Psychological Impairment as a Predictor of Suicide Ideation in Individuals with Anorexia Nervosa

Anorexia nervosa (AN) is an eating disorder characterized by severe food restriction resulting in low body weight and an intense fear of gaining weight. This disorder has one of the highest suicide rates of any psychiatric illness; however, few studies have investigated prospective predictors of suicide ideation (SI) in this population. Quality‐of‐life impairment may be particularly relevant for understanding suicide risk in AN, given associations with SI in other psychiatric disorders and associations with chronicity and severity in AN. This study explored associations between eating disorder‐related impairment and SI in individuals with AN (n = 113) who completed assessments at treatment discharge and 3, 6, and 12 months after discharge. Greater psychological impairment predicted future occurrence of SI controlling for age, depression, history of SI, and eating disorder variables. Associations were specific to psychological impairment as other domains of impairment did not predict SI over time. Findings highlight the potential importance of targeting interpersonal–psychological consequences of AN to decrease future suicide risk.     

Mental Disorders,Comorbidity, and Pre‐enlistment Suicidal Behavior Among New Soldiers in the U.S. Army: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

We examined the associations between mental disorders and suicidal behavior (ideation, plans, and attempts) among new soldiers using data from the New Soldier Study (NSS) component of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS; N = 38,507). Most new soldiers with a pre‐enlistment history of suicide attempt reported a prior mental disorder (59.0%). Each disorder examined was associated with increased odds of suicidal behavior (ORs = 2.6–8.6). Only PTSD and disorders characterized by irritability and impulsive/aggressive behavior (i.e., bipolar disorder, conduct disorder, oppositional defiant disorder, and attention‐deficit/hyperactivity disorder) predicted unplanned attempts among ideators. Mental disorders are important predictors of pre‐enlistment suicidal behavior among new soldiers and should figure prominently in suicide screening and prevention efforts.     

Treatment‐Resistant Depression and Risk of Suicide

We evaluated whether treatment‐resistant depression (TRD) as measured by the Massachusetts General Hospital (MGH) staging method was associated with suicide in a large U.S. health system. Data from the Veterans Health Administration and the National Death Index were used to conduct a case–control study of patients newly diagnosed with depression who received antidepressant treatment between 2003 and 2006. Suicide cases (N = 499) were matched with nonsuicide controls (N = 1994). Conditional logistic regression was used to assess whether MGH stage at time of suicide (or matched date) was associated with case status, adjusting for patient demographic characteristics, comorbidity, and service use. Results indicated 11.6% of suicide cases had MGH stage 3 or greater (indicating at least two antidepressant trials) compared to 6.4% of controls (p < .001). In adjusted analyses, suicide was not significantly more likely among patients with stage 3 or greater (OR 1.52; 95% CI: 0.98, 2.37) or stages 1.5–2.5 (OR 1.19; 95% CI: 0.91, 1.55) compared to patients with stage 1 or less (<10 weeks of antidepressant medication). Staging TRD using MGH criteria is unlikely to substantially improve suicide risk assessment of depressed patients beyond existing measures contained in health system records.     

Social and emotional loneliness and self‐reported difficulty initiating and maintaining sleep (DIMS) in a sample of Norwegian university students

Social and emotional loneliness negatively impact several areas of health, including sleep. However, few comprehensive population‐based studies have evaluated this relationship. Over 12,000 students aged 21–35 years who participated in the student survey for higher education in Norway (the SHoT study) were assessed. Loneliness was assessed using the Social and Emotional Loneliness Scale. Difficulty initiating and maintaining sleep (DIMS) was assessed by a single‐item subjective response on the depression scale of the Hopkins Symptoms Checklist (HSCL‐25). Social loneliness was associated with more serious DIMS (unadjusted proportional odds‐ratio [OR] = 2.69, 95% CI = 2.46–2.95). This association was attenuated following adjustment for anxiety (adjusted OR = 1.92, 95% CI = 1.75–2.10) and depression (adjusted OR = 1.48, 95% CI = 1.34–1.63), however was not substantially altered when all demographics and psychological distress were accounted for (fully adjusted OR = 1.46, 95% CI = 1.30–1.63). Emotional loneliness was also associated with more serious DIMS (unadjusted proportional OR = 2.33, 95% CI = 2.12–2.57). Adjustment for anxiety (adjusted OR = 1.96, 95% CI = 1.78–2.15) and depression (adjusted OR = 1.64, 95% CI = 1.48–1.80) attenuated, but did not extinguish this relationship in the fully adjusted model (adjusted OR = 1.22, 95% CI = 1.09–1.31). Mediation analyses revealed that the social loneliness‐DIMS association was fully attributed to psychological distress, while the emotional loneliness‐DIMS association was only partially mediated, and a direct association was still observed. Associations between social and emotional loneliness and subjective DIMS were embedded in a larger pattern of psychological distress. Mitigating underlying feelings of loneliness may reduce potentially deleterious effects on sleep health and psychological wellbeing in young adults.     

