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Reducing Suicide: A National Imperative (2002)

Chapter: 3 Psychiatric and Psychological Factors

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Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
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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.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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

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Population-attributable risk expresses the proportion of an outcome that could be eliminated if the risk factor were removed.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

(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

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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-

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

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;

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

Soloff et al., 1994b). Patients often need extensive mental health services; studies have shown that individuals with BPD have more extensive histories of psychiatric outpatient, inpatient, psychopharmacologic and psychosocial treament than both patients with major depressive disorder (Bender et al., 2001) and patients with other Axis II disorders (Zanarini et al., 2001). Yet newly developed specialty psychotherapy treatment called Dialectical Behavioral Therapy (DBT) can significantly improve functioning (Koerner and Linehan, 2000, see Chapter 7).

Between 4 and 8 percent of those with a personality disorder complete suicide (Linehan et al., 2000). Borderline personality disorder specifically carries approximately 10 percent lifetime risk of completed suicide (Frances et al., 1986; Stone et al., 1987), within the same range as for schizophrenia and major depressive disorder (Guze and Robins, 1970; Winokur and Tsuang, 1975). Approximately 40–90 percent of those with personality disorders have attempted suicide (Ahrens and Haug, 1996; Bornstein et al., 1988; Corbitt et al., 1996; Garvey and Spoden, 1980; Modestin et al., 1997). A large, psychological autopsy study of completed suicides in Finland found that personality disorder and major depressive disorder were diagnosed in equal percentages (31 percent) among completed suicides, while 59 percent had any mood disorder, and 7 percent had schizophrenia (Henriksson et al., 1993). Since BPD has a higher population prevalence, it may in fact account for more suicides than either schizophrenia or bipolar disorder.

Up to 65 percent of those with BPD have a concurrent major depressive episode (Paris et al., 1989; Soloff et al., 1994a), which increases the risk of suicide. Isometsa et al. (1996) found that 95 percent of suicide victims with cluster B personality disorders had comorbid depressive disorders, substance use disorders, or both. Fyer and colleagues (1988) found that individuals with comorbid BPD and mood or substance use disorders were more likely than other patients to make high lethality suicide attempts. In addition, borderline symptoms that do not reach criteria for a diagnosis of BDP in depressed patients increases the likelihood of a suicide attempt (Corbitt et al., 1996; Friedman et al., 1983; Joffe and Regan, 1989). In contrast, Soloff (1994a) found no increased risk of suicide attempt with comorbid affective or substance use disorders. Often suicidal behaviors in BPD occur in the absence of serious depressive symptoms, which some attribute to the impulsivity associated with BPD (Brodsky et al., 1997; Corbitt et al., 1996).

A history of child abuse or neglect in those with BPD increases risk of suicide (Brodsky et al., 1997; Brown and Anderson, 1991; Dubo et al., 1997; van der Kolk et al., 1991). There is a high frequency of abuse histories in those with BPD, and childhood abuse is posited to be a causative factor (Figueroa and Silk, 1997; Gunderson and Sabo, 1993; Paris, 1998).

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

The effects of childhood trauma on suicide risk are discussed in Chapter 5.

Alcohol Use

As of 1999, 64 percent of all American adults report some use of alcoholic beverages (non-abstention), and this has not changed appreciably since 1939 (The Gallup Organization, 2001). Annual consumption currently averages to the equivalent of approximately 2.2 gallons of pure ethanol per capita (NIAAA, 2001). Approximately 15–18 million Americans have an alcohol abuse disorder (NIAAA, 2001) with 8.2 million Americans dependent on alcohol in a 1999 government survey (SAMHSA, 1999).

Alcohol-related suicides vary by state and jurisdiction, from 28 percent in Ohio to 53 percent in Alaska (Table 3-1), consistent with increased frequency of alcohol associated suicides reported for the western “frontier” states (Hlady and Middaugh, 1988; May, 1995). Alcohol-related suicides are more frequently associated with death by firearms (Brent et al., 1987; Hlady and Middaugh, 1988). However, among some subpopulations of American Indians (May et al., In press), and in other countries such as Australia (Hayward et al., 1992), alcohol-related suicides are no more likely to be associated with firearms than with other methods (e.g., hanging and carbon monoxide poisoning).

As with the psychiatric disorders, the majority of those who consume alcohol and/or meet diagnostic criteria for alcohol abuse disorders do not attempt or complete suicide. Alcohol use, particularly heavy use and alcohol dependence, is highly associated with suicide in three ways:

  • Alcohol through its disinhibiting effects is related to suicide attempts and completions

  • Individuals with alcohol use disorders are at an increased risk of suicide as compared to the population at large

  • At the population level (nationally and internationally) alcohol consumption is correlated with suicide rate

Impulsivity, Relationship Loss, and Hopelessness

Acute alcohol intoxication acts as a disinhibitor in impulsive, angry suicides, often precipitated by loss of a relationship (Mayfield and Montgomery, 1972). On average (see Table 3-1) almost 25 percent of suicide victims are intoxicated (generally 0.10 gm/dl blood alcohol concentration or greater) at the time of death. The highest prevalence of intoxication is generally found among males under the age of 50 in most every popula-

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

TABLE 3-1 The Nature and Extent of Alcohol-Related Suicide in Selected Studies of LargePopulations

Study Population (years)

N of Suicides

% Alcohol-Related

% (Legally) Intoxicateda

Avg.BAC

Reference

Cuyahoga County (Cleveland), OH (1959-1974)

(830)

28

20

Ford et al., 1979

Alaska (1983-84)

(195)

53

31

Hlady & Middaugh, 1988

Alaska Natives

 

(79)

(54)

 

Alaska Whites

 

(48)

(20)

 

Erie County (Buffalo), NY (1972-1984)

(806)

33

20

28% >.05

Welte et al.,1988

North Carolina (1973-1983)

(8,146)

35

26

Smith et al., 1989

Western Australia (1986-1988)

(515)

36

20

Hayward et al., 1992

Oklahoma (1978-1984)

(3,082)

40

24

Goodman et al., 1991

New Mexico (1990-1999)

(3,044)

44

May et al., in press

NM American Indians(1980-1998)

(439)

(69)

(62)

.136 (all suicides)

.197 (alcohol positive only)

 

_ = 38.4

_ = 23.5

 

sd = 8.2

sd = 4.5

 

md = 36

md = 22

 

weighted _ = 37.4

weighted _ = 24.7

 

aDefined in most studies in the United States as BAC > 0.10 gm/dl of blood and in the Australia and New Mexico studies, as > 0.0 8 gm/dl, the same as legal intoxication for driving a motor vehicle.

