3
Psychiatric and Psychological Factors

In the United States, over 90 percent of suicides are associated with mental illness including alcohol and/or substance use disorders (Conwell et al., 1996; Harris and Barraclough, 1997; Robins et al., 1959). Recent estimates indicate 28–30 percent of the U.S. population has a mental or addictive disorder, or approximately 80 million people in the year 2000 (Kessler et al., 1994; Regier et al., 1993a). With 30,000 suicides each year, however, over 95 percent of these affected individuals do not complete suicide. Determining who among those with mental disorders will attempt suicide is paramount for individual intervention and prevention.

It is important to note that mental illness and substance abuse are not always the greatest risk factors for suicide. For instance, in a cross-cultural study, Bhatia and colleagues (1987) found that humiliation, shame, economic hardship, examination failure, and family disputes were the greatest risk factors for suicide in India, compared to the United States where mental illnesses and/or alcoholism, personal loss, and increased age were associated with the greatest risk. Psychopathology is less important as a risk factor for suicide in China as well. Despite the 30 percent overall higher suicide rate in China compared to the United States, the prevailing evidence is that there is a significantly lower prevalence of mental illnesses and substance use disorders in China (Shen et al., 1992). Since China and India are the world’s most populous countries, accounting for approximately 40 percent of the global population, it is important to keep in mind that suicide evidence in the United States and other Western countries may not be globally representative.



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Reducing Suicide: A National Imperative 3 Psychiatric and Psychological Factors In the United States, over 90 percent of suicides are associated with mental illness including alcohol and/or substance use disorders (Conwell et al., 1996; Harris and Barraclough, 1997; Robins et al., 1959). Recent estimates indicate 28–30 percent of the U.S. population has a mental or addictive disorder, or approximately 80 million people in the year 2000 (Kessler et al., 1994; Regier et al., 1993a). With 30,000 suicides each year, however, over 95 percent of these affected individuals do not complete suicide. Determining who among those with mental disorders will attempt suicide is paramount for individual intervention and prevention. It is important to note that mental illness and substance abuse are not always the greatest risk factors for suicide. For instance, in a cross-cultural study, Bhatia and colleagues (1987) found that humiliation, shame, economic hardship, examination failure, and family disputes were the greatest risk factors for suicide in India, compared to the United States where mental illnesses and/or alcoholism, personal loss, and increased age were associated with the greatest risk. Psychopathology is less important as a risk factor for suicide in China as well. Despite the 30 percent overall higher suicide rate in China compared to the United States, the prevailing evidence is that there is a significantly lower prevalence of mental illnesses and substance use disorders in China (Shen et al., 1992). Since China and India are the world’s most populous countries, accounting for approximately 40 percent of the global population, it is important to keep in mind that suicide evidence in the United States and other Western countries may not be globally representative.

