Adolescent suicide and defensive style.

This empirical study investigated the relation between ego defense mechanisms, diagnoses, and suicidality among 200 adolescent psychiatric patients ages 12 to 16 years. Based on a structured diagnostic interview, adolescents were divided into three groups: suicide attempters, suicidal ideators, and nonsuicidal patients. Using the Defense Mechanisms Inventory (DMI), suicidal adolescents scored higher on the defense of turning-against-self and lower on reversal, as compared to nonsuicidal adolescents. Although suicide was significantly more common among adolescents with an affective disorder, turning-against-self remained significantly associated with suicide attempt even when diagnosis was controlled for. Results demonstrate the importance of defense mechanisms in understanding adolescent suicidal behavior.     

Comparing suicide attempters, suicide ideators, and nonsuicidal homeless and runaway adolescents.

This study considers variables that best distinguish among attempters, ideators, and nonsuicidal youth in a sample of 527 homeless and runaway adolescents from four Midwestern states. Univariate results indicate that attempters are significantly more likely than ideators and nonsuicidal youth to have experienced physical or sexual abuse by an adult caretaker, to have experienced sexual victimization while on their own, and to have a friend who attempted suicide. Multivariate analyses reveal five variables that best distinguish among the three groups: self-esteem, depression, physical abuse, sexual abuse, and having a friend who attempted suicide. Further analysis suggests that the accumulation of these risk factors greatly increases the chance that these youth will engage in suicidal behavior.     

Social problem solving in adolescents with suicidal behavior: a systematic review

There is an increasing focus on deficiencies in problem solving as a vulnerability factor for suicidal behavior in general and hence a target for treatment in suicide attempters. In view of the uncertainty of evidence for this in adolescents we conducted a systematic review of the international research literature examining the possible relationship between deficiencies in social problem-solving skills and suicidal behavior in this population. This was based on searching two electronic databases: Medline 1966 to September 2003 and PsychInfo 1887 to September 2003. Twenty-two studies of social problem-solving skills in adolescents with suicidal behavior were found. Most of these studies, which compared adolescent patients with suicide attempts versus either nonsuicidal psychiatric or normal controls, found evidence for problem-solving deficits in the attempters; however, few of the differences remain after controlling for depression and/or hopelessness. Because most of the studies are cross-sectional, it is difficult to differentiate between the possibilities that deficiencies in problem-solving skills lead to depression when adolescents are faced by adversity and hence to suicidal behavior, or whether depression is the main factor which undermines problem-solving skills. Future research, preferably with longitudinal research designs, is required to determine the nature of the association between problem-solving skills and suicidal behavior in adolescents. This has important implications for therapeutic interventions.     

Physiological Reactions to a Suicide Film: Suicide Attempters,Suicide Ideators,and Nonsuicidal Patients

A film about two teenagers who commit suicide was shown to three groups of psychiatric inpatients: 17 who had attempted suicide, 20 who had expressed suicidal thoughts, and 10 who were not suicidal. Anxiety before and after the film was evaluated with psychometric (anxiety rating scale) and physiological tools (heart and respiration rate, blood pressure, electromyogram). Values noted before and after screening, and the degree of change in these values, were compared. In addition, psychomotor agitation was rated at several points during the film. Most results were negative. The suicide attempters had significantly lower postscreening heart rates and a significantly lesser change in heart and respiration rates than the other two groups. The suicide attempters revealed an increase in psychomotor agitation until the discovery of the suicide and a decrease thereafter, whereas the agitation of the nonsuicidal patients continued to increase from the start to the end of the film. The study suggests that on some parameters, suicide attempters reveal less anxiety than nonsuicidal psychiatric patients following exposure to a simulated suicide. The reaction of suicide ideators falls somewhere between the two groups.     