— data not available

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

tion studied (Ford et al., 1979; Hayward et al., 1992) and in suicides that occur at night and on weekends (Smith et al., 1989; Welte et al., 1988). Alcohol was involved for 15–64 percent of attempters (Roizen, 1982).

Common among alcohol-related suicides are impulsivity and relationship loss, both in adults (Welte et al., 1988) and youth (Brent et al., 1987). Similar patterns of impulsivity have been linked to alcohol-related suicide in particular cultures such as younger adults in Finland (Makela, 1996) and Native Americans (Bechtold, 1988; Ward, 1984). Relationship problems are frequently precipitants in alcohol-related suicides (Miles, 1977; Murphy and Robins, 1967; Rich et al., 1988) especially when there is ready access to a high-lethality means (Hayward et al., 1992; Welte et al., 1988). Suicides associated with chronic conditions such as long-term depression or physical disability are less likely to involve alcohol (Welte et al., 1988).

… Mostly, I’m a social drinker. Like everyone else, I’ve been drunk in my time but it’s not really my style; I value my control too highly. This time, however, I went at the bottle with a pure need, as though parched. I drank before I got out of bed, almost before my eyes were open. I continued steadily throughout the morning until, by lunchtime, I had half a bottle of whiskey inside me and was beginning to feel human… The important thing was not to stop. In this way, I got through a bottle of whiskey a day, a good deal of wine and beer. Yet it had little effect. Toward evening, when the child was in bed, I suppose I was a little tipsy, but the drinking was merely part of a more jagged frenzy….

After that, I remember nothing at all until I woke up in the hospital and saw my wife’s face swimming vaguely toward me through a yellowish fog. She was crying. But that was three days later, three days of oblivion, a hole in my head…. only gradually have I been able to piece together the facts from hints and snippets, recalled reluctantly and with apologies. Nobody wants to remind an attempted suicide of his folly, or be reminded of it (Alvarez, The Savage God: A Study of Suicide, 1971/1990:294-297).

Interpersonal loss seems to be a major acute precursor of suicide among many with alcohol use disorders (Murphy, 1992; Murphy et al., 1979). Murphy and colleagues (1979) demonstrated that 26–33 percent of alcoholics had experienced a loss of affectional relationships within 6 weeks of suicide and 48–50 percent had similar losses within the previous year. Duberstein et al. (1993) more recently replicated these findings among alcoholics/substance abusing subjects in finding that interpersonal stressors were present within 6 weeks (77 percent) or 1 year (90

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

percent) of suicides by alcoholics as compared to 22 and 59 percent, respectively, among suicides by persons with mood or anxiety disorders.

Hopelessness significantly predicted suicidal ideation more accurately than depression in alcoholics, as well as non-alcoholics (Beck et al., 1982). Alcohol has an effect on depression as well. Large doses of alcohol over time are associated with depressive activity (Mirin and Weiss, 1986; Tamerin and Mendelson, 1969). Some suggest that depression is secondary to the effects of heavy and chronic alcohol consumption, since depression wanes with withdrawal (Flavin et al., 1990; Nakamura et al., 1983). However, drinking can also begin as a reaction to depression.

Alcohol Use Disorders

Estimating the prevalence of suicide among those with alcohol use disorders is difficult because the data come from studies using varying approaches (retro- and prospective, and population studies) as well as highly variable follow-up periods. Harris and Barraclough (1997) found in their meta-analysis of 32 studies that alcohol-dependence and abuse increased suicide risk almost 6-fold. Murphy (1992) estimates that in a year, 25 percent of all suicides (approximately 7600 of 30,400) in the United States are of individuals with alcohol use disorders, and that these individuals have 115 times the risk of suicide compared to a psychiatrically healthy population. Lifetime risk of suicide has been estimated at 3.4 percent for those with severe alcohol abuse disorders requiring hospitalization (Murphy, 1992). Alcohol dependent individuals who complete suicide are most frequently male, white, middle-aged, unmarried, with hospitalization in the past year, and with a history of previous attempts (Roy and Linnoila, 1986). Yet alcohol-dependent females have a 20- to 30-fold greater risk of completing suicide than non-clinical female populations (Harris and Barraclough, 1997; Medhus, 1975).

Severity and time-course of the alcohol use disorder are associated with suicide risk. In a mortality study of 8060 individuals matched for age, sex, race, and cigarette smoking, the effects of alcohol intake were examined on a variety of causes of death over 10 years (Klatsky et al., 1981). Suicide accounted for 3.5 percent of all the deaths, and the heaviest drinkers, those consuming 6+ drinks daily, accounted for almost half of the suicides. Merrill and colleagues (1992) in England found increased alcohol consumption associated with increased rates of suicide attempt for males and females. The risk of suicide is highest in the late stages of chronic alcohol abuse, and is associated with similar high risk events and psychiatric symptoms found among non-alcoholic individuals (Kendall, 1983).

