross-sectional study of twin pairs discordant for lifetime cannabis dependence found that individuals who were cannabis dependent had odds of suicidal ideation and suicide attempt that were 2.5 to 2.9 times higher than those of their non-cannabis dependent co-twin (Lynskey et al. 2004).

Cocaine Patients with cocaine dependence have been shown to have a greater risk of suicidal behaviour. For example, Marzuk et al. (1992) found that one out of every five suicide victims in New York aged 21–30 tested positive for cocaine. A significantly greater risk of attempting suicide among cocaine abusers was also reported by the US Epidemiologic Catchment Area survey of 13,673 participants (Petronis et al., 1990). More recently, Darke and Kaye (2004), in their study of injecting and non-injecting cocaine users, found that 31 percent had attempted suicide, and 18 percent had done so on more than one occasion. Moreover, the injecting cocaine users were significantly more likely to have attempted suicide and used more violent methods than non-injecting cocaine users. The use of cocaine has also been found to be associated with suicidal ideation. In a sample of 777 patients referred for evaluation of chemical 235

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dependency in a psychiatric emergency service, Garlow, Purselle and D’Orio (2003) reported that 43.7 percent of the patients with only a cocaine use disorder expressed suicidal ideation, compared to 38 percent of those with both cocaine and alcohol use disorders, 24.3 percent with only an alcohol use disorder. Some of the characteristics of the cocainedependent patients who had attempted suicide are: a family history of suicidal behaviour, more childhood trauma, higher personality scores for introversion, neuroticism and hostility, more comorbidity with other substance dependence, and psychiatric and physical disorders (Roy, 2001).

Heroin and Other Opiates Suicide has been implicated as a frequent cause of death among heroin users. There are a number of reports indicating elevated rates of suicide and suicidal behaviour among opiate users (Oyefeso et al., 1999). The proportion of deaths among heroin users attributed to suicide has been found to range from 3 (O’Doherty and Farrington, 1997) to 35 percent (Engstrom et al., 1991). In their meta-analysis of the literature on suicide risk, Harris and Barraclough (1997) reported that death due to suicide among heroin users occurs at 14 times the rate of matched peers. A relatively recent study undertaken to determine the lifetime and recent histories of attempted suicide among entrants to treatment for heroin dependence reported that a lifetime history of attempted suicide was reported by 34 percent of subjects (Darke et al., 2004).

THE PRECIPITATING FACTORS The relationship between substance use and suicidal behaviour can be conceptualised from a biological, psychological and a socio-economic perspective. From a biological perspective there is evidence that alcohol influences the serotonin neurons in the brain stem and causes a reduction of serotonin transporter function in the prefrontal cortex (Malone, 1999). On the other hand, disorders of central serotonergic neurotransmission, as reflected by low levels of 5-HIAA, have been associated with suicidal behaviour (Mann et al., 1999). A deficient serotogenic system has also been 236


implicated as a predisposing factor to personality traits like impulsivity and aggression (Coccaro 1989; Linnoila et al., 1993), both of which are strongly associated with the use of substances such as alcohol, cocaine, cannabis and ecstasy (e.g., Donovan et al., 1998; Guy et al., 1994).

Impulsivity Individuals with more impulsive traits are known to be at greater risk for suicidal behaviour (Horesh et al, 1999). Studies of non-fatal suicidal behaviour have found 50 percent of attempters saying later that they did not think of it for more than one hour beforehand (Williams, 1997). At the other end of this relationship, impulsivity has been identified both as a risk factor and predictor of substance use and abuse (Guy et al., 1994). Studies exploring the association between substance use and impulsivity have reported two different aspects of the association—higher levels of impulsivity lead to acquisition of substance abuse and misuse, and substances of abuse increase impulsivity (Perry and Carroll, 2008). It must be noted, however, that while some studies have associated impulsivity with the use of drugs (Butler and Montgomery, 2004; Donovan et al., 1998), others have failed to find this association (McCann et al., 1994; Ricaurte et al., 1990). Further research is, therefore, required to better understand the role of impulsivity in the relationship between substance use and suicidal behaviour.

Aggression The alcohol–aggression relationship has been extensively researched in adolescents (Dembo et al., 1997) as well as adults (Giancola et al., 2002; Hoaken and Pihl, 2000). With respect to suicidal behaviour, aggressiveness has been shown to be a major underlying process facilitating such behaviour. Several studies have identified aggression as a factor that increases the risk of suicidal behaviour (Korn, et al., 1992; Plutchik and van Praag, 1989). It, therefore, seems plausible that the use of substances may intensify aggressive behaviour, which, in turn, may lead to suicidal behaviour. 237

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Deficient Cognitive Flexibility Several researchers have studied the effect of alcohol and other substances of abuse on the cognitive performance of individuals. Indeed, one of the cognitive functions most commonly found to be negatively correlated to substance use is cognitive flexibility. For example, Zorko and colleagues (2004) compared the performance of alcohol dependents with controls on a battery of neuropsychological tests and found that the alcoholics exhibited more impairment in cognitive flexibility than did the controls, amphetamine and heroin users (Ornstein et al., 2000). In their review of factors for suicide attempts, Rudd and Joiner (1998) listed cognitive rigidity as one of the factors that may increase the risk for suicidal behaviour. Lack of cognitive flexibility can, therefore, be seen as a possible link between substance use and suicidal behaviour, although further research is necessary to prove the causality.

Deficient Problem-solving Several studies comparing individuals displaying suicidal behaviour and controls have found significant differences in their performance on problem-solving tasks. Patsiokas, Clum and Luscomb (1979) compared a group of 49 male suicide attempters with 48 controls and found that the suicide attempters had greater difficulty in solving the problems. It is also a well established fact that the use of substances leads to impairment in problem-solving. Studies on cognitive impairments in alcoholics have largely pointed towards problem-solving as a significantly correlated factor (e.g., Zorko et al., 2004).

Psychosocial Stressors/Adverse Life Events Psychosocial stressors are commonly found in suicidal behaviour reported by clinical studies, with interpersonal conflicts (usually family or marital discord), break-up of a significant relationship, and financial problems being the most frequently reported (Weissman, 1974). In a retrospective study of adolescent suicides, Marttunen, Aro and Lönnqvist (1992) reported a high level of psychosocial stress in the year preceding the suicide. 238


Incidences of current separation, divorce and current employment have been reported to be higher among individuals with a history of suicide attempts (Preuss et al., 2002).

COMORBIDITY OF SUBSTANCE USE, PSYCHIATRIC DISORDERS AND SUICIDAL BEHAVIOUR Comorbidity of psychiatric illnesses and substance misuse leads to an increase in suicide attempts (Moselhy and Conlon, 2001). Alcohol abuse and use of illegal drugs was reported in 69.7 percent of suicide attempters. Comorbid depression and substance abuse is the most frequent category in suicide attempters. Substance abuse is major comorbidity in bipolar patients. Although rates decrease in older age groups, substance abuse is still present in the elderly. According to the National Comorbidity Survey (Kessler et al., 1997), the lifetime co-occurrence of psychiatric disorders with alcohol abuse and dependence in men was 35.8 percent for anxiety disorder (generalised anxiety disorder, panic, phobia), 28.1 percent for mood disorder (major depression, dysthymia, mania), 29.5 percent for drug dependence disorder and 16.9 percent for antisocial personality disorder. Among women with alcohol dependence, 60.7 percent had an anxiety disorder, 34.7 percent drug dependence disorder and 7.8 percent antisocial personality disorder. Various types of interactions are possible in case of comorbidity. The first is a causal relationship in which the psychiatric disorder results in alcohol and substance use disorder. On experiencing symptoms of psychopathology, the individual resorts to greater consumption of the substance thus resulting in substance use disorder. Second, a psychiatric disorder or symptoms may occur as a consequence of alcohol use, and may persist after abstinence. Third, a person’s problems with alcohol and psychiatric symptoms may develop simultaneously. Some of the risk factors associated with one disorder may also be associated with the other. In the fourth possibility, neither disorder may cause the other, but the two become meaningfully linked over time. Last, it is also possible that the disorders simply co-occur and co-exist with no meaningful interrelationship (Rosenthal and Westreich, 1999). 239

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Personality Disorder Addiction was historically thought to be a symptom of personality disorder. With the advent of DSM-III, substance use disorders were defined as a clinical syndrome and separated from personality pathology. Since then, psychiatric comorbidity in substance abusers is an area of research. Only a few studies have however assessed the influence of Axis II disorders on suicide attempts in substance use disorder (Koller et al., 2002; Ravandal and Vaglum, 1999). Studies have found borderline personality disorder (Darke et al., 2004; Ravandal and Vaglum, 1999) and antisocial personality disorder (Koller et al., 2002; Roy et al., 1990) to be associated with suicide attempts in this clinical group. The median rates for personality disorders across different studies range from a low of 44 percent for alcohol dependent individuals to a high of 79 percent for opioid dependent patients, Cluster B personality disorders—antisocial, borderline and less frequently narcissistic and histrionic personality disorders—are the most prevalent. In treated substance abusers, both Cluster C (avoidant and dependent and less frequently obsessive compulsive disorder) and Cluster A (paranoid and less frequently schizoid and shizotypal disorder) are most common. Rounsaville et al. (1998) found Cluster B disorders to be most prevalent (61 percent), followed by Cluster C (34 percent) and Cluster A (22 percent). Antisocial (46 percent), borderline (30 percent) and avoidant (20 percent) disorders were identified as the most common specific personality disorders.

Affective Disorder In a national epidemiological survey conducted in the United States, Grant et al. (2005) reported that among the 9.35 percent of substance abusers, 19.67 percent had at least one independent mood disorder during the same 12-month period. Nearly one-third of patients with major depressive disorder also have substance use disorders, and it has been associated with a greater risk of suicides and greater social and personal impairment (Davis et al., 2008; Kessler et al., 1999). Depressed alcoholics have significantly higher suicidality than subjects with either depression or alcohol dependence. Alcohol dependence and 240


depression act additively to produce greater suicide risk among subjects with both disorders (Cornelius et al., 1996). Periods of major depression during sustained abstinence are a risk factor for increased number of suicide attempts over the lifetime. Major depression with onset before the onset of substance dependence predicts severity of suicidal intent (Hasin et al., 2002). Adults aged 18 or older who reported binge alcohol consumption were more likely to report past year major depressive episode (MDE) than their counterparts who had not engaged in binge drinking (8.7 versus 7.3 percent). Adults with past year MDE and past month binge alcohol use reported more past year suicidal thoughts and suicide attempts than those with MDE who did not binge drink. Rates of past year suicidal thoughts and suicide attempts were also higher among adults with past year MDE who had used illicit drugs during the past month than adults with past year MDE who had not used illicit drugs (Substance Abuse and Mental Health Services Administration, 2003). Tondo et al. (1999) after a thorough review of literature reported association of alcohol abuse with major affective disorders and of some substance (polyabuse, alcohol, heroin, cocaine and even tobacco but not marijuana or hallucinogens) with suicidal behaviour. The study reported a tendency for bipolar I, mainly non-mixed patients, to have a relatively high risk of substance abuse and low risk of suicide attempts, proving that depressive or dysphoric (bipolar II, non-bipolar and bipolar I) are more lethal. An epidemiological study (Kessler et al., 1997) reported an association between alcoholism and mood disorders. A total of 60.7 percent of people with bipolar I disorder had a lifetime diagnosis of a substance use disorder; and 40.7 percent had a drug abuse diagnosis. Mania and alcohol use disorders are 6.2 times more likely to occur than would be expected by chance and they co-occur more often than do alcoholism and unipolar depression. Suicides in alcoholics are largely dependent on the co-occurrence of a depressive episode. In a Veterans Administration Study, Lehmann, McCormick and Mc Cracken (1995) found that 77 percent of suicide completers who were diagnosed with substance abuse had a diagnosis of affective disorder (39 percent). Of patients who completed suicide, 5 percent had a comorbid psychosis and substance abuse; 67 percent of people with Post Traumatic Stress Disorder (PTSD) who completed suicide had a comorbid disorder, usually an affective disorder or substance abuse. 241

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Substance use disorders comorbid with other psychiatric disorders, socio-demographic disadvantage and adverse childhood experiences are associated with increased suicidal risk (Beautrais et al., 1996). More men (49 percent) than women with bipolar disorder (29 percent) met the criteria for lifetime alcoholism. Bipolar disorder is found to be frequently comorbid with substance use disorders but it is difficult to diagnose among patients with active substance use (Sloan et al., 2000). When bipolar I disorder is compared with bipolar II disorder, Chengappa, Levine, Gershon and Kupfer (2000) found 57.8 percent subjects with bipolar I disorder to be dependent on one or more substances or alcohol, 28.2 percent dependent on two substances or alcohol and 11.3 percent abused three or more substances or alcohol. Alcohol was the only common drug among either bipolar I or bipolar II subjects. Bipolar I subjects had higher rates of these comorbid conditions than bipolar II subjects. Gender differences in lifetime prevalence of alcohol abuse and bipolar illness in the same study revealed that more men (49 percent) than women (29 percent) with bipolar disorder met the criteria for lifetime alcoholism. However, the risk for having alcoholism was greater for women with bipolar disorder.

Eating Disorders Bulimia nervosa, binge eating disorder and alcohol/drug abuse are frequently comorbid. Around 20–40 percent of females with bulimia also report a history of problems with alcohol or drug abuse (Beary et al., 1986; Hall et al., 1989). Amongst bulimic adolescents, substance use was found to be related to an increased likeliness of attempted suicide, stealing and sexual intercourse (Wiederman and Pryor, 1996). Stock, Goldberg, Corbett and Katzman (2002) concluded that adolescents with restrictive eating disorders used significantly less alcohol, tobacco and cannabis than the general adolescent population. They also found lower use of substances in adolescents with binging and purging symptoms. Personality traits, such as impulsivity, were discovered as a common factor between bulimia and substance abuse (Wiederman and Pryor, 1996). Guilt was regarded as one of the emotions associated with both eating and alcohol abuse (Frank, 1991; Potter-Efron, 1989) and high rates of social anxiety (Striegel-Moore et al., 1993). 242


It is proposed that substance abuse provides relief from anxiety, depression and other psychosocial problems, and an addictive personality predisposes individuals to both eating disorders and alcohol abuse. Individuals who develop an addiction to one substance may develop psychological and behavioural patterns that leave them vulnerable to develop addictions to other substances (Brisman and Siegel, 1984). Eating disorder patients are already at an increased risk for morbidity and mortality, so alcohol and drug use pose additional dangers for these patients.

Anxiety Disorder Goodwin and colleagues (2002) found prevalence of comorbid anxiety disorders, which is an undetected and untreated problem, among patients with severe affective disorders and substance use comorbidity. Thus, the most frequently diagnosed comorbid Axis I conditions are anxiety and mood disorders, while the most frequently observed Axis II disorders are Cluster B-borderline personality disorder (BPD) and antisocial personality disorder, followed by Cluster C, avoidant personality disorder (PD), passive aggressive PD and obsessive compulsive PD; and then Cluster A; schizoid PD. Polysubstance dependent subjects were more likely to be diagnosed with anxiety disorders or bipolar disorder than were those who were not polysubstance dependent or were dependent only on alcohol. Polysubstance dependent men were at highest risk of Axis II disorders (Salloum and Thase, 2000). Generalised anxiety disorder (GAD) serves as a protective factor in suicide attempts in substance abusers. This may be due to the fact that GAD is related to avoidant behaviour and greater impulse control.

PREVENTIVE MANAGEMENT OF SUBSTANCE USE AND SUICIDAL BEHAVIOUR Individuals suffering from substance use disorders, including alcoholism, are at increased risk for suicide; about 15–16 percent of which is higher than the general population (Murphy, 2000). Presence of depression, 243

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impulsive behaviour and social and financial problems increase the risk. Evidence suggests that comorbid psychiatric disorders are associated with poorer alcohol treatment retention and outcomes (Kranzler et al., 1996). Patients with personality disorders have high treatment dropout and relapse rates (Nace et al., 1986). Since comorbidity of substance use with other mental disorders is associated with additional risks and poor outcomes, it is essential that patients with substance use disorder should be screened for other mental health disorders. Before referring to a drug and alcohol treatment plan, it is important to consider whether the patient should be dealt with on an inpatient or outpatient basis. Full risk assessment for suicidal attempts in such a person and mental status examination are essential. Intervention is required as early as possible in the initial course of the illness because as the illness progresses, there is a need for more intense psychological and medical treatment as well as group and residential therapeutic community care. Managing in the ‘initial phase’ requires that the safety of the suicidal person first needs to be looked into. In the absence of a comorbid mental disorder, further contact may be unnecessary, although the opportunity for further follow-up should be left open. For those who are profoundly suicidal with a severe mental disorder, hospitalisation may be necessary. In the ‘subsequent phase’, the person may be allowed to deal with his or her current interpersonal difficulties by involving significant other people. In the ‘later phase’, the person needs to be encouraged to use his or her coping skills so that he or she is able to adapt to any future crises on his or her own. If there are signs and symptoms of a mental disorder, antidepressant, anti-anxiety or anti-psychotic medication may be provided to the suicidal individual. It is also imperative to be aware of the potential risk of suicide with such drugs because of the toxicity of the anti-depressant used. Individuals with comorbid disorders present a confusing array of symptoms. Social workers should therefore do continuous monitoring of symptoms that may emerge later in the treatment process. If symptoms disappear quickly during periods of abstinence from alcohol or substance use, they are not suggestive of a comorbid psychiatric disorder. Reevaluation of symptoms after a period of abstinence is needed. In case the symptoms were not present earlier, chances are there for the presence of an independent psychiatric disorder. Monitoring of phenomenology, time, course and aetiology is therefore needed (Rosenthal and Westreich, 1999). Questions that need to be asked are: Does the consumption of substance 244


provide relief or exacerbation of symptoms? Whether the amelioration of psychiatric symptoms has an effect on pattern of substance use? Social workers need to become acquainted with the symptoms of psychiatric disorders and have knowledge of the effects of intoxication and withdrawal of alcohol and other substances. They should be skilled in asking questions about the drinking or substance abuse intake pattern. Preventive management of substance use and suicide can be dealt at three levels: primary, secondary and tertiary. Considering the prevention of substance abuse suicidal cases at the primary prevention level requires effective treatment of mood and other psychiatric disorders (Sher et al., 2001) and modification of social, economic and biological conditions, like reduction of poverty, violence, divorce rates and promotion of healthy lifestyle (Maris, 2002). People with comorbid psychiatric disorders are difficult to manage, relapse more often and adhere poorly to treatment regimen (Sitharthan et al., 1999).Treating comorbid depression, which accompanies in most of these cases is another viable option (Mason and Kocsis, 1991). At the secondary level, decreasing the likelihood of a suicide attempt in the high-risk group is essential. It includes diagnosis and treatment of existing psychiatric illnesses, assessment of suicide risk and the reduction in access to lethal means (Mann, 2002). Useful questions in evaluation of psychological risk are: How has the patient reacted in response to stress in the past and how effective are his coping strategies? Has the patient attempted suicide in the past? If so, how frequently and under what circumstances? What are the similarities in the current circumstances? Questioning about current depression and suicidal thoughts in addition to one’s pattern of drinking and substance use are helpful. Providing support at the home front and removal of any lethal means is another preventive measure that needs to be adopted by family members (Brent et al., 1987). Training for recognition of at-risk behaviour is necessary. Not only the health workers but the family members and other people who come in contact with the client, like the teachers and police officers, need training in recognition of such behaviour. The American Association of Suicidology (Rudd et al., 2006) has developed a mnemonic (is path warm?) to help identify key warning signs for suicide. They are: Ideation: talking about or threatening to kill oneself Substance Abuse: increased substance abuse 245

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Purposelessness, Anxiety: anxiety, agitation or changes in sleep pattern Trapped: feeling like there is no way out Hopelessness, Withdrawal: from friends, family and society Anger, Recklessness, Mood changes

Tertiary prevention is aimed at diminishing the effects of suicide attempts through clinical treatment and rehabilitation. Education of mental health professionals and assessment of family members who are influenced by suicide attempt is needed. Some additional points that need consideration in preventive management of substance use and suicidal behaviour are as follows: 1. Implementing technically sound suicide prevention programmes at both the state and national levels and improvement and expansion of surveillance systems are needed. Ongoing collection of data at national and state level drawing attention to the magnitude of problem and evaluating the impact of suicide prevention strategies is needed. 2. Change in alcohol policies, like increasing the minimum legal drinking age (MLDA) from 18 to 21 years is needed as an increase in number of suicides in 18 to 20 years has been reported compared to a 21 year MLDA. 3. Treatment should focus on prevention of comorbidity and provision of rehabilitation. A methodical screening and assessment can ease the diagnostic challenge of distinguishing symptoms of comorbid disorders from manifestations of substance intoxication and withdrawal. Treatment should first focus on the medication that is effective for treating co-occurring substance use. 4. The stigma of mental illness and substance abuse prevents people from seeking help fearing prejudicial and discriminating behaviour. The media can play a significant role in influencing public attitudes, particularly if it is extensive, prominent, sensationalist and/or explicitly describes the method of suicide. Individuals who belong to the vulnerable group engage in imitative behaviour on reading or watching coverage on suicide. The media can act as a preventive means by educating the public about suicide, and by encouraging those at risk of suicide to seek help. Changing media representation of suicidal behaviour can help a lot in reducing suicide rates. 246


5. Health messages that provide young people with information, life skills and values are essential. 6. Better enforcement of regulations and strict penalties for the sale and supply of tobacco and alcohol to minors is needed. 7. More research is needed to improve the interface of addiction treatment with suicide interventions. Incorporating suicide prevention into drug abuse treatment and looking especially at the effects of intoxication and withdrawal on suicidal behaviours are other areas of concern.

BARRIERS TO PREVENTIVE MANAGEMENT OF SUBSTANCE USE AND SUICIDE Some of the barriers to effective preventive management of substance use and suicide are: poor integration of primary health and mental health services, difficulties in making an appropriate diagnosis, marginalisation and stigmatisation of clients and families, failure to involve families in treatment plan and lack of training skills and commitment of staff. These barriers, if overcome would result in better management and prevention of this widespread problem and its ill effects.

CONCLUSION AND FURTHER RESEARCH The focus of this chapter has been on the evidence for a link between substance use and suicidal behaviour, as well as on the possible factors that may mediate this relationship and suggestions on suicide prevention and intervention specifically for substance abusers. While the relationship between substance use and suicidal behaviour has been established beyond doubt, there still remains ambiguity about several aspects of this relationship. Methodological limitations in studies have resulted in a lack of consistency among them, which makes it difficult to generalise the findings. For instance, studies do not always distinguish between the different forms of suicidal behaviour or between the levels of severity of substance use. Studies are also often limited by the fact that alcohol 247

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and drugs are frequently both used together, which makes it difficult to disentangle their independent contribution. And finally, most such studies, relying on psychological autopsies and self-reports, may be limited by the personally sensitive nature of the issue of suicide as well as substance use; information may be withheld because of the illicit nature of these behaviours or to avoid social undesirability. Some areas of exploration for future research could be to study the variables that link the two behaviours either as mediating causal factors, or as moderating factors that influence the relationship between substance use and suicidal behaviour. It may be interesting to study the interplay between these different biological, personality, cognitive and psychosocial variables, along with demographic variables, in determining the risk for suicide. Does the risk of suicidal behaviour increase because of such associations? Other research questions that must be addressed are whether the different substances of abuse are associated with differential risk for suicidal behaviour and whether these associations are causal or merely correlational.

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Suicide Risk in Bipolar Disorder Maurizio Pompili, Marco Innamorati, Enrica De Simoni, Ilaria Falcone, Gaspare Palmieri, Laura Sapienza and Roberto Tatarelli

B

ipolar disorders (BD) are of particular public health significance as they are prevalent, severe and disabling. A review of the literature, published between 1988 and 2002, indicated that the lifetime prevalence rate of DSMIII or DSM-III-R diagnosed bipolar I (BD-I) and bipolar II (BD-II) in the population of the United States, the Netherlands and Hungary was 0.8–3.0, 0.2–2.0, and 4.4–15.8, respectively (Rihmer and Angst, 2005). Miklowitz and Johnson (2006), using data from the National Comorbidity Survey replication, estimated a lifetime prevalence rate of 3.9 percent for BD-I and BD-II (Kessler et al., 2005). However, prevalence of BDs much depends on the different criteria for diagnosis used in the different studies; including subsyndromal forms and using a BD spectrum dramatically increases the prevalence rates (Akiskal, 1996; Faravelli et al., 2006; Judd and Akiskal, 2003; Pompili et al., 2006; Rihmer and Angst, 2005). Research indicates that when subthreshold hypomania (i.e., subthreshold BD-II) is also considered, the combined lifetime prevalence of BD-I and BD-II disorders is more than 5 percent (Rihmer and Angst, 2005). Women and men are equally likely to develop BD-I, although women report more episodes of depression than men and, correspondingly, are more likely to meet or resemble the criteria for BD-II (Leibenluft, 1997; Schneck et al., 2004). 256

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The National Comorbidity Survey replication study reported that the median age of onset for BD was 25 years. Approximately 25 percent of patients had onset by age 17. The onset of BD appears to be occurring at a younger age with successive birth cohorts (Rice et al., 1987; Ryan et al., 1992; Wickramaratne et al., 1989). BD is often associated with elevated risks of premature mortality (Muller-Oerlinghausen et al., 2002), adverse outcomes of medical disorders, accidents and complications from comorbid substance use disorders. However, the major source of premature mortality in BD patients is suicide (Ahrens et al., 1995; Harris and Barraclough, 1997; Rihmer, 2005; Tondo and Baldessarini, 2005; Tondo et al., 2003). The risk of suicide is approximately 400–1400/100,000/year (about 0.9 percent/ year), or 25–90 times higher than the general population rate of 0.015 percent/year (Baldessarini, Pompili and Tondo, 2006a; Baldessarini et al., 2006; Tondo and Baldessarini, 2005; Tondo et al., 2003). Suicide accounts for 15–20 percent of deaths among BD patients (Baldessarini, Pompili and Tondo, 2006a; Baldessarini et al., 2006; Goodwin and Jamison, 2007; Tondo and Baldessarini, 2005). In a 40-year follow-up of 406 BD-I and BD-II patients admitted to the University Psychiatric Hospital of Zurich between 1959 and 1963, 11 percent of the patients committed suicide (Angst et al., 2005). As many as 50 percent of people with BD attempt suicide during their lifetime (Jamison, 2000). According to Akiskal (2007), the higher prevalence of suicide risk and acts among BD patients is due to the fact that BD-II accounts for 30–58 percent of all major depressions in psychiatric practice (versus a 5 percent prevalence of BD-II spectrum in the general population). Mixed states are very common in the BD-II spectrum even though the term mixed refers to mania and not hypomania. The cyclothymic temperament is the most prevalent temperament in BD-II. Rapid mood shifts are the hallmark of BD-II, and BD-II suicides are the most lethal—they use the most aggressive methods.