Hopelessness Predicts Suicide Ideation But Not Attempts: A 10‐Year Longitudinal Study

Hopelessness is one of the most commonly cited risk factors for suicidal behaviors. However, several retrospective studies suggest that hopelessness, while strongly correlated with suicide ideation, does not distinguish attempters from ideators without attempts. This study is the first to utilize a prospective design to disambiguate the relationship of hopelessness to ideation versus attempts. Participants were 142 depressed patients followed up over 10 years. Hopelessness and suicidality (ideation and attempts) were assessed using validated questionnaires and structured interviews. Both retrospective and prospective analyses revealed that hopelessness was higher among those reporting any suicidality (ideation or attempts) compared with nonsuicidal individuals. However, hopelessness failed to meaningfully distinguish attempters from ideators in both retrospective and prospective analyses. Taken together with results from previous studies, our findings suggest hopelessness is best conceptualized as a risk factor for suicide ideation but not progression from ideation to attempts.     

Characteristics of Suicidality Among Adolescents

The identification of high-risk adolescent suicide attempters in a population of depressed and suicidal adolescents is of crucial importance. This retrospective study examined characteristics of suicidality (recent and lifetime, active and passive) and psychopathology (depression, aggression, impulsivity, stressful life events, SCL-90 dimensions) among four groups of depressed adolescent outpatients: (1) suicide attempters who required medical treatment (n = 84), (2) suicide attempters who did not require medical treatment (n = 57), (3) suicidal ideators who had never made a suicide attempt (n = 40), and (4) nonsuicidal patients (n = 44). Results indicate that the nonsuicidal group could be differentiated from the three suicidal groups on the basis of suicidality and psychopathology, and that the three suicidal groups could be differentiated from one another on the basis of suicidality but not psychopathology. These findings are discussed in terms of the usefulness of certain self-report measures of suicidality for identifying suicidal adolescents and for differentiating among them. Furthermore, the findings suggest that psychopathological factors do not determine which suicidal adolescents make a medically dangerous suicide attempt and which do not.     

Impairment in risk-sensitive decision-making in older suicide attempters with depression

Suicidal behavior is a potentially lethal complication of late-life depression. In younger adults, suicide has been linked to abnormal decision-making ability. Given that there are substantial age-related decreases in decision-making ability, and that older adults experience environmental stressors that require effective decision-making, we reasoned that impaired decision-making may be particularly relevant to suicidal behavior in the elderly. We thus compared performance on a probabilistic decision-making task that does not involve working memory ("Cambridge Gamble Task") in four groups of older adults: (1) individuals with major depression and a history of suicide attempt (n = 25), (2) individuals with major depression with active suicidal ideation but no suicide attempt (n = 13), (3) individuals with major depression without suicidality (n = 35), and (4) nondepressed control subjects (n = 22). There was a significant effect of group on quality of decision-making, whereby the suicide attempters exhibited poorer ability to choose the likely outcome, compared with the nonsuicidal depressed and nondepressed comparison subjects. There were no group differences in betting behavior. The suicide attempters differed in several aspects of social problem-solving on a self-report scale. Quality of decision-making was negatively correlated with the score on the impulsive/careless problem-solving subscale. These data suggest that older suicide attempters have a deficit in risk-sensitive decision-making, extending observations in younger adults. More specifically, older suicide attempters seem to neglect outcome probability and make poor choices. These impairments may precipitate and perpetuate suicidal crisis in depressed elders. Identification of decision-making impairment in suicidal elders may help with designing effective interventions.     