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Reducing Suicide: A National Imperative This chapter explores the associations of mental illness and substance abuse that are risk factors for suicide in the United States and Europe. The first section of this chapter discusses suicide risk associated with mental and/or addictive disorders and what is known about who among those with these disorders is at greatest risk. Suicides in adolescents appear to be associated with a somewhat different set of variables, as discussed in a separate section. Next, the chapter explores psychological variables, including protective factors: those associated with reduced risk for suicide. Certain psychological factors distinguish and predict those who complete or attempt suicide. These include habits of thinking, problem solving, and expectations about the future, termed cognitive style or factors. These factors are modifiable through counseling and training, and their modification holds promise in reducing suicide. Finally, the chapter turns to temperament. Temperament has a significant genetic component (Goldsmith and Lemery, 2000) that interacts with environmental adversities to increase vulnerability to a number of unwanted outcomes, including suicide. PSYCHIATRIC/SUBSTANCE USE DISORDERS AND SUICIDE RISK Almost all psychiatric disorders, including alcohol and substance disorders, are associated with an increased risk of suicide. Depressive disorders are found in 30–90 percent of those who complete suicide, including the approximately 5 percent with bipolar disorder (Lönnqvist, 2000). Approximately another 5 percent are associated with schizophrenia (De Hert and Peuskens, 2000), 30 percent with a personality disorder (Davis et al., 1999; Henriksson et al., 1993; Isometsa et al., 1996), and 25 percent with alcohol abuse disorders (Murphy, 2000). Anxiety disorders including post-traumatic stress disorder (PTSD) are associated with approximately 20 percent of suicides (Allgulander, 2000). As many as 10 percent of those who complete suicide do not have a known psychiatric diagnosis. Around 20–25 percent of individuals who die by suicide are intoxicated with alcohol at death (see section on Alcohol Use below). Many individuals have multiple diagnoses concurrently, and comorbidity may in and of itself increase risk (Kessler et al., 1999), although there are little data on this issue, in part due to the hierarchical nature of the current psychiatric diagnostic system, in which mood and psychotic disorders are more heavily considered. Diagnoses associated with suicide attempts present a similar profile. Though there may be distinctions between sub-types of attempters and completers, they appear to be generally overlapping populations; current data do not allow resolution of this issue. This differentiation is further

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Reducing Suicide: A National Imperative complicated by the difficulties in defining suicide attempts as distinct from self-mutilation and/or other self-destructive behaviors including risk-taking behaviors (Poussaint and Alexander, 2000). Data from the National Comorbidity Survey (NCS) reveal that serious suicide attempters closely resemble suicide completers (Molnar et al., 2001). For men, substance abuse disorders were associated with a 6.2 times greater risk of serious suicide attempts, and mood disorders were associated with a 13.5 times greater risk. Women with substance abuse disorders had a 4.4 times greater risk of a serious suicide attempt, a 4.8 times risk with anxiety disorders (excluding PTSD), and an 11.8 time greater risk with a mood disorder. Overall, this study found that between 74 and 80 percent of the population attributable risk (PAR1) for serious suicide attempts was accounted for by psychiatric illness. Psychiatric disorders are diagnosed through interviews, including current and past behaviors, moods, and thoughts. The psychological autopsy technique is used to make post-humous diagnoses when there is no medical history of mental illness available (see Chapter 10). Diagnostic criteria used in the United States are those in the Diagnostic and Statistical Manual developed through a task force overseen by the American Psychiatric Association. The version used at this writing is the DSM-IV (APA, 1994). The DSM-IV provides five axes to describe the individual’s functioning. The mental and substance use disorders are coded on Axis I or Axis II. The Axis I disorders most frequently associated with suicide (also referred to as the major or serious mental disorders) include schizophrenia, bipolar disorder, depressive disorders, and alcohol and substance use disorders. The Axis II disorders are the personality disorders. Borderline personality and antisocial personality disorders are those most frequently associated with suicide. Mood Disorders Suicides in many nations including the United States are most commonly associated with a diagnosis of a mood disorder in adults (Lönnqvist, 2000) and adolescents (Goldman and Beardslee, 1999). Best estimates of lifetime risk of suicide for those with mood disorders is approximately 4 percent (see Chapter 10 for discussion of risk calculations). Estimated rates vary greatly depending on the severity of the illness (Goodwin and Jamison, 1990). These disorders are very common in the United States, with approximately 18.8 million American adults (Narrow, unpublished, cited by NIMH), or about 9.5 percent of those 18 and older 1   Population-attributable risk expresses the proportion of an outcome that could be eliminated if the risk factor were removed.