Bipolar depression We combined data from four studies (Isometsa et al., 1994; Rouillon et al., 1991; Tondo et al., 1998; Valtonen et al., 2005) and found that most 257

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suicides and suicide attempts (78–89 percent) occurred during times of major depression (pure or mixed depression), about 0–7 percent during the euthymic phase and 11–20 percent during the dysphoric (mixed) mania phase. The most robust short-term predictors of completed suicide are a strong wish to die, suicidal ideation or plans, the communication of suicide intent during depression and having few reasons for living (Hawton and van Heeringen, 2000; Isometsa et al., 1994; Oquendo et al., 2000). BD depressives with a history of suicide attempts have a more severe symptomatology in general, report more hopelessness, selfblame, guilt and current suicidal ideation, and have more aggressive/ impulsive personality traits than non-suicidal BD depressives (Bulik et al., 1990; Fagiolini et al., 2004; Leverich et al., 2003; Lopez et al., 2001; Oquendo et al., 2000, 2004). Recently, it has also been demonstrated that mixed depressive episodes (major depression plus three or more hypomanic symptoms, which is twice as common in BD-II depression than in unipolar depression [Benazzi, 2006] or agitated depression), that are greatly overlapping (almost identical) conditions (Akiskal and Benazzi, 2003; Akiskal et al., 2005; Benazzi et al., 2004; Maj et al., 2003), also increase the risk of all forms of suicidal behaviour in both unipolar and BD patients (Akiskal et al., 2005). Patients with mood disorders who exhibit volatile and erratic moods associated with dysphoria and agitation or who present the classic mixed states are at particularly high suicide risk. Akiskal et al. (2005) investigated the clinical and familial characteristics of patients with agitated and non-agitated unipolar depression. They found that depressive mixed states, distractibility, racing/crowded thoughts, talkativeness, weight loss, suicidal ideation and a familiy history of BD-II in first degree relatives were significantly more common in agitated than in non-agitated patients with unipolar depressive disorders, supporting the bipolar nature of agitated unipolar depression. Among the depressive mixed symptoms, they found an association between suicidal ideation, psychomotor activation and racing thoughts. A forward stepwise logistic regression found that agitated depression was predicted by depressive mixed states, talkativeness and suicidal ideation as the independent, significant, positive predictors. Suicidal behaviour in BD patients is not restricted exclusively to depressive episodes. Out of the 576 consecutively admitted BD-I manic 258


patients, 51 (9 percent) had suicidal ideation at admission, including 13 patients (3 percent) who attempted suicide during the index episode (Sato et al., 2004). However, if a distinction is made between dysphoric (mixed) and pure mania, it has been found that 26–55 percent of patients with mixed (dysphoric) mania had current suicidal ideation, in contrast to 2–7 percent of patients with pure mania (Dilsaver et al., 1994; Sato et al., 2004; Strakowski et al., 1996). A detailed analysis of the psychatric history of 31 consecutive suicide victims with BD-I showed that, in the vast majority of cases, the suicide occurred during a major depressive episode, and only in a few cases (11 percent) did it occur during a mixed (dysphoric) mania (Isometsa et al., 1994). Fiedorowicz et al. (2008) studied suicidality in participants with major affective disorders in the National Institute of Mental Health (NIMH) Collaborative Depression Study (CDS) who were followed prospectively for up to 25 years. A total of 909 participants meeting prospective diagnostic criteria for major depressive and BD were followed through 4,204 mood cycles. Suicidal behaviour was defined as suicide attempts or completions. Mixed-effects, grouped-time survival analysis assessed the risk of suicidal behaviour and the differential effects of risk factors for suicidal behaviour by polarity. In addition to polarity, the main effects of age, gender, hopelessness, marital status, prior suicide attempts and active substance abuse were modelled, with mood cycle as the unit of analysis. These authors found that, after controlling for age of onset, there were no differences in prior suicide attempts by polarity although bipolar participants had more prior severe attempts. During follow-up, 40 cycles ended in suicide and 384 cycles contained at least one suicide attempt. Age, hopelessness and active substance abuse, but not polarity, predicted suicidal behaviour. They concluded that the effects of risk factors did not differ by polarity. Valtonen and colleagues (2005) investigated the incidence of suicide attempts in different phases of BD as a part of a naturalistic, prospective, 18-month study representing psychiatric inpatients and outpatients with DSM-IV BD. These authors found that, compared to the other phases of the illness, the incidence of suicide attempts was 37-fold higher (95 percent confidence interval [CI] for relative risk [RR]: 11.8–120.3) during combined mixed and depressive mixed states, and 18-fold higher (95 percent CI: 6.5–50.8) during major depressive phases. In Cox’s proportional hazards regression models, combined mixed (mixed or 259


depressive mixed) or major depressive phases and prior suicide attempts independently predicted suicide attempts. No other factor significantly modified the risks related to these time-varying risk factors; their population-attributable fraction was 86 percent. These data indicate that the incidence of suicide attempts varies remarkably between illness phases, with mixed and depressive phases involving the highest risk by time. Time spent in high-risk illness phases is likely the major determinant of overall risk for suicide attempts among BD patients.

Substance abuse BD is often comorbid with substance abuse disorder (Baldessarini, Pompili and Tondo, 2006a; 2006b). In the Epidemiologic Catchment Area (ECA) study of substance abuse, Regier et al. (1990) found high lifetime prevalence rates of substance abuse or dependence in individuals with BD. These authors estimated that up to 56 percent of the subjects with BD had substance abuse or dependence and 44 percent had some type of alcohol-related diagnosis. People with dual disorders are best served when common aetiology, risk factors and treatments are assumed for the combined syndrome. Individuals with dual disorders frequently have their psychiatric symptoms misunderstood in substance abuse programmes or their substance abuse problems ignored at mental health centres. Substance abuse or dependence is associated with a higher suicide risk (Harris and Barraclough, 1997; Pompili, Lester et al., 2007). The comorbidity between two disorders both of which are associated with increased suicide risk is often the mixture that precipitates the suicide. Substance abuse mediates increased suicide risk by determining poorer outcome. Some of the factors that predispose to poorer outcome are listed in Table 12.1. Substance abuse may also result in a number of impairments that contribute to suicide risk such as worse cognitive performance, impairment of working memory, verbal learning and memory deficits, and lack of appropriate orientation engaging in problem-solving (Pompili, Lester et al., 2007). Akiskal et al. (2003) reported that, compared to non-cyclothymic BD-II patients, cyclothymic BD-II patients reported significantly more lifetime 260

Suicide Risk in Bipolar Disorder Table 12.1â•… Factors Contributing to Increased Suicide Risk in Cases of Comorbid Substance Abuse Disorder and Bipolar Disorder        

Earlier onset Several relapses Treatment non-adherence and more side effects from treatment Poor response to medication More hospitalisations Increased risk for violence Increased medical costs Dysphoric-irritable mixed states

Source: Authors.

suicide attempts (49 percent versus 38 percent) and had more current hospitalisations for suicidal risk (61 percent versus 50 percent). During a 2–4 year prospective follow-up of 80 juvenile inpatients with a current major depressive episode, having a cyclothymic-sensitive temperament at baseline, significantly predicted not only the bipolar outcome but also suicidal behaviour during the follow-up. Among these young patients 81 percent of those with a cyclothymic-sensitive temperament had at least one episode of suicidal ideation or attempt versus 36 percent of subjects without such a temperament (Kochman et al., 2005). Investigating the affective temperament profiles of 150 non-violent suicide attempters (121 of them with a current major depressive episode) and 717 healthy controls, research (Rihmer et al., 2007) indicated that, compared to controls, suicide attempters scored significantly higher on four of the five affective temperaments (depressive, cyclothymic, irritable and anxious temperaments). On the other hand, no significant difference between the suicide attempters and controls was found for the hyperthymic temperament. Maser et al. (2002) investigated temperament in completed suicides and attempted suicides. They found that attempters and completers shared core characteristics: previous attempts, impulsivity, substance abuse and psychic turmoil within a cycling/mixed BD. The temperament traits of impulsivity and assertiveness were the best prospective predictors of completed suicides beyond 12 months with a sensitivity level of 74 percent and specificity level of 82 percent. Pompili, Rihmer et al. (2008) investigated 150 psychiatric inpatients with BD-I, BD-II, Major Depressive Disorder (MDD) and psychotic disorders for temperament, personality traits and suicide risk. The patients 261


were administered the Temperament Evaluation of Memphis, Pisa, Paris and San Diego autoquestionnaire-Rome (TEMPS-A-Rome), the Minnesota Multiphasic Personality Inventory, 2nd edition (MMPI-2) and the Beck Hopelessness Scale (BHS) and evaluated for suicide risk through the critical items of the Mini International Neuropsychiatric Interview (MINI). Irritable temperament and social introversion were the strongest predictors of suicide risk, and the hyperthymic temperament appeared to be a protective factor both for hopelessness and suicide risk. Previous research has led to the hypothesis that patients with white matter hyperintensities in the brain may be at higher risk for suicide because of possible disruption of neuroanatomic pathways (Taylor et al., 2001). Mood regulation depends on the complex system composed of the prefrontal cortex, amygdala-hippocampus complex, thalamus, and basal ganglia and the extensive connections between these areas (Soares and Mann, 1997). Lesions in one specific part or disruption of interconnections can result in malfunctions in other areas. Mood regulation abnormalities could confer a biological vulnerability which, in combination with environmental stressors, results in suicidal behaviour. The aetiology of white matter hyperintensities with respect to suicidality and mood disorders could be hypoxic-ischemic insults during birth which are especially common in premature infants. Perinatal white matter lesions represent damage of association-commissural and projection fibres and may lead to disturbances in the organisation and use of neural systems (Judas et al., 2005; Peterson, 2003). Pompili and colleagues (Pompili, Ehrlich et al., 2007, Pompili, Innamorati et al., 2008) conducted two studies on inpatients with MDD or BD. The authors found an increased prevalence of white matter hyperintensities in adults with major affective disorders and a history of suicide attempt, compared to similar patients without such a history. In the most recent study (Pompili, Innamorati et al., 2008), the presence of periventricular white matter hyperintensity was robustly associated with suicidal behaviours even after controlling for age (odds ratio: 8.08).

Suicide attempts Attempted suicide, particularly in the case of BD, is one of the most powerful clinical predictors of repeated attempts (Oquendo et al., 2004; 262


Slama et al., 2004) and of completed suicide (Goodwin and Jamison, 2007; Hawton and van Heeringen, 2000; Isometsa et al., 1994). About one-third of BD patients have a lifetime history of one or more suicide attempts (Table 12.2), and up to 56 percent of suicides with BD have made at least one prior suicide attempt (Goodwin and Jamison, 2007; Isometsa et al., 1994; Romero et al., 2007). Table 12.2â•… A Check-list of Risk Factors for Suicidal Behaviour in Bipolar Disorder Risk factors

Protective factors





               

Early in the course of illness Younger age Depressive, mixed dysphoric-irritable states Caucasian ethnicity Unmarried Previous depression Previous dysphoric-agitated states

     

Good family and social support Pregnancy Post-partum period Children at home Holding strong religious belief Adherence to pharmacotherapy Participation in psychoeducation programmes

Hopelessness Prior suicide attempts Substance or alcohol abuse Impulsivity Poor compliance with treatment Stressful life events Childhood sexual/physical abuse Current suicidal ideation Limited access to support or clinical services Family history of suicide

Source: Authors.

The general population ratio of suicide attempts to completed suicides varies with such factors as age, sex, ethnicity, comorbid conditions and the accuracy of case identification, especially for suicide attempts of varied severity and potential lethality (Tondo and Baldessarini, 2005). Given these caveats, this ratio among BD patients may be as low as 3 (Carlson et al., 1974), and averages about 5 (Tondo et al., 2003). This ratio is much lower than that for the general population, in which the ratio of attempts/suicides is typically 10, as high as 25 in the United States, and averages about 16 internationally (Tondo et al., 2003; WHO, 2003). Baldessarini, Pompili and Tondo (2006a) recently reviewed 60 published studies of the risk of suicide attempts among more than 70,000 263


persons with mood disorders. The annual risk of suicide attempts was approximately 4.2 percent per year among patients with BD, suggesting that the great majority of such patients may make at least one attempt in their lifetime. The risk of an attempt was not significantly higher among those with BD as compared with those with depressive or unspecified mood disorders. In patients with major affective disorders, attempted suicide is the most powerful predictor of future completed suicide (Cheng et al., 2000; Gibb et al., 2005; King et al., 2001; Rihmer, 2005; Suominen et al., 2004). Considering the 10 studies (including a total of 3,187 patients) in which unipolar, BD-I and BD-II patients were analysed separately, it has been found that the lifetime rates of suicide attempts in unipolar, BD-I and BD-II patients were 13, 26 and 33 percent, respectively (Rihmer, 2005). Community-based epidemiological studies from the United States (Chen and Dilsaver, 1996; Kessler et al., 1999) and from Hungary (Szadoczky et al., 2000) have shown that the lifetime rate of prior suicide attempts was 1.5 to 2.5 higher in bipolar than in unipolar patients. Grunebaum et al. (2006) studied patients with BD for the presence or absence at baseline evaluation of a history of suicide attempt. The regression analysis showed that a history of suicide attempts in BD patients was associated with recent suicidal ideation, more psychiatric hospitalisations, lifetime aggressive traits and an earlier age at onset of a first mood episode. Investigating the frequency of current suicidal ideation in 605 unipolar major depressives, 103 bipolar II and 81 bipolar I depressives a recent study from Italy found that 16.5 percent of patients were actually suicidal, and the bipolar/unipolar risk of suicidality was 2.2 (Tondo et al., 2008).

Treatments for suicide in BD patients Lithium and Mood Stabilizers In a large population-based sample of more than 20,000 persons treated for BD, Goodwin et al. (2003) found that risk of attempted or completed suicide was 1.5 to 3 times higher during periods of treatment with divalproex than during periods of treatment with lithium. This difference in risk 264


was consistent across all outcome measures (suicide, a suicide attempt resulting in hospitalisation, and a suicide attempt treated in the emergency room—ER) and across the two study sites. Results for carbamazepine were qualitatively similar to those for divalproex but (reflecting the smaller sample size) much less precise. A recent, comprehensive meta-analysis of studies of lithium adds additional support to the impression that lithium has major beneficial effects against both suicide and suicide attempts and that these effects are found consistently across almost all trials reported over the past three decades, including trials involving randomisation and double-blind assessments (Baldessarini et al., 2006). This larger analysis considered a total of 45 reports involving 53,472 patients with BD or more broadly defined manic-depressive disorder (including unipolar recurrent major depressive and schizoaffective disorder) treated and evaluated for an average exposure of nearly 348,000 patient-years with or without lithium. Risks for both completed suicide and suicide attempts were reduced by nearly fivefold, or 80 percent. The US Food and Drug Administration (FDA, 2008) analysed reports of suicidality (suicidal behaviour or ideation) from placebo-controlled clinical studies of 11 drugs used to treat epilepsy as well as psychiatric disorders and other conditions. These drugs are commonly referred to as antiepileptic drugs. In the FDA’s analysis, patients receiving antiepileptic drugs had approximately twice the risk of suicidal behaviour or ideation (0.43 percent) as compared to patients receiving a placebo (0.22 percent). The increased risk of suicidal behaviour and suicidal ideation was observed as early as one week after starting the antiepileptic drug and continued for 24 weeks. The results were generally consistent among the 11 drugs. Patients who were treated for epilepsy, psychiatric disorders and other conditions were all at increased risk for suicidality when compared to a placebo, and there did not appear to be a specific demographic subgroup of patients to which the increased risk could be attributed. The relative risk for suicidality was higher in the patients with epilepsy compared to patients who were given one of the drugs for psychiatric or other conditions.â•¯ A growing number of anticonvulsants have demonstrated antimanic efficacy and are occasionally studied for possible long-term moodstabilising effects in patients with BD. Most of these agents remain largely unexamined for possible beneficial effects on suicidal behaviour. Yerevanian et al. (2007b) studied 405 veterans with BD followed for a mean of 3 years treated with lithium, divalproex and carbamazepine 265


monotherapies. These authors found that the three anticonvulsants showed similar benefits in protecting bipolar patients from non-lethal suicidal behaviour when careful analysis of clinical data was done to confirm medication adherence/non-adherence. The authors observed that there was a 16-fold increase in the non-lethal suicidal event rate after discontinuation compared with mood-stabiliser monotherapy.

Antidepressants Despite controversies in the involvement of antidepressant agents in the management of bipolar disorders, during acute depressive phases these agents can offer a valid therapeutic option (Henry and Demotes-Mainard, 2006), especially for BD-II (Amsterdam and Brunswick, 2003). To some extent, the lack of demonstrated effectiveness of antidepressant treatment in reducing suicide risk in some studies may reflect continuing low rates of closely supervised antidepressant treatment, particularly in young men, and inadequate dosing and duration of sustained treatment for many depressed patients (Baldessarini, 2006), as well as misdiagnosis of BD as unipolar depression and using antidepressant monotherapy in patients with unrecognised underlying bipolarity which is the one of the major sources of treatment-resistance and ultimately the worsening of depression (Inoue et al., 2006; O’Donovan et al., 2008; Sharma et al., 2005). Alternatively, suicidal behaviour may require more than depressed mood, and the relevant factors (possibly including elements of anger, aggression and impulsivity) may not be ameliorated by antidepressant treatment (Baldessarini et al., 2005). Moreover, in some vulnerable patients, mixed dysphoric-agitated states in BD can be induced by antidepressant monotherapy (unprotected by mood stabilisers or atypical antipsychotics/benzodiazepines). This may not be recognised clinically and thus not accurately differentiated from worsening depression (Akiskal and Mallya, 1987; Inoue et al., 2006; O’Donovan et al., 2008). Such states, as well as other adverse behavioural responses to antidepressant treatment (such as insomnia, restlessness, irritability, agitation and mixed states), in patients with mood disorder may well increase the risk of aggressive-impulsive acts, including perhaps suicidal behaviour in some adults and children, and such responses may be particularly likely among BD patients in depressive or mixed states (Baldessarini et al., 2005; O’Donovan et al., 2008). 266


Antipsychotics Among the various antipsychotics, clozapine has been reported as an antisuicidal agent in several studies (Hennen and Baldessarini, 2005), including an important randomised trial comparing clozapine with olanzapine (Meltzer et al., 2003). Despite insufficient proof of reduction in mortality and limitation only to the treatment of patients with chronic psychotic disorders (schizophrenia or schizoaffective disorders), this drug is the first treatment of any kind to receive regulatory approval by the FDA for reducing the risk of suicidal behaviour, a precedent-setting development. Clozapine treatment involves, like lithium prophylaxis, close medical supervision and regular blood testing to minimise the risk of potentially lethal side effects. Such procedures increase the levels of patient’s interaction with medical personnel which has been reported as a contributor factor for preventing suicide. A recent study by Yerevanian et al. (2007a) involving 405 bipolar patients demonstrated a higher risk of suicidal behaviour associated with antipsychotic treatment, compared with mood-stabiliser monotherapy. There was a nearly 10-fold greater risk of non-lethal suicidal behaviour during antipsychotic monotherapy compared with mood-stabiliser monotherapy, with intermediate risk during mood stabiliser + antipsychotic treatment periods. It is therefore suggested that clinicians who add antipsychotics to mood stabilisers to treat breakthrough (hypo)mania in BD patients should keep their patients on this supplementary medication for as short a time as possible since antipsychotics (particularly in longer use than needed) may increase the switch from (hypo)mania into depressive/mixed states and, therefore, increase the risk of suicidal behaviour.

Electroconvulsive Therapy (ECT) A study by Prudic and Sackeim (1999) found that ECT responders and non-responders showed a large decrease in scores on the suicide item of the Hamilton Rating Scale for Depression, and this decrease was greater than the average improvement on other items. This would confirm that some of the therapeutics available for psychiatric disorders may not have a real impact on symptoms but can have an independent effect on suicide risk. ECT is reported as being the most effective and rapid treatment for 267


emerging or ongoing suicidality in severe depressive illness and has been considered to be the treatment of choice in emergency situations involving high suicide risk (‘Consensus conference. Electroconvulsive therapy’, 1985; Weiner, 2000). However, the effectiveness of ECT for sustained suicide prevention has not been proven and requires further study, including in patients with BD (‘Practice guideline for the assessment and treatment of patients with suicidal behaviors’, 2003).

Psychosocial Interventions Recently, several effective psychosocial interventions for BD have been developed (including psychoeducation, cognitive-behavioural therapy, and interpersonal and social rhythm therapy) (Fountoulakis et al., 2008), primarily for noncompliant, drug-intolerant and drug-nonresponsive patients. These strategies may be effective alone, but are used mostly in combination with mood stabilisers (Bauer, 2001; Rucci et al., 2002). Since they are designed for relapse/recurrence prevention, these interventions might have efficacy for suicide prevention as well. However, at present, there is only one published study concerning the effect on suicidality of intensive psychosocial treatment that specifically targeted suicidality in BD. Rucci et al. (2002) investigated the lifetime rates of suicide attempts among 175 BD-I patients during a 2-year period of intensive pharmacotherapy (lithium, valproate, carbamazepine) and one of two adjunctive psychosocial interventions (either interpersonal and social rhythm therapy, which is a psychotherapy specific for BD, or intensive clinical management, which is a nonspecific psychosocial intervention). In addition to receiving mood stabilisers, patients were randomly assigned to treatment with one of the two psychosocial interventions. Forty-seven patients did not complete the acute phase, and 20 failed to complete the 2-year long maintenance phase. Before entry into the study, the rate of suicide attempts per 100 patient-months was 1.05. However, during the acute and the 2-year maintenance phase, the rates were 0.31 (a 3.4-fold reduction) and 0.06 (a 17.5-fold reduction), respectively (both differences were significant). Patients receiving psychotherapy specific for BD showed 3.7-fold lower frequency of suicide attempts during the maintenance phase than those receiving nonspecific intensive clinical management (0.07 versus 0.26 attempt per 100 patient-months, respectively, 268


a significant difference). Before the patients entered the protocol, 50 patients had made 72 suicide attempts, but none of them attempted suicide during the acute and maintenance phase of the study. The combined rate of suicide attempts per 100 patent-months during the acute and maintenance phase was 0.17, which is a six-fold reduction when compared with the pre-treatment period. The findings suggest that disorderspecific psychotherapy might be more effective than nonspecific clinical management in augmenting the effect of long-term treatment with mood stabilisers in BD-I patients.

Conclusions This comprehensive update supports the emerging conclusion that BD is a highly prevalent, often severe, sometimes disabling, and potentially fatal illness. It is associated with a very high risk of suicide, especially early in the illness when sustained clinical interventions, and even the diagnosis, may not have been established, and suicidal risk continues over many years, eventually accounting for perhaps 15 percent of deaths. The epidemiology of suicide risk in BD, specifically, is methodologically limited and has often been confounded by a lack of separation of BD-I and BD-II from each other, or from recurrent major unipolar depressive illnesses. The depressive and dysphoric-agitated mixed phases of BD, particularly following repeated episodes of severe depression, appear to be especially dangerous and life threatening, as well as being particularly challenging to diagnose and treat effectively and safely (Marneros et al., 2004). BD also is associated with very high rates of comorbid substance-use and anxiety disorders (Krishnan, 2005), as well as impulsivity, lack of insight and poor treatment-adherence, all further complicating the effective clinical care of such patients and probably adding to their suicidal risk. Rucci et al. (2002) found a consistent reduction in suicide attempt risk associated with a combination of pharmacotherapy (mostly lithium) and either a highly-structured psychosocial treatment designed specifically for individuals with BD-I or a more general supportive intervention offered in the context of a research clinic environment geared towards optimal care of patients with this condition. This reduction was more pronounced during the maintenance phase than during the acute phase. 269


Preliminary evidence suggests that intensive clinical management or psychotherapy adds to the effect of lithium or other appropriate pharmacotherapy. Short-term interventions that are widely accepted empirically for managing acute suicidality include close clinical supervision, rapid hospitalisation and use of ECT. However, there is little evidence that various types of clinical interventions, including specific mood-altering medical treatments and widely accepted psychosocial therapies, have long-term effectiveness in reducing suicidal risk in BD patients. Lithium maintenance treatment appears to be a unique exception in having considerable research support for a sustained reduction in the suicidal risk in persons with BD and possibly other forms of major affective illnesses, including demonstrated reductions in mortality. Anticonvulsant and atypical antipsychotic agents, as well as the less toxic modern antidepressants, all require specific research assessment of their long-term ability to limit premature mortality from all causes in BD and other major affective disorders, and specifically to reduce suicidal risk. Interventions such as social skills training, vocational rehabilitation and supportive employment are, therefore, very important in the prevention of suicide in patients. Broadly speaking, these kinds of therapies focus on working out daily problems rather than achieving psychological insight. It has become increasingly clear that supportive, reality-oriented therapies are generally of great value in the treatment of patients with BD. In particular, supportive psychotherapy aims at offering the patient the opportunity to meet with the therapist and discuss the difficulties encountered in daily activities. Patients are, therefore, encouraged to discuss concerns about medications and side effects as well as social isolation, money, stigma, etc. The therapist has an active role as he or she gives suggestions and shares good and bad periods empathically. The nature of these treatments and their availability vary greatly from place to place.

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277

13

Depression and Suicide EòA S«A½½Ù AÄ MAÄ¥Ù WÊ½¥ÙÝÊÙ¥

W

ithout any doubt, major depressive disorder is one of the most common psychiatric disorders worldwide. Furthermore, compared to other psychiatric disorders it is associated with the highest suicide risk. The lifetime prevalence for mood disorders in the newer World Mental Health Surveys (Kessler et al., 2007; Wittchen et al., 1999) is currently between 3.3 and 21.4 percent. The impact of depression on life quality is comparable with that of severe physical diseases. The comorbidity quota with other psychiatric disorders, for example, addiction, anxiety disorders, somatoform disorders, as well as physical diseases, is high. At present it is known that, on the one hand, it is depressive mood within psychiatric and physical diseases, on the other hand, it is major depression which are the primary affective disorders that lead to suicide rather than other psychiatric disorders (Bertolote et al., 2004; Harris and Barraclough, 1997, 1998; Schneider, 2003; Wolfersdorf, 2002, 2008). In this context, it becomes understandable that the current WHO/EU-health care policy points out the importance of depression prevention as well as prevention of suicidal behaviour and declares them as major topics of European and worldwide health policy. Depressive mood, feelings of worthlessness and insufficiency, guilt and hopelessness, lack of perspective, agonising states of uneasiness as well as mental and emotional pressure make patients suffering from major

278

Depression and Suicide

depression a high-risk group for suicidal behaviour (Haenel and Pöldinger, 1986; Hole, 1973; Sainsbury, 1986; Wolfersdorf et al., 1992, 2002). Suicidal tendency is defined as the sum of all ways of thinking and behaving that include the ambition to die or the acceptance of death due to risky behaviour. To this also belong active suicidal behaviour and the forbearance of activities to keep oneself alive (Wolfersdorf, 2002, 2008). Suicidal tendency therefore can be discussed as a human way of thinking and behaving but not as an illness itself. Griesinger (1845) described suicidal behaviour as ‘… not always the symptom or result of a psychiatric disorder but also due to a tiredness of life dependent on external circumstances’. Therewith he already made an essential distinction between suicidal tendencies as an expression of a life crisis, for example, reactive-depressive stress disorder on the one hand and suicidal tendency in the context of a psychiatric disorder on the other hand.