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×
Population Correlation

Over the last century alcohol and suicide rates have co-varied in a number of countries. A precipitous drop in suicide rates in the United States (from 15.3 to 10.2 per 100,000 between 1910 to 1920) occurred during the period of most acute reduction of alcohol consumption (Lester, 1995). Reductions in alcohol consumption secondary to rationing in the 1950s in Sweden, and large increases in price in Denmark in the early part of the twentieth century both coincided with significant reductions in the suicide rates (Wasserman, 1992). In Finland, a significant positive correlation was observed between alcohol consumption and suicide rates for males aged 15–49 from 1950 to 1991, but not for older males (Makela, 1996). A study examining the relationship between alcohol consumption and suicide in Denmark, Finland, Norway, and Sweden for up to 50 years found significant relationships only in Sweden and Norway (Norstrom, 1988). No relationship was observed for Finland (Norstrom, 1988). The single largest reduction in male suicides in the last 30 years occurred during the Perestroika in the USSR during the second half of the 1980s. This reduction was seen in all 15 republics of the USSR, with the greatest decrease, from over 65 per 100,000 to less than 40 per 100,000 occurring in the Russian Republic from 1984 to 1986 (Wasserman et al., 1998). During this time, alcohol consumption was significantly reduced due to a broad, multi-level national campaign to reduce alcoholism and to immeasurably increased hope from the economic and social restructuring under Gorbachev (Wasserman and Varnik, 2001). Population-level observations are difficult to interpret, since it is not known if the variables of interest are correlated within individuals (see also Chapter 6). Possible confounding issues include income, divorce and unemployment (e.g., Makela, 1996).

Substance Use Disorders

In 1999 almost 15 million Americans used illicit drugs and 3.5 million were dependent on these substances (SAMHSA, 1999). Drug dependence has been experienced by 7.5 percent of the population, and drug use without dependency by 4.4 percent of the population (Kessler et al., 1994). Substance abuse prevalence is increasing among younger cohorts (Kessler et al., 1994).

Abuse of illicit substances, like alcohol abuse, is associated with increased risk for suicide and suicide attempts. Treated opiate abusers had a suicide attempt rate 4 times that of the community surveyed, with a lifetime prevalence of 17.3 percent (Murphy et al., 1983). Reported estimates for completed suicide associated with illicit substance abuse

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

(mainly opiate use) range from 7 to 25 percent proportionate mortality3 (Flavin et al., 1990). Molnar and colleagues (2001) estimated the PAR for serious suicide attempts among substance abusers (including alcohol) to be 30.2 percent for females and 52.9 percent for males. The vast majority of studies focus either on alcohol disorders alone or combine alcohol and other substance abuse disorders in their analyses. Murphy (2000) in a recent review argues that such an approach is warranted because of the common co-morbidities and the similarities among those with alcohol use disorders and those with illicit substance use disorders. On the other hand, others find clinical factors that distinguish those who abuse illicit substances from those who abuse alcohol (Porsteinsson et al., 1997; Vaillant, 1966).

Substance abusers frequently have comorbid Axis I and II disorders. A cross-national investigation found that mood and anxiety disorders are often comorbid in substance-abusing individuals, and that of the Axis II disorders, conduct disorder and antisocial personality disorder are at increased prevalence in this population (Merikangas et al., 1998). Almost 18 percent of individuals with substance use disorders (non-alcohol) have anti-social personality disorder (Kessler et al., 1994), while 10–30 percent of treatment-seeking cocaine abusing and opioid dependent individuals have comorbid depression (Weiss and Hufford, 1999). The relationship of substance abuse disorders and comorbid psychiatric diagnoses to suicidal behavior is complex, since it is often unclear in what order the conditions arose, what causal links exist, and whether other characteristics of psychology, biology or social circumstance may mediate the relationships.

The same suicide risk factors are found in substance abusers as in other populations: family psychopathology (especially maternal depression), hopelessness, comorbid disorders, use of multiple substances, and poorer psychosocial functioning (Flavin et al., 1990). Impulsivity (Block et al., 1988) is associated with increased risk for developing substance use disorders, as are novelty-seeking/impulsive personality traits (see section below) (Fergusson and Lynskey, 1996; Fergusson et al., 2000). In addition to the associated risk factors, individuals who abuse substances often diminish their protective social networks, secondary to their drug-related behaviors (Vaillant and Blumenthal, 1990).

3  

Proportionate mortality describes the proportion of deaths in a specified population over a period of time attributable to different causes.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

Special Issues for Youth

Youth and Mental Disorders

About 20 percent of children ages 9–17 are estimated to have mental disorders with at least mild functional impairment, 6.2 percent of which have a mood disorder (Shaffer et al., 1996). Longitudinal data from New Zealand (Feehan et al., 1993) found a 21.5 percent prevalence rate of DSM-III disorders at age 15 and a 36 percent prevalence rate at age 18. The most prevalent conditions at age 15 were anxiety (8 percent) and conduct disorders (5 percent). At age 18, they were major depressive episode (17 percent), alcohol dependence (10 percent), and social phobia (11 percent). In the United States, depression is the strongest correlate of suicide for adolescent suicide victims and attempters (Brent et al., 1993; Shaffer, 1988), although some studies find conduct disorder more strongly associated with suicide attempts in adolescents (Borst and Noam, 1989). In four studies, between 40 and 53 percent of the youth suicides were diagnosed with a personality disorder (Brent et al., 1994; Lesage et al., 1994; Rich and Runeson, 1992; Rich et al., 1986). The prevalence of personality disorders in suicide appears to decline with age (Rich et al., 1986), perhaps due to a decreased population prevalence of personality disorders across the lifespan (Ames and Molinari, 1994; Cohen et al., 1994).

The nature and distribution, as well as symptom presentation, of mental disorders are somewhat different in children and youth as compared to adults, although the overall prevalence is comparable. Youth are more likely to exhibit irritability, acting out behaviors, and anger rather than exhibiting sad and depressed affect (APA, 1994). Bipolar disorder in youth often presents with symptoms typically diagnosed as conduct disorder and/or attention deficit disorder (Berenson, 1998; Mohr, 2001). It also may be that bipolar disorder in youth is frequently comorbid with these other disorders, complicating diagnosis and treatment (Berenson, 1998; Mohr, 2001).