Loneliness and Suicidal Ideation in Drug‐Using College Students

The college years are marked by social changes and behavioral experimentation which may increase risk of suicidal ideation. We propose a novel pathway for the development of suicidal thoughts between two established suicide risk factors, loneliness and drug use, which have not been examined in a nonclinical sample. Data were collected from 207 undergraduate drug‐using students at a large southeastern university. As hypothesized, suicidal ideation was positively correlated with both loneliness (r = .40) and drug use (r = .29). After controlling for several demographic variables, social desirability, and anxiety sensitivity, drug use was tested as a potential mediator in the loneliness–suicidal ideation link using a single‐mediator model. Results indicated a significant indirect (mediated) effect of loneliness on suicidal ideation via drug use (ab = 0.09, 95% CI: 0.02–0.18), suggesting that loneliness may contribute to suicidal ideation through increased drug use among college students. Identification of and intervention with students reporting loneliness and drug use may be a promising suicide prevention strategy on college campuses.     

Independent Effects of Mental Disorders on Suicidal Behavior in the Community

This study assessed the independent contributions of nine common mental disorders on suicide ideation and suicide attempt. A community‐based survey of Australian adults (N  = 3,175) was conducted to identify common mental disorders associated with recent suicide attempt. Nine disorders were assessed using DSM ‐5 clinical criteria. Logistic regression models indicated that all disorders were significantly and independently associated with suicide ideation. However, only obsessive‐compulsive disorder and posttraumatic stress disorder were significantly associated with suicide attempt among participants with ideation, independently of other disorders (OR = 2.0 for both). Increasing comorbidity had a significant monotonic association with suicide ideation but not attempts.     

A Five‐Month Longitudinal Study of Psychache and Suicide Ideation: Replication in General and High‐Risk University Students

Shneidman's (1993) model of psychache as the cause of suicide was evaluated in a 5‐month longitudinal study of psychological pain and suicide ideation. Replicating across general (N = 683) and high‐risk undergraduates (N = 262), psychache was significantly associated with suicide ideation, and change in psychache was significantly associated with change in suicide ideation. For general suicide ideation and suicide preparation, these significant results were maintained even when depression and hopelessness were statistically controlled. This research is a unique contribution being the first large‐sample longitudinal study that evaluates and supports Shneidman's psychache causal model of suicidality in general and high‐risk groups.     

Prior Mental Disorders and Lifetime Suicidal Behaviors Among US Army Soldiers in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

We report on associations of retrospectively reported temporally prior mental disorders and Army career characteristics with subsequent first onset of suicidal behaviors in a large, representative sample of US Army soldiers who participated in the Consolidated All‐Army Survey of the Army Study to Assess Risk and Resilience in Servicemembers (N = 29,982). Results reveal that among men and women, all self‐reported lifetime disorders measured (some assessed with screening scales) are associated with subsequent onset of suicide ideation. Among men, three disorders characterized by agitation and impulsiveness (intermittent explosive disorder, panic disorder, and substance disorders) predict the transition from suicide ideation to attempt. For both men and women, being in the Regular Army (vs. National Guard or Army Reserve) predicts suicide attempts in the total sample. For men, a history of deployment and junior rank are predictors of suicide attempts after adjusting for preenlistment disorders but not accounting for pre‐ and postenlistment disorders, suggesting that postenlistment disorders account for some of the increased suicide risk among these career characteristics. Overall, these results highlight associations between mental disorders and suicidal behaviors, but underscore limitations predicting which people with ideation attempt suicide.     

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.     

Psychosocial–Environmental Risk Factors for Suicide Attempts in Adolescents with Suicidal Ideation: Findings from a Sample of 73,238 Adolescents

We determined risk factors that discriminate between suicide attempt (SA) adolescents and suicidal ideation only (SI only) adolescents using data from the 2010 Korea Youth Risk Behavior Web‐based Survey (12–19 years; N = 73,238). In males, heavy alcohol use, drug use, and high perceived sadness/hopelessness showed significant effects on the presence of SA versus the presence of SI only. In females, along with these variables, low academic achievement, poor perceived health status, high perceived stress, and unhealthy coping strategy were also significantly related to the presence of SA versus SI only. Therefore, clinical interventions targeting adolescents' psychological distress are warranted to prevent suicide.     