MENTAL DISORDERS AND SUICIDE: AN OVERVIEW Psychiatric disorders are: next to acute psychosocial stresses and strains, former suicide attempts and consequently fewer inhibitions concerning suicide, as well as physical diseases accompanied by heavy pains and suffering, the most important risk factor for suicidal behaviour. According to Harris and Barraclough (1998), suicide mortality in patients suffering from major depression is increased by a factor of 21, with politoxicomania 13, with bipolar affective disorders 12 and with dysthymia by a factor of approximately 12 compared to the general population. Bertolote and colleagues (2004) recently pointed out the important role of psychiatric disorders for suicidal tendencies. In the general population, affective disorders clearly dominate with a prevalence of 44 percent, followed by addiction with a prevalence of 19 percent and schizophrenia with 7.5 percent. By contrast, with inpatients, affective disorders account for 21 percent, followed by schizophrenia with 20 percent. This represents the current knowledge that in the context of inpatients, young schizophrenic men are at a similar risk to commit suicide in a psychotherapeutic setting as patients suffering from major depressive disorder (Morgan and Stanton, 1997; Roy, 1984; Wolfersdorf, 1989). 279

Eva Schaller and Manfred Wolfersdorf

In Table 13.1, all psychological autopsy studies with the focus on affective disorders of which we are aware are listed. Both the large percentage of men as well as the numerous occurrences of affective disorders, which are between 30 and 100 percent in suicidal tendencies and behaviour, clearly appear in all studies. Harris and Barraclough (1997) found a standard mortality rate (SMR) of 1,209 for psychiatric diseases, 2,035 for major depression, 1,505 for bipolar affective disorders and 1,210 for dysthymia. According to these figures, major depression seems to bear the highest suicide mortality rate among all affective disorders. Within a group of 479 people who died from suicide in southern Germany, Wolfersdorf, Faust and Hölzer (1992) found 36 percent suffering from the beginning of a depressive episode, another 27 percent at the point where the depressive episode was fading away, and within about one-third of all suicides, typical depressive symptomatology could be diagnosed. Kung, Pearson and Lin (2003) reported on the results of the National Mortality Followback Survey in the United States. In a group of men aged between 45 and 64 years and in women of all age groups, they found depressive symptomatology significantly higher in suicides compared to the control group. Cheng (1995) examined suicides, looking for presuicidal risk factors. They identified the following risk factors: loss events, suicidal behaviour in first degree relative, major depressive episode to International Classification of Diseases 10 (ICD-10) within 87.1 percent, emotionally instable personality disorder within 61.9 percent and substance dependencies within 27.6 percent (comparison of 113 suicides with 226 controls). Also in the European Study on the Epidemiology of Mental Disorders (ESEMED), Bernal and colleagues (2007) investigated in total 21,425 people from Belgium, France, Germany, Italy, the Netherlands and Spain for suicidal tendency in the quest for risk factors. Suicide attempts were found to be most common among patients suffering from general anxiety disorders (12 percent), followed by alcohol dependence (12 percent), major depressive disorder (8 percent) and dysthymia (10 percent), as well as PTSD (11 percent). Hall and Platt (1999) found major depressive episodes in 43 percent of analysed suicide attempts, followed by adjustment disorders with anxiety and depression (15 percent), anxiety disorders (10 percent) as well as schizophrenia (2 percent). Mann, Waternaux, Haas and Malone (1999)

280

Robins et al. (1959) Dorpat and Ripley (1960) Barraclough and Pelles (1975) Beskow (1979) Chynoweth et al. (1980) Mitterauer (1981) Rich et al. (1986) Arato et al. (1988) Shaffi et al. (1988) Runeson (1989) Asgard (1990) Petronis et al. (1990) Marttunen et al. (1991) Apter et al. (1993) Wolfersdorf et al. (1992) Brent et al. (1992) Henriksson et al. (1993) Lesage et al. (1994) Cheng (1995) Rhimer et al. (1995) Conwell et al. (1996) Shaffer et al. (1996) Heilä et al. (1987)

Authors/Year/ Country

134 114 100 271 135 145 283 200 21 58 104 40 53 43 454 67 229 75 116 115 141 120 1,397

77 68 53 100 63 n.a. 71 64 n.a. 72 0 30 83 n.a. 72 n.a. 75 100 62 77 80 n.a. n.a.

Male (%) n.a. n.a. n.a. n.a. n.a. n.a. n.a. 58 52 43 60 60 52 n.a. 66 39 n.a. 53 87 50 47 57 n.a.

45 30 70 45 55 n.a. 47 34 n.a. 36 35 53 23 n.a. 66 n.a. 59 40 87 16 28 n.a. n.a.

n.a. n.a. n.a. n.a. n.a. n.a. n.a. 24 n.a. 5 1 7 n.a. n.a. n.a. n.a. n.a. n.a. 0 22 1 n.a. n.a.

Affective Major depressive Bipolar disorder disorders (%) episode (%) (%)

Psychiatric Disorders, Especially Depressive Disorders and Suicide in a Community-based Study Using Psychological Autopsy

Number of suicides

Table 13.1

2 12 n.a. n.a. 4 18 6 9 n.a. 16 5 n.a. 6 n.a. 7,5 n.a. n.a. 9 7 6 16 n.a. 7 (Table 13.1 Continued)

n.a. n.a. n.a. n.a. n.a. n.a. n.a. 2 n.a. 2 20 n.a. 4 n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. n.a. 11

Dysthymia Schizophrenia (%) (%)

Number of suicides

Foster et al. (1997) 117 Appleby et al. (1999) 84 Brent et al. (1999) 140 Vijayakumar and Rajkumar (1999) 100 Phillips et al. (2002) 519 Coryell and Young (2005) 33 Bertolote et al. (2004)(meta-analyse) 19,716 Schneider et al. (2001) 163 Agoub et al. (2006) 51(suicidal ideation) McGirr et al. (2007) 156 Bernal et al. (2007) 686/159 (suicidal ideation)

Authors/Year/ Country

(Table 13.1 Continued)

36 23 48 30 66 100 30 37 45 156 45/29

81 48

156 34/13

32 n.a. n.a. n.a. 36 80 n.a. 18 24 0 n.a.

n.a. n.a. n.a. n.a. n.a. 20 n.a. 5 n.a.

Affective Major depressive Bipolar disorder disorders (%) episode (%) (%)

79 81 85 n.a. 48 45 n.a. 64 n.a.

Male (%)

0 11/16

n.a. n.a. n.a. n.a. 30 n.a. n.a. 5 21

0 n.a.

11 19 0 n.a. n.a. n.a. 14 14 n.a.

Dysthymia Schizophrenia (%) (%)


compared 184 people after suicide attempts to a control group and found no difference concerning the severity of depression or psychosis in an assessment by others, while in the self-evaluation scale (Beck’s Depression Inventory) patients reported significantly higher scores compared to the matched controls; they also reported higher scores in aggression scales, hostility scales and impulsiveness scales among patients with suicide attempts. In summary, it can be said that among psychiatric diseases, suicide risk is clearly increased, which makes them an important risk factor for suicidal behaviour.

DEPRESSION AND SUICIDE Depression and Suicidal Behaviour: Epidemiological Data In all psychological autopsy studies, major depressive disorders are the most frequent psychiatric disorders and hence form the high risk group for suicidal behaviour, while among psychiatric inpatients, it is above all young psychotic patients (Wolfersdorf, 2000). According to psychological autopsy studies, 40–60 percent of all people who died by committing suicide suffered from a primary depressive episode at the time of suicide. Lifetime suicide mortality in depression (all grades of severity) is estimated at 3–4 percent (Blair-West et al., 1997; Wolfersdorf, 2002, 2008), suicide mortality in major depression is currently between 12 and 15 percent (Guze and Robins, 1970; Miles, 1977; Wolfersdorf, 2007). In a more than 40-year long follow-up study with 406 patients suffering from affective disorders, Angst and colleagues (2005) found a standard mortality ratio (SMR) of 26.4 for the unipolar and 11.7 for the bipolar affective disorders, both significant with p < .05. Schneider, Philipp and Müller (2001) observed 280 patients with a major depressive episode for more than 5 years and found 16 suicides (5.7 percent). Coryell and Young (2005) observed 785 patients with Research Diagnostic Criteria (RDC) major depressive disorder form 1976 to 1990 and found 33 (4.2 percent) suicides.

283


Risk Factors for Suicide in Depression: Psychopathology The last two decades of suicide research were marked by the attempt to describe different risk factors for suicide to reduce the likelihood of future suicidal behaviour. Various current studies provide evidence of specific psychopathological phenomena and their meaning for acute short-term or long-term suicide prevention. By means of discriminate function analysis, Pokorny (1983) describes the following predictors: diagnoses of depression and schizophrenia, a prehistory of suicide attempts, sleeplessness and feelings of guilt. However, the predictive usefulness was low: only 35 of 67 suicides could be identified. Goldstein and colleagues (1991) investigated 1,906 patients with affective disorders and found the usual risk factors as number of former suicide attempts, occurrence of the suicide ideas per admission, frequency of bipolar disorders, male gender or outcome by discharge. But this model also did not allow a reliable identification of those who passed away by suicide later. Researchers (Steiner et al., 1992, 1993) explored the interaction between hopelessness, measured with Beck’s Hopelessness Scale and suicidal behaviour in the course of depressive illnesses within the scope of a one-year follow-up. The motive for doing so was Beck’s notice (Beck et al., 1985, 1990) that raised scores in the hopelessness scale are linked to a raised suicide risk. From a total of 62 depressed patients, two passed away by suicide in the year of follow-up and eight committed suicide attempts, so that a total of 16 percent of the whole group showed suicidal actions in the first year after inpatient therapy at a special depression unit. This reveals a clear trend, although not statistically significant. McGirr and colleagues (2007) compared depressive suicides to depressive controls without a suicide attempt (Table 13.2): significant differences were found in the suicides with regard to loss of appetite, sleeping disturbances, feelings of worthlessness and guilt, as well as suicide ideas and desires to die. According to Bernal and colleagues (2007), the risk factors for suicidal behaviour can be summarised as follows: female gender, younger age, divorced or widowed; also the existence of a psychiatric diagnosis like major depressive disorder, dysthymia, general anxiety disorder, post-traumatic stress disorder or alcohol dependency. Schneider et al. (2001) investigated psychopathological predictors which can be assigned to 16 suicides of 280 depressive patients. During a five-year follow-up they found highly 284

Depression and Suicide Table 13.2 Major Depressive Disorder and Suicide: Comparison of Depressive Suicide versus Depressive Non-suicide Controls Symptoms

Suicides (%)

Depressed mood Anhedonia/apathy Weight or appetite loss Weight or appetite gain Insomnia Hypersomnia Psychomotoric disturbance Fatigue Feelings of worthlessness/guilt Concentration or indecisiveness Thoughts of death or suicidal ideation Psychotic features

95.4 84.9 85.3 14.3 60.3 33.3 61.0 95.2 69.8 61.5 96.1 6.9

Controls (%)

OR (95% CI)

91.9 1.668 84.7 .863 68.2 2.564 (p < .05) 19.7 .834 2.371 (p < .05) .531 (p < .05) 49.4 1.583 .229 (p < .05) 53.2 2.389 (p < .01) 75.9 .493 (p < .05) 67.5 12.585 (p < .001) 2.5 1.222

Source: Adapted from McGirr et al. (2007).

significant mood congruent preoccupations and delusions (p = .008) (suicides 88 percent, non-suicides 54 percent), hypochondrical preoccupations and delusions (p = .002, suicides 37 percent, non-suicides 8 percent), severe hopelessness (p = .022; suicides 68.8 percent, nonsuicides 39.7 percent), delusions of reference (p = .06), initial insomnia (p = .02) and recurrence (p = .01). Keller and Wolfersdorf (1993) found an increased suicide risk for the existence of hopelessness; Wolfersdorf and Vogel (1987) described ‘delusional depression’ as a risk factor. In their long-term follow-up between 1976 and 1990, Coryell and Young (2005) identified that suicides were significantly more often in inpatients (p = .05), had significantly more former suicide attempts (p = .018), reported significantly more frequent hopelessness (p = .02) and in total scored higher on measurement of suicidal tendencies (p = .002). Rhimer, Rutz and Pihlgren (1995) tested suicide attempts in the forefront of completed suicide; within 48 percent of 25 suicides of depressive patients they found significantly (p < .05) more suicide attempts than with non-depressive suicides (23 percent). Also, Isometsä and colleagues (1994), Barraclough and Pelles (1975), Pokorny (1983) and Fawcett and colleagues (1987) described the impact of former suicide attempts several times. In their Finnish study, Sokero and colleagues (2003) examined 269 patients with DSM-IV diagnosis of major depression concerning suicidal tendencies, and found suicide ideas during the current period of depression in 58 percent of all patients, and actual suicide attempts by 15 percent of patients. 285


As significant risk factors for suicide ideas, they found hopelessness, alcohol abuse, poor social integration, lack of social support; as risk factors for suicide attempts they saw major depression, existing alcohol abuse, younger age and bad social adaptation. The study by Vuorilehto and his colleagues (2006) showed that 32 percent of 137 patients with DSM-IV major depressive disorder have already had suicide ideas, 17 percent reported suicide attempts in the prehistory; lifetime suicide mortality was predicted by psychiatric anamnesis as well as the existence of a comorbid personality disorder; suicide attempts were predicted most reliably by severity of depressive episode. Wolfersdorf (1989) found in a multiple prediction analysis of depressed patients who later died from suicide and depressed patients without suicidal behaviour, a common prediction value with Multiple Preanalysis (MUP) Lambda = 0.31, that is, the combination of hopelessness, depressive delusion and psychomotoric inhibition resulted in an allocation security of 31 percent for the identification of suicides. If one suicide attempt in the prehistory is added to this, allocation security protection rises to 35 percent. The existence of hopelessness, depressive delusion and a lack of psychomotoric inhibition allow the identification of about one-third of all deaths by suicide. To summarise, the comparison of non-suicidal and suicidal depressed inpatients shows significant differences: suicidal depressed patients show significantly more frequent sleeping disturbances, in particular, problems in getting to sleep, suicide attempts before stationary admission, stationary admission due to suicidal tendency, developmental disturbances in early childhood and youth as well as suicide attempts among relatives (Metzger and Wolfersdorf, 1988; Modestin and Knopp, 1988). If one looks at the data of the Weissenauer follow-up study (Steiner et al., 1993; Wolfersdorf, Steiner et al., 1990) concerning the scores in different self-judgement scales, as well as assessments by others for acquisition of depression, hopelessness or physical discomfort, non-suicidal depressive patients do not differ from the ones reporting suicide ideas, death wishes or former suicide attempts. Anxiety disorders and reduced level of self-esteem are exhibited by suicidal depressed patients at time of stationary admission; suicidal depressed patients with suicide ideas describe themselves as suffering from significantly more hopelessness, more anxious and also diminished self-esteem. Suicidal depressed patients with suicide attempts in their prehistory suffer from significantly reduced 286


self-esteem. Consequently, lack of self-esteem, hopelessness and anxiety distinguish suicidal depressives from non-suicidal depressives, besides the other risk factors mentioned earlier. Besides, well-known psychosocial risk factors such as living alone, being unmarried, divorced or widowed are to be considered especially among men, but so are unemployment or migration background. Religion on the other hand works as a significant protective factor. An interesting approach has been time-related clinical predictors of suicide, an approach in particular used by Fawcett and his colleagues (1990) as well as Coryell and Young (2005). In a group of 154 suicides, McGirr, Renaud, Séguin, Alda and Turecki (2008) found that 74.7 percent commited suicide during their primary depressive episode, 18.8 percent during the second and 6.5 percent during further episodes. At the same time, alcohol abuse as well as anxiety was reported during the index episode. Coryell and Young (2005) stated that in suicides that happen one year after a depressive episode, significantly more suicide intentions are reported than earlier occurring suicides (see Table 13.3). Table 13.3 Suicidal versus Non-suicidal Depressed Inpatients of the Weissenau Depression Treatment Unit Therapist´s Assessment at Admission (Significantly Discriminating Variables of a Patient´s Questionnaire) Non-suicidal (n = 67) Variables of the questionnaire Paranoid ideas Insomnia, especially early insomnia Suicide attempt prior to admission Admission because of suicide intent Developmental disturbances in early childhood Suicide attempts among relatives

(n) 8 42 16 5 8 1

(%) 13 63 24 8 12 2

Suicidal (n = 66) (n) 1 52 28 33 18 7

(%) 2 81 42 55 29 11

Chi ∗ ∗ ∗ ∗∗ ∗ ∗

Source: Wolfersdorf et al. (1990). Note: ∗ p ≤ .05; ∗∗ p ≤ .01.

Fawcett and his colleagues (1990) distinguished predictors for suicide in the first year after stationary treatment related to alcohol abuse, anhedonia, anxiety, concentration loss and sleeping disturbances, and later occurring suicides which distinguished themselves above all by hopelessness and suicide ideas. In addition, significant psychosocial factors for suicidal behaviour were male gender, being unmarried, separated or widowed and 287


having had previous suicide ideas or suicide intentions. Other authors (Beck et al., 1985; Keller and Wolfersdorf, 1993; Schneider et al., 2001; Wolfersdorf and Niehus, 1993; Wolfersdorf et al., 1987; Wolfersdorf, Hole et al., 1990) found hopelessness and delusional symptomatology during the index-episode significantly more often with suicide deaths.

Suicide and Bipolar Affective Disorder Bipolar affective disorders are considered as a high risk group for suicide. In their cumulative 17-year follow-up in Scotland, Sharma and Marker (1994) found a suicide rate of 16 percent in all deaths and calculated a 23 times higher suicide risk for those with bipolar illness than in the general population. In Finland, 46 of 1,297 (3 percent) suicide cases within one year were identified as having bipolar illness (Isometsä et al., 1994; Isometsä and Lonnqvist, 1997). According to our own overview (Table 13.1), there is a range of 1–22 percent, nevertheless, the majority is clearly less than 10 percent. Lönnqvist (2000) reports on psychological autopsy studies according to DSM-III criteria with data of 1–5 percent. Within suicides, the depressive episodes dominate at the time of suicide with most suicides being men. Because most of the suicides take place in a depressive or mixed manic-depressive state, most of the risk factors also apply to the depressive suicides with basic bipolar affective disorder (Dilsaver et al., 1994; Lester, 1993; Wolfersdorf et al., 2005).

The Suicidal Depressed Patient: Clinical Picture Against the background of the description of discerning factors between suicides and non-suicides made earlier, as well as the inclusion of clinical experience, the clinical, psychopathological picture of a suicidethreatened patient is outlined in Table 13.4. Thereby, cognitive symptoms, psychomotoric symptoms, physical symptoms and also the behaviour of the patient are distinguished. The typical suicide-threatened depressive patient whose suicidal actions happen quite close to acute psychopathology is depressive for the first time or has had several depressive episodes. He suffers predominantly from feelings of worthlessness, thoughts of guilt and self-depreciation, 288

Depression and Suicide Table 13.4 z z z z z z z z z

Symptoms Significantly Differentiating Suicides and Non-suicides in Studies with Depressive Disorder Patients

Severity of depression Thoughts of death, suicide ideations, threatening suicide Thoughts of worthlessness and guilt Thoughts of helplessness and hopelessness Somatic symptoms especially insomnia, fatigue and anhedonia , as well as loss of appetite and weight Disturbances of concentration or decisiveness Psychotic features (delusions, hallucinations, paranoid ideas) Comorbidity with drug or alcohol abuse/dependency, anxiety disorders, personality disorders Tendency to impulsivity and aggression

Source: Authors’ compilation from various sources (e.g., Wolfersdorf, 1995, 2000, 2007, 2008; Wolfersdorf, Steiner et al., 1990; Wolfersdorf et al. 1992; Wolfersdorf and Niehus, 1993; Wolfersdorf and Vogel, 1987).

but also altruistic ideas, for example, that it would be better for others if he was no longer there (Metzger and Wolfersdorf, 1988; Steiner et al., 1993; Wolfersdorf, 1995, 2007; Wolfersdorf and Niehus, 1993; Wolfersdorf and Vogel, 1987; Wolfersdorf, Hole et al., 1990). Lacking self-esteem, feelings of hopelessness, increasing tendency towards favouring a suicidal solution, as well as in particular cases a delusional disturbed perception, are typical for the depressive patient with a heightened suicide risk. Moreover, there are feelings of restlessness and agitation, sleeping disturbances as well as retreatment and loss of social contacts at the behavioural level (Table 13.5). It becomes clear that, in this case, it concerns the description of a heavily depressed person who shows a raised suicidal risk. If one look, however, at long-term predictors for raised suicide risk, it is not the acute clinical picture, but the aforementioned hopelessness with regard to the expected course of disease which is most important. A greater closeness to suicidal tendencies and not least insufficient or missing continuity of treatment are also crucial factors.

Suicide Prevention in Depressed Patients Primary preventive considerations predominantly deal with the health care politics field and extend from awareness programmes to de-stigmatisation, 289

Eva Schaller and Manfred Wolfersdorf Table 13.5 The Depressed Patient with Suicide Risk—Clinical Psychopathological Picture in the Presuicidal Situation

Cognitive symptoms Ideas of worthlessness Ideas of guilt and selfdepreciation Altruistic ideas (the world would be better without oneself) Lack of self-esteem Feelings of helplessness and hopelessness Narrowness of thinking Depressive delusions

Psychomotoric symptoms

Psychosomatic symptoms

Inner restlessness Agitation

Sleep disturbances, Loss of contacts insomnia and relations with others, retreat Hostility Cry for help Verbal signs of ambivalence

Behaviour

Source: Authors’ compilation from various sources (e.g., Wolfersdorf, 1995, 2007; Wolfersdorf, Steiner et al., 1990; Wolfersdorf and Niehus 1993; Wolfersdorf and Vogel, 1987).

whereas secondary preventive measures contain above all early detection, as well as outpatient, inpatient and post-stationary treatment. However, tertiary preventive approaches deal in particular with questions of relapse prophylaxis, treatment of comorbidity groups, addiction prophylaxis, pain treatment and also old people’s care. In suicide prevention the main features in establishing a good and reliable therapeutic relationship are diagnostic clarification of suicidal tendency and of the psychosocial crisis or psychopathology; caring therapeutic measures, including high frequency protective care; therapy of the basic illness by crisis intervention, adequate psychopharmacotherapy and psychotherapeutic intervention. Today, general depression treatment encompasses the pillars: psychotherapy, biological measures of treatment, sociotherapeutic-psychoeducative and occupational therapeutic elements, as well as self-help programmes and cooperation with relatives. In the treatment of acute suicidal tendency within major depressive disorder, however, alongside high frequency caring therapeutic conversation and sedating-anxiolytic psychopharmacotherapy, a crucial aspect is safeguarding measures to come through the phase of acute suicidal tendency. According to relapse-prophylactic aspects, long-term psychopharmacotherapy and psychotherapy, as well as the comprehension of relatives are important suicide-preventive factors. 290


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Sharma, R. and H.R. Marker (1994). Mortality in affective disorder. Journal of Affective Disorders, 31(22), 91–96. Sokero, T.P., T.K. Melartin, H.J. Rytsälä, U.S. Leskelä, Lestelä- P.S. Mielonen and E.T. Isometsä (2003). Suicidal ideation and attempts among psychiatric patients with major depressive disorder. Journal of Clinical Psychiatry, 64(9), 1094–100. Steiner, B., M. Wolfersdorf, F. Keller and G. Hole (1993). The relationship between hopelessness and a tendency to commit suicide in the course of depressive disorders. In K. Böhme, R. Freytag, C. Wächtler and H. Wedler (Eds), Suicidal behavior. The state of the art (pp. 769–74). Regenburg: Roderer. Steiner, B., M. Wolfersdorf and F. Keller (1992). The course of disease in delusional depressed patients. Fundamenta Psychiatrica, 6, 31–36. Vijayakumar, L. and S. Rajkumar (1999). Are risk factors for suicide universal? A casecontrol study in India. Acta Psychiatrica Scandinavica, 99(6), 407–11. Vuorilehto, M., T. Melartin and E. Isometsä (2006). Suicidal behaviour among primarycare patients with depressive disorders. Psychological Medicine, 36(2), 203–10. Wittchen, H.U., U. Müller, H. Pfister, S. Winter and B. Schmidtkunz (1999). Affective, somatoform and anxiety disorders in Germany – First results from the nationwide survey. Gesundheitswesen, 61, 216–22. Wolfersdorf, M. (1989). Suicide in psychiatric inpatients (pp. 1–297). Regensburg: Roderer. Wolfersdorf, M. (1995). Depression and suicidal behaviour: Psychopathological differences between suicidal and non-suicidal depressive patients. Archives of Suicide Research, 1(4), 273–88. Wolfersdorf, M. (2000). The suicidal patient in hospital (pp. 1–222). Stuttgart: Wissenschaftliche Verlagsgesellschaft. Wolfersdorf, M. (2002). Depression and suicide: New clinical aspects and research results. In G. Laux (Ed.), Depression 2000 (pp. 163–81). Berlin: Springer. Wolfersdorf, M. (2007). Depression and suicide prevention. In O. Elmer (Ed.), Psychotherapie affektiver Störungen (pp. 71–89). Tübingen: DGVT-Verlag. Wolfersdorf, M. (2008). Depression and Suicide. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz, 51(4), 1–8. Wolfersdorf, M. and E. Niehus (1993). Depressive inpatients and suicidal behaviour: A comparison of suicidal and non-suicidal depressives. Schweizer Archiv für Neurologie und Psychiatrie, 144(6), 575–83. Wolfersdorf, M. and R. Vogel (1987). Types of hospital suicide and depression: Some selected results of a study on suicides committed during psychiatric hospitalization. Crisis, 8(1), 37–48. Wolfersdorf, M., B. Lehle and L. Adler (2005). Bipolar affective disorders and suicide during psychiatric in-patients treatment. Archives of Suicide Research, 9(3), 261–66. Wolfersdorf, M., B. Steiner, F. Keller, M. Hautzinger and G. Hole (1990). Depression and suicide. Is there a difference between suicidal and non-suicidal depressed inpatients? European Journal of Psychiatry, 4(2), 235–52. 295


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14

The Suicidal Soldier LRÝ M«½çÃ Ä Lã« NRç¦«Ã

E

pidemiology and empirical research in the fields of mental health, the social sciences and biology have contributed to the increasing recognition of the multi-dimensional and overlapping risk factors of suicidal behaviour. It is common to include the spectrum of suicidal ideation, via deliberate self-harm with either expressed or inferred suicidal intent or suicide when using the term ‘suicidal behaviour’. Completed and attempted suicide share many common aspects: depressive and other psychiatric disorders, psychological aspects such as poorer problem-solving skills and higher levels of impulsitivity, social factors such as adversities during childhood and alcohol habits, and biological factors such as increased age. However, differences between completed suicides and attempted suicides also exist, such as increased vulnerability of the male gender for completed suicide and the female gender for attempted suicide. Understanding thus gained has been used to design national prevention strategies in the early 1990s, especially in developed nations witnessing strong increases in their suicide rates, such as Norway and Finland. Although some promising treatment approaches have been identified (Hawton et al., 2000), our knowledge of effective treatments of suicidal individuals is quite limited. Furthermore, suicide prevention directed at high-risk groups such as psychiatric patients, even if proven effective in preventing suicide among patients, is likely to have very limited impact in non-clinical populations.

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Lars Mehlum and Latha Nrugham

Collective societies such as the armed forces is a typical non-clinical arena requiring specialised suicide prevention strategies, adapted to specific challenges and needs. A collective society is one wherein the individual, more or less willingly, takes on a collective identity or, in other words, accepts himself as a part of a collective identity, with the interdependency of the parts determining the roles and functions of the parts. The goal of the collective is considered more important than personal goals which are subservient to the collective’s goals. Although, this subservience of personal goals can, by itself be stressful and threatening to personal integrity, the collective is also expected to take care of the individual’s needs at all levels. Similarly, a threat to the collective is also supposed to elicit an appropriately defensive response from the individuals. This kind of specific and complex organisation, whether formal or informal, is the hallmark of collective societies. Therefore, suicidal phenomena within a collective society, like the defence forces, needs to be dealt with differently than the rest of society. A study of US Air Force, Army, Marine Corps and Navy recruits from 1980 through 2004 revealed that overall suicide rates among military recruits were lower than those of comparably aged US civilians (Scoville et al., 2007). This is the usual finding when suicide in the military is compared with other segments of the population of the same gender and age (Hytten and Weisaeth, 1989; Mahon et al., 2005; Wasserman, 1992), including long-term (20 years) mortality of suicide attempters (Mehlum, 1994). This is probably due to what is commonly known as ‘healthy worker effect’ and is seen as the selection effect of the ruling out of many psychiatric conditions while being admitted to the armed forces and continuing health monitoring. Although US army personnel with service in Iraq had higher suicide rates than the average US army rates, it was lower than the civilian male population rate (Nelson, 2004). However, there are exceptions to this pattern in military subgroups and in certain countries. For example, a significantly increased standard mortality rate (SMR) of 1.4 was found among former peacekeepers from Norway, which only disappeared when adjusted for marital status, indicating the vulnerability of single military personnel (Thoresen et al., 2003). This study also found significant increases in suicide by firearms, as early and recent studies of suicides among active military duty personnel in the United States have, indicating the continuing importance of gun control as a prevention strategy regardless of geography (Helmkamp, 1995; Scoville et al., 2007; 298

The Suicidal Soldier

Thoresen et al., 2003). The vulnerability of male as compared to female military recruits is the same as in the rest of society (Scoville et al., 2007). Military personnel in the age range of 17 to 24 years have been found to be the most vulnerable, accounting for 48 percent of the suicides and the highest age group-specific rate (Helmkamp, 1995). It is also known that while suicide is the eighth leading cause of death in the United States, it is the third leading cause of death in its military population (Sentell et al., 1997). Suicide is also the leading cause of sudden violent deaths (deaths by unintentional injuries, suicide or homicide) (Scoville et al., 2004) which account for three-fourths of active duty military deaths (Helmkamp and Kennedy, 1996; Powell et al., 2000). Therefore, effective management of suicidal behaviour in the military has an important role to play in decreasing the overall death rate among military personnel. In this chapter, we will try to describe the emergence, maintenance and prevention of suicidal behaviour in military settings by examining environmental and individual factors, using published research and our own experiences with suicide and suicide prevention within Norwegian Armed Forces and in other nations. This examination will have three parts: risk factors, protective factors and assessment, wherein each part is composed of specific topics. Assessment of risk and protective factors will be dealt with in the environmental and individual contexts. The individuals we refer to are basic trainees, officers and veterans. We continuously use the male gender while referring to the individual as the bulk of soldiers are male. However, a section is also devoted to the nature of risks faced by the female soldier, as female soldiers are now increasing in numbers. Unless specifically mentioned as suicide attempts or suicidal ideation, we use available information on suicide in the military setting throughout this chapter. A summary of this information and knowledge will also include suggestions for effective prevention measures.

