Recognizing and responding to a suicide crisis.

Data from therapists who were treating 26 patients when they committed suicide were utilized to identify signs that warned of a suicide crisis. Three factors were identified as markers of the suicide crisis: a precipitating event; one or more intense affective states other than depression; and at least one of three behavioral patterns: speech or actions suggesting suicide, deterioration in social or occupational functioning, and increased substance abuse. Problems in communication between patient and therapist were identified as factors interfering with crisis recognition. Evaluation of the identified affects and behaviors may help therapists recognize a suicide crisis.     

Determination of precipitating events in the suicide of psychiatric patients

Data from therapists who were treating patients when they killed themselves were used to provide information about precipitating events that was missing from accounts obtained from suicide victims' relatives and friends. Among 26 patient suicides studied, the therapists identified a precipitating event in 25 cases; in 19 of these, supporting evidence linked the identified event to the suicide. A schema was developed that identifies nine types of evidence provided by therapists in determining that an event precipitated the suicide. Use of the schema is likely to improve accurate identification of events that precipitate patient suicides, and distinguish them from unrelated coterminous events or suicide 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.     

Inadequate Response to Therapy as a Predictor of Suicide

The role of response to cognitive therapy as a predictor of suicide was investigated by comparing 17 outpatients with mood disorders who committed suicide with 17 matched patients who did not commit suicide. The suiciders attended significantly fewer sessions of cognitive therapy and dropped out of therapy more frequently: 88% of the suiciders, compared to 53% of the controls, were rated by their therapists as requiring more treatment at termination. They also had higher levels of hopelessness at the termination of therapy. The results suggest that premature termination of therapy and inadequate response to treatment have unfavorable prognostic significance for eventual suicide.     

Suicide attempts: Patients with and without an affective disorder show impaired autobiographical memory specificity

A number of studies have shown reduced recall of specific autobiographical memories (AMs) in patients after attempted suicide, but in all of them the study samples were confounded with diagnoses of affective disorders. The present study aims to demonstrate impaired specific autobiographical memory in patients after a suicide attempt without a diagnosis of an affective disorder. Four groups were compared: (1) patients with an actual major depression and a suicide attempt; (2) patients after a suicide attempt without a lifetime history of an affective diagnosis; (3) patients currently suffering from major depression without a suicide attempt; and (4) control persons not suffering from either of the two conditions during their entire life. Individuals with major depression and a suicide attempt showed reduced specificity of AM and, most importantly, patients with a suicide attempt—despite the absence of an affective disorder—were equally impaired with recall of specific AMs as were patients with major depression. The authors propose that reduced specific AM is a common vulnerability factor that can lead either to the development of an affective disorder and/or to a suicide attempt.     

Reported childhood trauma and suicide attempts in schizophrenic patients

Childhood traumas are associated with suicidal behavior but this aspect has not been examined in relation to schizophrenia. In this study, 50 chronic schizophrenic patients who had attempted suicide were compared with 50 chronic schizophrenic patients who had never attempted suicide for their scores on the 34-item Childhood Trauma Questionnaire (CTQ). It was found that schizophrenics who had attempted suicide reported significantly higher CTQ scores for emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect than schizophrenics who had never attempted suicide. Therefore, childhood trauma may be a risk factor predisposing schizophrenic patients to attempt suicide.     

The working through of patients' suicides by four therapists.

In 1976 four psychotherapists in training at one institution had patients who committed suicide. The therapists met as a group over a one-year period. This paper presents brief case summaries, explores the reactions of each therapist, presents conclusions regarding the mourning process following patients' suicides, and puts forth implications and suggestions for training programs. The authors conclude that it is necessary for therapists, supervisors, and training programs to recognize the inevitability of crises and tragedies when working with disturbed persons and that, though the process of mourning must be worked through individually, training settings can permit therapists to experience the pain and loneliness while providing opportunities for mastery and growth.     