Differentiating Suicide Ideators from Attempters: Violence—A Research Note

Which factors distinguish suicide attempters from suicide ideators is a relatively neglected question in suicidology. Data from the 2001 Youth Risk Behavior Survey, encompassing 1,439 youth suicide ideators and 1,097 attempters, was used to explore which factors best differentiate suicide attempters from ideators, with a focus on violence involvement. Measures of violence include the contexts of fights, dating, and weapons carrying. Controls were incorporated for psychiatric disorders, risky sexual behavior, school integration, and demographics. Controlling for the other variables, violence differentiated attempts from ideation: fighting (OR = 2.18) and weapon carrying (OR = 1.13). Psychiatric factors that predicted attempts over ideation included major depression (OR = 1.86), use of cocaine (OR = 2.34), and having a suicide plan (OR = 2.69), while demographic factors included gender, age, residence in the Midwest, and Hispanic, African American, or Asian ethnicity. A supplementary analysis (N = 11,546) determined that violence also helped to differentiate suicide ideators from nonsuicidal youth. Four factors (including violence involvement, eating disorders, and gender consistently) differentiated both between suicide attempts and ideation, and also between suicide ideators and nonsuicidal youth. The link between violence involvement and suicidality is interpreted in terms of the capability for suicide from the interpersonal theory of suicide.     

Nonlinear Change Processes During Psychotherapy Characterize Patients Who Have Made Multiple Suicide Attempts

Research suggests that multiple suicide attempters experience considerable variability in suicide ideation and longer‐duration suicidal crises, which suggests the possibility of two states of stability (one low risk and one high risk). To date, however, few studies have examined nonlinear change processes in suicide ideation among patients. In a sample of 76 active duty U.S. Army soldiers receiving brief cognitive behavioral therapy for acute suicide risk, we examined differences in the ebb and flow of suicide ideation among multiple attempters, first‐time attempters, and ideators. Results indicated that multiple attempters were characterized by two states of stability corresponding to low and high intensity suicide ideation; these states were separated by a region of instability corresponding to moderate intensity suicide ideation. In contrast, ideators and first‐time attempters were characterized by only a single state of stability corresponding to low intensity suicide ideation. Among patients who have made multiple suicide attempts, suicide ideation may function as a bimodal rather than a continuous construct.     

Effective problem solving in suicide attempters depends on specific autobiographical recall.

The relationship between over-general autobiographical memory and interpersonal problem solving was investigated by comparing a group of suicide attempters with a nonsuicidal psychiatric control group and a normal control group. Results showed that suicide attempters were more over-general in memory and displayed significantly poorer problem solving than the other two groups. Furthermore, suicide attempters who were more over-general displayed greater deficits in problem solving. It was concluded that effective problem solving in suicide attempters depends on specific autobiographical recall.     

Sociodemographic and Clinical Differences Between Suicide Ideators and Attempters: A Study of Mood Disordered Patients 50 Years and Older

Our study sought to characterize mood disordered suicide ideators and attempters 50 years and older admitted to a psychiatric ward either for a recent suicide attempt or for ongoing suicidal ideation. We enrolled 50 patients with suicide ideation consecutively admitted to an inpatient department and 50 patients admitted for a suicide attempt made in the last 48 hours. Suicide attempters more frequently had low social support and an age of onset of mood disorder of 46 years and older, and less frequently had a history of suicidal behaviors in the family members and pharmacological treatment, despite the fact that the groups did not differ with regard to antidepressants prescribed. The groups were not distinguishable based on several variables assumed to be risk factors for suicide behavior, such as proximal life events and stressors or alcohol use disorders. In both samples, comorbidity with organic diseases, the presence of stressful life events in the past 12 months, and a diagnosis of major depression were frequently reported. In conclusion, the presence of low social support and the absence of a pharmacotherapy may increase suicidal behaviors in patients at risk.     

Predictors of Multiple Suicide Attempts among Suicidal Black Adolescents

Psychopathology, social support, and interpersonal orientation were studied in relation to suicide attempt status in acutely suicidal, psychiatrically hospitalized Black adolescents and a matched sample of White adolescents. In the total sample, multiple attempters were differentiated by lower perceived support. Within the Black youth subsample, social comparison and positive stimulation from others differentiated multiple attempters from single attempters/ideators. Only suicidal ideation predicted multiple attempts among White youth and only higher interpersonal orientation predicted multiple suicide attempts within Black adolescents.     