SUICIDAL BEHAVIOUR IN MILITARY SETTINGS In this section, we examine the various environmental and individual factors which contribute to suicidal behaviour among military personnel, whether as independent/solitary factors or as interacting/ 299


combining factors. For most military personnel, the armed forces serve as a total institution, comprising not only of a job and working hours, but most areas of life (Mehlum and Schwebs, 2001). As such, we discuss risk and protective factors of suicide in the military as an environment in which many soldiers spend most of their time, round the clock.

RISK FACTORS SelecƟon and Training Processes Due to the traditionally stringent requirements of military selection processes which uses several steps to ensure that the healthiest candidates are selected, persons with severe mental health problems or other vulnerabilities which might impair their functioning have little chance of getting into the military. The healthy young adults who are thus selected are then trained to become healthier and provided with support to maintain their physical, mental and social health. This means that the suicide rates within the military have often remained lower than comparable civilian populations, regardless of time and place, as stated earlier. However, exposure to certain conditions and environments may provide elevated risk levels to both basic trainees, active duty personnel and veterans resulting in increases in mental health problems and in suicidal phenomena such as suicidal ideation and suicide attempts.

Rapid Changes in Social IntegraƟon Although a high level of social integration is a protective factor of suicidal behaviour, rapid decreases in levels of social integration may result in higher suicide rates (Durkheim, 1897) as was seen among Norwegian youth in the 1980s (Mehlum et al., 1999). Rapid transitions in the immediate social environment imply a high level of uncertainty and unpredictability to which the individual must adjust. In environments where such rapid transitions are frequent and the individual has limited capacities to adjust or is not able to adjust can result in a perceived loss

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of social support, loss of face, shame and dishonour. In certain cases, this may result in the development of a feeling of being trapped without any escape routes other than suicide as a viable alternative. Such helplessness is taken up in the job demand-control model of suicide (Karasek and Theorell, 1990) and has been empirically tested among male Japanese workers in a multicentre study with supportive findings (Tsutsumi et al., 2007). The authors conclude that job redesign aimed at increased worker control could be a worthwhile strategy in preventing, or at least reducing the risk of death by suicide. The military lifestyle with frequent moves and relocations implies constant changes in the social environment which may be perceived as enriching but which may also make it difficult for usual social relationships to be developed or maintained and for family structures to survive. Among male peacekeepers, the suicidal vulnerability of being single has been documented (Thoresen and Mehlum, 2006; Thoresen et al., 2003). This vulnerability may be extended to those military personnel who are in uncertain and unpredictable work environments.

Loss of Individualism and Conformity Pressure The stamp of the collective can be so strong as to suppress individualism to an extent that the person experiences a loss of individualism. In a military setting, the uniformity expected and required may disturb the balance between interdependence and autonomy. What might be experienced as group cohesion and social support providing safety and insurance to most might be experienced as eradication of the individual personality by those who are vulnerable. This threat of eradication of individualism may by itself, if large and intense enough, or in combination with several other factors such as loss of social support and loss of meaning, lead to the consideration of suicide as a viable option (Mehlum, 1992). Not only are military personnel required to adhere to the uniformity requirements of their work setting, but they are also required to conform to a prescribed set of norms and codes during times when they are not at work. The inability of those who desire to be different yet are afraid of facing the consequences of non-conformity may build up as internal tension, which over a period of time, may also lead to considering suicide as a real option.

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Military Lifestyle The earlier mentioned frequent residential moves and changes in job profiles so typical to the military lifestyle with their potential for increased stress in the individual, family and social life may lead to detrimental effects on families such as interpersonal conflicts, alcohol abuse, divorce, anger outbursts and violence which may not or may be self-directed. The easy availability of alcohol and the military traditions of drinking have been reported to be risk factors of suicidal behaviour (Mehlum et al., 2006; Rossow and Amundsen, 1997; Thoresen and Mehlum, 2004).

TraumaƟc Stress Exposure The exposure of military personnel to high rates of traumatic events during combat and peacekeeping operations is logically expected and scientifically documented (Mehlum and Weisaeth, 2002; Prigerson, et al., 2001, 2002). Exactly how and specifically how much such exposure contributes to later mental health issues has been extensively investigated, with much evidence for a positive association (Mehlum and Weisaeth, 2002; Sareen et al., 2007, 2008; Southwick et al., 1995) but also with some negative findings (Horn et al., 2006; Unwin et al., 1999; Wong et al., 2001). The differences in these findings may be reflections of real differences between the contexts of the samples studied or methodological differences as is possible between sample compositions, questionnaire and interviews used as assessment tools, and cross-sectional and longitudinal designs. These methodological differences are often highlighted as the rationale for new studies using uniform or standard assessment methodology (Sareen et al., 2007; Thoresen et al., 2003; Unwin et al., 1999). Recently published reports, although cross-sectional and retrospective in nature, overcome many of the limitations of the earlier studies and reveals that deployment to combat operations and witnessing atrocities were associated with increased prevalence of mental disorders, including suicidal ideation and perceived need for care (Sareen et al., 2007, 2008). Further, their findings also reveal that after adjusting for the effects of exposure to combat and witnessing atrocities, deployment to peacekeeping operations was not associated with an increased prevalence of mental disorders (Sareen et al., 2007). 302


The latest published report on the subject investigated Norwegian male peacekeepers seven years after redeployment (Thoresen and Mehlum, 2008). In this sample, 6 percent of the veterans and 17 percent of the subset of prematurely repatriated personnel reported suicidal ideation. Service stress exposure level, even after adjustment for background factors, repatriation status, negative life events, social support, alcohol consumption, marital and occupational status, predicted suicidal ideation. The findings indicated that post-traumatic stress disorder (PTSD) symptoms and general mental health problems combined to mediate the relationship between service stress exposure and suicidal ideation. In a fine-grained analysis on how negative events could be related to suicidal crises among predominantly young male US army personnel it was found that negative events were related to the intensity of suicidal crises among single attempters along with non-attempters but not among multiple attempters, while negative events were related to the duration of suicidal crises among multiple attempters but not among single attempters and non-attempters (Joiner and Rudd, 2000). Although the study was based on correlational data which eliminates causal inferences and demonstrated relatively small effect sizes, the findings revealed that persons highly vulnerable to suicide and a higher risk of suicide (multiple attempters) reported persistent states of distress and lack of responsiveness to external events. In other words, the authors state that negative events and severity of suicidality were relatively independent for multiple attempters in this sample, replicating a similar relationship between stress and depression, explained by a sensitisation of previous suicide-related experiences which make the suicidal behaviours more accessible to the individual, making it easier for a suicidal crisis to be triggered, which is likely to be more severe than the earlier ones. It is useful to note here that an in-depth study of suicides among Norwegian soldiers over an eight-year period led the authors to conclude that the suicides were frequently precipitated by acute crises and the distance from home to the duty post had an important role as a possible causal factor (Hytten and Weisaeth, 1989).

Loss of Meaning This is one of the comparatively lesser researched dimensions of suicidal phenomena in military settings. An early study of the concept named 303


‘sense of coherence’ (Antonovsky, 1993) and its relationship to suicidal ideation among basic military trainees found that those reporting suicidal ideation had lower mean scores of a sense of coherence, indicating that when environmental stress may more easily initiate a suicidal process in individuals with a low sense of coherence (Mehlum, 1998). This finding has been replicated in other military samples (Giotakos, 2003). A later study investigated peacekeepers from Norway nearly seven years after service and found that perceived lack of meaningfulness with respect to military mission significantly and multivariately predicted a higher level of posttraumatic stress symptom scores (Mehlum and Weisaeth, 2002). Loss of meaning is the term used to describe the concept of ‘existential vacuum’ espoused by Frankl (1967), which he believed could arise when an individual experienced a sense of loss of meaning in life, a sense of complete emptiness and an absence of a purpose for continuing to live, wherein suicide may appear as a plausible alternative to the distress generated by such experiences of loss. This loss of meaning may be related to the distress or mental pain considered unbearable by the individual experiencing it and which has been termed as ‘psychache’ by Shneidman (1993). A sense of inner rupture, being damaged and shattered, losing parts of the self, losing self-coherence, losing the ability to function fully and losing connectedness with others have been found to be at the core of mental pain (Bolger, 1999). Empirical evidence of the relationship between suicidal behaviour and a loss of meaning has been published (Harlow et al., 1986; Lester and Badro, 1992; Mehlum, 1998; Orbach, Mikulincer, Gilboa-Schechtman and Sirota, 2003; Orbach, Mikulincer, Sirota and Gilboa-Schechtman, 2003; Petrie and Brook, 1992).

Loss of Social Support This is also one of the lesser researched dimensions of suicidal phenomena in the military. However, Durkheim’s theory (1897), with and without its criticisms, provides theoretical pillars for explanations about how social support could be related to suicide rates. Durkheim postulates that both, a too high and too low level of social integration, can result in higher suicide rates. This perception of the presence and absence of social support by the individual and its acceptance or rejection is the level and grade of

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connectedness experienced by the individual to the group he either belongs or desires to belong to. Social support could also mean the presence of those relationships that a person desires to have and has. The suicidal impact of the disruption of such relationships or the unavailability of circumstances to form age-appropriate relationships, such as romantic relationships, due to the unique nature of military settings has also been documented (Thoresen and Mehlum, 2006; Thoresen et al., 2003). A report of greater social isolation was one of the variables associated with higher suicidal intent among emergency department patients (Haw and Hawton, 2008). It is important to underline here that it is the perception of the individual of the social support that has been found to be associated with suicidal phenomena, not the objective assessment of social networks or social supports available to the individual. This perception of loss of social support by the individual at risk may not be easy to detect among military personnel as in civilian settings due to the regimentation of daily life and the increased levels of group life in military settings. Remote postings with little contact with other group members or possibilities for a normal social life may be situations resulting in loss of support. In other cases, social exclusion of vulnerable or randomly selected individuals is seen and may result in them being bullied, which in reality represents negative group processes.

Downsizing and Involuntary RepatriaƟon While employment has its own set of stresses that an employee has to cope with, unemployment comes with an additional set of stresses which the employee may not be able to cope with, such as loss of face and fellowship, loss of rank and income, loss of role and function, loss of residence and opportunities to lead a family life, amongst other losses such as special privileges, perks and social status. During unstable economic times, downsizing travels under different names such as budget adjustments, staff re-organisation, workforce optimisation and streamlining before moving on to more clear ones such as free-time, pay-cuts, reduction in force, voluntary retirements, lay-offs, attrition and downsizing. Military work settings are placed in the larger contexts of their own societies and cannot remain untouched by the

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stability or instability of these societies. With war becoming more of a remote threat than an actual event, maintaining a military with personnel not in combat can drain national budgets. During prolonged periods of peace, a large number of ready-for-combat personnel may appear to be redundant and disaster tasks may not be as frequent as to require the maintenance of a relatively large military force on a continuous basis. Thus, staff-on-assignment may appear to be an attractive proposition, leading to military personnel having to involuntarily leave the work and life they prepared for and chose for themselves. With personnel available for hire on task basis, the long-term commitments of the employer also lessen and when financial leashes pull the budget, ex-servicemen may be disillusioned ex-heroes experiencing the pain and distress of dishonour for reasons beyond their control and not directly attributable to themselves. Unemployment rates have been well-documented as correlates of higher suicide rates in civilian settings (Agerbo et al., 2007; Blakely et al., 2003; Kposowa, 2001). Among ex-military personnel, the additional stresses of seeking employment in civilian settings and not being trained to work or live in such settings may be present. Involuntary repatriation also led to re-adaptation problems in a prospective study of among UN military observers in South Lebanon (Mehlum et al., 2006). The authors found that these veterans reported significantly higher levels of war zone stressors than peacekeepers, and significantly more post-traumatic stress (PTS) symptoms at follow-up (four years later), higher alcohol consumption levels during service and at follow-up, and more social adaptation problems to their lives at home after service. Exposure during the mission and problems with social adaptation after homecoming predicted PTS symptoms at follow-up in this sample. A similar finding on repatriation was also reported among Norwegian male veterans of peacekeeping operations (Thoresen et al., 2006). Among Vietnam veterans, longitudinal models estimated causal relationships among PTSD, drug dependence and suicidality over a 25year period (Price et al., 2004). Their results revealed evidence of strong continuity of PTSD, drug dependence and suicidality over time. The causal role of drug dependence on PTSD and suicidality was limited to young adulthood while evidence was stronger for self-medication during later adulthood in this sample.

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Psychopathology The variable ‘mental disorders’ had the strongest association with suicide in a review of psychological autopsy studies (Cavanagh et al., 2003). Depressive syndromes and alcohol abuse/dependence were the two most prevalent disorders in a psychological autopsy of all suicides in a calendar year in Finland (Lonnqvist et al., 1995). Among Axis II disorders, borderline personality disorders have shown excessive mortality by suicide in several studies (Black et al., 2004). Among depressed patients, panic attacks, severe psychic anxiety, diminished concentration, global insomnia, moderate alcohol abuse and anhedonia were associated with suicide within one year, and three other symptoms: severe hopelessness, suicidal ideation and history of previous suicide attempts were associated with suicide occurring after one year (Fawcett et al., 1990). Imperative hallucinations, hopelessness, impulsivity and aggression are psychopathological phenomena considered sufficient to explain an outcome of suicide directly, without diagnoses (Maris et al., 2000). Five constructs have been consistently associated with completed suicide: impulsivity/aggression, depression, anxiety, hopelessness and self-consciousness/social disengagement (Conner et al., 2001). Among severely suicidal predominantly young adult males in the US army, hopelessness, depressive symptoms and suicidal ideation was found to be a single syndrome (Shahar et al., 2006). This finding may not be due to the gender differential of this sample as a similar association was found in a cross-sectional study of university students who were predominantly female (Chioqueta and Stiles, 2005). A greater risk of suicidal acts was found in the combination of major depression, PTSD and a Cluster B personality disorder than major depression alone among outpatients (Oquendo et al., 2005). However, as most psychiatric patients do not attempt suicide and as most suicide attempters do not suicide, a psychiatric disorder and a previous history of suicide attempt are both to be considered as necessary but insufficient conditions for suicide (Mann et al., 1999). These authors found that suicide attempters reported higher scores on subjective depression and suicidal ideation, greater rates of lifetime aggression and impulsivity, higher frequencies of comorbid borderline personality disorder, smoking, past substance use disorder or alcoholism, family history of suicidal acts, head injury and childhood abuse history with fewer reasons for living. On the

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basis of these findings, the authors proposed a stress-diathesis model in which the risk for suicidal acts is determined not merely by a psychiatric illness (the stressor) but also by a diathesis. Whether findings from clinical studies in non-military samples such as these may directly apply to military populations is unclear. The stressdiathesis model is, however, probably relevant to apply when trying to understand suicidal behaviour in a high stress environment such as is the case often in the military. For example, studies exploring the risk of suicide among peacekeepers found that although peacekeeping per se does not increase overall suicide risk, military lifestyles may strain interpersonal relationships, encourage alcohol abuse and contribute to psychiatric illness and suicide in a minority of vulnerable individuals irrespective of peacekeeping assignment (Thoresen and Mehlum, 2004; Thoresen et al., 2003; Wong et al., 2001).

Easy Access to Firearms The best documented environmental risk factor of suicide in military settings is easy access to firearms (Desjeux et al., 2004; Helmkamp, 1995, 1996; Hytten and Weisaeth, 1989; Mahon et al., 2005; Marttunen et al., 1997; Scoville et al., 2007; Thoresen and Mehlum, 2006; Thoresen et al., 2003). Among other occupations with easy access to lethal means are doctors and nurses, who die of overdose (Agerbo et al., 2007). When the range of alternatives is limited, the ‘ease of access’ (attainability) and the ‘readiness for use’ (availability) probably are most likely to define the choice of a particular method for suicide, for example jumping from tall buildings in New York, insecticides in Sri Lanka, drowning in Norway, firearms in the United States and Norway (Maris et al., 2000; Thoresen and Mehlum, 2006). Firearms have been documented to be the preferred means of suicide across studies of suicide among military personnel (Helmkamp, 1995; Scoville et al., 2007; Thoresen et al., 2003). The preference for firearms is in keeping with the choice of male suicides for irreversible means of death, involving negligible or nil probability of rescue or survival. Such use of firearms also indicates the negative implications of imparting knowledge of and training in the use of lethal means. The overwhelming majority of suicidal gunshot wounds result 308


from single shots, most of which were aimed at the head, with multiple wounds in roughly 1 percent of suicides in the general population (Maris et al., 2000). Among regular duty Irish military personnel, suicides that took place on duty occurred predominantly when personnel were alone shortly after duty commencement in the morning (Mahon et al., 2005).

Females in the Military It was when the impact of combat trauma on women was explored that sexual harassment, assault and trauma among both genders were revealed (Fontana et al., 1997, 2000; Himmelfarb et al., 2006; Kang et al., 2005; Suris and Lind, 2008; Yaeger et al., 2006). Most of these studies simultaneously reported on the positive relationship between PTS symptoms/disorder and unwanted sexual harassment/contact, which was found to be the same for both genders. However, none of these studies studied the link between this specific vulnerability and suicidal phenomena.

PROTECTIVE FACTORS Leadership During the implementation of the suicide prevention strategy for the Norwegian Armed Forces, the following statement was made by the first author of this chapter when he took on the task of selling the strategy into the different levels of leadership throughout the organisation: ‘Good military leadership is good primary suicide prevention in the military.’ The suicide prevention programme in the Norwegian Armed Forces represents a comprehensive strategy involving a range of initiatives and measures, and may be regarded as the military sector’s contribution to the Norwegian National Strategy for Suicide Prevention launched in 1994 (Norwegian Board of Health, 1995). The impact of leadership on suicide prevention has been documented earlier (Mehlum and Schwebs, 2001). In a military unit, there is a danger that a suicide may lead to erosion of essential qualities such as group 309


cohesion, motivation and confidence in the leadership. Hence, the attitudes of the leaders to suicide prevention should not only be guided by the general and self-evident ethical obligation to prevent tragic deaths, but also by the need to protect the unit and counteract destructive group processes. This is one of the reasons why the Norwegian Armed Forces regard their leaders as a natural backbone of their suicide prevention programme. The competence of the leaders in handling personal relations, building groups out of individuals, their multi-faceted roles versus their men, and the sheer number of leaders and their widespread distribution throughout the organisation—these are factors that we should not forget when planning for prevention of suicide in an organisation such as the military. Leaders have great influence over the daily lives of their men. They set standards and values, give orders, control outcomes and provide information, support and care. They certainly have a lot more possibilities than medical doctors to counteract the negative tendencies in individuals or groups of military personnel. Good military leadership will inherently represent good primary suicide prevention. In addition to this, it is essential that leaders possess basic knowledge about the high-risk signs of suicide. Their task is, however, not to give any form of treatment; this is the responsibility of medical personnel to whom persons at risk should be immediately referred. The strong demands put on the individual to adapt to the organisation and the group will usually give rise to growth and maturation in the young man and woman. But in some this is a highly stressful situation causing adjustment reactions or formation of psychiatric symptoms in some way or the other. The process of group formation may sometimes result in destructive group processes. There is always the possibility of ‘scape-goating’ or alienation or bullying of individuals characterised by a minority language, colour, religious belief or sexual orientation. Leaders have a responsibility of counteracting such negative consequences of socialisation and group formation. Fortunately, there are some potentially protective resources in the military that should be utilised for preventive purposes. First, we should mention the clear and visible signs of authority and rules. Second, the clear expectation that everybody must take part in essential activities and perform their best and that leaders will control the quality. Third, the systematic emphasis put on the small group as the forum for acquiring social and military skills and fostering group cohesion. 310


These are factors that may protect against alienation, symptom formation and suicidal behaviour. The armed forces deal with and educate large groups of young people under crucial years of their development. Most leaders see it as an obvious responsibility for the military organisation to fulfil its mission in a way that enhances growth and maturation in the individual and reduces the risk of developing emotional problems or personal crises. Hence, the suicide prevention strategy has been very well received throughout the organisation. One success factor has probably been to anchor the suicide prevention strategy in the line of command and to involve a wide range of different professional groups. Medical personnel played an important role giving professional advice, teaching, evaluating and conducting research and clinical work. But the responsibility of suicide prevention has remained with commanders where it rightfully belongs. In Norway, the Chief of Personnel at the National Military Headquarters took the initiative to form and lead a Council for Suicide Prevention with the mandate to survey the different elements of the suicide preventive strategy, see to it that they are really implemented and to ensure that the different parts of the organisation collaborated as good as possible in order to reach the common goals. This council has served as a very important forum for collaboration, to discuss and to decide upon new initiative, to evaluate results, to counteract inefficient use of resources and to keep suicide prevention on the agenda. An increasing number of nations are currently establishing national strategies for suicide prevention according to recommendations from the World Health Organization. The armed forces of every nation should take part in these collaborative efforts to face one of the most serious challenges to the public health of the world today.

Training OpportuniƟes Experiences from the implementation of suicide prevention in the Norwegian Armed Forces also reveal that the training period is a timewindow of opportunities. This has also been documented before (Mehlum and Schwebs, 2001). Studies within the Norwegian Armed Forces have shown that the majority of soldiers who attempt suicide display more or 311


less specific prodromal signs and symptoms of suicide (Mehlum, 1990, 1992; see Rudd et al., 2006 and Van Orden et al., 2006 for a list of warning signs and myths). However, these signals have often been inadequately perceived and misunderstood by peers, leaders and medical personnel. It is reasonable to believe that these problems may be due to a lack of knowledge in the military personnel about the warning signs of suicide. In order to increase both, the awareness in military personnel about suicide and the knowledge about suicide prevention in health care personnel and other specialised groups within the military, a wide range of education measures were undertaken. Such an educational approach actually implies a tremendous task in a large and complex organisation like the military. The first group to be targeted was the privates for whom a specific twohour information package was developed. This package, consisting of a video, a lecture and an outline for a group discussion, focuses on basic knowledge about the high risk signs of suicide and where to get help during an emotional crisis. The package is administered during the first couple of weeks in the conscript’s basic training period. Suicide and suicide prevention are now included as topics in leadership lectures at officers’ schools, military and staff academies. Finally, medical personnel and other specialised personnel groups such as chaplains and welfare personnel, being key groups in suicide preventive work, have been updated through their specific continued education courses.

Clarity of Roles and Tasks Due to the highly organised and detailed nature of the responses required from the military, be they combat operations, peacekeeping operations or disaster responses; clarity of roles and tasks of each person is of paramount importance to keep the chain working and the links functioning. In order that one’s fellow solider, subordinate and superior can function as expected, clear expectations and performances are required at each level. This clarity removes much of the ambiguity that could jeopardise the organisation and also provides each person with a role and function, instilling in them a sense of purpose by being specifically useful to the team and the larger organisation, which is again placed within the larger society. 312


Common Goals and MoƟvaƟon As an individual is not expected to function alone or in isolation but as a team member, he necessarily shares the motivation of the team and its goal. This is crucial to the team’s functioning and well-being. In life-threatening missions/tasks, this sharing is life-saving and its absence can lead to negligence or at the worst, to him becoming a traitor and jeopardising not only the success of the mission/task, but also the lives of his fellow soldiers, subordinates and superiors, if not more. The trust required in being part of such a team ensures that the team works together to bring the sharing of motivation and goals to the appropriate level. This pulling together of the team can function as a protective factor for a suicidal solider in ways similar to ways in which parents of young children refrain from carrying out a suicidal plan, stopped by their own sense of responsibility towards the care of their children or unable to bear the thought of letting their children down.

Common Value Systems A member of team having a clear understanding of his own role and function, performing in alignment with the team’s goal and motivation and sharing the team’s value systems is the ideal team member desired by each one of us, regardless of the setting, whether civilian or military. The degree to which the team is able to balance individual identity with the team identity indicates its capacity to perform and deliver results as expected. This would also mean stepping in with support for each other as and when required, which often leads to strong emotional bonds and interpersonal relationships, as the team is not allowed to be vulnerable despite individual vulnerabilities. Such opportunities present themselves often in military settings and are utilised as such.

Group Cohesion and a Sense of Coherence Such a group as described here would logically have a high level of cohesion. As the cohesion is task based and limited to time, place and situation, 313


it can also be very specific in nature, allowing a high level of flexibility once its role and function are over, with the possibility of coming together again as per requirement. This flexibility and openness removes from the unit the suffocation which could otherwise be reasonably expected. It has been found that a well-functioning social network is a protective factor against suicidal phenomena in late adolescence (Ystgaard, 1997; Ystgaard et al., 1999). This purposeful connectedness to the team leads to a sense of coherence, at the individual and unit level, which is reflected back to the organisational level. This sense of coherence in the individual which implies a tendency for the individual to regard life as having some purpose, to believe that difficulties can be overcome and that the world is understandable was found to be associated with a lower level of current suicidal ideation (Mehlum, 1998).

Social Support and Welfare Systems Mehlum and Schwebs (2001) report on how the welfare service of the armed forces can give valuable contributions in reducing some of the inherent stress of the military lifestyle. Individually tailored services can be offered in order to solve social or financial problems. Even more important are group-oriented measures for improvement of the social milieu; sports, culture, education or hobby activities. For basic trainees, the welfare services represent a very important resource easing their social integration and reducing the stress of adaptation. Mental and suicidal crises may arise at times, in places or in situations where professional help or support from comrades, colleagues or leaders is unavailable. Furthermore, even if they need it desperately, many regular employees will feel it problematic to take the first step to seek help from medical personnel who belong to the same military system as themselves in fear of losing prestige or career opportunities. In order to lower the threshold for help-seeking and to reach as many persons as possible regardless of time of day or place, the Norwegian Armed Forces established a crisis telephone service in 1994. This is called the ‘Green Line’ and is open 24 hours a day. Its use is free of charge, even if long-distance and it is possible to call anonymously. An evaluation performed after the first three years of operation showed that this service has become well known

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in the essential target groups and that they experienced it as a valuable service that they would want to use if ever in need of it. It is estimated that each year about 2–3 percent of all Norwegian military conscripts use this telephone service at least once. Although interpersonal support was not directly assessed in a study of the catharsis effect of a suicidal crisis among predominantly young males attending a US army medical centre, decreased suicidality was found, but due to the increased severity of symptoms of the attempters, single and multiple as compared to ideators, the authors chose to interpret the decreased suicidality as the gradual action of interpersonal support rather than as emotional catharsis (Walker et al., 2001). Perception of increased social support was a predictor of lower levels of suicidal ideation, independent of the severity of depression and hopelessness, minimised by the level of life satisfaction and level of exhibited self-esteem in university students (Chioqueta and Stiles, 2007).