Recent Biologic Studies on Suicide

This paper selectively reviews the author's recent studies on suicidal behavior in depression. Data are reviewed from a study of depressed patients who had monoamine metabolites measured in both the cerebrospinal fluid (CSF) and urine. Depressed patients who had attempted suicide had significantly reduced CSF concentrations of the dopamine metabolite homovanillic acid (HVA) and significantly lower urinary outputs of HVA than patients who had not attempted suicide. Similarly, patients who went on to reattempt suicide over a 5-year follow-up period had both significantly reduced CSF concentrations of HVA and lower urinary outputs of HVA than patients who did not reattempt. These data suggest a role for diminished central dopaminergic neurotransmission in suicidal behavior in depression. Patients who had made a violent suicide attempt also showed evidence of dysregulation of the hypothalamic-pituitary-adrenal axis.     

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.     

The relationship between forgiveness and history of suicide attempt

The sentiment of forgiveness in relationship to suicide attempts/completions has been mostly examined through studies of suicide notes and the experiences of survivors and therapists – not attempters. In a cross-sectional sample of 304 consecutive primary care patients, we examined sentiments about forgiveness using the Forgiveness Scale, comparing those individuals with versus without past suicide attempts. According to findings, individuals with past suicide attempts (N?=?55; 19.1%) evidenced significantly lower composite scores on the Forgiveness Scale. As for individual items, compared to participants without past suicide attempts, those with past suicide attempts were significantly less believing of forgiveness by others, were less likely to forgive themselves, and to a lesser degree, were less forgiving of others. There were no between-group differences with regard to confession of wrongdoing or existential forgiveness by God. Findings may offer some salient avenues of therapeutic inquiry and endeavour in the psychological healing of individuals with past suicide attempts.     

Suicide of a Patient: Gender Differences in Bereavement Reactions of Therapists

Emotional reactions of therapists who experienced the death by suicide of one or more of their patients were investigated. Data were collected by a questionnaire containing both objective and open-ended items from 27 men and 36 women, psychiatrists and psychologists, working in psychiatric hospitals in Slovenia. The most frequently reported reactions by the therapists were of increased caution in the treatment of their patients and an increase in conferring with colleagues, partners, and supervisors. About two thirds reported experiencing strong guilt feelings along with other commonly reported survivor feelings of grief, depression, and loss. Gender differences were apparent (women more often felt shame and guilt, sought consolation, or doubted their professional knowledge). No significant differences appeared between disciplines and years of work experience. Agreement was general that support was important both professionally and personally. Suggestions are offered to help the therapist work through the trauma of a patient's suicide.     

Association of solitary binge drinking and suicidal behavior among emerging adult college students

[Correction Notice: An Erratum for this article was reported in Vol 26(3) of Psychology of Addictive Behaviors (see record 2012-13892-001). In the article, there is an error in the introductory paragraph. The number of students who had seriously considered attempting suicide in the Barrios, Everett, Simon, & Brener (2000) study should have been reported as 11.4%, not 1.4%. Additionally, in the Participants section, data for the study were collected from March 2009 to September 2010, not March 2009 to January 2010 as reported.] Emerging adult college students who binge drink in solitary contexts (i.e., while alone) experience greater depression and suicidal ideation than do students who only binge drink in social contexts, suggesting that they may be at greater risk for suicidal behavior. This study examined the association of a previous suicide attempt, one of the best predictors of future suicide attempts and suicide, and severity of recent suicidal ideation with drinking in solitary and social contexts. Participants were binge drinking, emerging adult (18- to 25-year-old) college students (N = 182) drawn from two studies of college drinkers. A logistic regression analysis revealed that both suicide attempt history and severity of suicidal ideation were significantly associated with a greater likelihood of being a solitary binge drinker as opposed to only a social binge drinker. Students with a previous suicide attempt were nearly four times more likely to be solitary binge drinkers. Multiple regression analyses revealed that suicide attempt history was significantly associated with greater frequency and quantity of drinking in solitary, but not social contexts. Suicidal ideation was significantly associated with drinks per solitary drinking day, but not frequency of solitary drinking once suicide attempt history was accounted for. Given the associations found between solitary binge drinking and a history of suicide attempts, as well as greater severity of recent suicidal ideation, it appears that these students are in need of suicide prevention efforts, including treatment efforts aimed at reducing binge drinking. (PsycINFO Database Record (c) 2012 APA, all rights reserved).     

