Interpersonal precipitants and suicide attempts in borderline personality disorder

Borderline personality disorder (BPD) is often characterized by multiple low lethality suicide attempts triggered by seemingly minor incidents, and less commonly by high lethality attempts that are attributed to impulsiveness or comorbid major depression. The relationships among life events, impulsiveness, and type of suicidal behavior has hardly been studied in BPD and mood disorders. This study compared depressed attempters with and without BPD to identify specific suicide precipitants and risk factors in BPD and their relationship to severity of suicidal behavior. Attempters with comorbid BPD and major depressive disorder (MDD) had a higher number of lifetime suicide attempts; made their first attempt at a younger age; reported more interpersonal triggers; and had higher levels of lifetime aggression, hostility, and impulsivity, compared with attempters with major depression only. Environmental triggers of attempts in BPD are more likely to be interpersonal stressors. Lethality of attempts in BPD plus MDD is equal to that in MDD only, indicating that the seriousness of precipitants is unrelated to the lethality of the suicidal behavior. The differences between groups suggest that risk assessment and treatment should target both depression and personality disorder in those with combined illness.     

Suicidal behavior in schizophrenia and schizoaffective disorder: examining the role of depression

Understanding the relationship between depression and suicidal behavior among individuals with schizophrenia and schizoaffective disorder can aid assessment and treatment. In this study, 86 individuals with schizophrenia and schizoaffective disorder were assessed for past and current suicidal behavior, depression, hopelessness, and reasons for living. Thirty-four percent reported a history of suicide attempts. Suicidal behavior typically occurred 4.5 years after the onset of psychosis and 7.5 years after the onset of the first major depressive episode for those who had a history of major depression. Depression was frequent among both attempters and non-attempters, but only half of the attempters reported a suicide attempt during an episode of major depression. And almost half of those with depression never made a suicide attempt despite a long history of illness. Although depression is a potential stressor for triggering suicidal behavior in a vulnerable subset of individuals with schizophrenia, schizophrenia research must identify other risk factors for suicidal behavior. Clinicians should remember that even without a depressive episode there is still a significant risk for suicidal behavior in schizophrenia.     

The cycle of schizoaffective disorder, cognitive ability, alcoholism, and suicidality

In this study we investigated the putative role of cognitive dysfunction, diagnosis (schizoaffective versus schizophrenia disorder), and alcoholism as risk factors for suicidal behavior among individuals with DSM-TV schizophrenia or schizoaffective disorders. Subjects received cognitive tests and medical records were reviewed for evidence of a history of suicide attempts or suicidal ideation. Discriminant analysis was used to identify cognitive test performance measures that distinguished those with versus those without suicidal behavior. None of the cognitive measures discriminated between the two groups. The rates of suicidal behavior (suicidal ideation and suicide attempts) did not differ between participants with versus those without comorbid alcohol use. An association was found between suicidal behavior and the diagnosis of schizoaffective disorder. It was concluded that the history of prominent mood syndromes characteristic of schizoaffective disorder contributes to increased risk of suicidal behaviors. Cognitive dysfunction and/or alcoholism did not contribute additionally to risk in this study.     

Suicidal Risk in Adolescent Residential Treatment: Being Female Is More Important Than a Depression Diagnosis

We investigated the relationship between gender and clinician diagnosis of a depressive disorder at intake on variables reflecting depression among adolescents in residential treatment. It was hypothesized that females diagnosed with a depressive disorder would have the highest scores on measures of suicide risk, the number of symptoms of a major depressive episode, suicidal behavior, and suicidal ideation. Results indicated partial support for the predicted comparisons. Females diagnosed with a depressive disorder scored significantly higher on measures of depressive symptom count and suicidal ideation. Surprisingly, females without a diagnosis of a depressive disorder had higher suicide risk scores than the remaining groups. The results of this study highlight the importance of assessment and treatment of internalizing disorders in youth entering residential programs, particularly female adolescents.     

Affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts

The purpose of this study was to examine affective, behavioral, and cognitive functioning in adolescents with multiple suicide attempts. Forty-seven adolescents with a history of multiple suicide attempts (MA) were compared to 74 single suicide attempters (SA) on psychiatric diagnosis, depressive symptoms, affect regulation, self-mutilation, alcohol use, and hopelessness. Results revealed that the MA group was more likely to be diagnosed with a mood disorder, and reported more severe depressive symptoms and anger, in comparison to the SA group. Behaviorally, the MA group had higher rates of disruptive behavior disorders and higher levels of affect dysregulation and serious self-mutilation than the SA group. Further, greater levels of hopelessness were reported by the MA than the SA group. After controlling for a mood disorder diagnosis, only differences in anger, affect dysregulation, and serious self-mutilation remained significant. Overall, results suggest that treatment with adolescent suicide attempters might specifically target anger and affect dysregulation to reduce risk for future suicidal behavior.     

Suicide in bipolar disorder: Risks and management

Bipolar disorders are prevalent, often severe, and disabling illnesses with elevated lethality largely due to suicide. Suicide rates average approximately 1% annually, or perhaps 60 times higher than the international population rate of 0.015% annually. Suicidal acts typically occur early in bipolar disorders and in association with severe depressive or mixed states. The high lethality of suicidal acts in bipolar disorders is suggested by a much lower ratio of attempts:suicide (approximately 3:1) than in the general population (approximately 30:1). Risk factors can help to identify patients at increased suicidal risk, but ongoing clinical assessment is essential to limit risk. Empirical short-term interventions to manage acute suicidal risk include close clinical supervision, rapid hospitalization, and electroconvulsive therapy. Remarkably, however, evidence of the long-term effectiveness of most treatments against suicidal behavior is rare. A notable exception is lithium prophylaxis, which is associated with consistent evidence of major (approximately 80%), sustained relative reductions of risk of suicides and attempts, and lower lethality (increased attempts:suicide ratio). Such benefits are unproved for other treatments commonly used to treat bipolar disorder patients, including anticonvulsants, antipsychotics, antidepressants, and psychosocial interventions. Applying available knowledge systematically, with close and sustained clinical supervision, can enhance management of suicidal risk in bipolar disorders patients.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Affective instability and suicidal ideation and behavior in patients with borderline personality disorder

This study employed an Experience Sampling Methodology (ESM) to test whether various elements of affective instability can predict future suicide ideation in patients with borderline personality disorder (BPD) and a history of recurrent suicidal behavior. Eighty-two individuals with BPD and a history of recurrent suicidal behavior were followed prospectively for one month during which time they recorded their current mood states, 6 times daily over three weeks. Accounting for a set of robust suicide risk factors in multiple regression analyses, only negative mood intensity was significantly related to intensity of self-reported suicide ideation and to number of suicidal behaviors over the past year. Other elements of affective instability examined (e.g., mood amplitude, dyscontrol, and reactivity) were not associated with future suicide ideation or with recent suicidal behavior. Affective instability in patients with BPD is highly variable from one individual to another and is characterized by high levels of intense negative mood. These negative mood states, versus other aspects of mood variability, seem to be more closely tied to the occurrence of suicidal ideation and behavior.     

Suicidal behavior and prophylactic lithium treatment of major mood disorders: a review of reviews

This paper briefly summarizes and discusses at length two recent reviews. Their main findings were the following: (1) During prophylactic lithium treatment the overall mortality of patients with major mood disorders was much lower than in such patients in general. (2) The frequency of suicidal acts was many times lower in patients on lithium than in patients not on lithium. The limitations of the studies reviewed and the difficulty of interpreting their findings are discussed. It is concluded that prophylactic lithium treatment is indicated in patients with major mood disorders who are at high risk of committing suicide, that is, those with severe depressions or depressions with persistent suicidal thoughts or with suicide attempts in the past.     

A case control study of suicide and attempted suicide in older adults

Risk factors for serious suicidal behavior among older adults were examined in a case control study of 53 adults aged 55 and older who died by suicide or made medically serious suicide attempts and who were compared with 269 randomly selected comparison subjects. Multivariate analyses suggested that risk of serious suicidal behavior was elevated among those with current mood disorders (OR = 179, CI = 52.8-607.6), psychiatric hospital admission within the previous year (OR = 24.4, CI = 1.9-318.7), limited social network (OR = 4.5, CI = 1.4-14.6). The predominant role of mood disorders was confirmed by population attributable risk (PAR) estimates (73.6%), suggesting that the improved detection, treatment and management of mood disorders should be the primary focus of suicide prevention strategies for older adults.     