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Reducing Suicide: A National Imperative (Regier et al., 1993b), afflicted in a given year. Also called affective disorders, they include three diagnoses: (1) major depressive disorder, (2) dysthymic disorder, and (3) bipolar disorder. Each year, almost two times as many women (12.0 percent) as men (6.6 percent) suffer from a depressive disorder. These percentages correspond to 12.4 million women and 6.4 million men in the United States (Narrow, unpublished, cited by NIMH). For those born in recent decades, depressive disorders may be appearing earlier in life compared to prior cohorts (Klerman and Weissman, 1989). In addition, depressive disorders often co-occur with other mental and bodily disorders, including schizophrenia and anxiety, personality, and substance use disorders (Regier et al., 1998), as well as cardiac disease (e.g., Appels, 1997; Lesperance and Frasure-Smith, 2000). Major Depressive Disorder and Dysthmia Major depression, which is often episodic, recurrent, or even chronic, is diagnosed upon the occurrence of a major depressive episode. A major depressive episode includes at least five of a list of nine criteria symptoms persisting for a minimum of 2 weeks including: depressed or irritable mood, diminished interest in usual activities and pleasures, changes in eating and sleeping, and suicidal thoughts. A major depressive episode and borderline personality disorder are the only diagnostic entities in the DSM-IV system that include suicidality as a symptom. Dysthymic disorder is diagnosed when an individual is depressed and sad more days than not for at least 2 years, but does not have symptoms that meet criteria for a major depressive disorder. Death from many causes is increased in major depression. For example, Zheng and colleagues (1997), using data from the U.S. National Health Interview Survey in 1989, found a 3.1 adjusted hazard rate ratio for white males for all-cause mortality in major depression during a 2.5-year follow-up study, and a 1.7 rate for white females. In Harris and Barraclough’s meta-analysis of suicide in mental illness (1998), they found that deaths in those with major depressive disorder from natural causes were 1.3 times more frequent than expected, whereas suicide deaths were 21 times the population rate, and deaths by other violent causes 2.3 times expected. The lifetime risk of suicide in those with major depression is difficult to ascertain for a number of reasons. Most studies examining lifetime mortality from suicide follow patients after release from the hospital and compare their rate of suicide compared to either other patients or the population at large. Rates reported from such estimates may be artificially higher since they often follow the most severely affected patients (those hospitalized) for only a few years after hospitalization, which is also the time of highest risk (Lönnqvist, 2000). In addition, a commonly

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Reducing Suicide: A National Imperative used calculation for suicide mortality, as Bostwick and Pankratz (2000) evaluated, appears to have artificially increased estimates of lifetime suicide mortality rate as discussed in Appendix A. Taking all of this into account, the best estimates are that approximately 4 percent of those with depressive disorders will die by suicide. More than half of those with depressive disorders have thoughts of suicide. The severity of their thoughts, plans, and attempts increase with increasing severity of the disorder. The suicidality often remits along with the other symptoms of depression (e.g., Harrington et al., 1998; Joiner et al., 2001b, see Chapter 7). A study of over 35,000 insured people receiving treatment for depression showed greater rates of suicide by those receiving more intensive treatments, considered an indication of the severity of the depression. The highest suicide rate was among those receiving inpatient treatment and lowest among those receiving outpatient treatment with medication. No suicides were observed in those being treated on an outpatient basis without medication (Simon and Von Korff, 1998). Other studies suggest a disconnect between the response of depressive symptoms and suicidal behavior (Brent et al., 1997; Lerner and Clum, 1990). Other depressive symptoms predictive of suicidality are hopelessness (Beck et al., 1975; Beck, 1986) as well as feelings of guilt, loss of interest in usual activities, and low self-esteem (Van Gastel et al., 1997). Mann and colleagues (1999) showed that the objective severity of current depression or psychosis did not distinguish the 184 patients of 347 consecutive psychiatric admissions who had attempted suicide compared to those who never attempted. Rather, higher scores of subjective depression and higher scores of suicidal ideation, as well as fewer “reasons for living” as measured by the Reasons for Living Inventory (Linehan et al., 1983) distinguished those who had attempted suicide (Mann et al., 1999). Hopelessness, as discussed in the psychological factors section below, is a better predictor of suicide than the objective measures of depressed affect, not only in depressive disorders (Beck et al., 1993) but in physical illnesses as well (Chochinov et al., 1998). Bipolar Disorder Bipolar disorder affects approximately 1.2 percent of the U.S. population age 18 and older (Weissman et al., 1988). Twenty-five to 50 percent of those with bipolar disorder will attempt suicide at least once (Goodwin and Jamison, 1990). Suicides by those with bipolar disorder account for only 1–5 percent of all suicides as found in a number of countries including Finland, New Zealand, the United States, and Northern Ireland (Conwell et al., 1996; Foster et al., 1997; Isometsa et al., 1994; Joyce et al., 1994). A review of 14 studies by Harris and Barraclough (1997) from