Common problems and coping strategies II: Findings with adolescent suicide attempters

This study investigated the most common precipitants of adolescent suicide attempts and the strategies used to cope with such problems. Adolescent suicide attempters were compared with both distressed and nondistressed nonsuicidal adolescents on problems reported and coping strategies utilized. All three groups reported four problems as occurring most frequently: school, parents, friends, or boyfriend/girlfriend. The suicide attempters and distressed controls reported problems with parents more frequently than did nondistressed controls, while this latter group reported problems at school more frequently than did suicide attempters or distressed controls. Suicide attempters used social withdrawal, problem solving, and emotional regulation more than did nondistressed controls, but not more frequently than distressed controls. Distressed controls used wishful thinking and resignation more than did suicide atempters. Results are discussed in terms of the similarities between suicide attempters and nonsuicidal distressed adolescents and the need to more closely investigate specific subgroups of suicide attempters.     

Suicidal behavior in chemically dependent adolescents

Among 250 adolescents in a short-term residential treatment program for chemical dependency, 20% had attempted suicide in the two years prior to admission. Females, however, were found to have a higher attempt rate than did males. Suicide attempters were compared with a group of 50 nonsuicidal adolescents from the same treatment program and 50 non-chemically dependent, nonsuicidal high school students. Each adolescent was administered the Symptom Checklist 90-Revised (SCL-90-R), and a biographical history was obtained. The suicidal group was found to be more psychologically distressed than were the other two groups. Post hoc analysis revealed that there were significant differences between the chemically dependent groups (suicidal, nonsuicidal) on the Global Severity Index of the SCL-90-R, as well as the following subscales: Somatization, Depression, Anxiety, and Phobic Anxiety. It was also found that the majority of suicidal gestures or attempts had gone untreated beyond medical management. It was found that only 28% of the suicide attempters had received crisis intervention or emergency room treatment, and only 27% had received some type of follow-up treatment or counseling. These results are discussed, particularly in regard to the issue of "covert suicide."     

Social skills and depression in adolescent suicide attempters

The relationship among depression, social skills, and suicidal behavior was examined in a sample of 41 adolescents hospitalized in a general medical setting following a suicide attempt. These subjects were compared to 40 nonsuicidal psychiatrically hospitalized adolescents. Level of depression, assessed using the Children's Depression Inventory (CDI), and social skills, assessed via the Matson Evaluation of Social Skills with Youngsters (MESSY), were evaluated for all subjects. The suicide attempters and psychiatrically hospitalized patients were not found to differ on either the CDI or MESSY. However, multiple regression analyses revealed the factor scores of the MESSY to be related to depression in both patient groups. The data provide support for the relationship between social skills and depression. Results are also discussed in terms of the similarities between adolescent suicide attempters and nonsuicidal psychiatrically disturbed adolescents.     

The 24 hours before hospitalization: factors related to suicide attempting

Fifty-nine psychiatric inpatients were interviewed concerning the psychological and environmental events that occurred in the 24 hours prior to their hospitalization. Independent raters then performed a content evaluation of these accounts, allowing for comparisons among patients admitted for a suicide attempt, suicide ideation, or non-suicide-related complaints. Results showed that suicide attempters were more likely to have used alcohol or marijuana and less likely to have contacted a health care professional than suicide ideators, even when past history of suicide behavior was controlled for. Suicide ideators were more likely to have contacted a mental health professional. Implications for suicide risk assessment and intervention are discussed.     