How do personality disorders modify suicide risk?

There is a lack of psychological autopsy studies assessing the influence of axis II disorders on other risk factors for suicide. Therefore, we investigated if the estimated suicide risk for axis I disorders and socio-demographic factors was modified by personality disorders. Psychiatric disorders were evaluated by a semi-structured interview including the Structured Clinical Interview for DSM-IV Axis I (SCID-I) and Personality Disorders (SCID-II) by psychological autopsy method in 163 completed suicides and by personal interview in 396 population-based control persons. Personality disorders modify suicide risk, differently for affective disorders, substance use disorders, smoking, life events during the last three months, and socio-demographic factors such as being single. Estimated suicide risk for socio-demographic factors and life events is not substantially altered following adjustment for affective disorders or substance use disorders. These findings suggest that treatment of personality disorders is essential for suicide prevention.     

Psychiatric and substance use disorders as risk factors for attempted suicide among adolescents: a case control study

The objective of this research was to test substance-related and non-substance-related psychiatric disorders as predictors of attempted suicide among adolescents. Ninety-six psychiatrically disordered suicide attempters were matched one-to-one to 96 psychiatrically disordered non-attempters on age, race, gender, and the presence/absence of major depression. Conditional logistic regression was used to test psychiatric risk factors for their power to predict attempted suicide among adolescents. Bipolar disorder, cocaine use disorders, and conduct disorder were found to be predictive of attempted suicide in univariate testing. Bipolar disorder, inhalant use disorders, cocaine use disorders, and hallucinogen use disorders were found to be predictive of attempted suicide, after adjusting for all other covariates. Loglinear analyses revealed high odds ratios associated with the comorbidities of alcohol use disorder with conduct disorder and drug use disorders with conduct disorder in both groups. Higher rates of cocaine use disorder/conduct disorder, hallucinogen use disorder/conduct disorder, and alcohol use disorder/ conduct disorder were found among suicide attempters. Evaluation of these particular comorbid conditions should be part of the adolescent suicide risk assessment.     

Encountering the Body at the Site of the Suicide: A Population‐Based Survey in Sweden

Encountering the body of a child who died by suicide at the site of death is believed to be especially harmful for bereaved parents. We investigated the association between encountering the body at the site of the suicide and psychological distress in 666 suicide‐bereaved parents. Parents who had encountered their child's body at the site of the suicide (n = 147) did not have a higher risk of nightmares (relative risk [RR] 0.95, 95% confidence interval [CI] 0.67–1.35), intrusive memories (RR 0.97, 95% CI 0.84–1.13), avoidance of thoughts (RR 0.97, 95% CI 0.74–1.27), avoidance of places or things (RR 0.91, 95% CI 0.66–1.25), anxiety (RR 0.93, 95% CI 0.64–1.33), or depression (RR 0.94, 95% CI 0.63–1.42) compared with parents who had not encountered the body (n = 512). Our results suggest that losing a child by suicide is sufficiently disastrous by itself to elicit posttraumatic responses or psychiatric morbidity whether or not the parent has encountered the deceased child at the site of death.     

Body Mass Index Is an Important Predictor for Suicide: Results from a Systematic Review and Meta‐Analysis

Public health concerns for the independent management of obesity and suicidal behavior are rising. Emerging evidence suggests body weight plays an important role in quantifying the risk of suicide. In light of these findings, we aimed to clarify the association between body mass index (BMI) and suicidal behavior by systematically reviewing and evaluating the literature. Studies were identified by searching MEDLINE, EMBASE, PsycINFO, and CINAHL from inception to January 2015, supplemented by hand and grey literature searches. Study screening, data extraction, and risk of bias assessment were conducted in duplicate. We included 38 observational studies. Meta‐analyses supported an inverse association between BMI and completed suicide. Pooled summary estimates demonstrated that underweight was significantly associated with an increased risk of completed suicide (HR = 1.21, 95% CI 1.07 to 1.36, p = .002), and obesity (HR = 0.71, 95% CI 0.56 to 0.89, p = .003) and overweight (HR = 0.78, 95% CI 0.75 to 0.82, p < .0001) were significantly associated with a decreased risk of completed suicide relative to normal weight. A qualitative summary of the literature demonstrated conflicting evidence regarding the association between BMI and attempted suicide and revealed no association between BMI and suicidal ideation. BMI may be used to aid the assessment of suicide risk, especially that of completed suicide. However, unmeasured confounders and systematic biases of individual studies limit the quality of evidence.     