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Reducing Suicide: A National Imperative seven countries, for a total population of 3700 people with bipolar disorder, found a rate of suicide 15-fold higher than would be expected in the general population. The risk of death from suicide in bipolar disorder is greater than the mortality rate for some types of heart disease (Goodwin and Jamison, 1990). Bipolar disorder (also called manic depressive disorder), is a biological disorder with significant genetic heritability (Alda, 1997; Blackwood et al., 2001). Bipolar disorder includes depressive and manic episodes (APA, 1994). Depressive episodes are described in the section above on depressive disorders and include long-lasting sad, apathetic or irritable mood, altered thinking, activity, and bodily functions. Manic episodes include periods of abnormally and persistently elevated, expansive, or irritable mood; inflated self-esteem; decreased need for sleep; extreme talkativeness; distractibility; high levels of activity; and increased pleasure-seeking and risk-taking behaviors. Symptoms of psychosis including delusions and hallucinations can also occur in bipolar disorder (APA, 1994). Currently, there are two recognized types of bipolar disorder, Type I and Type II. Bipolar II may have an increased risk for suicide and differs from Type I in that the manic periods are less severe and thus are termed hypomania. Bipolar II disorder is frequently misdiagnosed as major depression (Goodwin and Jamison, 1990). Whereas much is known about variables associated with increased risk for all of those with mood disorders, few studies have examined bipolar disorder separately. Unlike the usual gender difference with more men than women completing suicide, women with bipolar illness complete suicide at a rate almost equal to that of men with bipolar illness (Weeke, 1979). The greatest risk of suicide is early in the course of illness, within the first 5 years of the initial diagnosis (Guze and Robins, 1970; Roy-Byrne et al., 1988; Weeke, 1979). Severity of the disorder is also associated with increased risk for suicide (Hagnell et al., 1981), and those with more severe cases of bipolar disorder will have more frequent hospitalizations. Discharge from the hospital is a period of high risk. Inadequate treatment, whether due to non-adherence, unavailability, or lack of treatment response, is associated with increased suicide risk; inadequate levels of mood stabilizers or antidepressants are found in the majority of those who die by suicide (Isometsa et al., 1994). The time after discharge from the hospital may also carry high risk because the person must rebuild their life while facing a future with a recurrent, life-disrupting disorder. In addition, family and employers may inadvertently increase stress on the individual by having unrealistic expectations of an immediate return to full functioning (Appleby, 2000; Goodwin and Jamison, 1990). Those with bipolar type II disorder, which includes periods of hypomania, but not mania, is associated with increased risk of suicide (Dunner