Inpatient suicide in a Chinese psychiatric hospital

Little is known about the risk factors for suicide among psychiatric inpatients in China. In this study we identified the risk factors of suicide among psychiatric inpatients at Guangzhou Psychiatric Hospital. All psychiatric inpatients who died by suicide during the 1956-2005 period were included in this study. Using a case-control design, 64 inpatients with schizophrenia who died by suicide were compared with a matched 64 controls. The results indicate that the rate of suicide was 133.1/100,000 admissions (95%CI 103.4-162.9). There were no significant differences in the method, location, or time of suicide between male and female inpatients. The number of hospitalizations was significantly larger in the suicide group than that in the control group. In logistic regression analyses, guilty thought, depressive mood, and suicidal ideation and suicide attempt 1 month before hospital admission were identified as independent predictors of suicide among inpatients with schizophrenia. The findings of risk factors for schizophrenic inpatient suicide should be taken into account when developing interventions to prevent suicide among these patients.     

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.     

Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder

A childhood history of sexual or physical abuse is highly prevalent in borderline personality disorder (BPD) and is associated with self-destructive behavior in clinical and nonclinical samples. Viewing BPD as a "high risk" disorder, we asked if childhood abuse was a risk factor for adult suicidal behavior or if it was related to other known risk factors for suicide in BPD. A semistructured Abuse History was obtained in 61 criteria-defined BPD patients, who were characterized by structured interviews and self-reports for Axis I disorders, Suicide History, BPD severity, hopelessness, impulsivity, impulsive-aggression, and antisocial traits. Occurrence and severity of childhood sexual abuse, but not physical abuse, predicted adult suicidal behavior independent of other known risk factors. The odds of a sexually abused patient attempting suicide in adulthood was over 10 times that of a patient who was never sexually abused. Given a history of childhood sexual abuse, the risk of adult suicidal behavior in BPD was increased by antisocial traits, severity of BPD, hopelessness, or comorbid major depressive episode (MDE).     

Suicidal attempt and psychiatric disorders in Iran

This study is part of broader research aimed to determine the lifetime prevalence and pattern of comorbidity on self-reported suicidal attempts in the general population of Iran. Overall, 25,180 subjects were interviewed, face-to-face, at home; the lifetime prevalence was 1.4% (0.9% males and 2% females). The majority of attempters were 26-55 years of age, married, more highly educated, female, retired, and lived in urban areas. Many of the attempters (45.3%) reported at least one psychiatric disorder during their lifetime; major depressive disorder (22%), panic disorder (6.3%), and obsessive compulsive disorder (6%) was the most common. Because less than half of suicidal attempters reported a psychiatric disorder, the existence of other pathways to suicide may be important foci for prevention. Many of the demographic correlates of suicidal behavior in Iran are very similar to those seen in Western cutlures; however, the sociodemographic factors such as few working women and very low levels of divorce is quite different to that of Western populations.     

Reports of attempted suicide among Brazilian addicts

Both substance dependence and depressive mood seem to be associated with increased suicide risk. Clinical information on suicide attempts and depressive symptoms were obtained from a sample of 211 psychoactive substance dependents attending a university clinic program for addicts in Brazil. 49 subjects (23.4%) had attempted suicide at least once, and the frequency of reporting attempts was 4.32 times greater among women than among men. Male addicts also tended to engage in potentially more dangerous attempt methods than women. Depressive male addicts were 2.17 times more likely to have attempted suicide than nondepressive addicted men. Among women, no association could be established between having attempted suicide and the presence of depression. Substance addicts have a relatively high risk of attempting suicide and the co-occurrence of depression seems to increase prevalence of suicidal behavior among men.     