Hopelessness, an important risk and predictive factor for adult suicide (see below), is also associated with suicidality in adolescents. Hopelessness predicts repeat suicide attempts and differentiates suicidal from non-suicidal psychiatrically disturbed youths (for reviews, see Brent et al., 1990; Weishaar and Beck, 1990). The severity of depression may be a stronger predictor of suicidality than hopelessness in younger populations (e.g., Asarnow et al., 1987; Cole, 1989; Goldston et al., 2001), which may reflect the time-course of cognitive development (c.f., Nolen-Hoeksema et al., 1992). On the other hand, positive expectations are one of the strongest predictors of resilient people from childhood through

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

adulthood in longitudinal studies (Werner, 1995; Werner and Smith, 2001; Wyman et al., 1993).

Adolescents, Alcohol, and Substance Abuse

The relationship between alcohol and younger suicide victims (i.e., those younger than 35 years of age) is not simple. Brent et al. (1987) found a very strong link between alcohol use prior to suicide and firearm use among youth less than 20 years of age. Teenage suicide victims who use firearms to complete suicide are 4.9 times more likely to have been drinking than those who used other methods.

Substance abuse among youth is another of the most significant risk factors for suicidal behavior (for review, see Brent and Kolko, 1990). The 3-fold rise in adolescent suicide that occurred in the United States throughout the 1960s and 1980s has been attributed to a rise in use of alcohol and illicit drugs. Among the youthful suicides in San Diego, California, the occurrence of drug abuse was reported more frequently in the 1970s and early 1980s; it was the major difference between suicide precursors in younger and older victims (Rich et al., 1986). Multiple substance use or polysubstance abuse (alcohol and other drugs) was common among younger suicide victims in San Diego, although the direction of the relationship of substance abuse to other diagnoses such as depression was not clear (Fowler et al., 1986). Difficulty in pinning down the extant relationship between alcohol, drugs, and suicide has been noted elsewhere (Neeleman and Farrell, 1997).

Family dysfunction and personality traits can contribute to the effects of alcohol and substance abuse on suicide among youth. Frequent illicit substance abuse and intoxication with alcohol can be an important predictor of hopelessness, particularly among lonely youth (Page et al., 1993). A psychological autopsy of 20 adolescents revealed a history of drug or alcohol abuse in 70 percent of those completing suicide compared with 29 percent of controls (Shafii et al., 1985). Other significant risk factors were antisocial behavior, an inhibited personality, and previous suicide attempts or suicide communications. Surveys of youth, parents, and respondents in psychological autopsies of deceased youth in California point to alcohol and substance abuse as important risk factors for suicide. Family dysfunction, individual psychopathology and distress, and interpersonal problems were also cited as contributing factors (Nelson et al., 1988).

King et al. (1993) examined the relationship between alcohol consumption, family dysfunction, and depression to suicidality in adolescent female inpatients. Both alcohol consumption and family dysfunction predicted the severity of clinician documented suicidal ideation and behav-

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

ior. Self-reported ideation, however, was not predicted by alcohol consumption, but rather by the severity of depression and family dysfunction.

Comorbidity of Psychiatric Disorders

Comorbidity of psychiatric disorders with other psychiatric illnesses including substance use disorders or with somatic disorders increases risk of suicide (Lönnqvist, 2000). Co-occurrence of mental disorders and substance abuse disorders increases the risk of suicide beyond that for each of these disorders singly (Suominen et al., 1996). Methodological practices in psychiatry present obstacles to understanding this increased risk posed by comorbidity. It is common to provide only one “primary” psychiatric diagnosis (e.g., Roy and Draper, 1995). Since this primary diagnosis is often the only one analyzed, important data on co-occurrence of disorders is minimized or lost. Some researchers believe it is the co-occurrence of psychiatric disorders itself that mediates suicide risk (Goldsmith et al., 1990). The importance of comorbidity may be part of the increased risk for suicide that cumulative risk factors confer.

PSYCHOLOGICAL DIMENSIONS OF SUICIDE RISK

Information from a number of fields has converged over the last 30 years on an understanding of how genetic, developmental, environmental, physiological, and psychological factors all effect health through multiple, complex causal pathways (IOM, 2001). A growing body of data shows that the physiological responses to stress are potent contributors to physical illnesses including cardiac diseases and cancer, as well as mental disorders including depression and post-traumatic stress disorder (Heim et al., 1997; Nemeroff, 1996). The physiological response to stress can be modified through psychosocial components (e.g., Koenig et al., 1997), including learning new coping skills and thinking habits (Antoni et al., 2000; Bandura, 1992; Cruess et al., 2000a; 2000b).

These psychosocial and learning interventions significantly improve psychological responses to stressors, as well (e.g., Antoni et al., 2001; Cruess et al., 2000b; Gillham et al., 1995; Jaycox et al., 1994; Wyman et al., 2000). “Resilience” represents positive adaptations in the face of life stress. Resilience has been studied alternately as an individual trait or quality, an outcome, or, more recently, as an interactive process of positive factors and negative factors within and between individuals and their environments (see Glantz and Sloboda, 1999; Kaplan, 1999; Kumpfer, 1999, for reviews). Psychological research on resilient outcomes largely focuses on habits of thinking, problem solving, and expectations about the future

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

that appear to protect individuals from developing psychiatric disorders, and on how to enhance such “cumulative competence and stress protection” (Wyman et al., 2000). The enhancement of resiliency through modification of these factors has developed into a field of study and is used in prevention programs for numerous unwanted outcomes including suicide, both in the United States and in other nations (see Chapter 8). Building resiliency is included in one of the four aims of the Surgeon General’s National Strategy for Suicide Prevention (PHS, 2001) and is promoted as a necessary part of national and school-based suicide reduction strategies by the United Nations (1996) and World Health Organization (1999).

The opportunity for enlisting these psychosocial factors to reduce suicide appears potent, but remains largely untested. This section discusses the psychological factors in these stress–response pathways, their relationship to suicide, and what is known about their protective effects against suicide. Chapter 5 provides a developmental context for the role of psychological factors in responses to trauma. These psychological processes form the basis for some of the treatment and prevention strategies described in Chapters 7 and 8.