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Reducing Suicide: A National Imperative et al., 1976; Stallone et al., 1980). One study found that out of 100 consecutive suicides, 46 percent had bipolar II, 1 percent had bipolar I, and 53 percent had non-bipolar major depression (Rihmer et al., 1990). This particular vulnerability of those with bipolar II may be due to increased mixed states that include depressive and manic symptoms at the same time (see Chapter 7), and can also include severe agitation. There is a significantly increased rate of alcohol and/or substance use disorder in individuals with bipolar disorder (Brady and Sonne, 1995; Goodwin and Jamison, 1990), understood in part as an attempt to “self-medicate.” The co-occurrence of these two disorders is associated with increased rates of suicide above that for each single disorder (see section on alcohol and substance use below). Anxiety Disorders Anxiety disorders are ubiquitous across the globe and are the most common mental disorders in the United States (Kessler et al., 1994; Regier et al., 1993a; Weissman et al., 1997). The 1-year prevalence for the adult population has been estimated between 16 and 25 percent (Kessler et al., 1994; Regier et al., 1993a; Weissman et al., 1997). Anxiety disorders carry significant comorbidity with mood and substance abuse disorders (Goldberg and Lecrubier, 1996; Magee et al., 1996; Regier et al., 1998) that seem to eclipse the general clinical significance of anxiety disorders. Although a few psychological autopsy studies of adult suicides have included a focus on comorbid conditions (Conwell and Brent, 1995), it is likely that the specific contribution of anxiety disorders to suicidality has been underestimated. Research from the last decade has started correcting this, however. A recent study using the National Comorbidity Survey data (Molnar et al., 2001) found that for all anxiety disorders including PTSD, the population attributable risk for serious suicide attempts is almost 60 percent for females, and 43 percent for males. Anxiety disorders encompass a group of eight conditions2 (APA, 1994) that share extreme or pathological anxiety and fear as the principal disturbance of mood, with accompanying disturbances of thinking, behavior, and physiological activity. The longitudinal course of these disorders is characterized by relatively early ages of onset, chronicity, relapsing or recurrent episodes of illness, and periods of disability (Gorman and 2   The eight anxiety disorders in the DSM-IV: panic disorder (with and without a history of agoraphobia), agoraphobia (with and without a history of panic disorder), generalized anxiety disorder, specific phobia, social phobia, obsessive-compulsive disorder, acute stress disorder, and post-traumatic stress disorder.

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Reducing Suicide: A National Imperative Coplan, 1996; Keller and Hanks, 1995; Liebowitz, 1993; Marcus et al., 1997). Of the eight anxiety disorders diagnosed via the DSM-IV, the two most frequently associated with suicide in existent studies are panic disorder (Schmidt et al., 2000) and PTSD (Kessler, 2000), discussed in turn below. Panic Disorder Weissman and colleagues (1989) provided the first overview of panic disorder in relation to suicide and found an almost 20-fold increased risk for suicide attempts compared to those without any psychiatric disorder. Follow-up studies of completed suicides suggest approximately 20 percent of suicide deaths are due to panic disorder (Schmidt et al., 2000). A large follow-up study in Sweden found a suicide rate for pure panic disorder comparable to major depression and other serious psychiatric illness requiring inpatient care (Allgulander and Lavori, 1991). The comorbidity of panic disorder with other mental illnesses conveys the greatest suicide risk (Schmidt et al., 2000). In one of the few studies investigating clinical predictors of suicidality in panic disorder, Schmidt and colleagues (2000) confirmed that co-occurring agoraphobia as well as depression significantly increase risk for suicidality, but found that depression likely mediates the relationship between panic disorder and suicidality. This suggests that co-occurring depression in panic disorder may actually be a secondary disorder that develops in response to the panic disorder. This study also found that patients’ avoidance of bodily sensations and their anticipatory anxiety significantly predict suicide attempt, offering clues for assessment and intervention regarding suicidality in this population. Post-Traumatic Stress Disorder Post-traumatic stress disorder has demonstrated the strongest association with suicidality of any of the anxiety disorders (Kessler, 2000; Molnar et al., 2001). It predicts subsequent first onset of a suicide attempt with an odds ratio of 6, as compared to other anxiety disorders with an odds ratio of 3, and mood disorders at 12.9 times the increased risk (Kessler et al., 1999). Furthermore, PTSD appears to have an equal or greater odds ratio than mood disorders or other anxiety disorders for making a suicide plan and for making impulsive suicide attempts (Kessler et al., 1999). Recent analyses of the data from the National Comorbidity Survey have significantly increased knowledge about PTSD within the U.S. population, including finding it far more common (7.8 percent lifetime preva-