Medical Support The experiences of the Norwegian Armed Forces have been documented on this factor too (Mehlum and Schwebs, 2001). Although the Norwegian Armed Forces have found it necessary to drastically expand the scope of suicide prevention beyond the medical service and to extend the responsibility for the implementation of its various aspects to wider groups of personnel, medical personnel remain an indispensable resource. A crucial function is to diagnose and treat persons in acute suicidal crises. This is done both by the general military physicians and by personnel working in the psychiatric services in the armed forces. In some cases, the suicidal crisis is evoked by some stressor or problem that can be rapidly alleviated and the soldier can continue his service. Some soldiers have more severe mental problems or personality disorders that make it necessary to separate them from further service. Frequently soldiers find it difficult to seek medical personnel for emotional, social or existential problems. To seek the military chaplain is an alternative to many of these and many are those soldiers whose suicidal crises have been uncovered by the chaplain. In most cases, these soldiers will be referred to medical personnel.

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ASSESSMENT AND MANAGEMENT As specific tools to assess the performance of an organisation or a unit with reference to its suicide prevention do not exist; routine check-ups of the organisation’s member individual’s proneness towards suicidal phenomena can work as a proxy indicators of the way in which the organisation is able to prevent and manage suicidal behaviour. However, it is important to mention here that a systematic review of suicide prevention strategies around the world reported on the study of five preventive strategies: education and awareness for the general public and for professionals; screening tools for at-risk individuals; treatment of psychiatric disorders; restricting access to lethal means; and responsible media reporting of suicide (Mann et al., 2005). The authors concluded that physician education in depression recognition and treatment, and restricting access to lethal means where the method was common were found to prevent suicide and thus reduce suicide rates while the other interventions needed more evidence of efficacy. They also mention, as part of means restriction, that restrictions on access to alcohol coincided with decreases in overall suicide rates in the former Union of Soviet Socialist Republics and Iceland. A specific recommendation made to reduce suicide attempts by firearms in the military was to implement stringent ammunition control procedures and placing weapons in racks immediately after coming off the line (Scoville et al., 2004). At the individual level, several questionnaires and clinical interviews with excellent psychometric properties to assess psycho-social and psychiatric dimensions are available, as seen in the studies referred to earlier. Management of suicidal behaviour is a difficult clinical task and only a handful of empirically-tested clinical approaches with theoretical bases are available (Brown et al., 2005; Cipriani et al., 2005; Jobes, 2006; Jobes et al., 2005; Linehan, 1993; Rudd et al., 2001). Of particular interest to the armed forces is the Collaborative Assessment and Management of Suicidality (CAMS) tested by Jobes and associates with outpatients from the US airforce. The CAMS assessment uses both qualitative and quantitative responses, assessing psychological pain, stress, agitation, hopelessness, self-hate and overall suicide risk, with a heavy emphasis on the clinician’s collaboration

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with the patient. In CAMS, the patient’s perspective is treated as the assessment gold standard, modification of clinician behaviours is also an objective and suicidality itself is the primary focus of care instead of treating suicidality as a symptom of a psychiatric disorder. It is also pertinent to note here a study on discrepancies between clinician and self-ratings of suicidal symptoms in a predominantly young male sample from attendees of a major US army medical centre, which found that clinicians were more likely to assess the patient as high in suicidality than the patients themselves approximately in 50 percent of the assessments (Joiner et al., 1999). This finding need not necessarily be due to the gender or age skewness of this sample as a similar discrepancy between experts and clinicians was revealed in a later study of case vignettes and authors of both the studies concluded that this discrepancy had much to do with the better-safe-than-sorry attitude of the clinicians which is protective of themselves and the patients (Wagner et al., 2002).

SUMMARY The prevention of suicidal phenomena in the military presents unique challenges and opportunities. The organised nature of the military provides an opportunity for preventive intervention and post-event management, and evaluation while the knowledge and training imparted along with the unsupervised access given to lethal means makes it into an implementation challenge. Similarly, the predominance of the male gender and the stamp of the collective on the individual, the fellowship, the group cohesion, the preparation for combat and disaster responses make suicide prevention here simultaneously a challenge and an opportunity. The abstract disconnection between the collective and the individual may lead to a sense of entrapment if the individual is unable to move out of the collective which requires such an adherence from him. We see that some of those very factors which were discussed earlier in the section on risk factors were now discussed as protective factors. This is an indicator of the complexity of the processes involved in the making and unmaking of a suicidal soldier.

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Tsutsumi, A., K. Kayaba, T. Ojima, S. Ishikawa, N. Kawakami and Jichi Medical School Cohort Study Group (2007). Low control at work and the risk of suicide in Japanese men: a prospective cohort study. Psychotherapy and Psychosomatics, 76(3), 177–85. Unwin, C., N. Blatchley, W. Coker, S. Ferry, M. Hotopf, L. Hull et al. (1999). Health of UK servicemen who served in Persian Gulf War. The Lancet, 353(9148), 169–78. Van Orden, K.A., T.E. Joiner, Jr., D. Hollar, M.D. Rudd, M. Mandrusiak and M.M. Silverman (2006). A test of the effectiveness of a list of suicide warning signs for the public. Suicide and Life-Threatening Behavior, 36(3), 272–87. Wagner, B.M., S.A. Wong and D.A. Jobes (2002). Mental health professionals’ determinations of adolescent suicide attempts. Suicide and Life-Threatening Behavior, 32(3), 284–300. Walker, R.L., T.E. Joiner, Jr. and M.D. Rudd (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144–52. Wasserman, I.M. (1992). Economy, work, occupation and suicide. In R.W. Maris, A.L. Berman, J.T. Maltsenberger and R.I. Yufit (Eds), Assessment and prediction of suicide (pp. 520–40). New York: The Guildford Press. Wong, A., M. Escobar, A. Lesage, M. Loyer, C. Vanier and I. Sakinofsky (2001). Are UN peacekeepers at risk for suicide? Suicide and Life-Threatening Behavior, 31(1), 103–12. Yaeger, D., N. Himmelfarb, A. Cammack and J. Mintz (2006). DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma. Journal of General Internal Medicine, Supplement 3, S65–69. Ystgaard, M. (1997). Life stress, social support and psychological distress in late adolescence. Social Psychiatry and Psychiatric Epidemiology, 32(5), 277–83. Ystgaard, M., K. Tambs and O.S. Dalgard (1999). Life stress, social support and psychological distress in late adolescence: A longitudinal study. Social Psychiatry and Psychiatric Epidemiology, 34(1), 12–19.

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15

Suicidal IdeaƟon and Behaviour among Asian Adolescents AÄ¦½ N¦-ÃÄ LçÄ¦, Cã«ù Yç®-«® FÊÄ¦ Ä Cã«Ù®Ä A½øÄÙ MBÙ®-C«Ä¦

S

uicide is a major issue of concern among adolescents worldwide. This chapter is an attempt to focus on trends related to suicide and suicidal ideation among teenagers in Asia. Besides this overview, adequate consideration will be given to different factors related to adolescent suicide trends, encompassing psychological, environmental and socio-cultural influences. Among these, Internet stands out as particularly important for clinicians and researchers to consider in future studies. Although parts of this chapter will highlight issues that are of particular concern for Asian adolescents, some findings seem relatively universal across societies. Suicide research on adolescents from across the globe will be reviewed here, but with the goal of discussing its particular relevance to Asian cultures. The chapter will conclude with review of some signs and proposed preventive measures for fighting against adolescents’ suicide.

ADOLESCENT SUICIDE IN ASIA: PATTERNS AND TRENDS Given the large population of Asia, suicidal deaths in Asia account for more than 60 percent of the world’s total number of suicides (WHO Mortality 324

Adolescents’ Suicide in Asia

Database, 2008). Nevertheless, because most studies concerning suicide have been carried out in Western cultures, mostly in the United States of America, there are relatively less known facts about suicide in Asia (Beautrais, 2006). As the research concern about suicide deaths in Asia is increasing, researchers have attempted specific profiles of suicide in Asian countries so as to facilitate the development of suicide prevention programmes that can fit the unique cultures and situations of various Asian nations. According to recently updated statistics (Hendin et al., 2008), suicide is one of the leading causes of death among adolescents but not among older people, although the elderly are the age group with the highest suicide rate in most Asian countries. In Hong Kong, Japan and the Republic of Korea, completed suicide was the most common cause of death among young people aged 15–24 years in 2006. For some other Asian countries such as Thailand and Sri Lanka, young people actually had the highest suicide rates across any age group, while China had high rates among both the young and the old. Table 15.1 shows statistical data of suicide death rates of adolescents (aged 15–24) in for some Asian countries from year 1990 to 2006. The adolescent suicide rate in China stayed at a high rate of around 15 per 100,000 per year throughout the 1990s, but showed a decreasing trend near the beginning of the 2000s, especially among young women (as shown in Table 15.1). This downward tendency in this decade was noted in Philips’s (2008) study on China’s changing rates and patterns in suicide from 1987 to 2006. In contrast, rates in Japan rose overall from seven in 1990 to 14.1 (per 100,000) in 2006, together with a rise in the ranking of suicide as the leading cause of death among adolescents from its previous ranking as third (WHO Mortality Database, 2008). Suicide rates in Hong Kong, Korea, Thailand and Singapore have also undergone fluctuations within the range of 6–12.2 per 100,000 in the past decade or so (WHO Mortality Database, 2008). The relatively low suicide rate in Taiwan has remained stable over time with small increases since the year 2000 (Department of Health of the Republic of China, 2008). According to police records from India (National Crime Records Bureau, 2006), the suicide rate for youths in 2006 was 10.5 (per 100,000) and the rate for the total population in the country remained around the same rate from 1996 to 2006. However, these government data may be subject to considerable underestimation owing to inaccurate population counts with registration systems varying in efficiency (especially in 325

Angel Nga-man Leung et al. Table 15.1 Suicide Rates in Alternate Years among 15–24-year-old Adolescents per 100,000 of the PopulaƟon in Selected Asian Countries/Regions (1990–2006) Year/Area 1990

1992

1994

1996

1998

2000

2002

2004

2006

China M F T M F T M F T M F T M F T M F T M F T M F T M F T

10.7 22.2 16.2 11.4 23.9 17.4 10.0 20.1 14.8

5.4 8.6 6.9

9.2 4.5 6.9

Hong Kong 7.4 6.9 7.1 9.7 6.6 8.2 9.5 8.7 9.1 11.4 7.2 9.3 13.9 7.5 10.7 8.0 5.8 6.5 13.2 8.8 12.6 15.6 8.8 12.2 11.6 5.2 9.3

Japan 9.2 4.7 7.0 10.2 4.7 7.5 12.0 5.1 8.6 11.3 5.4 8.5 16.8 7.4 12.2 15.8 6.9 11.5 14.7 6.3 10.7 16.9 8.4 12.8 18.2 9.7 8.8

Korea Singapore Thailand Taiwan 10.7 5.5 8.1 10.8 5.3 8.1 11.0 5.9 8.5 14.4 9.0 11.8 15.1 9.4 12.3 10.2 7.0 8.7 9.7 7.1 8.5 11.3 8.0 9.7 9.7 8.8 9.3

13.1 9.2 10.8 9.2 4.1 6.7 10.8 8.8 9.8 9.1 2.8 6.0 10.2 7.2 8.7 6.5 7.7 7.1 6.9 9.5 8.2 5.7 4.5 5.1 6.2 1.3 3.8

12.9 9.0 11.0 12.3 8.3 10.3 7.8 4.3 6.1 17.6 6.2 11.9 18.1 5.6 11.9 18.0 4.7 11.4 13.8 3.8 8.9

5.0 3.5 4.3 5.3 2.5 4.3 6.1 2.6 4.4 5.5 2.9 4.2 5.1 3.3 4.2 4.7 3.3 4.0 7.7 3.6 5.9 8.2 4.2 6.2 9.2 4.5 6.9

Source: WHO Mortality Database (2008); Department of Health of the Republic of China (2008).

rural areas). In addition, inaccuracy is likely because people are often unwilling to bear the social and legal consequences associated with suicide (Hendin et al., 2008). For example, the suicide rate in rural India reported in a study using verbal autopsies (Joseph et al., 2003) was nine times that of the official figure (Gururaj and Isaac, 2001). Suicide trends and patterns for some other major countries in Asia with insufficient official data (e.g., India) can perhaps be better understood by referring to findings of local studies. Considering possibility of significant differences in the standard of data collection and the verdict of suicide death across countries, suicide rates should be interpreted with caution 326


in generalising these patterns in relation to regional differences and over the time changes in suicidal behaviour (Cheng and Lee, 2000). Among young people, suicide risk tends to increase with age in adolescence (Pelkonen and Marttunen, 2003) across both male and female populations (Shek et al., 2005). The major reason for the growing suicide rates with age is the prevalence of psychopathology such as depression and substance abuse in older adolescents (Granello and Granello, 2007). Moreover, older adolescents are cognitively more able to make plans and execute a lethal suicide attempt than are younger adolescents (Groholt et al., 1998). Although some previous studies have reported a higher number of males than females committing suicide overall (e.g., Cheng and Lee, 2000), the male-to-female ratio of suicides in Asian adolescents tends to be higher than those of Western countries. Compared with the international mean of 3.6 (males):1 (female) (Kelleher and Chambers, 2003), the average gender ratios for Japan, Hong Kong, the Republic of Korea and Taiwan were quite closer across the genders, that is within the range of 1.3–2.1 to 1 (see WHO Mortality Database [2008] and Table 15.1), from the year 2000 onwards. Indeed, the gender ratio was reverse in China. Chinese young women were at higher risk for suicide than were Chinese young men. This exceptional pattern has been attributed to the high rate of suicide deaths for young females in the rural regions, which may be the result of lower social status and marital problems for Chinese women (Zhang et al., 2002). Yip’s (2001) studies reported a male/female suicide ratio of 0.8:1 and 0.5:1 in urban and rural areas, respectively, in the age group of 15- to 24-year-olds. However, newer studies (Yip and Liu, 2006; Yip et al., 2005) have demonstrated a significant decrease in the rate of suicide among young women in rural areas and a consequent increase in the gender ratio for suicides in China. Authors of these studies further pointed out that Chinese male-to-female ratios of suicide may come to resemble those ratios of Western/developed countries, because of the expected rising level of urbanisation in China and associated demographic changes (e.g., the decline of the young female population in rural areas) and cultural changes (e.g., in family and employment systems) (Yip and Liu, 2006; Yip et al., 2005). Hendin and colleagues (2008) reviewed the most common methods of suicide across Asia. In Japan, Pakistan and Thailand, most people killed themselves by hanging. In Hong Kong and Singapore, jumping 327

Angel Nga-man Leung et al.

(especially from apartment buildings) was the preferred method of suicide. In countries with large rural populations, such as India, China and the Republic of Korea, pesticides poisoning has been widely used, and importantly, the prevalence of this suicide method is regarded as one major reason for the particularly high female suicide rate in these countries. Compared to young females in Western countries, for whom the most frequently used means of suicide tends to be self-poisoning with medication, a method that often has relatively low lethality, Asian women in rural areas have more access to agricultural pesticides, which have much higher toxicity (Philips, 2002). A study of 10- to 19-year-olds in a rural region in southern India (Aaron et al., 2004) reported an alarmingly high suicide rate of 148 per 100,000 for women, and 58 per 100,000 for men. The easy availability of pesticides in these rural homes is perhaps largely to blame for these high rates of suicide deaths, especially for young females. Along with the conventional methods, other newer methods of suicide have emerged in individual regions in Asia as well. For example, the recent surge in suicide attempts by hydrogen sulphide intoxication in Japan and the widespread circulation of the method of producing the gas from household detergents via Internet messages have been reported in local and international news articles (Lewis, 2008). According to the report issued by the National Police Agency of Japan, within the first five months of 2008, nearly 520 people in Japan killed themselves by using hydrogen sulphide gas, while there were only 30 such cases in the same period in 2007 (Kubota, 2008). Another example of novel suicide methods in Asia is charcoal burning in Hong Kong (Yip, 2006).

SUICIDE RISK FACTORS IN ASIAN ADOLESCENTS Risk factors for suicidal behaviour vary across ages and cultures (Guetzloe, 1989). The following discussion focuses on common risk factors cited in the literature, particularly as they concern suicide in Asian adolescents. The risk factors suggested here are categorised into: (a) psychological, (b) environmental and (c) socio-cultural risk factors. In terms of psychological risk factors, most studies of attempted and completed suicide in adolescents indicate a high prevalence of 328


mental health disorders (Nrugham et al., 2008). Population-based psychological autopsy studies on suicide in Asia (including Taiwan, China, India and Singapore) show that 68–97 percent had diagnosable psychiatric disorders (Vijayakumar, 2005). Depression is often the most frequently cited diagnosis associated with suicide (Waldrop et al., 2007). Although individual psychological factors may have been somewhat under-researched in Asia as compared to the West (Vijayakumar, 2005), large-sample studies have found that depressive symptoms significantly distinguish suicide attempters from non-attempters equally in Eastern and Western cultures (e.g., Stewart et al., 2006). Depression has been either directly or indirectly implicated in the association between adverse events and suicide attempts (Dube et al., 2001). Lee and colleagues (2006) have showed that depression mediated the associations of academic- and familyrelated risks and suicide ideation in a sample of Hong Kong adolescents. Substance use is also a risk factor for adolescent suicide (Waldrop et al., 2007). Studies indicate that many attempters have ingested alcohol and/or illicit drugs at the time of their suicidal gestures (Hufford, 2001). Chemical dependence has been found to be associated with suicide attempts at higher rates in adolescents than adults (Holland and Griffin, 1984). Other psychological risk factors for suicide include low self-esteem, hopelessness, impulsivity and anxiety (Strauss et al., 2000; Wetzler et al., 1996). Of these, hopelessness tends to be the most salient predictor of both—the new onset of suicidal behaviour and the progression from general depression to a high risk for suicide (Beautrais et al., 1999). Based on a 13-year longitudinal study, Kuo, Gallo and Eaton (2004) revealed that hopelessness is an independent risk factor for completed suicide, suicide attempts and suicidal ideation, regardless of the presence of depression or other mental health disorders. This pattern of association between hopelessness and suicide behaviours and ideation tends to be similar in Western and Asian countries (Zhang et al., 2002). Family dynamics are related to suicide risk as well. Adolescents who exhibit suicide behaviour have often experienced some form of family dysfunction (Bridge et al., 2006). For example, those living in families with high levels of conflict and other major stressors, are prone to depression (Waldrop et al., 2007). This tends to be especially true for those in traditional Chinese society, where great emphasis is placed on close interpersonal ties, mutual dependence and harmony in the family 329


(Harris and Molock, 2000). One example of family dynamics as a risk factor is the range of children’s behavioural and emotional problems including a higher risk for suicidal behaviour, resulting from parental divorce in Chinese families (Dong et al., 2002). In addition, family physical maltreatment is associated with greater risk for adolescents’ attempted suicide and chronic suicidal behaviour in both Western (Santa Mina and Gallop, 1998; Ystgaard et al., 2004) and Asian cultures (Lau et al., 2003). Zeng and Le Tendre (1998) noted that, apart from family stresses, schooling and examination expectations are major sources of stress and problems related to suicide among students in Hong Kong, Japan, South Korea and Taiwan, cultures with a notoriously strong emphasis on educational attainment and exams. Owing to the strong impact of Confucian tradition on the values of education and family life, for example, Chinese children’s parents particularly emphasise the need for academic success (Tse and Bagley, 2002). Children’s failures to succeed academically are virtually universally attributed either to a lack of hard work or disrespect for parents and teachers (Tse and Bagley, 2002). Such interpretations may make unremarkable students more prone to depression and hopelessness in Asia as compared to the West. Hong Kong adolescents have rated academic concerns as one of the top stress-related domains in their lives (Lee et al., 2006), and examination pressure itself has been found contributing to adolescents’ mental health problems, including depression and suicide intention (Lau et al., 1998). Apart from family and academic concerns, the peer group is a third major factor in adolescents’ psychosocial adjustment and, conversely, suicide ideation. Peer victimisation and poor peer relationships are strong predictors of adolescent suicidality (Granello and Granello, 2007). Peer victimisation in both direct (i.e., physical or verbally bullying) and relational (i.e., social exclusion, rumour-spreading) forms are associated with suicidal thinking and behaviour (Baldry and Winkel, 2003), and this is the case for both victims and bullies (Toros et al., 2004). Moreover, suicidal individuals tend to have poor interpersonal relationships with peers (King and Merchant, 2008). In a longitudinal study of 659 families (Johnson et al., 2002), eight types of interpersonal difficulties were found to account for suicide attempts, including difficulty in making friends, frequent arguments or anger with peers, social isolation and lack of close friends. Peer isolation is not merely a cause of loneliness and unhappiness, such isolation also prevents further problem-solving because of a lack of 330


social resources (Johnson et al., 2002). In part, because of the power of peer relationships, teenagers whose peers have either attempted or completed suicide tend to be at greater risk for suicidal ideation themselves (Ho et al., 2000). Although research on peer groups in relation to suicidal behaviour in Asian adolescents remains sparse, links between peer difficulties and depression are consistent across cultures (e.g., Lam et al., 2004). The media is another additional factor in actual suicide cases across societies. Considerable evidence for imitation effects from suicide reported via newspaper and television has accumulated (Stack, 2000a). A likely explanation for the media-related contagion effect is that vulnerable individuals, who may have had some predispositions towards suicide ideation but normally would not have carried out a suicidal attempt, may be encouraged to act on their suicidal impulses because of media reports. When newspaper stories about suicides are featured prominently, imitation effect tends to be particularly strong. Moreover, such imitation effects are particularly likely to affect young people (Stack, 2000b). Romer, Jamieson and Jamieson (2006) found that increased numbers of television news reports of suicides were associated with a significant increase in suicides for those under the age of 25. Similarly, greater numbers of newspaper reports on suicide were associated with suicide deaths across age groups in a four-month study period. Recently in Hong Kong, deaths by suicide increased substantially following the death of a well-known Hong Kong pop singer who jumped from a high building (Yip et al., 2006). This phenomenon again underscored the importance of extensive and dramatic media coverage of suicides. The influence of the Internet on adolescent suicide is a new concern for researchers and the general public. Adolescents spend a large proportion of their free time on computers and the Internet (Stanger and Gridina, 1999). There are worries about the shocking number of websites providing detailed methods and means to commit suicide (Thompson, 1999). Alao and Pohl (2006) summarised nine suicide attempts or completed suicides related to the Internet. Five of the cases involved adolescents and young adults from ages 16 to 25 years, while the rest ranged from 34 to 42 years old. The adolescents and young adults had all gained information about lethal means of committing suicide from the web. Some of them were encouraged by others in chat rooms to commit suicide. Teenagers, especially those lacking social support, may be particularly vulnerable to biased opinions in those chat rooms (Alao and Pohl, 2006; Mehlum, 2000). 331


Cases of Internet-related suicide pacts are also alarming. For instance, in 2004, there were two suicidal pacts involving seven young people, ranging in age from 20 to 30 years, who committed suicide together as arranged via the Internet (Harding, 2004). Another Internet suicide pact in 2006 in Japan resulted in six deaths (Harding, 2004). Although Internet-related suicide pacts are rare (indeed, suicide pacts are themselves a rare act), there has been a sharp increase in the number of cases reported. For example, in Japan, there were 34 Internet suicide pacts made in 2003, 55 in 2004 and 91 in 2005 (Harding, 2004). Apart from the use of online chat rooms and forums, young people have increasingly tended to express suicidal ideation in their blogs. The Samaritan Befrienders Hong Kong found more than 3,000 blogs expressing emotional problems and suicidal ideations (Yahoo News, 2008b). Furthermore, in 2008, at least five youngsters who expressed suicidal thoughts or left death notes in their blogs subsequently committed suicide (Yahoo News, 2008a). One of them left entries in his blog culminating in a 24-day countdown to his suicide. He did actually commit suicide at the end of that time (Yahoo News, 2008a). Thus, bloggers sometimes communicate with one another about suicide, exchanging suicidal methods or thoughts. The influence of the Internet on adolescents in relation to suicide likely depends on the nature of the Internet chat rooms and the group components of the online chat rooms with which they become involved. For instance, website users have reported gaining support, sympathy and understanding from other online users about suicidal thoughts and even actions as an online community (Baker and Fortune, 2008; Miller and Gergen, 1998). Some believe that expressing their suicidal thoughts or depression online is a reasonable way of coping and reducing their self-harming behaviour (Baker and Fortune, 2008). The debate about the influence of the Internet on adolescent suicide is ongoing. However, research in this area is vital given the increasing prominence of the Internet in modern society.

WARNING SIGNS FOR ADOLESCENT SUICIDE ATTEMPTS OR BEHAVIOUR Suicide seldom occurs without warning signs, and being able to identify those common signs is important for future work with adolescents. Most of 332


such warning signals fall into one of the four major categories: behavioural, emotional, physical and verbal (The Hong Kong Jockey Club, 2005). Physical signs of suicidal ideation in adolescents may include sudden changes in eating habits (e.g., loss of hunger or overeating) and altered sleeping patterns (e.g., oversleeping or insomnia). Some chronic or unexplained pains and illness can serve as signs as well. Suicidal adolescents may also neglect their personal appearance or present a dramatic change in personal appearance, particularly when the new style is thoroughly out of character (Kalafat, 1990). Emotional signs of suicidal thoughts relate to signs of apparent motivation or mood. For example, when young people become suicidal, they may lose interest in friends, hobbies or other activities formerly enjoyed; they sometimes also present a dramatic change in personality, such as becoming withdrawn when they were formerly extroverted (Caruso, n.d.). In addition, a sudden improvement after a long period of emotional turmoil may actually signal an imminent suicide (Granello and Granello, 2007); the outward feeling of calmness may indicate that nothing matters anymore to them now since they have already made a decision to carry out a suicide attempt. Other behaviours correlated with suicide sometimes present themselves as suicide-related gestures or attempts, including overdosing and self-cutting (Rudd et al., 2006). Finally, some individuals may also make their suicidal ideation clear, either by direct verbal warnings or through indirect and abstract statements. Most victims of suicide had expressed their intentions through some type of verbal ‘cry for help’ previously (Granello and Granello, 2007). Such patterns are likely to be similar across cultures.