Psychological Variables

The psychological variables that have been studied in relation to suicide include aspects of thinking, reasoning, and behavior, as listed below.

  • Memory and Cognitive Distortions

  • Hopelessness and Hope

  • Self-Efficacy

  • Locus of Control

  • Coping Style and Affect Regulation

Memory and Cognitive Distortions

Individuals with mental disorders, especially those with depression, often display cognitive distortions such as rigid or dichotomous thinking, overgeneralization, exaggeration or minimization of events, drawing conclusions based on insufficient/contradictory evidence or selectively attending to relevant information, and falsely attributing causality to themselves (for review, see Weishaar and Beck, 1990). Unlike self-reports of high depression, which predict depression remission after treatment, high levels of cognitive distortion appear difficult to modify and may predict continued depression (Brent et al., 1998). Studies have found greater cognitive distortions among suicidal youths and adults than among nonsuicidal mentally ill or healthy controls (see Brent and Kolko, 1990;

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

Weishaar and Beck, 1990). In particular, cognitive rigidity (dichotomous thinking) seems to more strongly characterize suicidal than nonsuicidal individuals. Such rigid thinking appears related to the interpersonal and general problem-solving deficits commonly seen in suicidal individuals (see below). Cognitive behavioral and problem-solving therapy specifically target such variables and appear effective in reducing suicidality (see Chapter 7).

Recent reports address the association between suicidality and memory. A neuropsychological study indicated that executive function deficits, and not general memory deficits, differentiate suicidal from nonsuicidal mentally ill and nonmentally ill individuals (Keilp et al., 2001). Several studies have found a pattern of “over-general,” or non-specific, autobiographical memory in suicidal vs. nonsuicidal persons that demonstrates high correlations with interpersonal problem-solving deficits (Evans et al., 1992; Pollock et al., 2001; Sidley et al., 1997). Investigators posit that the inability to retrieve specific memories of negative events may serve as a means of emotion regulation (e.g., Startup et al., 2001), but hinders effective problem-solving by restricting information retrieval (Pollock et al., 2001). These findings suggest a benefit of targeting problem-solving treatments for suicidality (Chapter 7) to this memory pattern (Pollock et al., 2001).

Hopelessness and Hope

The relationship between hopelessness and suicidality has been studied for over 25 years (for reviews, see Abramson et al., 2000; Beck et al., 1975; Brent and Kolko, 1990; Weishaar and Beck, 1990). Hopelessness predicted suicide ideation better than depression in a sample of 1306 people with at least one mood disorder and 488 patients without mood disorders (Beck et al., 1993). In longitudinal studies, Beck and colleagues (1990; 1989; 1985) found that elevated scores on the Beck Hopelessness Scale (Beck et al., 1974) predicted 91–94 percent of suicides in both inpatients and outpatients over 5–10 years. Hopelessness appears trait-like, exhibiting stability and chronicity over the course of mental illness and remaining even after remission of major depression (Brent et al., 1998; Minkoff et al., 1973; Rifai et al., 1994). A high level of hopelessness during one psychiatric episode predicts high hopelessness in later episodes (Beck et al., 1985). Evidence suggests that hopelessness represents a distinct phenomenon that can arise separately from mood disorders and occurs across psychiatric diagnoses (Bonner and Rich, 1991; Joiner et al., 2001a; Minkoff et al., 1973). Treatment strategies that focus solely on the mood symptoms may therefore miss a critical, modifiable risk factor for reducing suicide.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

Hopelessness appears to arise from multiple sources, including low self-esteem combined with interpersonal losses and the lack of confidence in one’s ability to regulate mood or solve personal problems (negative coping efficacy beliefs, e.g., Catanzaro, 2000; Dieserud et al., 2001). Cognitive behavioral therapy (CBT) is designed to reduce clinical symptoms by changing thoughts and behaviors (Weishaar and Beck, 1990). Numerous studies show CBT is effective in reducing depression and hopelessness in various populations including adolescents (Brent et al., 1999; Brent et al., 1998). Reductions in suicidal ideation and attempt have also been reported (see Chapter 7), but there are no published findings on the specific effect of reducing hopelessness on rates of suicidality.

Alternatively, positive expectations regarding the future (hope) and positive ways of assigning causality to events (optimistic attributional style) powerfully buffer the effects of life stress on mental, behavioral, and physical health (e.g., Beck et al., 1976; Linehan et al., 1983; Range and Penton, 1994; Scheier and Carver, 1992; Taylor et al., 2000; Werner, 1996; Wyman et al., 1993). Research suggests that optimism enables individuals to procure and engage potent protective factors such as adaptive coping skills and increased self-efficacy (described below), reinterpreting adverse experiences to find meaning and benefit, and seeking and perceiving social support (Antoni et al., 2001; Benight et al., 1999a; Brissette et al., 2002; Scheier et al., 1986). Chapter 6 discusses how religious beliefs and involvement can increase hope. Several research groups have designed cognitive–behavioral interventions that teach optimism, and results suggest that children and adults can learn positive, hopeful thinking patterns that attenuate psychological distress and depression and make subsequent episodes of depression less likely (Antoni et al., 2001; Brissette et al., 2002; Gillham and Reivich, 1999; Gillham et al., 1995; Jaycox et al., 1994). Although studies indicate that hope protects against suicidality (Linehan et al., 1983; Malone et al., 2000; Range and Penton, 1994), no published studies on the effect of optimism training on suicidality are currently available.