Suicidal Asian patients: recommendations for treatment

I was given an opportunity to learn how suicide prevention programs are administered in the United States. Not surprisingly, treatment for suicidal patients is conducted in terms of the basic tenets of Western culture. When American therapists are seeing Asian patients, especially suicidal individuals who are regressed and show cultural characteristics, the therapists should be aware of the importance of cultural differences. This report discusses recommendations for treating suicidal Asian patients.     

When Suicide Is at Stake: Some Thoughts on the Therapeutic Space between Therapists and Adolescents

Looking at adolescence as a period of turmoil as well as abrupt physical and mental changes, it is not surprising that in western countries suicide is the primary cause of death in adolescents and young adults ages 15–24. Most therapists treating adolescents encounter patients who frequently engage in suicidal behavior. This significantly challenges the therapeutic bond and influences the therapeutic space in a unique way. In this article, we address the challenges specific to the therapeutic alliance in treating adolescents presenting suicidal behaviors. While literature on the nature of the therapeutic bond with adult suicide attempters is available, literature on the distinguishing characteristics of the therapeutic bond with adolescent attempters is lacking. Two vignettes are presented to illustrate this distinctive alliance.     

Suicide Attempters in Norway

ABSTRACT: A personal follow-up study is presented of 74 patients consecutively admitted to a Norwegian psychiatric hospital who had attempted suicide during the six months prior to admission. The mean observation time subsequent to discharge was eight years. Of these 74 patients, 5 later committed suicide (6.8 percent) and 16 (26 percent of the living) repeated the suicide attempt. The clinical and social course for the living patients is described. A previous report of a similar follow-up study on patients in a psychiatric department had demonstrated a much lower frequency of subsequent suicide and suicide attempts and a higher percentage of clinical cure and social rehabilitation. These differences are discussed and ascribed mainly to the greater proportion of psychotic patients in the hospital sample (82 percent versus 34 percent).     

Characteristics of suicide attempters and nonattempters with schizophrenia in a rural community

In this study, demographic and clinical characteristics of individuals with schizophrenia in a Chinese rural community who had attempted suicide at some time in their lives and those who had not made a suicide attempt were compared. Among individuals with schizophrenia, subjects with (n = 38) and without (n = 472) a lifetime history of suicide attempt were assessed with the Present State Examination. The results indicate that attempters had a significantly younger age, higher level of education, higher rate of lifetime depressed mood and hopelessness, and a larger number of positive symptoms than patients without suicide attempts. The logistic regression models also indicated that hopelessness, the number of positive symptoms and age were the most important predictors. Early interventions focusing on reducing hopelessness and controlling positive symptoms may help reduce the risk of suicide attempts among patients with schizophrenia.     

Impact of a Suicide‐Specific Intervention within Inpatient Psychiatric Care: The Collaborative Assessment and Management of Suicidality

A growing body of literature indicates that suicidal patients differ from other psychiatric patients with respect to specific psychological vulnerabilities and that suicide‐specific interventions may offer benefits beyond conventional care. This naturalistic controlled‐comparison trial (n = 52) examined outcomes of intensive psychiatric hospital treatment (mean length of stay 58.8 days), comparing suicidal patients who received individual therapy from clinicians utilizing the Collaborative Assessment and Management of Suicidality (CAMS) to patients whose individual therapists did not utilize CAMS. Propensity score matching was used to control for potential confounds, including age, sex, treatment unit, and severity of depression and suicidality. Results showed that both groups improved significantly over the course of hospitalization; however, the group receiving CAMS showed significantly greater improvement on measures specific to suicidal ideation and suicidal cognition. Results are discussed in terms of the potential advantages of treating suicide risk with a suicide‐specific intervention to make inpatient psychiatric treatment more effective in reducing risk for future suicidal crises.     

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.