PREVENTION Considering the variety of risk factors for adolescent suicide, in addition to the fact that suicide itself is a multi-faceted phenomenon, there are a number of potential preventive measures that can be considered in any community. Early on, the Centre for Disease Control (CDC, 1992) suggested that early screening programmes taking place at school showed promising results. Such programmes are viewed as a cost-effective way to locate high-risk students despite locating a fair number of ‘false positive’ atrisk students as well (Shaffer and Craft, 1999). Alternatively, programmes 333


aimed at skills training for adolescents can be considered more widely. Workshops and training on improving stress and social management, enhancing self-esteem, and increasing problem-solving skills are promising for promoting the healthy development of adolescents (Pelkonen and Marttunen, 2003). These kinds of training may be especially important for preventing suicides in Asian adolescents, given that academic performance is highly valued in most Asian countries (China, Hong Kong, Japan, Korea) often to the extent of being detrimental of emotional and social development (Zeng and Le Tendre, 1998). It is important to provide opportunities for adolescents to understand that they can realise their potential in areas other than academic success (Chia, 1999). In addition, systematic training in problem-solving techniques (D’Zurilla and Nezu, 1990; Orbach, 2003) could be taught in groups to adolescents in an attempt to prevent suicidal thinking or actions. Klingman and Hochdorf (1993) suggested that by changing automatic negative thoughts and irrational thinking, negative self-beliefs could become more positive and low self-esteem could be raised, eventually resulting in a better self-image (Orbach, 2003). Community gatekeepers, who are in close contact with adolescents, including teachers, counselors, coaches and even physicians, police, recreational staff, could be better trained to notice warning signs for suicide or suicidal ideation in adolescents as well. Training can help to provide these gatekeepers with the tools to identify at-risk teens, handle their emotional episodes, and refer them to appropriate mental health services (Gould and Kramer, 2001). Tierney (1994) showed that after attending training programmes, the knowledge, attitudes and intervention skills of community helpers increased significantly. Other community-based prevention programmes, though not necessarily used in the adolescent population, can also help to prevent suicides. For an example, Rihmer, Rutz and Pihlgren (1995) trained physicians to identity depression. Such training resulted in a significant reduction in suicide in the community. In another multi-layered intervention programme aimed at reducing risk factors and enhancing protective factors launched by the American Air Force, a large drop of risks for suicide was observed (Knox et al., 2003). In Hong Kong, a community-based prevention programme was launched by the Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP, 2004), on Cheung Chau Island in 2002. This island is infamous among Hong Kong people because of the number 334


of suicides using burning charcoal that have taken place there. Training sessions for holiday flat owners, police and others interested in preventing suicides were provided to educate them about warning signs of suicide. Some practical strategies such as putting up posters with encouraging statements, suggesting that holiday flat owners not rent to people who seemed depressed, and convincing storekeepers not to sell medicines to teenagers were implemented. Perhaps correspondingly, there was a marked decrease in the number of suicides in Cheung Chau, from 50 deaths in total in 1998–2002 to 11 in 2003–04 (CSRP, 2004). Thus, a focus on public awareness may be helpful for reducing suicide attempts and completions. Attention to the media can clearly cut down on suicides as well. After implementing media guidelines on reporting suicide cases, there has been a significant drop in suicide rates (Etzersdorfer et al., 1992). Thus, the CDC (1994) recommends that front-page coverage of suicidal cases should be avoided. Also, detailed descriptions of the means of suicide, as well as stories of the deceased, should not be reported. In addition, referral resources involving mental health professionals should be included along with any news about suicide in published materials (CDC, 1994). Methods of suicides, very much a product of the region in which one lives, can also be more carefully monitored and controlled in an effort to cut down on suicides. For example, one of the most common means by which adolescents commit suicides in Western countries (e.g., America) is by using firearms (Gould and Kramer, 2001). Past studies have shown that restrictions on access to firearms could reduce adolescent suicide rates (Carrington and Moyer, 1994). However, in Asia, the most common methods used for committing suicides are hanging, jumping from highrise buildings, ingesting pesticides and charcoal burning. Accordingly, legislation aimed at preventing access to toxins such as pesticides should be passed wherever possible. For example, in Sri Lanka, safer storage of pesticides has reduced suicide rates (Hawton, 2008). Chia (1999) noted that 75 percent of young suicide victims in Singapore jumped from kitchens in their own home and, therefore, suggested that barriers should be placed in kitchens. Window bars with locks could also be added. For charcoal burning, popular in Hong Kong and nearby Macau, researchers have suggested that crisis hotlines from suicide prevention centres could be printed on the packages of charcoal to help those who plan to commit suicide (Yip, 2006). 335


For individuals, parents in particular, having the skills to talk with suicidal people, especially adolescents, is particularly important. Many adolescents faced with suicidal thoughts lack the appropriate coping skills and knowledge to seek help. In 2006, the Suicide Crisis Intervention Centre in Hong Kong (SCIC, 2006) suggested some simple tactics for handling those who show some warning signs of suicidal behaviour. They advise that others trust and accept that these individuals are really having thoughts of suicide, listen carefully, and be patient in interacting with suicidal adolescents who are expressing their feelings. Both encouraging professional help and maintaining an ongoing relationship with these adolescents are essential. In extreme cases, parents or other adults can even consider removing lethal or toxic substances and locking up window bars to reduce the means by which a suicide could be attempted as well. The major treatments for suicidal attempters and ideators include psychosocial and biological methods. Pelkonen and Marttunen (2003) compared the efficacy of eight psychosocial treatments. They found that cognitive-behavioural therapy (CBT), which aims at correcting the cognition of adolescents, rather than correcting their depressive feelings and behaviours, work well for most adolescents. Interpersonal psychotherapy can also significantly reduce depression symptoms in adolescents (Rossello and Bernal, 1999). Although research on the usefulness of selective serotonin reuptake inhibitors (SSRIs) is still limited, there is evidence for their effectiveness in treating major depressive disorders in children and adolescents (Rossello and Bernal, 1999). Mood stabilisers are regarded as a relatively good and effective first-line medication for teenagers and children who are suffering from depression as well (Pelkonen and Marttunen, 2003).

CONCLUSIONS Suicide risk increases with age throughout adolescence. Adolescent suicide is a complicated issue involving different risk factors, ranging from psychological to environmental and socio-cultural. It is important for the government, general public, teachers, parents and teenagers themselves to be aware of the problem of adolescent suicide. A multifaceted approach to suicide prevention, ideally involving governments, 336


schools and the mass media, in addition to peers and families, will likely be most effective in limiting suicides in Asia. Meanwhile, every one of us can learn simple techniques for interacting with teenagers at-risk for suicide, and a combination of strategies aimed at providing support and care to adolescents around us, may be especially helpful at a local level.

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About the Editors and Contributors

The Editors Updesh Kumar, PhD, Scientist ‘F’ is Head of the Mental Health Division, Defence Institute of Psychological Research (DIPR), Defence R&D Organisation (DRDO), Ministry of Defence, Government of India, Delhi. Dr Kumar obtained his doctorate degree from Panjab University, Chandigarh. He specialises in the area of suicidal behaviour and personality assessment. Starting with his doctoral thesis in the area of suicidal behaviour, Dr Kumar, as principal investigator, has carried out many major research projects related to suicidal behaviour. As Head, Mental Health Division, he has psychologically analysed many suicide incidents of defence personnel and followed the performance of cadets in various training academies, namely National Defence Academy, Indian Military Academy, Officers Training Academy, Air Force Academy, Air Force Technical College and Naval Academy. With more than 18 years of service as scientist, Dr Kumar has been the psychological assessor (Psychologist) in various Services Selection Boards for eight years for the selection of officers in Indian Armed Forces. Dr Kumar has developed many psychological tests and assessment tools for the selection of officers and recently the psychological test battery and manual for the selection of Other Ranks (PBOR) in Indian Armed Forces. Dr Kumar has authored a field manual on ‘Suicide and Fratricide: Dynamics and Management’ for defence personnel, ‘Managing Emotions in Daily Life & at Work Place’ for general population and ‘Overcoming Obsolescence & Becoming Creative in R&D Environment’ for R&D organisations. Dr Kumar has conducted many workshops and a National conference on the theme of psychology related topics. Dr Kumar has edited a book, Recent Developments in 343

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Psychology, along with many other academic publications in the form of journal articles and chapters in books. Manas K. Mandal, PhD, Scientist ‘H’, Outstanding Scientist, is Director, Defence Institute of Psychological Research (DIPR), Delhi. Dr Mandal has obtained his Postgraduate and doctorate degrees from Calcutta University in 1979 and 1984, respectively. He has completed his post-doctoral research programme at Delaware University (Fulbright Fellow), USA in 1986–87 and at Waterloo University (Shastri and Natural Sciences and Engineering Research Council [NSERC] Fellow), Canada, in 1993–94. Dr Mandal was a Professor of Psychology at IIT Kharagpur. He was also a visiting professor at Kyushu University, Japan in 1997. During 2003 he was a Fulbright Visiting Lecturer, Harvard University, USA. He has been awarded various research fellowships and scientific awards at national and international levels, such as International Scientific Exchange Award (Canada), Fulbright Fellowship (USA), Shastri Fellowship (Canada), Seymour Kety grant (USA), Career Award (India), University Gold Medal. Recipient of four prestigious awards from the prime ministers of India, Young Scientist Award (1986), Agni award for excellence in self-reliance (2005), Scientist-of-the-Year Award (2006), Technology Spin-off award for DIPR (2007), Dr Mandal has to his credit six books, and over 100 research papers/chapters in books (80 international and 25 national) published in peer-reviewed journals/books. These researches are cited in 125 international journals and books with more than 500 citations.

The Contributors Kathryn Kanzler Appolonio, Psy.D., is an active-duty USAF staff psychologist for the Mental Health Clinic and the Clinical Health Psychology Service at Lackland Air Force Base, Texas. She trains clinical psychology interns in empirically-based treatments in her role as a core faculty member in the Department of Psychology at Wilford Hall Medical Center’s APA-accredited psychology internship programme. Dr Appolonio received her doctorate in clinical psychology from La Salle University and completed her internship at Wilford Hall Medical Center. Dr Appolonio’s 344


clinical and research interests involve clinical health and primary care psychology, as well as clinical suicidology. Craig J. Bryan, Psy.D., is the Chief of Primary Care Psychology Services at Kelly Family Medicine Clinic, and Suicide Prevention Program Manager for Lackland Air Force Base, Texas. He is also a core faculty member in the Department of Psychology at Wilford Hall Medical Center’s APAaccredited psychology internship programme, where he trains clinicians in the primary care behavioural health model. Dr Bryan received his doctorate in clinical psychology from Baylor University, and completed his clinical psychology internship at Wilford Hall Medical Center. Dr Bryan’s primary areas of research include clinical suicidology and behavioural health effectiveness research for integrated primary care clinics. Erminia Colucci holds a Diploma in Education, and a first class honours degree in Clinical Psychology from the University of Padua (Italy), Erminia (Emy). She was trained as a researcher at The Australian Institute for Suicide Research and Prevention (AISRAP), Griffith University, Brisbane. In 2003 she won the Australian International postgraduate research scholarships (University of Queensland International Postgraduate Research Scholarship [UQIPRS] and International Postgraduate Research Scholarship [IPRS]), which supported her PhD project ‘The Cultural Meaning of Suicide: A Comparison between Italian, Indian and Australian Students’ at The University of Queensland, where she was awarded a PhD in Cultural Psychiatry. Her project was awarded the 2004 UQ Travel Award and the 2005 Dr Helen Row–Zonta Memorial Prize. Since the last few years she is a Research Fellow in the Centre for International Mental Health (School of Population Health, The University of Melbourne), where she is the Research Program Coordinator. She has also given lectures in universities in India, Japan, Italy and Australia. Erminia has presented papers on the cultural aspects of suicide, spirituality, gender issues, qualitative research and arts-based research/prevention nationally and internationally. She has also authored journal papers, book chapters and other publications on these topics. Enrica De Simoni, MD, is a resident in psychiatry at II Faculty of Medicine, Sapienza University of Rome, Italy. She is interested in studying the role of religion in mediating suicide risk. She recently carried out a number of 345

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review studies dealing with suicide risk related to sport activities, religion and smoking. Ilaria Falcone, MD, is a resident in psychiatry at II Faculty of Medicine, Sapienza University of Rome, Italy. She is interested in studying the role of impulsivity and aggression in mediating suicide risk. She has been involved in the prevention of suicide in primary care. She carried out studies dealing with suicide and pharmacological treatment. Sandor Fekete, MD, PhD, is Professor and Head of the Department of Psychiatry and Psychotherapy, University of Pecs, Hungary. He is a psychiatrist, psychotherapist and neurologist as well as senior lecturer in graduate/postgraduate education at the university, principal investigator of collaborative studies on suicidal behaviour, and national focal point in the WHO/EURO Network of Suicide Prevention and Research. Cathy Yui-chi Fong obtained her Bachelor’s degree in psychology from The Chinese University of Hong Kong. She was to begin her PhD studies with a specialisation in educational psychology at the University of Hong Kong in fall 2009. She has been involved in a number of research studies on Chinese children’s reading development and impairment, including co-authoring a chapter on this topic for a forthcoming book entitled The Handbook of Chinese Psychology. Her interests include school readiness and language and reading development, particularly in young children. Marco Innamorati, Psy.D., is cognitive and behavioural psychotherapist and Professor of Clinical Psychophysiology at Università Europea di Roma. He collaborated at the validation for the Italian population of the Beck Hopelessness Scale. He works for the prevention of suicide in high risk groups such as youths and elderly. Farah Kidwai holds a PhD in ‘Emotional Intelligence and Leadership’. She specialises in the field of Applied Social Psychology and Personality Assessment. She has a number of research studies to her credit and has conducted several workshops in the area of interpersonal relations, emotional intelligence and leadership in diverse organisations. A Scientist ‘E’ in the Defence R&D Organisation, she is the recipient of a number 346


of scholarships and awards including Scientific Advisor’s Award for the year 2001 by DRDO and Vice Chief of Army Commendation in 2008 by Indian Army. She was also recommended for the Award of Commonwealth Scholarship for Doctorate Degree in 1999 in Psychology by the Government of India. Angel Nga-man Leung obtained her Bachelor’s degree in Social Sciences from the University of Hong Kong and her M.Phil. degree in psychology from The Chinese University of Hong Kong. She is now a PhD candidate in the Psychology Department of The Chinese University of Hong Kong specialising in developmental psychology. Her major research interests are parenting, adolescent depression and suicide ideation, and the influences of online gaming on the social development of early adolescents. Carmel McAuliffe is a Senior Researcher with the National Suicide Research Foundation (NSRF) in Cork, Ireland. She is a psychology graduate of University College Cork and has worked in suicide research since 1996 when she joined the NSRF as a Research Psychologist under the direction of the late Dr Michael J. Kelleher. She has worked on several projects relating to people who engage in deliberate self-harm including the WHO/EURO Multicentre Study on Suicidal Behaviour and a randomised controlled trial of Group Interpersonal Problem-Solving Skills Training for medically treated deliberate self-harm patients. She has published in a number of scientific peer-reviewed journals. She is currently working on a pilot Suicide Support and Information System in the Cork region which aims to better understand the causes of suicide and to improve the provision of support to families bereaved by suicide. Catherine Alexandra McBride-Chang is a Professor in the Psychology Department of the Chinese University of Hong Kong specialising in developmental psychology. She has published journal articles on a variety of topics, including adolescent suicide ideation, parenting, child abuse, peer relations, creativity, and reading development and impairment. She has also edited one book on Chinese children’s reading development and authored a book entitled Children’s Literacy Development. She currently serves as the Director of the Developmental Centre at The Chinese University of Hong Kong. 347

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Lars Mehlum, MD, PhD, is the founding director of the National Centre for Suicide Research and Prevention at the Institute of Psychiatry, University of Oslo, Norway. He completed his medical training at the University of Bergen in 1982, and his PhD at the University of Oslo in 1995. He is a board specialist of psychiatry in Norway and trained in psychodynamic psychotherapy and dialectical behaviour therapy. He has been a coordinator of the National Strategy for Suicide Prevention in Norway since 1993, established a master’s degree on suicide prevention at the University of Oslo, established a suicide preventive programme in the Norwegian Armed Forces, headed a national suicide preventive training programme for gate keepers, and co-founded the Norwegian Association for Suicide Survivors. He has been actively supporting a number of international suicide preventive initiatives throughout the years and was president of the International Association for Suicide Prevention (IASP) from 2003 to 2005. He has acted as an advisor for national suicide preventive strategies in several countries. He is member of the Scientific Advisory Council of the American Foundation for Suicide Prevention, member of IASP, International Academy of Suicide Research and the American Association of Suicidology. Apart from being the founding editor of the journal Suicidologi published since 1996, he is also a member of the editorial board of Suicide & Life-Threatening Behaviour and Archives of Suicide Research. With his research group he focuses on the clinical course of suicidal behaviour with respect to aetiological and prognostic factors such as stressors and negative life events, major psychiatric illness and the effectiveness of interventions, among them Dialectical Behaviour Therapy. He has also conducted studies of the epidemiology of deliberate self-harm and completed suicide in the general population and various non-clinical populations. He has published several empirical papers in scientific journals, book chapters and books. He has received several national and international awards in recognition of his work. Alec L. Miller, Psy.D., is Professor of Clinical Psychiatry and Behavioural Sciences, Chief of Child and Adolescent Psychology, Director of the Adolescent Depression and Suicide Program, Director of Mental Health Services at P.S. 8 School-Based Mental Health Program, and Associate Director of the Psychology Internship Training Program at Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Dr Miller has published widely on adolescent suicide, Dialectical 348


Behaviour Therapy (DBT), and borderline personality disorder, and has trained thousands of mental health professionals in DBT. He is co-author of Dialectical Behavior Therapy for Suicidal Adolescents. Nishi Misra is Scientist ‘D’ at Defence Institute of Psychological Research, Delhi. She obtained her postgraduation from Allahabad University and M.Phil. in Medical & Social Psychology from Central Institute of Psychiatry, Ranchi. She specialises in the area of Clinical Psychology and has also served as an assessor in Services Selection Board, Allahabad. She has worked extensively in the area of suicides and fratricides, job stress and post-traumatic stress in Armed Forces. She is the co-author of the popular field manual for the officers of the Indian Armed Forces titled ‘Suicide and Fratricide: Dynamics and Management’. She counsels DRDO personnel as well. She has to her credit number of research projects and publication’s. Chad E. Morrow, Psy.D., is currently a captain and psychologist in the United States Air Force. He is stationed at Maxwell AFB in Montgomery where he serves as the Chief of the Mental Health Element, Alcohol and Drug Abuse Prevention and Treatment (ADAPT) program manager, Traumatic Stress Response program manager, Drug Demand Reduction program manager and the Suicide Prevention program manager. Dr Morrow received his doctorate in clinical psychology from La Salle University, and completed his clinical psychology internship at Wilford Hall Medical Center. Dr Morrow’s current research involves garnering empirical support for managing risk/suicide in different settings, for certain models of suicidal behavior, for the efficacy of integrated primary care, and for the modification and use of empirically supported protocols in primary care settings. Swati Mukherjee is Scientist ‘C’ at Defence Institute of Psychological Research, Delhi. She has obtained her M.Phil. degree from Delhi University. She has been a gold medalist throughout her undergraduate and postgraduate study in applied psychology. She is involved in many major research projects of the institute. She has to her credit a few research publications. She has edited a volume on ‘Recent Development in Psychology’ and has published a manual on ‘Suicide & Fratricide’. She is currently working in the area of personality assessment for personnel selection. Her areas of interests are Social Psychology and Peace Psychology. 349

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Pritha Mukhopadhyay is Professor in the Department of Psychology at University of Calcutta, teaching both postgraduate and M.Phil. (Clinical Psychology) courses and regularly renders services to the community as a mental health professional. She has research experience of above 25 years in clinical psychology from psychophysiological and psychoendocrinological perspectives. She has published over 40 research papers in national and international journals and has authored four book chapters. She was awarded Fulbright post doctoral fellowship and was fellow in Indian Council of Medical Research (ICMR) projects, and has conducted UGC, All India Council for Technical Education (AICTE) and Department of Science and Technology (DST) projects for research programmes, including intervention in problem behaviour of children, using biofeedback in clinical population and industrial personnel along with detection of neuropsychological impairment in psychiatric disorders through neuroimaging and neuropsychological techniques. Her recent research interest is on academic readiness in children from Piagetian perspective and shared dysfunction in Autistic sibship. She has supervised Doctoral thesis on neuropsychological research in brain lesions and psychiatric illness, endophenotypes in obsessive compulsive disorder and psychopathology in personality disorders including psychosocial and neuropsychological approaches. Latha Nrugham is currently working as Researcher with the National Centre for Suicide Research and Prevention at the Institute of Psychiatry, University of Oslo, Norway. She is also a Research Fellow at the Norwegian University of Science and Technology (NTNU), pursuing her Doctorate in Philosophy (PhD) in community medicine on attempted suicide among Norwegian youth. She completed her M.Phil. in Psychiatric Social Work from the National Institute of Mental Health and Neurosciences (NIMHANS), India in 1994 and Master of Arts (MA) in Social Work from the Tata Institute of Social Sciences (TISS), India in 1988 after finishing her graduation in science from the University of Mumbai in 1986. She has worked as Project Social Worker and Researcher with the fieldprojects of TISS and University of Mumbai, and has been a Fellow of Child Relief and You (CRY) and Consultant to Department for International Development (DFID) in India. She has also worked as Clinical Social Worker in hospital and outpatient settings in India and Norway. She has published empirical papers in scientific journals and book chapters on attempted suicide. 350


Rory C. O’Connor is Professor of Psychology at University of Stirling and a chartered health psychologist. He leads the Suicidal Behaviour Research Group at Stirling which is the only dedicated suicide research group in Scotland. He has an international reputation for his work on the risk and protective factors associated with suicide and self-harm. Over the past 14 years he has co-authored some 70 peer-reviewed publications on the psychological factors associated with suicide, self-harm and well-being. He is the co-author of the book Understanding Suicidal Behaviour and is one of the co-editors of the forthcoming book the International Handbook of Suicide Prevention: Research, Policy and Practice (Wiley Blackwell). He is a member of the American Association of Suicidology, the International Academy for Suicide Research and the International Association for Suicide Prevention. He is also the UK National Representative of the International Association for Suicide Prevention (IASP). Peter Osvath, MD, PhD, is an associate professor, psychiatrist and psychotherapist. He presently works in the Department of Psychiatry and Psychotherapy, University of Pecs, Hungary. He is also a senior lecturer in graduate/postgraduate education at the university, and participant in many collaborative studies on suicidal behaviour. Gaspare Palmieri, MD, is a psychiatrist and psychotherapist at Casa di Cura Villa Igea, Modena, Italy. He has been involved in studies dealing with the Reasons for Living Inventory in various clinical and non-clinical populations. He is engaged in research projects dealing with suicide risk among psychiatric patients. Maurizio Pompili, MD, psychiatrists and psychotherapist, is Professor of Suicidology, II Faculty of Medicine, Sapienza University of Rome, Italy. He is part of the community of the McLean Hospital—Harvard Medical School, USA. He is a dedicated researcher of suicidology with more that 200 scientific publications in the field. He was the recipient of the American Association of Suicidology’s 2008 Shneidman Award for outstanding early career contributions to Suicidology. He is the National Representative to the International Association for Suicide Prevention. Amri Sabharwal is presently working as a Research Investigator at the Defence Institute of Psychological Research, New Delhi. She completed 351

Suicidal Behaviour

her M.Sc. degree in Cognitive Neuropsychology from the University of Essex, UK in 2006, with a dissertation on the dual process theory of recognition memory. For her Bachelor’s degree from Osmania University in 2005, she was awarded the gold medal for best overall performance in psychology. She has been involved in defence-related research pertaining to mental health, personality assessment and test development for personnel selection, as well as other non-defence projects on cerebral lateralisation and emotion recognition. Her area of research includes Cognitive Psychology and Neuropsychology. Laura Sapienza, MD, is a resident in psychiatry at II Faculty of Medicine, Sapienza University of Rome, Italy. She is a member of the International Association for Suicide Prevention. She is involved in suicide prevention among psychiatric outpatients. She carried out researches dealing with suicide risk among military personnel, psychiatric patients and nonclinical populations. Eva Schaller is psychologist and cognitive-behavioural orientated psychological psychotherapist. At the State Mental Hospital Bayreuth, Academic Hospital for Psychiatry of the University of Erlangen-Nuremberg, she works at a unit for major depression, and also in outpatient care for patients suffering form depressive and bipolar affective disorders. She was born in Muenchberg, Bavaria, Germany. She studied psychology at the University of Wuerzburg; after graduation she worked as a research associate at the professorship for clinical psychology at the University of Wuerzburg. Her focuses were anxiety disorders, especially specific phobias and panic disorders. Her research topics are treatment of depressive disorders, suicidal behaviour and outpatient care. Roberto Tatarelli, MD, is Full Professor of Psychiatry and Chairman of the Residency Training in Psychiatry at II Faculty of Medicine, Sapienza University of Rome, Italy. He is the chairman of the Department of Neuroscience at Sant’Andrea Hospital in Rome, Italy. He is a leading expert on suicide and full member of the International Academy of Suicide Research. He is author of more than 400 scientific publications. Jitendra Kumar Trivedi is a Professor in the Department of Psychiatry, Chhatrapati Shahuji Maharaj Medical University, Uttar Pradesh (formerly 352


King George Medical University, Lucknow), India, since 1995. He has taken the charge of Head, Department of Psychiatry recently. He has done his medical graduation (MBBS) from the King George’s Medical College, Lucknow University, Lucknow in 1973 and later MD in Psychiatry from the same institute in 1977. He was appointed in the faculty in the Department of Psychiatry, K.G. Medical College, Lucknow in 1978 and since then is working at the same institution in various positions. He has been a principal investigator for more than 25 multinational clinical trials as well as ICMR and WHO sponsored projects. He has more than 200 publications in national and international journals as well as chapters in books. He has made presentations on various aspects of mental health in both national and international conferences. He has been the editor of Indian Journal of Psychiatry (IJP) for six years and has been associated with IJP for more than 18 years in various capacities. He was President of Indian Psychiatric Society for the year 2004. He has been Zonal Representative for Southern Asia—Zone-XVI of World Psychiatric Association from year 2005 to 2008. Kimberly A. Van Orden, MS, is a doctoral candidate in clinical psychology at Florida State University and is completing her pre-doctoral internship at Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. Kim has a primary interest in suicide risk assessment and has coauthored numerous papers on suicidal behaviour. She is also a co-author of The Interpersonal Theory of Suicide: Guidance for Working with Suicidal Clients. She received the American Association of Suicidology’s Student Research Award, a Dissertation Research Award from the Melissa Institute for Violence Prevention and Treatment, an APF/COGDOP Graduate Research Scholarships, and a Scholar Award from P.E.O. International. Sannidhya Varma is currently pursuing his Master’s degree in Psychiatry from the Department of Psychiatry, CSM Medical College, Lucknow, India. He has done his MBBS from Government Medical College and Hospital, Chandigarh, and has been a meritorious student throughout. He is academically and clinically oriented and has been active participant in various zonal and national conferences. During his tenure of residency, he has got training in the fields of general adult, child and adolescent, geriatric, sex clinic and de-addiction psychiatry. 353

Suicidal Behaviour

Viktor Voros, MD, psychiatrist, Assistant Professor at the Department of Psychiatry and Psychotherapy, University of Pecs, Hungary. Besides clinical work, he is also a lecturer in graduate and postgraduate education at the university, and participant in many collaborative studies on suicidal behaviour. Manfred Wolfersdorf, Professor, Dr med. Dr h. c., is psychiatrist and psychodynamic orientated psychotherapist. He is medical director of State Mental Hospital Bayreuth, Academic Hospital for Psychiatry of the University of Erlangen-Nuremberg, head of the clinic for psychiatry, psychotherapy and psychosomatic medicine and docent for ethics in psychiatry at the University of Ulm and for psychiatry at the Stradins University of Riga, Latvia. Professor Wolfersdorf was born in Amberg, Bavaria, Germany, studied medicine at the University of ErlangenNuremberg and got his medical education to become a psychiatrist at the University of Ulm. In 1985 and 1987 he worked at the Institute on SelfDestructive Behaviour and Suicide Prevention at the USC in Los Angeles, USA. His research topics are depression treatment, severe depression and suicidal behaviour.