Self-Efficacy

Self-efficacy beliefs, the assessment of one’s ability to manage or control external and internal threats, exert a primary influence on human emotion, cognition, and behavior (Bandura, 1982; 1991). Positive self-efficacy beliefs represent the opposite of hopelessness and appear to protect individuals from suicidality (Linehan et al., 1983; Malone et al., 2000; Range and Penton, 1994; Strosahl et al., 1992). Coping self-efficacy beliefs affect physiological stress responses involving the catecholamines, opioids, and the hypothalamic-pituitary-adrenal axis (see Chapter 4)

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

(Bandura, 1982; 1992; Bandura et al., 1988; 1985; Benight et al., 1997), and directly contribute to emotional arousal, psychological distress and well-being, and anxiety (Bandura, 1988; 1991; Benight et al., 1997; 1999a; 1999b; 2001; Catanzaro and Mearns, 1999). Positive self-efficacy beliefs further increase the establishment and use of protective factors such as social support and active coping strategies (e.g., Bandura, 1982; 1988; 1992; Benight et al., 1999a; Green and Rodgers, 2001). Although some studies show coping efficacy beliefs buffering suicidality, very little research exists on modifying suicidality via increasing self-efficacy. Emerging research on school-based suicide prevention programs for at-risk youth, described in Chapter 8, demonstrates increased self-efficacy and decreased suicidality in program participants.

Locus of Control

Another area within cognitive psychology, “learned helplessness,” recently expanded to include studies on hopelessness and suicidality. Briefly, the learned helplessness paradigm shows that exposure to uncontrollable stress results in long-term passivity, or the belief that other stressors are also out of an individual’s control, and exposure to uncontrollable stressors specifically elicits neuroendocrine stress responses (see Chapter 4) and psychological distress (Frankenhaeuser, 1982; Grossi et al., 1998; Hyyppa, 1987; Maier and Seligman, 1976; Seligman, 1975). Explanatory, or attributional style describes how people assign meaning to positive and negative life events by attributing them either to stable (long-lasting), pervasive (global), and internal causes, or to unstable, specific, and external causes (see Weishaar and Beck, 1990). Meta-analyses of studies from the 1980s and early 1990s show a relationship between attributional style and depression in children and adults across psychiatric diagnoses. Specifically, attributing negative life events to internal, stable, global causes while explaining positive life events via external, unstable, specific causes increases self-reported and clinical depression (Gladstone and Kaslow, 1995; Joiner and Wagner, 1995; Sweeney et al., 1986). The reformulation of the learned helplessness model (Abramson et al., 1978) combines helplessness expectancies with depression, hopelessness, and suicidality (see Abramson et al., 2000 for a review). A number of prospective studies and one using path analysis (Abramson et al., 1998; Bonner and Rich, 1991; Hankin et al., 2001; Joiner and Rudd, 1995; Yang and Clum, 2000) have demonstrated that a negative explanatory style interacts with stressful life events to predict hopelessness and suicidality in youth and adults. The aforementioned interventions to teach optimism specifically target attributional style, and follow-up evaluation has demonstrated sustained changes in children’s style a number of years after program participation

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

(Gillham and Reivich, 1999). No study to date, however, has investigated how changing attributional style affects suicidality.

Coping Style and Affect Regulation

Coping and emotion regulation styles refer to how individuals manage stressful conditions or events (actively or passively) and how they regulate their own emotional, physiological, behavioral, and cognitive reactions to stress (Lazarus and Folkman, 1984). Coping styles contribute to physical (see IOM, 2001) and mental health following stressors or trauma (e.g., Beaton et al., 1999; Benight et al., 1999a; Boeschen et al., 2001; Sandler et al., 1994; Schnyder et al., 2001). Specifically, active coping styles such as planning, engaging problems, and seeking social support, and cognitive reinterpretation coping (finding meaning and benefit from adverse events) appear to decrease symptoms of psychological disorder and attenuate hypothalamic-pituitary-adrenal responses to stress (e.g., Antoni et al., 2001; Benight et al., 1999a; Cruess et al., 2000b; Taylor et al., 2000). Likewise, religious coping positively influences physical and mental health (see Chapter 6). Maladaptive coping styles, however, generally correlate with negative outcomes and are such a cardinal feature of suicidal individuals that some have suggested including measures for these variables in assessment tools for suicidality (Shneidman, 1992; Yufit and Bongar, 1992).

Suicidologists consistently find ineffective coping styles for mood and impulse regulation and interpersonal problem-solving among suicidal individuals (for reviews, see Catanzaro, 2000; Weishaar and Beck, 1990). Suicidal individuals use fewer active coping strategies and more avoidant (passive) coping styles such as suppression and blame (Amir et al., 1999; Asarnow et al., 1987; Horesh et al., 1996; Josepho and Plutchik, 1994). Compared to other psychiatric patients, suicidal patients are also less likely to use cognitive coping strategies to de-emphasize the importance of a negative outcome or stressor (Horesh et al., 1996; Kotler et al., 1993). Impulsive problem-solving style and difficulty regulating mood is related to increased rates of suicide attempts (Brent and Kolko, 1990; Catanzaro, 2000). For some suicidal individuals, these inadequate coping styles appear during depressive episodes (are state-dependent); for others, especially those with personality disorders or alcoholism, these skills deficits are characteristics or traits of the individual (Linehan et al., 1987; Weishaar and Beck, 1990).

Many psychotherapeutic interventions target coping and emotion regulation skills (see Chapter 7). Coping skills are also relatively easy to target in school-based primary prevention, with many such programs

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

showing good mental health outcomes (Durlak, 1997; Durlak and Wells, 1997; NRC, 2002). Chapter 8 describes school-based coping skills training programs that appear to reduce youth suicide. Longitudinal studies of children at risk for behavioral and mental health problems reveal that effective problem-solving skills correlate with positive outcomes in adulthood (Felsman and Vaillant, 1987; Rutter and Quinton, 1984; Werner, 1995).

The psychological variables reviewed in this section interact with each other and with environmental and biological factors in their influence on suicidality. Yet these attributes have not been broadly addressed in an integrated way. Coping, attributional style, and self-efficacy beliefs have largely been studied separately from hopelessness and suicidality. As described in Chapter 8, recent suicide prevention programs across the world have incorporated skills training and efficacy enhancement into their efforts, and evaluation of such interventions should yield critical information about the relationship between these variables and suicide.