Suicidal Ideation in Elderly Bereaved: The Role of Complicated Grief

This study examined whether symptoms of complicated grief at baseline predicted suicidal ideation during a depressive episode in elderly bereaved individuals. Over a 17-month period, serial ratings of suicidal ideation, hopelessness, and symptoms of depression, anxiety, and complicated grief were obtained from 130 elderly participants who had lost their spouses within the past 2 years. Groups of active and passive suicidal ideators, as well as nonideator controls, were compared via analysis of variance (ANOVA) with respect to levels of complicated grief, depression, and anxiety. Elderly bereaved with both active and passive suicidal ideation were found to have higher symptomatic levels of depression, hopelessness, complicated grief, and anxiety, as well as lower levels of perceived social support, than nonideators at study entry. Fifty-seven percent of the patients with high complicated grief scores were found to be ideators during the follow-up versus 24% of the patients with low complicated grief scores. Patients with any suicidal ideation had higher symptom levels of depression, anxiety, and complicated grief when they were ideators as compared with periods when they denied ideation. Fifteen out of the 39 ideators had recurrent depressive episodes versus 5 of the 91 nonideators. Patients with a history of suicide attempts were more likely to be ideators after loss than other bereaved. Thus, the condition of having high levels of complicated grief symptoms and depressive symptoms appears to make bereaved individuals vulnerable to suicidal ideation. Detection of high levels of complicated grief could help clinicians identify patients who may be at heightened risk for suicide.     

Clarifying the Relationship of Dissociative Experiences to Suicide Ideation and Attempts: A Multimethod Examination in Two Samples

Fears of pain, injury, and death may represent key barriers to acting on suicidal thoughts. Dissociation, which involves a disconnection from one’s body, may reduce fears and sensations of pain associated with harming the body, in turn facilitating suicide attempts. This study examined whether dissociation differentiated individuals with a history of suicide attempts from those with a history of suicide ideation, and investigated whether other relevant constructs explain this relationship. Sample 1 included 754 undergraduates (M_age = 21, 79% female) who completed a battery of self-report measures. Sample 2 included 247 undergraduates (M_age = 19, 74% female) who completed a self-report measure of dissociation, a clinical interview regarding suicide history, and four counterbalanced behavioral pain tolerance tasks. In both samples, dissociation was elevated in lifetime attempters compared to ideators (d = 0.28; d = 0.46; ps = 0.01) and slightly elevated in lifetime ideators compared to nonsuicidal individuals (d = 0.19, p = .02; d = 0.24, p = .47), though this effect was non-significant in the latter sample. In Sample 1, dissociation no longer differentiated attempters from ideators after controlling for clinical covariates. In Sample 2, dissociation was unrelated to behavioral pain tolerance tasks, and these tasks did not account for the association between dissociation and attempts. Overall, dissociation differentiated individuals with a history of suicide attempts from those with ideation alone in both samples. Pain tolerance did not explain this association; instead, it is possible that the relationship of dissociation to suicide attempts is due to “third variables” associated with both phenomena, such as symptoms of borderline personality disorder or posttraumatic stress disorder.     

Variation in functioning, psychosocial characteristics, and six-month outcomes among suicidal youth in comprehensive community mental health services

In this study we compared the psychosocial (n = 7,896) and clinical (n = 4,664) characteristics and 6-month functional outcomes (n = 2,594) of suicidal and nonsuicidal youth. Repeat and previous attempters were more likely than first-time and never attempters to experience psychosocial problems and to be functionally impaired in a variety of domains. Differences in functional impairment persisted at 6 months. Among those who were not severely functionally impaired at baseline, repeat attempters were more likely to be severely impaired at 6 months. Subgroups of suicide attempters may present to treatment differently, have a different expression of problems over time, and have different treatment needs.     

The Course of Post‐Crisis Suicidal Symptoms: How and for Whom Is Suicide “Cathartic”?

We investigated suicide "catharsis" as evidenced by decreased suicidality following a suicide attempt. Past research has examined this issue with mixed results (Bronisch, 1992; Davis, 1990; van Praag & Plutchik, 1985). In the present study, we examined Modified Scale for Suicide Ideation (MSSI) scores for 198 suicidal men during suicidal crisis, prior to entry into a treatment study, and again at 1-month and 12-month follow-ups. Patients were divided into ideators, single attempters, and multiple attempters. We found evidence for decreased suicidality, but interpreted it as the gradual action of interpersonal support, rather than as emotional catharsis. Also, multiple attempt status affected the long-term course of post-crisis suicidality.