Diagnostic morbidity and its relationship to severity of ideation for a nonpsychiatric sample of chronic and severe suicide ideators

This study examined the relationships of frequency and type of psychiatric diagnosis to suicidality within a sample of chronically and severely ideating college-aged students (N=78). The most common diagnoses were the depressive disorders, comprising 43% of all diagnoses, followed by anxiety disorders, comprising 17% of all diagnoses. Retrospective reports of childhood diagnoses were also quite common, comprising 38% of all diagnoses. Number of psychiatric diagnoses was significantly correlated with severity of suicidal ideation (r=.27,p<.02). Hierarchical regression analyses revealed that retrospective childhood diagnoses of attention deficit hyperactivity disorder (ADHD) and separation anxiety disorder significantly predicted 19% of the variance in severity of suicidal ideation after controlling for current diagnoses of major depression and PTSD. When entry of childhood and current diagnoses were reversed, PTSD significantly predicted 4% of the variance in severity of suicidal ideation, while major depression was rendered nonsignificant. Severe suicide ideation, therefore, may be a product of early psychological problems as well as the number of such problems.     

Soluble interleukin 2 receptor levels, temperament and character in formerly depressed suicide attempters compared with normal controls

An imbalance of the immune system and mixed personality profiles in suicide attempters have been reported. As suicidal behavior is common in patients with psychiatric disorders within the spectrum of depressive features, in this study we measured soluble interleukin-2 receptor concentrations in plasma (sIL-2R) and investigated temperament and character profile and their potential correlation in formerly depressed patients with a history of suicide attempt. We studied sIL-2R levels in plasma and personality characteristics (using Cloninger's Temperament and Character Inventory [TCI]) of formerly depressed patients who had attempted suicide a mean of 3 years previously (n = 25), and age and gender matched normal controls (n = 25). There was no significant difference in sIL-2R levels between formerly depressed suicide attempters and age and gender matched normal controls (0.23 ng/ml +/- 0.25 vs. 0.19 ng/ml +/- 0.16). When compared to normal controls, suicide attempt patients had a significantly higher score on the temperament dimension "harm avoidance" and a lower score on the character dimension "self-directedness." No significant correlation was found between sIL-2R values and TCI dimensions. We propose that the liability to suicidal behavior among suicide attempters susceptible to depressive symptomatology may be related to high harm avoidance and low self-directedness.     

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.     

Mortality of geriatric and younger patients with schizophrenia in the community

Little is known about the differences in mortality among non-institutionalized geriatric and younger patients with schizophrenia. In this study long-term mortality and suicidal behavior of all the geriatric (age > or = 65 years), middle-age (age 41-64 years), and young (age 15-40 years) subjects with schizophrenia living in a Chinese rural community were compared. A 10 year follow-up investigation among a 1994 cohort (n = 510) of patients with schizophrenia was conducted in Xinjin County, Chengdu, China. Compared with young subjects, geriatric subjects with schizophrenia were more likely to be female, have more previous physical illness, never accepted treatment, and practice religious (p < or = 0.01). There were no significant differences of suicide attempts among the three groups. Young subjects had a higher rate of suicide (1,033.8 per 100,000 person-years), and geriatric subjects had a higher rate of deaths due to other causes (accident and natural causes) (4,314.2 per 100,000 person-years). Standardized mortality ratios for both suicide and deaths due to other causes were highest in young subjects and the lowest in geriatric subjects. Patients with schizophrenia in all age groups had a marked increase in mortality and suicide. Specific intervention strategies for decreasing mortality and suicide should be developed for patients with schizophrenia in different age groups.     

The Relation of Self-Hatred and Suicidality in People With Schizophrenia-Spectrum Symptoms

It is well known that depressive symptoms represent a risk for suicidality in general. It is less clear, however, that general depressive symptoms comprise a definite suicide risk factor for people with schizophrenia. Based on this, as well as on the early writings of E. Bleuler (1911/1987), it was hypothesized that there may be a particular aspect of depressive symptoms that combines with schizophrenia to encourage suicidality. Specifically, schizophrenia may impart to self-concept a quality of self-hatred that encourages suicidality in schizophrenic people. If so, then an index of self-hatred should be more correlated with suicidality among people with schizophrenia-spectrum symptoms than among people with fewer such symptoms. Two studies evaluated this possibility. In Study 1 on 243 suicidal outpatients affiliated with the military, self-hate and suicidality were more correlated among people with schizotypal symptoms than among other patients. In Study 2 on 113 VA psychiatric inpatients, self-hate and suicidality were more correlated among people with a diagnosis of schizophrenia than among patients with a diagnosis of major depression. Study limitations were noted, and it was suggested that self-hatred be a focus of suicide risk assessment in schizophrenic people.