Temperament and Personality

Research shows that mental health and the experience of stress is confounded with aspects of temperament and personality—individuals higher in emotionality report more negative life events and daily stresses than individuals lower in emotionality (Aldwin et al., 1989). One longitudinal study of older men found that personality characteristics accounted for 25 percent of the variance in mental health (Levenson et al., 1988). Classic studies linking certain personality types high in hostility, anger, stress, and anxiety to a greater susceptibility to coronary heart disease (for review, see IOM, 2001), along with evidence showing that subjective, rather than objective, life stress predicts suicidal outcomes among depressed patients (Malone et al., 2000) highlight the importance of disentangling the relationships between temperament, personality, stress and suicide. Chapter 5 provides a developmental perspective on how stress can affect psychology, but the converse also needs to be better understood. The various personalities and temperaments of individuals may necessitate different treatment, intervention, and prevention strategies for suicidality.

Two temperament types, impulsive/aggressive and depressive/withdrawn, are highly associated with suicide in adults (Kotler et al., 2001; Plutchik, 1995) and in adolescents (Apter et al., 1995; Brent et al., 1994). A cluster analysis of personality traits (Rudd et al., 2000) revealed that three clusters of personality traits describe 97 percent of suicidal psychiatric patients:

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
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  • Negativistic, avoidant

  • Negativistic, avoidant, and dependent

  • Negativistic, avoidant, and antisocial

The first two overlapped with depressive/withdrawn temperament while the third overlapped with impulsive/aggressive temperament.

Among the impulsive/aggressive types, suicide often occurs in the absence of an affective disorder (Apter et al., 1995; 1991). Individuals with irritable/aggressive temperaments have increased risk of violence and suicide. Suicide among this group is associated with antisocial personality traits, impulsiveness, uncontrolled emotions, high novelty-seeking, alcohol and substance abuse, and histories of childhood adversity, including sexual abuse (Fergusson et al., 2000; Verona and Patrick, 2000).

Impulsivity (Eaves et al., 2000) and related sensation-seeking (Hur and Bouchard, 1997) show partial heritability related to physiological markers such as the Lewis red blood cell phenotype (Harburg et al., 1982), and a significant but modest association with the gene for a receptor of the brain chemical norepinephrine, the adrenergic alpha 2A receptor (Comings et al., 2000). Alterations in the serotonin system have also been implicated in studies of impulsivity’s relationship to aggression and suicide (Goldston, 2001; Lesch and Merschdorf, 2000; Mann et al., 2001; Verona and Patrick, 2000, see also Chapter 4).

Animal analog studies show that genetic strains with greater novelty-seeking/impulsivity are more susceptible to environmental insults (Piazza et al., 1991; 1993; 1996), with consequent increases in self-administration of addictive substances (Piazza et al., 1991; 1993; 1996). Other animal studies demonstrate that genetic influences on aggressive behavior interact with rearing environment, and that aggressive behavior and defeat experiences alter serotonin levels, future behavior, and genetic expression in the brain (Miczek et al., 2001; 1994; Nikulina et al., 1998; 1999; van Erp and Miczek, 2000). Such studies may provide models of how genetic and neurobiological aspects of impulsive/aggressive temperament interact with environmental factors to increase risks for suicide (see also Chapter 4).

The depressive/withdrawn personality traits are also termed “neuroticism.” This temperament is highly correlated with negative affect, poor regulation of emotions, and high anxiety, as well as suicide (Catanzaro, 2000; Goldsmith et al., 1990). High neuroticism was found linked with increased suicide attempts in a 21-year, prospective, study of 1265 children in New Zealand (Fergusson et al., 2000). Like those individuals at risk for suicide with the irritable/aggressive traits, those with high neuroticism who attempted suicide were also more likely to have experienced childhood trauma, including abuse and inadequate relationships with caretakers (see Chapter 5).

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×

Temperament emerges as an important feature in long-term studies of resiliency (Rutter and Quinton, 1984; Werner, 1995; 1996). Temperament interacts in cumulative ways with the environment. For example, Holahan and Moos (1990) found that personality characteristics function as protective factors under high stress, primarily by influencing coping style. The temperament of an infant also evokes different responses from caregivers, creating either positive or negative social experiences for the child. These experiences cumulate as differential social resources throughout childhood and adolescence (Werner, 1996). Youth with psychological problems or psychiatric disorders are at greater risk for behavior-dependent adverse life events, thereby increasing exposure to stressors and trauma, which in turn affects personality development, thus creating a cyclical pathway of greater psychopathology (Ge and Conger, 1999; Sandberg et al., 1998).

Temperament and personality emerge early in life and remain relatively stable over the life-course, and thus may be less easily modifiable than other psychological variables. However, given that their effects on stress and health are often mediated by other cognitive mechanisms such as coping and explanatory style, opportunities for intervention do exist. Constructive strategies to interrupt the pathway leading from pre-existing disposition to self-destructive behavior can be taught. For example, teaching specific strategies for coping with stress have proven successful (Antoni et al., 2000; Linehan et al., 1991, see also Chapter 7).

Knowledge of personality traits and temperament and the psychological variables discussed above needs to be integrated with what is known about stress response and suicidal outcomes in order to design appropriate interventions. Longitudinal life-course studies can help to foster more in-depth knowledge of the role of personality in the development of suicidality over a person’s life.

Psychic Pain

Psychic pain represents a particular risk factor for suicide that deserves special comment. One of the founders of suicide theory and research, Edwin Schneidman, wrote about the state of perturbation he observed in highly suicidal individuals (1971; 1984; 1992). He later termed this state “psychache” (Shneidman, 1993), a state of psychic pain that an individual experiences as intolerable and resistant to any efforts to produce relief. Indicators of acute suicidality (see Chapter 7) such as severe anxiety, depression, and agitation may overlap with this state of pain. As described in Chapter 1, psychic pain may be an overarching description of the experiential/phenomenological state that leads an individual to seek death through suicide as an escape.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
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A study by Malone and colleagues (2000) found that subjective reports of depression and distress more strongly predict suicide than objective measures. Kovacs et al. (1975) report that 56 percent of suicidal patients wanted to commit suicide to escape their psychic pain. Those reporting this motive had high levels of hopelessness. Those who did not report psychic pain as their reason for suicide were more often motivated by a desire to manipulate and control others, and were less likely to exhibit hopelessness. Suicidal ideation and attempts in depressed patients are highly correlated with affective factors such as sadness and crying spells and with cognitive factors like self-hate, and not as strongly with somatic symptoms of depression (Beck and Lester, 1973; Beck et al., 1973; Lester and Beck, 1977). Furthermore, suicidal behavior among those with borderline personality disorder, for example, often represents a strategy to regulate psychic pain (see Catanzaro, 2000).