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self‐Injury in Iraq/Afghanistan‐Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD ) and self‐injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p  = .045) and nonsuicidal (OR = 5.12, p  = .009) self‐injury. CUD was the only variable significantly associated with self‐injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans’ risk for self‐injurious behavior.     

Psychological distress and resilience as risk and protective factors of psychoactive substance use among Chinese nonengaged youth

Nonengaged youth (NEY) are those who have neither been working nor studying for a prolonged period of time. They are at risk of psychoactive substance use, but relevant studies are scarce. Based on a population‐based telephone survey and referrals, we anonymously interviewed 479 Hong Kong Chinese NEY aged 15–24 years. Of them, 14.8–23.7% reported moderate to severe depression, anxiety, and stress. Moreover, one fourth of the participants (24.8%; n = 119) had used psychoactive substances. Adjusted analyses showed that these three psychological distress variables were positively associated with, while resilience was negatively associated with, both ever‐use of psychoactive substances and intention to use such substances in the next 12 months. Loneliness was associated only with intention to use psychoactive substances. The mediating role of psychological distress was shown: Anxiety significantly mediated the association between resilience and ever‐use of psychoactive substances, whereas depression mediated that between resilience and behavioural intention. Resilience was not a significant moderator on the relationship between psychological distress and ever‐use of psychoactive substance use or behavioural intention to use those substances. The findings suggest that anti‐drug interventions should outreach NEY and should include mental health support as well as building up resilience, as NEY are prone to psychological distress that increases risk of substance use.     

Associations Between Symptoms of Borderline Personality Disorder,Externalizing Disorders,and Suicide-Related Behaviors

Borderline personality disorder and externalizing disorders are associated with suicide-related behaviors. The present study examined whether symptoms of borderline personality disorder mediate the relationship between externalizing disorders and suicide-related behaviors. Diagnostic interviews were administered to 344 participants (n = 233 women). Results indicated that symptoms of antisocial personality disorder, alcohol use disorders, and drug use disorders each were significantly associated with suicide threats and self-injurious behavior in women and symptoms of antisocial personality disorder were associated with suicide attempts in women. With the exception of the association between symptoms of alcohol dependence and self-injurious behaviors, borderline personality disorder symptoms mediated or partially mediated all associations between externalizing disorders and suicide-related behaviors in women. These results highlight the importance of assessment and treatment of borderline personality disorder symptoms in individuals with externalizing disorders, particularly in the presence of suicide-related behaviors.

Nonsuicidal Self‐Injury Is Predictive of Suicide Attempts Among Individuals with Mood Disorders

Nonsuicidal self‐injury (NSSI) prior to age 18 was evaluated as a risk factor for adulthood suicide attempt (SA). Archival data from 222 mood‐disordered participants were analyzed using multivariate Cox proportional hazards analysis. Participants with a youth SA were excluded. The hazards of SA among adult participants with a history of youth NSSI were twice than those of mood‐disordered participants without youth NSSI (hazard ratio = 2.00, 95% confidence interval = 1.16–3.44, p = .01). Moreover, participants who had both youth and adult NSSI attempted suicide significantly earlier than participants who began NSSI as an adult. Youth NSSI is associated with persistent, elevated SA risk in adulthood.     

Predicting Suicide Ideation in the Military: The Independent Role of Aggression

The purpose of this study was to examine the longitudinal relationship between aggression and suicide ideation when controlling for other externalizing (i.e., alcohol misuse and risk‐taking) and internalizing (i.e., depression and sleep problems) risk factors in an active duty, military sample. Preexisting data from a longitudinal study were analyzed to assess the wellness of service members across the deployment cycle. Participants were 944 active duty service members (95% male, 48% between 18 and 24 years old) who completed surveys upon initial return from deployment and approximately 3 months later. After controlling for other externalizing (alcohol misuse, risk‐taking) and internalizing (depression, sleep problems) risk factors, service members reporting aggression were significantly more likely to report suicide ideation than those reporting no aggression (OR = 3.19; OR 95% CI: 1.16–8.80). The independent nature of the relationship between anger and suicidality suggests aggression may be an important indicator of suicidality for service members. Understanding the role of aggression in suicidality may improve the ability to identify at‐risk service members and to develop effective interventions to reduce suicide risk.