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Reducing Suicide: A National Imperative lence) than earlier, less sensitive estimates (Kessler, 2000; Kessler et al., 1995). Using time series analysis, Kessler (2000) found that current PTSD significantly predicts subsequent first onset of all other anxiety disorders, substance use disorders, major depression, and dysthymia for males and females. Furthermore, PTSD predicts the onset of mania in males, with an odds ratio of 15.5. Given the overwhelming presence of co-occurring mental disorders in those with PTSD (Chu, 1999), Kessler (2000) made another significant discovery in demonstrating that only those with active PTSD are at increased risk for comorbidity. With remission of PTSD symptoms, this increased risk for secondary diagnoses disappeared. Animal and human research on neurobiological changes in the body’s stress response system after trauma suggests a physiological mechanism for the development of post-trauma affective disorder and PTSD (Garland et al., 2000; Heim and Nemeroff, 2001; Heim et al., 1997). Post-traumatic stress disorder involves unusual physiological and metabolic patterns of the major stress hormones such as cortisol and norepinephrine. The disorder further alters the serotonergic, dopamine, and opioid systems. Those with the diagnosis also suffer psychophysiological effects of trauma such as hyper-arousal and conditioned startle responses, and evidence abnormalities in the regions of the brain involved in memory and emotion (see van der Kolk, 1996). These same neurobiological pathways are consistently shown to be involved in substance use disorders (below), developmental trauma (Chapter 5), and in suicide (Chapter 4). Schizophrenic Disorders Approximately 2.2 million American adults (Narrow, unpublished, cited by NIMH) or about 1.1 percent of the population age 18 and older in a given year (Regier et al., 1993b) have schizophrenia. Schizophrenia affects men and women with equal frequency and has an onset in early adulthood (Robins and Regier, 1991). Symptoms of schizophrenia include delusions, hallucinations, disorganized speech, thought and movements. These are also termed “positive symptoms,” in that they are additional behaviors. Others, termed “negative symptoms” are the absence of normative behaviors such as flattened emotions or reduced spontaneous behaviors, social interaction, and volition (APA, 1994). Schizoaffective disorder includes periods of illness during which there is either a major depressive episode, a manic or mixed episode, concurrent with the criterion symptoms for schizophrenia. People with this disorder are often diagnosed with schizophrenia upon expression of those symptoms, making calculation of the prevalence as a separate disorder difficult. For the purpose of this report, those with either diagnosis will be referred to as those with schizophrenic disorders.