In depression, this faith in deliverance, in ultimate restoration is absent. The pain is unrelenting, and what makes the condition intolerable is the fore-knowledge that no remedy will come—not in a day, an hour, a month, or a minute. If there is mild relief, one knows that it is only temporary; more pain will follow. It is hopelessness even more than pain that crushes the soul. So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying—or from discomfort to relative comfort, or from boredom to activity-—but moving from pain to pain…. And this results in a striking experience—one which I have called, borrowing military terminology, the situation of the walking wounded. For in virtually any other serious sickness, a patient who felt similar devastation would be lying flat in bed, possibly sedated and hooked up to the tubes and wires of life-support systems, but at the very least in a posture of repose and in an isolated setting. His invalidism would be necessary, unquestioned and honorably attained. However, the sufferer from depression has no such option and therefore finds himself, like a walking casualty of war, thrust into the most intolerable social and family situations. There he must, despite the anguish devouring his brain, present a face approximating the one that is associated with ordinary events and companionship. He must try to utter small talk, and be responsive to questions, and knowingly nod and frown and, God help him, even smile (Styron, Darkness Visible: A Memoir of Madness, 1990:62–63).

Life satisfaction, existential and spiritual well-being, and/or beliefs that one can survive and resolve the pain without resorting to suicide are protective against suicide and suicidality (Bonner and Rich, 1991; Ellis

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
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and Smith, 1991; Koivumaa-Honkanen et al., 2001; Malone et al., 2000, see also Chapter 6). Positive coping self-efficacy beliefs can directly reduce psychic distress (e.g., Benight et al., 1999b; Catanzaro and Mearns, 1999). Self-efficacy enhancement can be provided through a number of psychotherapeutic approaches such as mastery experiences, verbal persuasion, and modeling/teaching. Studies examining phenomenological and neuroscience variables (e.g., social cognitive neuroscience) have been neglected, but some researchers suggest such integrative studies would be useful for prevention (e.g., Beskow et al., 1999).

FINDINGS

  • Approximately 50 percent of those who complete suicides are not in treatment, despite that the vast majority are suffering from psychiatric disorders. Those that are in treatment are often inadequately medicated, insufficiently followed after acute treatment, and/or do not adhere to treatment plans.

Adequate training is essential so that primary care physicians and specialty care physicians understand the appropriate doses of psychopharmacological medications to prescribe and how to follow up to ensure adherence.

  • Suicide most commonly is associated with a diagnosis of depression. Recent research has increasingly established anxiety disorders and borderline personality disorder as significantly elevating suicide risk. Comorbidity of psychiatric disorders and/or substance abuse is common and further increases suicide risk. About 90 percent of suicides are associated with mental illness, but over 95 percent of those afflicted never even attempt suicide.

Additional research, especially prospective, longitudinal, and ecological-transactional research, is necessary to understand the etiological pathways to suicide and what identifies those who are at risk.

  • About one fourth of all suicides in the U.S. are individuals with alcohol use disorders. Alcohol inebriation is indicated in up to 64 percent of suicide attempts. Abuse of illicit substances also is associated with a significant increase in suicide rate.

Alcohol and substance abuse are important risk factors for suicide and should be heeded by physicians as indicators of potential for suicide.

Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
×
  • Alcohol or substance use disorder, conduct disorder, and impulsivity/sensation-seeking often co-occur and represent particular suicide risk for youth.

The evidence regarding the links between suicide and aggression/ impulsivity is growing. This relationship requires additional attention, particularly regarding its developmental etiology.

  • Hopelessness is related to suicidality across age, diagnoses, and severity of disorder, yet the field lacks research on the pathways to hopelessness, interrelationships between hopelessness and other psychological aspects of suicide risk, and on the specific effects of reducing hopelessness on suicide. Effective treatments exist for reducing hopelessness.

Clinical trials are needed on the specific effects of reducing hopelessness on suicide.

  • Optimism and coping skills enhance both mental and physical health. Research suggests that these can be taught. The opportunity for building resilience through modification of coping and cognitive styles appears potent, but effects of such interventions on suicidality remains largely untested.

Evaluation of mental health promotion programs is needed on the efficacy of reducing suicide via resilience enhancement.

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Suggested Citation:"3 Psychiatric and Psychological Factors." Institute of Medicine. 2002. Reducing Suicide: A National Imperative. Washington, DC: The National Academies Press. doi: 10.17226/10398.
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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

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Reducing Suicide: A National Imperative Get This Book
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Every year, about 30,000 people die by suicide in the U.S., and some 650,000 receive emergency treatment after a suicide attempt. Often, those most at risk are the least able to access professional help.

Reducing Suicide provides a blueprint for addressing this tragic and costly problem: how we can build an appropriate infrastructure, conduct needed research, and improve our ability to recognize suicide risk and effectively intervene. Rich in data, the book also strikes an intensely personal chord, featuring compelling quotes about people’s experience with suicide. The book explores the factors that raise a person’s risk of suicide: psychological and biological factors including substance abuse, the link between childhood trauma and later suicide, and the impact of family life, economic status, religion, and other social and cultural conditions. The authors review the effectiveness of existing interventions, including mental health practitioners’ ability to assess suicide risk among patients. They present lessons learned from the Air Force suicide prevention program and other prevention initiatives. And they identify barriers to effective research and treatment.

This new volume will be of special interest to policy makers, administrators, researchers, practitioners, and journalists working in the field of mental health.

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