354

Author Index

Author Index

Aaron, R., 328 Agerbo, E., 154, 306, 308 Agoub, M., 282 Ahrens, B., 257 Akiskal, H.S., 32, 256–258, 260, 266 Alao, A., 331 Alda, M., 287 Alexopoulos, G.S., 161 Allan, S., 7 Allebeck, P., 235 Allport, 1950, in Hill and Pargament, 2003, 124 American Foundation for Suicide Prevention, 183 American Psychiatric Association (APA), 21, 27, 31–32, 232 Amsel, L., 58 Amsterdam, J.D., 266 Amundsen, A., 302 Andreasson, S., 235 Angst, F., 283 Angst, J., 256–257, 283 Anguelova, M., 51 Antonovsky, A., 304 Apospori, E., 113 Appelby, L., 282 Applebaum, S., 65 Appleby, L., 140, 231 Appolonio, K.K., 20 Apter, A., 92, 109, 281 Arango, V., 45–46

Arato, M., 44, 281 Arensman, E., 71, 73 Arensman et al., 2001, 66, 72 Aro, H.M., 238 Arsenault-Lapierre, G., 232 Asberg, M., 45, 154 Asgard, U., 281 Ashton, J.R., 176–177 Averill, J.R., 101 Baca-Garcia, E., 54, 154 Badro, S., 304 Bagley, C., 330 Baker, D., 332 Baldessarini, R.J., 49–50, 257, 260, 263, 265–267 Baldry, A.C., 330 Bale, E., 65 Ballard, C.G., 112 Banaji, M.R., 218 Bancroft, J., 65 Bandura, A., 101 Banki, C.M., 44 Barbe, R.P., 157 Barkey, K., 122 Barnes, R., 233 Barraclough, B., 30, 32, 140, 154, 176–177, 232–233, 236, 257, 260 Barraclough, B.M., 278–281, 285 Basu, J., 219 Basu, S., 195

355

Suicidal Behaviour

Borowsky, I.W., 112 Boyd-Barrett, O., 179 Boyer, R., 34 Braham, P., 179 Braucht, G.N., 68 Breault, K.D., 122 Breed, W., 92 Brent, D.A., 50, 56, 154–155, 158, 160, 163, 231, 245, 281–282 Breslow, N.E., 232 Brezo, J., 53–54 Bridge, J.A., 160, 329 Brisman, J., 243 Bristowe, E., 95 Bronfenbrenner, V., 95 Brook, R., 304 Brown, G.K., 34, 66, 73, 153–154, 156, 193, 316 Brown, G.L., 45, 195 Brown, J., 29, 157 Brown et al., 2000, 32 Brown G.K., 194, 198, 208 Bruce, M.L., 161 Brunswick, D.J., 266 Bryan, C.J., 20 Bryan, C.J., 21, 28, 34–37 Buchanan, A., 158 Bucik, V., 238 Buka, S.L., 231 Bulik, C.M., 258 Bunney, W., 44 Burkhardt, M.A., 124 Burstein, A.G., 21 Burt, V.K., 94 Busch, K.A., 156 Butler, G.K.L., 237 Buzan, R.D., 20

Bauer, M.S., 267 Baumeister, R.F., 6–7, 65, 211 BBC, 179 Bear, D.M., 98 Beary, M.D., 242 Beautrais, A.L., 154, 158, 182, 230, 232, 234, 242, 325, 329 Beck, A.T., 12, 32, 194, 197, 199, 201–202, 211, 213, 215, 231, 234, 284, 288 Becker, E.S., 57 Bellack, K., 219 Bellivier, F., 52 Ben, C.D., 47 Benazzi, F., 32, 258 Berk, M.S., 195 Berkman, L.F., 231 Berkowitz, L., 100, 182 Bernal, G., 336 Bernal, M., 280, 282, 284 Bernasco, W., 94 Bertolote, J.M., 231, 278–279, 282 Beskow, J., 281 Beuhring, T., 112 Bhattacharya, S., 176 Bhugra, D., 111, 119 Biddle, L., 141 Biegon, A., 48 Bille-Brahe, U., 75 Birckmayer, J., 246 Biswas, S., 111 Björkqvist, K., 183 Black, D.W., 284, 307 Blair-West, G.W., 283 Blakely, T.A., 306 Block, J., 101 Blumenthal, S.J., 161 Boehm, S., 215 Boldt, M., 107, 115–116 Bolger, E.A., 304 Bolton, C., 9 Bond, A., 65 Bongar, B., 21, 26 Borges, G., 231–234

Caces, F.E., 233 Canetto, S.S., 136–139 Canli, T., 52 Carlson, G.A., 263 Carrington, P.J., 335 356

Author Index

Colman, A.M., 96 Colucci, E., 107, 110–114, 116, 120–122, 124–125, 127 Colucci, E.I., 127 Colucci (2008c), 128 Conlon, W., 238 Conner, K.R., 156–157, 234, 307 Consensus conference. Electroconvulsive therapy, 268 Conwell, Y., 154, 156–159, 163, 281 Cook, P.J., 155 Cooper, J.M., 96 Cooper-Patrik, L., 223 Corbett, S., 242 Cordess, C., 97 Cornelius, J.R., 241 Coryell, W., 282–283, 285, 287 Coulter, P., 175 Craft, L., 161, 333 Crane, C., 72 Crosby, A.E., 154 Crouter, A., 95 Crumbaugh, J.C., 124 Cull, J.G., 198, 203 Currier, D., 3 Curtin, L., 199, 203

Carriss, M.J., 68–69, 71 Carroll, M.E., 237 Cartensen, L.L., 177 Caruso, K., 333 Cavan, R., 99 Cavanagh, J.T., 157, 307 Cebasek-Travnik, Z., 238 Centre for Disease Control (CDC), 333, 335 Chabrol, H., 235 Chagnon, F., 143 Chambers, D., 327 Chang, E.C., 67 Chauchard, E., 235 Chemtob, C.M., 20 Chen, R., 110 Chen, T.H.H., 174, 177 Chen, Y.W., 264 Cheng, A.T., 264 Cheng, A.T. (the year is mismatching), 280–281 Cheng, A.T.A., 137, 174, 177, 327 Chengappa, K.N., 242 Chenier, T., 233 Chia, B.H., 334–335 Chiles, J., 65 Chioqueta, A.P., 307, 315 Chithiramohan, R.N., 112 Chow, Y.W., 329 Chynoweth, R., 281 Ciarrochi, J., 12 Ciffone, J., 200 Cipriani, A., 316 Cittadini, A., 262 Clark, D.C., 34 Clum, G., 3 Clum, G.A., 67–68, 70–71, 199, 203, 238 Coccaro, E.F., 48, 237 Cohen, A.R., 101 Cohen, D., 95 Cohen, Y., 109 Cohen-Sandler, R., 154 Collins, J.B., 95

Dahlberg, L.L., 91 Dahm, P.F., 70 Daly, M., 97 Darke, S., 235–236, 240 Davidson, L.E., 174 Davis, L., 240 Day, N.E., 232 Deakin, B., 47 Dean, P.J., 7 de Catanzaro, D., 159 Dein, S., 119 de Lara C., 51 De Leo, D., 107–108, 156 De Luca, V., 51–54 Dembo, R., 237 Demotes-Mainard, J., 266 357

Suicidal Behaviour

Eronen, M., 94 Eshun, S., 112–113, 121 Eskin, M., 110 Etzendorfer, E., 173–174 Etzersdorfer, E., 335 Evans, J., 67 Everall, R.D., 115 Exline, J.J., 121 Exner, J., 220

Department of Health of the Republic of China, 325 De Pisa, E., 262 Dervic, K., 121, 154, 157–158, 195 De Simoni, E., 256 Desjeux, G., 308 D’Haenan, H., 46 Dhar, S., 195 Dieserud, G., 67, 69, 72, 156 Dilsaver, S.C., 259, 264, 288 Dogra, A.K., 195 Dollard, J., 100 Domino, G., 113 Dong, Q., 330 Donnan, S., 176–177 Donnerstein, E., 183 Donovan, J.M., 237 Doob, L.W., 100 D’Orio, B., 236 Dorpat, T.L., 281 Douglas, J. D., 115–116 Dube, S.R., 329 Duberstein, P.R., 154, 156, 158, 162, 234 DuRand, C.J., 94 Durkheim, as Boldt (1988), 115 Durkheim, E., 99, 109, 127, 136, 300, 304 Dusevic, N., 107 Dwivedi, Y., 53, 55 D’Zurilla, T., 66 D’Zurilla, T.J., 66–67, 81, 334

Fagg, J., 65 Fagiolini, A., 258 Falcone, I., 256 Faravelli, C., 256 Farberow, N.L., 115 Farrell, M., 230 Farrington, A., 236 Faupel, C.E., 122 Faust, V., 280 Fawcett, J., 20, 34, 44, 285, 287, 307 Fekete, S., 136, 138, 141, 144–145, 147–148 Feldman, B.N., 21 Feldman, M., 220 Felts, W.M., 233 Ferguson, T.J., 182 Fergusson, D.M., 182, 235 Ferracuti, F., 98 Feshbach, S., 100 Fetzer Institute, 124 Fiedorowicz, J.G., 259 Firestone, L.A., 212 Firestone, R.W., 212 Fishman, G., 178 Flamenbaum, R., 7 Flett, G.L., 13, 156, 217–218 Flitcraft, A., 95 Flouri, E., 158 Folger, R., 101 Fontana, A., 309 Fortune, S., 332 Foster, T., 282 Foster, V.A., 20

Eaton, W.W., 329 Eddleston, M., 34 Egeland, J.A., 29 Eggert, L.L., 159 Ehrlich, S., 262 Elias, N., 200 Ellis, T.E., 199 Engel, G.L., 4 Engstrom, A., 236 Erdõs, B.M., 144 Erikson, E., 145 Erlangsen, A., 158 358

Author Index

Gooding, P., 72 Goodwin, F.K., 257, 263–264 Goodwin, R.D., 243 Gorall, D.M., 220 Gould, M., 173 Gould, M.S., 152, 157, 159, 161–162, 174, 200, 334–335 Granello, D.H., 327, 330, 333 Granello, P.F., 327, 330, 333 Grant, B.F., 240 Greenberg, T., 200 Greenberger, V., 48 Greening, L., 128 Gridina, N., 331 Griesinger, W., 279 Griffin, A., 329 Groholt, B., 327 Gross, L., 178–179 Grossoehme, D.H., 122 Grunebaum, M.F., 264 Guetzloe, E.C., 328 Gundlach, J., 178 Gururaj, G., 326 Gutheil, T.G., 123 Gutierrez, P.M., 111–112 Guy, J.D., 21 Guy, S.M., 237 Guze, S.B., 283

Fountoulakis, K.N., 267 Fowler, R.C., 230 Francis, L.J., 121 Frank, E.S., 242 Frankl, V.E., 304 Fredrickson, B.L., 16 Freedenthal, S., 21 Freud, S., 91, 99 Fu, Q., 32 Fusé, T., 111 Fuster, J.M., 45 Gallo, J.J., 329 Gallop, R.M., 330 Gamma, A., 283 Garbarino, J., 95 Garlow, S.J., 236 Gelder, M., 200 Gellis, Z.D., 154 Genuis, M.L., 95 Gerber-Werder, R., 283 Gerbner, G., 178–179 Gergen, K., 332 Gershon, S., 242 Giancola, P.R., 237 Gibb, S.J., 264 Gibbons, R.D., 160 Gil, A., 113 Gil, A.G., 112–113 Gilbert, P., 7 Gilboa-Schechtman, E., 304 Gill, W.S., 198, 203 Giotakos, O., 304 Girabet, J., 235 Glinski, J., 158 Goldberg, E., 242 Goldfried, M.R., 66, 81 Goldney, R.D., 148 Goldstein, B., 180 Goldstein, R.B., 193, 284 Goldstein, R.C., 11 Goldstein, T.R., 157 Goldston, D.B., 194, 198

Haaga, D.A., 195 Haas, G.L., 280 Haenel, T., 279 Hafner, H., 177 Hall, R.C., 242 Hall, R.C.W., 280 Hall, S., 65 Hamilton, M., 213 Hammad, T.A., 160 Hanau, M., 48 Handy, S., 112 Hansburg, H.G., 209 Harding, A., 332 Harford, T., 233 359

Suicidal Behaviour

Hoaken, P.N.S., 237 Hochdorf, Z., 334 Holden, R.R., 7, 206 Holding, T.A., 177 Hole, G., 279 Holland, S., 329 Hölzer, R., 280 Home Office, 97 Hong, C.J., 51 Hong Kong Jockey Club Centre for Suicide Research and Prevention (CSRP), 333–335 Hong Kong Journalists Association, 185 Hood, R.W., 124 Horesh, N., 237 Horn, O., 302 Horner, S.D., 112 Horowitz, M., 221 Horwood, L.J., 182 Houle, J., 143, 148 Houston, K., 71 Hoyer, G., 156 Hsiung, S.C., 47 Hufford, M.R., 329 Hughes, D., 154 Hungarian Central Statistical Office, 146 Hunter, E.C., 12, 14 Huston, A.C., 181 Huth-Bocks, A.C., 156 Hytten, K., 298, 303, 308

Harlow, L.L., 304 Harmatz, M., 21 Harris, C.E., 278–280 Harris, E.C., 30, 32, 140, 154, 232–233, 236, 257, 260 Harris, T.L., 330 Harriss, L., 65, 71, 155 Harrow, M., 32 Harter, S., 232 Hartless, G., 111, 113 Hasin, D., 241 Haw, C., 71, 305 Hawton, K., 65–66, 71–72, 136–140, 142, 144, 156, 174–175, 177, 258, 263, 297, 305, 335 Hayes, J.A., 121 Hayes, L.M., 154 He, L., 51 Heeringen, van K., 258, 263 Heide, K.M., 93 Heilä, H., 281 Heisel, M.J., 156, 159, 163 Heisel, M.J., 111, 156 Helmkamp, J.C., 298–299, 308 Hempel, A.G., 96 Hemenway, D., 246 Hendin, H., 325–327 Hendin (1964, cited in Boldt, 1988), 115 Hennen, J., 49–50, 267 Henriksson, M., 122 Henriksson, M.M., 230, 281 Henriques, G.R., 65 Henry, A., 92 Henry, C., 266 Heppner, P., 69 Hershberger, S.L., 158 Hewitt, P.L., 13, 217 Hill, P.C., 124 Hillman, S.D., 232 Himmelfarb, N., 309 Hishinuma, E.S., 113 Ho, L.W., 52 Ho, T.P., 331

Innamorati, M., 256, 262 Inoue, T., 266 Insel, B.J., 159 Inskip, H.M., 233 Ireland, M., 112 Isaac, M.K., 326 Isometsa, E.T., 257–259, 263 Isometsä, E.T., 285, 288 Jacobs, D., 194 Jamieson, K.H., 331 Jamieson, P.E., 331 360

Author Index

Kennedy, R.D., 299 Kerkhof, A., 65, 75 Kerkhof, A.J.F.M., 71 Kerkhof, J.F.M., 94 Kessler, R.C., 231, 238, 240–241, 256, 264, 278 Keyes, C.L., 124 Kidwai, F., 173 Kim, C.D., 49 Kinderman, P., 4–5 King, C.A., 330 King, E.A., 264 Kingsbury, S., 112 Kingsbury, S.J., 162 Kirmayer, L.J., 111 Kleespies, P., 154 Kleespies, P.M., 20 Klein, P.S., 47 Klempan, T., 43 Klimes-Dougan, B., 154 Klingman, A., 334 Knox, K.L., 334 Kochman, F.J., 261 Kockott and Feuerlein (1968), 234 Kocsis, J.H., 245 Koivumaa-Honkanen, H., 156 Koller, G., 240 Kopp, W. (coming as Knopp in text), 286 Korn, M.L., 237 Kotila, L., 154 Kovacs, M., 214 Kposowa, A.J., 306 Kral, M.J., 108, 110, 125 Kramer, R.A., 334–335 Kranzler, H.R., 244 Kreitman, N., 155 Krieger, G., 44 Krishnan, K.R., 269 Krug, E.G., 91, 97 Kubota, Y., 328 Kumar, U., 91, 230 Kung, A.C., 280 Kung, H.C., 235

Jamison, K.R., 257, 263 Jin, S., 113, 125 Jobes, D.A., 16, 155, 162, 195, 198, 207, 316 John, S., 108 Johnson, C.V., 121 Johnson, J., 9 Johnson, J.G., 330–331 Johnson, S.L., 256 Johnson, W.B., 194 Joiner, T., 6, 159, 238 Joiner, T.E., 3, 29–30, 32, 34, 153, 155, 157–158, 196, 218 Joiner, T.E. Jr., 303, 317 Joseph, A., 42, 326 Joukamaa, M., 94 Joyce, P.R., 234 Judas, M., 262 Judd, L.L., 256 Kaizar, E.E., 160 Kalafat, J., 200, 333 Kaltiala-Heino, R., 158 Kamal, Z., 121 Kamali, M., 46 Kang, H., 309 Kaplan, A., 125 Kaplan, H.I., 136, 139 Kaplan, J.R., 48 Kaplan, K.J., 32 Karasek, R., 301 Karege, F., 47 Katzman, D.K., 242 Kavoussi, R.J., 48 Kaye, S., 235 Kazarian, S.S., 108–109 Kazdin, A., 217 Kazdin, A.E., 156 Kehoe, N.C., 123 Kelemen, G., 144 Kelleher, M.J., 327 Keller, F., 285, 288 Kelly, H.H., 101 361

Suicidal Behaviour

Loewenthal, K.M., 121 Lonnqvist, J., 122, 154, 234 Lonnqvist, J.K., 307 Lönnqvist, J.K., 238, 288 Lopez, J.F., 44 Lopez, P., 258 Losada, M.F., 16 Louma, J.B., 140 Lozano, R., 91 Ludwig, J., 155 Lund, E., 156 Luoma, J.B., 160–161 Luscomb, R.L., 238 Lynskey, M.T., 235

Kuo, W.H., 329 Kupfer, D.J., 242 Lalovic, A., 48, 55 Lam, T.H., 331 Lau, S., 330 Lau, T.F., 330 Lazerwitz, B., 115 Leach, M.M., 113, 122, 125–128 Lee, C.S., 137, 327 Lee, C.T.C., 174 Lee, T.Y., 329–330 Leenaars, A.A., 6, 110, 114, 211 Lehmann, L., 241 Leibenluft, E., 257 Leiner, A.S., 157 Lesage, A.D., 281 Lester, D., 107–109, 114, 118, 121, 152, 234, 260, 288, 304 Lester (1987, cited in Zonda and Lester, 1990), 107 Lesyna, K., 177 Le Tendre, G., 330, 334 Lettieri, D., 231 Lettieri, D.J., 67 Leverich, G.S., 258 Levine, J., 242 Levine, R.E., 96 Lewis, L., 328 Li, D., 51 Li, X., 47 Liem, M., 95–96 Lin, X., 280 Lind, L., 309 Linehan, M.M., 26, 29, 34, 67, 73, 155, 199, 205, 209–210, 316 Link, B.G., 94 Linnoila, M., 46, 237 Linz, D., 183 Lion, J.R., 94, 98, 102 Lipschitz, D.S., 154 Liu, K., 327 Loeber, R., 93

Mabila, J.D., 235 MacLean, P.D., 7 MacLeod, A.K., 12–13, 70 Madge, N., 65 Mahon, M.J., 298, 308–309 Maj, M., 258 Mallya, G., 266 Malone, K.M., 34, 236, 280 Maltsberger, J.T., 26 Mancinelli, I., 125 Mandal, M.K., 91 Mann, J.J., 3, 31–32, 46, 56, 58, 154, 230, 236, 245, 262, 280, 307, 316 Mansell, W., 13 Marecek, J., 118 Marion, M.S., 128 Maris, R., 114 Maris, R.W., 32, 49–50, 65, 115, 138, 152, 196, 200, 245, 307–309 Marker, H.R., 288 Marneros, A., 269 Marsella, A.J., 109, 125 Marshall, H., 127 Martin, B.C., 101 Martin, G., 110–114, 120–122, 127, 157 Marttunen, M., 231, 308, 327, 334, 336 Marttunen, M.I., 238 Marttunen, M.J., 281 362

Author Index

Miller, N.E., 100 Minnix, J.A., 34 Mishara, B.L., 108, 127–128, 143 Misra, N., 230 Mitra, S., 143 Mittendorfer-Rutz, E., 50, 138–139 Mitterauer, B., 281 Miyamoto, R.H., 113 Modestin, J., 286 Molnar, B.E., 231 Molock, S.D., 330 Montgomery, A.M.J., 237 Morgan, H.G., 279 Morrow, C.E., 20 Mortensen, P.B., 137, 140 Moscicki, E., 43 Moscicki, E.K., 136 Moselhy, H.F., 238 Moskos, M., 158 Motto, J.A., 199 Mowrer, O.H., 100 Moyer, S., 335 Mukherjee, S., 91 Mukhopadhyay, P., 193 Mulder, R.T., 234 Müller, M.J., 283 Muller-Oerlinghausen, B., 257 Munchua, M.M., 208 Murphy, G., 234 Murphy, G.E., 139, 141, 243

Marusic, A., 238 Marzuk, P.M., 93–95, 235 Maser, J.D., 153, 261 Mason, B.J., 245 Maxfield, M.G., 95 Mayer, P., 108, 141 Mazza, J.J., 159 McAdams, C.R., 20 McAuliffe, C., 65, 75, 78–80 McAuliffe et al., 2005, 77 McBride-Chang, C., 329 Mcbride-Chang, C.A., 324 McCann, U.D., 237 McCormick, R.A., 241 Mc Cracken, L., 241 McGirr, A., 282, 284–285, 287 McIntosh, J.L., 43, 110, 154 McLeavey, B., 80 McLeavey, B.C., 66–67, 72, 79, 81 McLeod, L.D., 206 McManus, B.L., 163 Mehlum, L., 297–298, 300–302, 304–306, 308–309, 311–312, 314–315, 331 Meichenbaum, D., 194 Meloy, J.R., 96 Melton, D.A., 47 Meltzer, H.Y., 267 Meng, L., 115 Meninger, K., 230 Menninger, K., 92 Merchant, C.R., 330 Mercy, J.A., 91 Metalsky, G.I., 218 Metzger, R., 286, 289 Metzner, J.L., 154 Michel, K., 141, 147–148 Miklowitz, D.J., 256 Mikulincer, M., 304 Miles, C., 283 Miller, A.L., 152, 158 Miller, D.N., 161 Miller, I.W., 202 Miller, J., 332

Nace, E.P., 244 Nahulu, L.B., 113 Nasrallah, A., 284 National Crime Bureau, Ministry of Home Affairs, Government of India, 42 National Crime Records Bureau, 325 National Institute of Aging, the, 124 National Suicide Research Foundation, 65, 80 Neeleman, J., 230 Negron, R., 197, 207 Nekanda-Trepka, C.J.S., 70 363

Suicidal Behaviour

Parker, G., 221 Parker, R.N., 92 Patsiokas, A.T., 67, 79, 238 Paykel, E.S., 222 Payne, S., 138–143 Pearson, J.H., 280 Pearson, J.L., 140 Peck, D.L., 99 Pelkonen, M., 327, 334, 336 Pelles, D.J., 281, 285 Penn, J.V., 154 Penrod, S., 183 Perkins, D.F., 111, 113 Perry, J.L., 237 Persad, E., 108–109 Peterson, B.S., 262 Peterson, L., 34 Petrie, K., 78, 304 Petronis, K., 235 Petronis, K.R., 281 Pettit, J.W., 34 Pfeffer, C.R., 153, 155–156, 161–163, 206 Pfennig, A., 44 Philipp, M., 283 Philips, M.R., 325, 328 Phillips, D.P., 177 Phillips, M.R., 282 Pihl, R.O., 237 Pihlgren, H., 285, 334 Pillemer, K.A., 95 Pirkis, J., 108 Pirkola, S.P., 233 Platt, D.E., 280 Platt, J.J., 218 Platt, S., 155 Plutchik, R., 34, 92, 210, 219, 237 Pohl, E., 331 Pokorny, A.D., 284–285 Pöldinger, W., 279 Pollock, L.R., 7–8, 65–67, 70 Pompili, M., 256–257, 260–263 Pope, K.S., 20 Potter, L.B., 34, 212

Nelson, R., 298 Nemeroff, C.B., 44 Neuringer, C., 67, 79 Newman, C.F., 199 Nezu, A.M., 66–67, 81, 334 Nga-man Leung, A., 324 Niehus, E., 288–290 Nishiguchi, N., 51–52 Nock, M.K., 93–95, 144, 156, 218 Nordentoft, M., 65, 156 Norstrom, P., 230 Norstrom, T., 234 Norwegian Board of Health, 309 Nrugham, L., 297, 329 O’Carroll, P.W., 24, 66, 194 O’Connor, D.B., 3, 7, 13 O’Connor, R., 12–13 O’Connor, R.C., 3, 7, 9–10, 12–16, 211 O’Doherty, M., 236 O’Donovan, C., 266 Ohberg, A., 233–234 Ohtani, M., 51 Oldnall, A., 124 Olson, D.H., 220 Olson, Gorall and Tiesel, 2004, 220 Oquendo, M., 307 Oquendo, M.A., 258, 262 Orbach, I., 154, 222, 304, 334 Ornstein, T.J., 238 Osbourne, T.R., 119 Osman, A., 156, 203 Osvath, P., 136, 141, 144–145, 147–148 Oyefeso, A., 236 Paight, D.J., 177 Palermo, G.B., 96, 98–99, 102 Palmieri, G., 256 Paloutzian and Ellison, 1982 cited in Ellison, 1983, 124 Pandey, G.N., 47, 55 Paolucci, E.O., 95 Pargament, K.I., 124 364

Author Index

Rosenthal, P.A., 157, 159 Rosenthal, R.N., 239, 244 Rosenthal, S., 157, 159 Rosovsky, H., 234 Rossello, J., 336 Rossow, I., 234, 302 Rotheram, M.J., 162 Rouillon, F., 257 Rounsaville, B.J., 240 Roy, A., 29, 233, 236, 240, 279 Rubenowitz, E., 32, 158 Rubenstein, J.L., 158 Rucci, P., 267, 269 Rudd, M.D., 3, 20–21, 23, 28, 30, 32, 34–37, 70–71, 74, 153–155, 205, 238, 245, 303, 312, 316, 333 Ruderman, A.J., 7 Rule, B.G., 182 Rumbold, B.D., 123 Runeson, B., 154, 281 Rutz, W., 142, 285, 334 Ryan, N.D., 257 Ryff, C.D., 124

Potter-Efron, R.T., 242 Powell, K.E., 299 Poznanski, E.O., 215 Practice guideline for the assessment and treatment of patients with suicidal behaviors, 267 Prescott, D., 95 Preuss, U.W., 238 Price, R.K., 306 Prigerson, H.G., 302 Prudic, J., 267 Pryor, T., 242 Purselle, D., 236 Qin, P., 137–138, 140, 156 Rajab, M.H., 70 Rajkumar, S., 233, 282 Raleigh, V.S., 111 Range, L.M., 7, 108, 125, 128 Rasmussen, S., 9 Ravandal, E., 240 Regier, D.A., 260 Renaud, J., 287 Resnick, M.D., 112 Resnik, H.L.P., 231 Rew, L., 112 Reynolds, W.M., 155, 161, 204, 214 Rhimer, Z., 281, 285 Ricaurte, G.A., 237 Rice, J., 257 Rich, C.L., 231, 281 Rihmer, A., 261 Rihmer, Z., 137, 140–142, 148, 256–257, 261, 264, 334 Rinck, M., 57 Ripley, H.S., 281 Roberts, C.R., 110 Roberts, R.E., 110, 156 Roberts, R.S., 72 Robins, E., 234, 281, 283 Romer, D., 175, 331 Romero, S., 263

Saavedra, J.M., 55 Sabbath, J.C., 159 Sabharwal, A., 230 Sackeim, H.A., 267 Sadock, B.J., 136, 139 Saini, S., 109 Sainsbury, P., 279 Sakinofsky, I., 65–66, 71–72, 76 Sakinofsky, L., 136–138 Salloum, I.M., 243 Samaraweera, S., 157 Sandin, B., 67, 69, 78 Sanislow, C.A., 154 Sansone, R.A., 157 Santa Mina, E.E., 330 Sapienza, L., 256 Sarason, I.G., 221 Sareen, J., 302 Sargent, P.A., 47 365

Suicidal Behaviour

Shneidman, E., 26 Shneidman, E.S., 6, 26, 304 Short, J., 92 Shroff, S., 143 Siegel, M., 243 Sil, M., 195 Silveira, W.R., 112 Silverman, M.M., 24–25 Simkin, S., 65 Simon, R.I., 154–155 Simon, T.R., 35 Sirota, P., 304 Sitharthan, T., 245 Skog, Ole-Jorgen, 234 Slama, F., 263 Slee, N., 66, 73 Sloan, K.L., 242 Smith, E.G., 160 Smith, forthcoming, 156 Smith, M.D., 92 Snyder, C.R., 216 Soares, J.C., 262 Sokero, T.P., 285 Somers-Flanagan, J., 36 Somers-Flanagan, R., 36 Sorenson, S.B., 111 Sorri, H., 122 Southwick, S.M., 302 Speilberger, C.D., 209 Spirito, A., 109 Spivack, G., 218 Springer, L.S., 122 Stack, S., 122, 156, 158, 173–175, 177–178, 233, 331 Stambolic, V., 47 Stanger, J.D., 331 Stanley, B., 30, 154 Stanton, J., 124 Stanton, R., 279 Stark, E., 95 Steadman, H.J., 94 Steen, M.D., 141 Steer, R.A., 202, 213