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Reducing Suicide: A National Imperative The schizophrenic disorders are associated with premature death, with approximately a 4–10 percent lifetime risk of suicide (Tsuang et al., 1980). The risk of suicide for those with schizophrenic disorders is approximately 30–40 times that of the general population (Caldwell and Gottesman, 1992; Harris and Barraclough, 1998). Individuals with schizophrenic disorders account for 25–33 percent of suicides occurring in psychiatric hospitals (Proulx et al., 1997; Roy, 1982). Suicide attempts among this population are more likely to be moderately to severely lethal with high levels of intent (Funahashi et al., 2000; Harkavy-Friedman et al., 1999; Radomsky et al., 1999). Approximately 50 percent of those who complete suicide had made prior attempts (Drake et al., 1985; Heila et al., 1997; 1998). This is markedly lower than the 65 percent rate of prior attempts among people who complete suicide with borderline personality disorder, which likely reflects in part the high lethality of suicidal behavior in those with schizophrenia. Suicide risk may be highest early in the disorder (within the first 5–10 years) (Funahashi et al., 2000; Harkavy-Friedman et al., 1999; Mortensen and Juel, 1993; Nyman and Jonsson, 1986; Saarinen et al., 1999). Those with suicidal behavior have more frequent hospitalizations either directly due to the suicidal behaviors or to the exacerbation of symptoms (Roy et al., 1984). The greatest risk for suicidal behavior is during hospitalization and within the first 6 months post-discharge (Funahashi et al., 2000; Landmark et al., 1987; Peuskens et al., 1997; Qin et al., 2000; Rossau and Mortensen, 1997). For those in outpatient treatment, the majority of the suicide victims have been recently seen by a mental health professional (Heila et al., 1998; Saarinen et al., 1999). Often the suicidality was communicated to the clinician, but it is not always acted on clinically (Breier and Astrachan, 1984; Qin et al., 2000). In schizophrenic disorders as compared to the population at large, gender differences in rates are non-existent for suicide attempts (Bromet et al., 1992; Roy et al., 1984) and reduced for completions (Caldwell and Gottesman, 1990; Drake et al., 1985; Wiersma et al., 1998). Co-occurrence of schizophrenia with depressive symptoms increases risk of suicide (Amador et al., 1996; Fenton et al., 1997; Roy, 1990). Severity of positive symptoms including command hallucinations (voices repeatedly ordering the individual to do something) also have been related to increased suicide rates (Falloon and Talbot, 1981), while negative symptoms may be related to lower suicide rates (Fenton et al., 1997; Hellerstein et al., 1987). Self-awareness of symptoms is related to increased suicide rates (Amador et al., 1996). Better premorbid functioning (prior to the onset of the illness) is associated with less severe morbidity of the disorders, but possibly with increased suicide rates. For example, some researchers find higher suicide

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Reducing Suicide: A National Imperative rates among those with higher IQ and educational attainment—indications of better premorbid functioning (Dingman and McGlashan, 1986; Drake et al., 1984; Peuskens et al., 1997; Westermeyer et al., 1991). This may be due to the more severely dashed life’s hopes and aspirations these individuals experience upon onset of this severe mental disorder. Related to this, those with better premorbid functioning also tend to have fewer negative symptoms (Bailer et al., 1996; Fennig et al., 1995). Personality Disorders Approximately 10–15 percent of the population has a personality disorder (Ottoson et al., 1998; Ucok et al., 1998; Weissman, 1993). Personality disorders are enduring patterns of behaviors and inner experiences that both deviate from an individual’s cultural norms and significantly impede functioning (APA, 1994). There are 10 types of personality disorders grouped into three clusters. Less is known about etiology and effective treatment for personality disorders than for other psychiatric illnesses. In addition, there is a general tendency to consider Axis II disorders subordinate in their effect on the clinical condition of the individual, possibly leading to the underestimation of the importance of the Axis II disorders for clinical outcomes including suicide. Yet, increasing evidence indicates that personality disorders interfere with treatment for numerous comorbid Axis I mental and substance use disorders (e.g., Green and Curtis, 1988; Jenike et al., 1986; Kroll and Ryan, 1983; Reich, 1988; Turner, 1987), including depression (Pfohl et al., 1984; Pilkonis and Frank, 1988; Poldrugo and Forti, 1988). Borderline Personality Disorder Borderline personality disorder (BPD) is the most frequently studied personality disorder in relation to suicide, in part due to the high rate of self-injurious behaviors and suicide attempts. In fact BPD is one of only two diagnoses in the DSM system for which suicidal behavior is listed as a symptom, with depressive episode as the other (APA, 1994). Borderline personality disorder is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior, which seriously interferes with functioning. Originally thought to be at the “borderline” of psychosis, people with BPD suffer from a disorder of emotion regulation. Borderline personality disorder is more prevalent than either schizophrenia or bipolar disorder, affecting 2 percent of adults, mostly young women (Swartz et al., 1990). There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases (Gardner and Cowdry, 1985;

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Reducing Suicide: A National Imperative What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion. —WILLIAM STYRON Darkness Visible: A Memoir of Madness