Sato, T., 259 Schaller, E., 278 Schamda, G., 102 Schlesinger, L.B., 92 Schmidtke, A., 65, 144 Schneck, C.D., 257 Schneider, B., 278, 282–284, 288 Schotte, D., 3 Schotte, D.E., 67–68, 70–71 Schreurs, P.J.G., 77 Schuckit, M.A., 233 Schulsinger, F., 50 Schwebs, R., 300, 309, 311, 314–315 Scmidtke, A., 177 Scott, T.A., 175–176 Scoville, S.L., 298–299, 308, 316 Sears, R.R., 100 Segal, M., 48 Séguin, M., 287 Sentell, J.W., 299 Serpi, T.L., 233 Serretti, A., 51 Sexson, S.B., 128 Shaffer, D., 154, 158, 161, 163, 200, 281, 333 Shaffi, M., 281 Shafii, M., 231 Shafran, R., 13 Shafranske and Malony (1996), cited in Johnson and Hayes, 2003, 119 Shahar, G., 307 Shaltiel, G., 52 Shapiro, J.R., 159 Sharma, R., 288 Sharma, V., 266 Sharp, S.F., 110 Shea, S.C., 155, 162 Sheehy, N.P., 13 Shek, D.T.L., 327 Shen, H., 111 Sher, L., 245 Sherbourne, C.D., 211 Shiang, J., 110 366

Author Index

Theorell, T., 301 Thibaut, J.W., 101 Thomas, N., 112 Thompson, S., 331 Thoresen, S., 298–299, 301–303, 305–306, 308 Tierney, R.J., 334 Tondo, L., 241, 257, 260, 263–264 Toros, F., 330 Tortolero, S.R., 110 Townsend, E., 71, 73 Trivedi, J.K., 42 Trovato, F., 110 Tsai, S.J., 51 Tse, W.L., 330 Tseng, W.S., 108–109, 111 Tsutsumi, A., 301 Turecki, G., 43, 51, 287 Turvey, C.L., 34, 156–157 Tyrer, P., 73

Steiner, B., 284, 286, 289 Stepakoff, S., 157 Stewart, A.L., 211 Stewart, S.M., 329 Stiles, T.C., 307, 315 Stock, S.L., 242 Stoppelbein, L., 128 Strakowski, S.M., 259 Strauss, J., 329 Stravynski, A., 34 Strickland, P.L., 49 Striegel-Moore, R.H., 242 Strohbach, D., 57 Strosahl, K., 65, 156 Strube, M.J., 101 Stuss, D.T., 42 Substance Abuse and Mental Health Services Administration, 241 Suicide Crisis Intervention Centre (SCIC), 336 Suicide Prevention Resource Center (SPRC), 21 Suokas, J., 234 Suominen, K., 264 Suris, A., 309 Sussex, J.N., 29 Swahn, M.H., 34 Swanson, J.W., 94 Swinton, J., 124, 128 Szadoczky, E., 264

UC Atlas of Global Inequality, 42 Underwood, L.G., 124 Underwood, M.D., 45 Unwin, C., 302 U.S. Food and Drug Administration (FDA), 265 US Food and Drug Administration Public Health Advisory, 160 Vaglum, P., 240 Valtonen et al., 2005, 257 Valtonen et al. (2008), 259 van Heeringen, K., 4 Van Orden, K.A., 31, 152, 159, 312 Van Praag, H., 237 Van Praag, H.M., 92 Varma, S., 42 Varnik, A., 138–139 Vega, W.A., 112–113 Velting, D.M., 162, 200 Videtic, A., 51 Vijayakumar, L., 108, 233, 282, 329

Tabachnick, B.G., 20 Takahashi, Y., 114 Tanney, B.L., 43 Tarakeshwar, N., 124 Tarrier, N., 72 Tassava, S.H., 7 Tatarelli, R., 256 Taylor, K., 72 Taylor, W.D., 262 Teresi, J.A., 124 Thase, M.E., 243 Thatcher, W.G., 112 367

Suicidal Behaviour

Violato, C., 95 Virkkunen, M., 46 Vogel, R., 285, 289–290 Volavka, J., 94 Voros, V., 136 Vörös, V., 144–145 Vuorilehto, M., 286

Wickramaratne, P.J., 257 Widom, C.S., 95 Wiederman, M.W., 242 Wilcox, H.C., 233 Williams, J.M., 71 Williams, J.M.G., 3, 6–8, 11–12, 65–67, 70, 237 Willner, P., 11 Wilson, A., 220 Wilson, M., 97 Wilson, Passik and Kuras, 1989, 220 Wilson, S.T., 195 Wingate, L.R., 30, 36, 154 Winkel, F.W., 330 Winokur, G., 284 Wintemute, G.J., 35 Wittchen, H.U., 278 Witte, T.K., 154 Wolfersdorf, Hole et al., 1990, 288–289 Wolfersdorf, M., 278–281, 283, 285–286, 288–290 Wolfgang, M., 98 Wong, A., 302, 308 Wong, B., 329 Worden, J.W., 211 World Health Organization (WHO), 107, 183, 185–186, 230, 263 Woznica, J.G., 159 Wright, J.C., 181

Waern, M., 156 Wagner, B.M., 157, 317 Waldrop, A.E., 329 Walker, R.L., 315 Walters, E.E., 231 Warheit, G., 113 Warheit, G.J., 112–113 Wasserman, D., 54, 234 Wasserman, I.M., 177, 298 Wasserman, L., 122 Waternaux, C., 280 Watt, T.T., 110 Webb, D., 119 Weiger, W.A., 98 Weimann, G., 178 Weiner, R.D., 268 Weisaeth, L., 298, 302–304, 308 Weissberg, M.P., 20 Weissman, A.D., 211 Weissman, M.M., 238 Wender, P.H., 50 Wen-Hung, K., 156 Westermeyer, J., 96 Westreich, L., 239, 244 Wetzler, S., 329 Whiteford, H., 108 Whitters, A.C., 233 WHO, 91 WHO Global Consultation on Violence and Health, 91 WHOQOL SPRB Group, 124 WHO (World Health Organization) Mortality Database, 324–325, 327

Yaeger, D., 309 Yahoo News, 332 Yamada, A.M., 123 Yang, B., 68, 71 Yazdani, A., 127 Yerevanian, B.I., 265, 267 Yip, P.S., 175, 327–328, 331, 335 Young, E.A., 282–283, 285, 287 Ystgaard, M., 314, 330 Yuen, N.Y., 113 Yui-chi Fong, C., 324

368

Author Index

Zahl, D.L., 65 Zeng, K., 330, 334 Zhang, J., 113, 125, 327, 329 Zhang, X., 139 Ziaian, T., 108 Zill, P., 52

Zillmann, D., 101 Zimmerman, R., 113 Zimmerman, R.S., 112–113 Zonda, T., 107 Zorko, M., 238 Zwi, A.B., 91

369

Suicidal Behaviour

Subject Index

Acceptance-based behavioural therapy, 76 Acquired immune deficiency syndrome (AIDS), 154 Active handling, 78 Active suicidal episode, 23 Acute periods, of suicidal crises, 23 Acute risk, for suicide, 28–29, 31–34 Adolescents and suicidal behaviour, 110–114. see also Asian adolescents, suicidal deaths predictors of death by suicide, 154–155 Adult Dispositional (Trait) Hope Scale, 216 Adult Suicidal Ideation Questionnaire (ASIQ), 197, 204 Affective disorder and substance abuse, 240–242 African Americans, suicide rates among, 110 risk factors, 112 Age groups, of suicide victims, 42 Aggressiveness, as a predisposing factor, 100–101, 154 and substance abuse, 237 A1438G variant, 52 Alcohol abuse and suicidal behaviour, 43, 94, 113, 233–234, 240–242 Alcohol intoxication, 234 Amok, 96–97

Anger, 32 Antisocial personality disorder, 243 Anxiety, 32 Anxiety disorders and substance abuse, 243 Apolipoprotein E4 (APOE4) gene, 55 Asian adolescents, suicidal deaths patterns and trends, 112, 324–328 preventive measures, 333–336 risk factors, 328–332 warning signs for attempts, 332–333 Attitudes, towards suicide, 113 Attitude towards Youth Suicide scale (AtYS), 121 Availability of means, 34–35 Avoidant personality disorder (PD), 243 Baseline risk, for suicide, 23, 28–31 Baumeister’s model of suicide, 5–6 Beck Depression Inventory (BDI), 198, 213 Beck Depression Inventory-II (BDI-II), 198 Beck Hopelessness Scale (BHS), 12, 197–198, 215 Beck Scale for Suicide Ideation (BSSI), 202 Behavioural contagion theory, 176 Benzodiazepines, 147 Bereavement, 154 ‘Beyond the Front’ interactive video, 175 370

Subject Index

Child Suicide Potential Scale (CSPS), 206 Cholecystokinin (CCK) gene, 55 Chronic suicidality, 36 Chronic suicide, 231 Chronological Assessment of Suicide Events, 162 Clinical assessment, 194–195 Clinical responses, to risk levels, 37 Clinical work, with suicidal patients, 26–27 Clozapine, 267 Cocaine dependence and suicidal behaviour, 235–236 Cognitive-behavioural therapy (CBT) interventions, 72–73 Cognitive behaviour therapy, 12 Cognitive flexibility impairment, 238 Cognitive impairment, due to substance abuse, 238 Cohesion, impact on suicide prevention, 313–314 Collaborative Assessment and Management of Suicidality programme (CAMS), 16, 162, 195, 316–317 Collective identity, 298 Collective society, 298 Columbia University Teen Screen Program, 161 Co-morbidity, 43 Completed suicide, 231 Contents, in risk assessment differential manifestations of risk, 157–159 factors unique to adolescents and children, 160 risk factors, 153–155 warning signs, 155–157 Coping behaviour, 69 Copycat suicide, 174 Criminals and suicidal behaviour, 94–95 Cry of pain (CoP) model, of suicidal behaviour, 7–9 communications from suicidal patients, 9–11

Binge eating disorder, 242 Biopsychosocial model, of suicidal behaviours, 4–6, 22–24 fluid vulnerability theory, 23 importance to clinicians, 22–23 Bipolar affective disorder, 43 age of onset, 257 antidepressant therapy, 266 antipsychotic therapy, 267 depression, 257–260 electroconvulsive therapy (ECT), 267–268 lithium and mood stabilizer therapy, 264–266 prevalence, 256 psychosocial interventions, 268–269 risks of premature mortality, 257 with substance abuse disorder, 260–262 suicide attempts, 262–264 suicide risks, 257–259, 288 Borderline personality disorder (BPD), 43, 73, 94, 243 Brady Act, 155 Brain cancer, 154 Brain-derived neurotrophic factor (BDNF), 53 Bulimia nervosa, 242 Cannabis abuse/dependence and suicidal behaviour, 234–235 Carbamazepine, 147 Case behaviour, of suicidal behaviour, 232 Catechol-O-methyltransferase (COMT), 53 Child and Adolescent Perfectionism Scale (CAPS), 218 Children’s Depression Inventory (CDI), 214 Children’s Depression Rating Scale (CDRS-R), 215 Children’s Hope Scale, 216 371

Suicidal Behaviour

Cultivation theory, 178–180 Cultural factors, of suicidal behaviour Asian countries vs Western countries, 108 Chinese women, 143 comparisons across Italian, Indian, and Australian youths, 116–119 discourses on meaning, 114–116 ethnic differences, 110–114 gender differences, 108. see also gender differences, in suicidal behaviour impacts, 107–110 psychopathology, effects on, 109–110 in risk assessment, 122–125 spirituality/religion, impact of, 119–122 Cyanoimipramine, 46 Cyclic AMP responses, 54–55

stress and, 67–69 treatment outcomes and follow-up measures, 81–82 Depression, role in suicidal behaviour, 4–5 CSF 5-HIAA level, 45 epidemiology, 283 female depressive suicides, 141 Hawaiian students, 113–114 multiple suicide attempters, 30 during periods of acute symptomatology, 32 psychopathology, 288–289 risk factors, 284–288 role of neurotransmitter serotonin (5-HT), 45 ST deficiency, 46 suicide prevention in, 289–290 Depressive-mood disorder, 43 Deterrents, to suicidal behaviour, 33 Developmental issues, of suicide risk assessment. see risk assessment, of suicide Diagnostic and Statistical Manual-IV (DSM-IV), 94 Dialectical Behaviour Therapy, 73 Diathesis, role in suicidal behaviour, 56–57 Diathesis-stress-hopelessness model, of suicidal behaviour, 68 Dopamine genes, synthesis of, 53

Defeat Scale, 211 Deliberate self-harm (DSH) association with optional thinking ability, 79–80 association with problem-solving process, 66–67, 69 cognitive characteristics, 67 coping difficulties, 76 factors common to repeaters, 76 hopelessness and, 69–71 influence of early life experiences, 68–69 male repeaters, 76–77 methodological problems with identification of risk factors, 74–75 motives for repeated, 75–76 optional thinking ability and, 79–80 passive and avoidant problem orientations, 77–79 problem-solving orientation among repeaters, 77–81 problem-solving style of repeaters of, 79 repeated, 65–66

Eating disorder and substance abuse, 242–243 Ego Function Assessment Scale-Modified (EFA-M), 219 Ego Function Test (EFA) test, 198 Entrapment model, of suicidal behaviour, 7–9 Epigenetic Assessment Rating System (EARS), 220 Escape-motivated suicides, 6–7 Escape Potential Scale (EPS), 211 372

Subject Index

European Americans, suicidal behaviour, 113 European Parasuicide Study Interview Schedule, 75 Explicit intent, 33 Extended Attributional Style Questionnaire (EASQ), 218 Extended suicide, 96

Generalised anxiety disorder (GAD), 243 Genetic factors, in suicidal behaviours, 29 apolipoprotein E4 (APOE4) and cholecystokinin (CCK) genes, 55 cyclic AMP responses, 54–55 family, twin, and adoption studies, 49–50 GABAergic and glutamatergic genes, 54 hypothalamo-pituitary-adrenal (HPA) axis gene dysfunction, 53, 55 markers, 50 mutations in nitric oxide synthase (NOS), 55 neurotrophic genes, 53–54 norepinephrine changes, 58 phoshpoinositide signalling systems, 54–55 serotonergic system, 50–52, 58 shortcomings in studies, 55 synthesis of noradrenaline and dopamine genes, 53 Glutaminergic systems, 54 Glycogen synthase kinase-3-β, in suicide victims, 47 Gotland project, 200 Group Interpersonal Problem-Solving Skills Training programme (PST), 80 Guilt, 32

Familicide, 92 Family Adaptability and Cohesion Evaluation Scales (FACES IV), 220 Female self-poisoners, 72 Fenfluramine challenge test, 48–49 Filicide, 92 Firearms, suicide attempts using, 35 Firestone Assessment of Self-Destructive Thoughts (FAST), 212 Fluid vulnerability theory (FVT), 23 Fratricide, 92 Frustration–aggression hypothesis, 100 Future Thinking Task (FTT), 12 GABAergic gene variations, 54 Gender differences, in suicidal behaviour choice of methods, 139 deaths using drugs, 147 family roles, protective effect of, 141 help-seeking behaviour, 141–142 incidence rate, 137 marriage, protective effect of, 140–141 masculinity vs femininity, 139–140 mental illnesses, 140 occupational factors, 138 pregnancy, protective effect of, 140 social support, 138 socio-cultural aspects, 142–143 socio-economic risk factors, 138–139 suicide attempts, 137, 144–147 in therapy, 147–149 ‘typical’ female suicide attempter, 144–145 urban living, 138–139

Hamilton Depression Rating Scale (HDRS), 213 Hamilton Rating Scale for Depression (HRSD), 198, 267 Hamlet, 57 Health services, for suicide prevention in military personnel, 315 Healthy worker effect, 298 Heroin users and suicidal behaviour, 236 Heterogeneity, 194 Homicide classifications, 92–93 cultural differences, 97–101 dynamic and interdisciplinary nature of behaviour in, 92 373

Suicidal Behaviour

prediction based on developmental indicators, 93 theories, 93 vs suicide, 93–97 Homicide–suicide phenomenon, 95–97 Hong Kong, suicide rates, 175 Hopelessness, 27–28 assesment of presence, severity and duration, 33 as a predictor of suicidal behaviour, 156 and problem-solving process, 69–71 SPP and, 14 Hopelessness Scale For Children (HPLS), 217 Hostile aggression, 100 HPA axis dysfunction, 55 5-HT 2 A receptors, role in suicidal behaviours, 47–48 Hungary, suicide rates, 145–147 Hypothalamic-pituitary-adrenal (HPA) axis activity, in suicidal behaviour, 3 gene, 53

Language, related to suicidality. see standard terminology, related to suicidality Leadership, impact on suicide prevention, 309–312 Lethality, of a suicide attempts, 34–35 role of spirituality in preventing, 121–122 Lethality Scales (LS), 211 Levodopa, 53 Life events, influence on cognitive ability, 68–69 Life Event Scales, 198 Life Experience Survey (LES), 221 Life Style Index (LSI), 219 Limbic-hypothalamus-pituitary-adrenal axis (LHPA Axis), relation with suicidality, 44 Limbic-hypothalamus-pituitary-thyroid axis (LHPT Axis), relation with suicidality, 44 Lipid metabolisms, related to suicide, 48 Longitudinal studies, of suicidal behaviour, 232

Imipramine, 46 Impact of Events Scale (IES), 221 Impulsive multiple attempters, 31 Impulsive traits, as a predisposing factor, 28, 31, 154 substance abuse, 237 Impulsivity Control Scale (ICS), 210 Imu, 96 Incarceration, 154 India, suicide rates, 42, 111 Instrumental aggression, 100 Intent for suicide, 155 Intimate-partner violence, 95 IS PATH WARM mnemonic, 155, 161

Major depressive disorder, 43 The Making of a Martyr, 180 Meaning, of suicide, 114–116 Means–End Problem-Solving Procedure, 218 Measures, of suicide-related behaviours, 196–199 tools, 201–223 Media reporting, of suicides arousal state, effects on, 183 attentional and comprehension processes, effects on, 181 attitudes, effects on, 182–183 attributions and moral evaluations, effects on, 182 choice of methods, 177 educating the public about risks for suicide, role in, 184–186

Jumping Frenchman, 96 Knowledge, of suicidal behaviours biopsychosocial model of, 22–23 terminology and language, 23–25 374

Subject Index

emotional habituation, effects on, 183–184 guideline on suicide reporting, 185–186 imitation effects from, 174–178 media images, impact of, 180 proactive role, 187 social learning theory aspect of, 173 and suicide rate, 173–174 television viewing, effects of, 178–180 Meprobamate, 147 Migration and suicide rates, 111 Military personnel and suicidal behaviour assessment and management, 316–317 contributing factors, 299–300 due to stringent requirements of military selection, 300 easy access to lethal means, 308–309 impact of combat trauma on women, 309 involuntary repatriation, 305–306 lack of meaningfulness, 303–304 lack of social support, 304–305 loss of individualism and conformity pressure, 301 and low levels of social integration, 300–301 military lifestyle, 302 peacekeepers from Norway, 298 prevention strategies, 309–315 protective factors, 309–315 psychopathology, 307–308 risk factors, 300–309 traumatic events, exposure of, 302–303 US Air Force, Army, Marine Corps and Navy, 298 Mindfulness-based cognitive therapy, 76 Minnesota Multiphasic Personality Inventory (MMPI), 194

Models Baumeister, 5–6 biopsychosocial model, 22–23 clinical implications, 14–16 Kinderman, 4–5 neurobiological, 56–57 stress-diathesis, 58 Williams and colleagues, 7–9 Modified Scale for Suicide Ideation (MSSI), 197, 202 Monoamine oxidase A (MAOA), 52 Motives for parasuicide questionnaire (MPQ), 75 Multi Attitude Suicide Tendency Scale for Adolescents, 222 Multi-dimensional Hope Scale, 215 Multi-dimensional Perfectionism Scale (MPS), 217 Multiple attempters, 23, 30 Multiple sclerosis, 154 Negative life events and suicidal behaviour, 4 Neurobiological factors, for suicide fenfluramine, role of, 48–49 5-HT2A receptors, 47–48 lipid metabolisms, 48 models, 56–57 norepinephrine transporters, role of, 49 transmitter non-specific neuroendocrine studies, 44 transmitter specific neuro-endocrine studies, 45–47 Neurotrophic genes, 53–54 Nitric oxide synthase (NOS), mutations in, 55 Non-suicidal self-injurious behaviour (NSSI), 153 Noradrenaline genes, synthesis of, 53 Norepinephrine, 49 Norwegian National Strategy for Suicide Prevention, 309 375

Suicidal Behaviour

Opiate users and suicidal behaviour, 236

family rigidity and adolescent abilities, 69 hopelessness and, 69–71 influence of early life experiences, 68–69 as a maintenance factor, 71–72 negative self-appraisal of, 70 psychosocial stress and, 69 sequential model of social, 66–67 training for repeated DSH, 77–81 as a vulnerability factor for suicidal behaviour, 67–69 Protective factors, 34 Psychache Needs Questionnaire (PNQ), 198, 208 Psychiatric illness, and liability for suicide, 43, 279–283 Psychological autopsy studies, of suicidal behaviour, 232 Psychological factors, on suicidal behaviour biopsychosocial model, 4–6 clinical implications, 14–16 cognitive ability, 3 cry of pain (CoP) or entrapment model of, 7–9 escape-motivated suicides, 6–7 personality traits, 3 positive future thoughts, 12–13 socially prescribed perfectionism (SPP), 13–14 spoken communications of suicidal patients, 9–11 Psychopathology, effects of culture on, 109–110 Psychosis, 32 Psychosocial stress and suicidal behaviour, 69, 238–239

Parental Bonding Instrument (PBI), 221 Partoxetine, 46 Passive-avoidance, 77–78 Patient–clinician relationship, role in risk assessment. see therapeutic relationship, role in risk assessment Paykel Suicide Items (PSI), 222 Perfectionism, 3 socially prescribed, 13–14 Personality disorders and substance abuse, 240 and violence, 94 Phoshpoinositide signalling systems, 54–55 Physical illnesses, 154 PI3-K/Akt signalling pathway, in suicide victims, 47 Platelet aggregation response, in suicidal behaviours, 47–48 Positive and Negative Suicide Ideation Inventory (PANSI), 203 Positive future thinking, 12 Predictors, of suicidal behaviours, 33 hopelessness, 156 intent for suicide, 155 severe anxiety/agitation, 156 sleep disturbances, 157 social isolation, 156 Predispositions, to suicidality, 28–30 Preparatory behaviours, 33 Prevention of Suicide in Primarycare Elderly: Collaborative Trial (PROSPECT), 161 Problem orientation, defined, 66–67 Problem-solving deficits, 154 and substance abuse, 238 Problem-solving process definition of, 66 discussions, 83–84 efficacy in treating self-harm, 72–73

Reasons for Attempting Suicide Questionnaire (RASQ), 206 Reasons for Living Inventory (RFL), 197, 205 376

Subject Index

Religion, impact on suicide, 119–122 Rescue Scale, 211 Resilience, 12 Reynolds Adolescent Depression Scale-2 (RADS-2), 214 Risk assessment, of suicide acute, 31–34 APA guidelines, 21 availability of means, 34–35 baseline, 29–31 content. see contents, in risk assessment cultural factors, role of, 122–125 defining common goal of pain remediation, 26–27 empirically-supported areas for, 28 identification of variables, 34 process and context of risk, 160–163 risk categories, 35–36 risk levels and clinical responses, 37 significance in clinical decisionmaking, 163 temporal factors influencing, 36 therapeutic relationship, role of, 26–27 understanding suicide, 22–25 Risk categories, of suicidal patients, 35 Risk factors, common across the lifespan, 153–155 antidepressant prescription as, 160 childhood physical and sexual abuse, 157 interpersonal conflict, 158 intimate partner violence, 157 lowered competence, 159 mental disorders, 157–158 perceived expendability, 159 personality traits, 158 Risk-Rescue Rating Scale (RRR), 211 Rorschach Inkblot test, 194 Rorschach Suicide Index Constellation (RSIC), 220

Scale for Suicide Ideation (SSI), 197, 201 Scale for Suicide Ideation-Worst (SSI-W), 197, 201 Schizophrenia, 43, 94, 140 Screening for suicide, 161 Selective serotonin reuptake inhibitors (SSRIs), 160 Self-destructive pathways, 4–5 Self-esteem, 78 Self-harm, 25 Self-Inflicted Injury Severity Form (SIISF), 212 Self-inflicted unintentional death, 25 Self-injurious behaviours, 30 Self Injury Implicit Association Test (SI-IAT), 218 Self Monitoring Suicide Ideation Scale (SMSI), 197, 203 Separation Anxiety Test (SAT), 209 Seppuku, 109 Sequential Emotion and Event Form for Suicidal Adolescents (SEESA), 197, 207 Serotonergic system, 50–52 Serotonin (5-HT), role in suicidal behaviour, 45–47 Severe anxiety/agitation, 156 Sexual assault, 95 Shame, 32 Siblicide, 92 SLC6A4, 51 Social isolation, 156 Socially prescribed perfectionism (SPP), 13–14 Social problem-solving capacity, in suicidal patients, 3 Social support, impact on suicide prevention, 314–315 Sociopathic personality disorder, 43 Spirituality, impact on suicide, 119–122 Spiroperidol, 46 Standard terminology, related to suicidality, 23–25 377

Suicidal Behaviour

State Hope Scale, 216 State–Trait Anger Expression Inventory, 209 Stress-diathesis model of suicide, 58 Stressor, role in suicidal behaviour, 56 Substance abuse, 43, 94, 113 aggressiveness, as a predisposing factor, 237 barriers to effective preventive management, 247 and cognitive impairment, 238 due to comorbidity of psychiatric illnesses, 239–243 impulsive traits, as a predisposing factor, 237 preventive managament, 243–247 and problem-solving impairment, 238 San Diego Suicide Study, 231 studies exploring the association between suicide and, 232 types of substances, 232–236 Suicidal Behaviors Questionnaire (Revised) (SBQ-14), 210 Suicidal ideation, 33, 36, 57, 112, 195, 232 in childhood, consequences, 153 and religion, 120–121 Suicidal Ideation Screening Questionnaire (SIS-Q), 223 Suicidality, 20 Suicidal tendency, 279 Suicidal thoughts, assessment, 33–34 Suicide, definitions, 25, 91–92 Suicide attempts, 25, 112, 232 in childhood, consequences, 153 Suicide Behaviours Questionnaire (SBQ), 197, 209 Suicide contagion, 159, 174–178 Suicide Ideation Scale (SIS), 205 Suicide intent, 196 Suicide Intent Scale (SIS), 208

Suicide plan, 25 Suicide prediction, 21 Suicide Probability Scale (SPS), 197, 203 Suicide Status Form (SSF), 207 Suicide threat, 25 Suttee, 109 Temporal factors, of suicide risk assessment, 36 Thematic Apperception Test (TAT), 194 Therapeutic relationship, role in risk assessment, 26–27 Therapy interfering behaviours, 26 Tryptophan hydroxylase (TPH), 52 Tyrosine hydroxylase (TH), 53 Undetermined suicide-related behaviour, 25 US Army, suicide rate, 176 US suicide rates, across the lifespan, 152 Utrecht Coping List (UCL), 77 Uxoricide, 92 Violence defined, 91 in Diagnostic and Statistical ManualIV (DSM-IV), 94 dynamic nature of, 95 influence of early life, 95 neurochemical basis of, 98 psychological perspective, 99–101 sociological explanations, 98–99 Warning signs, of suicidal crises, 155–157 among Asian adolescents, 332–333 WHO/EURO Multicentre Study on Suicidal Behaviour, 75, 144 objectives of, 77 Wihtico psychosis, 96 Willingness to disclose, on suicidal behaviours, 162

378

Suicidal Behaviour: Assessment of People-At-Risk

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