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.
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
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.
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
(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
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 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
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
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 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
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.
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-
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).
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.
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
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).
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;
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).
The effects of childhood trauma on suicide risk are discussed in Chapter 5.
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-
TABLE 3-1 The Nature and Extent of Alcohol-Related Suicide in Selected Studies of LargePopulations
Study Population (years)
N of Suicides
% (Legally) Intoxicateda
Cuyahoga County (Cleveland), OH (1959-1974)
Ford et al., 1979
Hlady & Middaugh, 1988
Erie County (Buffalo), NY (1972-1984)
Welte et al.,1988
North Carolina (1973-1983)
Smith et al., 1989
Western Australia (1986-1988)
Hayward et al., 1992
Goodman et al., 1991
New Mexico (1990-1999)
May et al., in press
NM American Indians(1980-1998)
.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
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
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).
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
(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).
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
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-
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
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.
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
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;
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.
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 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)
(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
(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
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:
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).
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 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.
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
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).
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.
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.
Abramson LY, Alloy LB, Hogan ME, Whitehouse WG, Cornette M, Akhavan S, Chiara A. 1998. Suicidality and cognitive vulnerability to depression among college students: A prospective study. Journal of Adolescence, 21(4): 473-487.
Abramson LY, Alloy LB, Hogan ME, Whitehouse WG, Gibb BE, Hankin BL, Cornette MM. 2000. The hopelessness theory of suicidality. In: Joiner TE, Rudd MD, Editors. Suicide Science: Expanding the Boundaries. (pp. 17-32). Norwell, MA: Kluwer Academic Publishers.
Abramson LY, Seligman MEP, Teasdale JD. 1978. Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology, 87: 49-74.
Ahrens B, Haug HJ. 1996. Suicidality in hospitalized patients with a primary diagnosis of personality disorder. Crisis, 17(2): 59-63.
Alda M. 1997. Bipolar disorder: From families to genes. Canadian Journal of Psychiatry, 42(4): 378-487.
Aldwin CM, Levenson MR, Spiro A 3rd, Bosse R. 1989. Does emotionality predict stress? Findings from the normative aging study. Journal of Personality and Social Psychology, 56(4): 618-624.
Allgulander C. 2000. Psychiatric aspects of suicidal behaviour: Anxiety disorders. In: Hawton K, van Heeringen K, Editors. The International Handbook of Suicide and Attempted Suicide. (pp. 179-192). Chichester, UK: John Wiley and Sons.
Allgulander C, Lavori PW. 1991. Excess mortality among 3302 patients with ‘pure’ anxiety neurosis. Archives of General Psychiatry, 48(7): 599-602.
Alvarez A. 1971/1990. The Savage God: A Study of Suicide. New York: W.W. Norton.
Amador XF, Friedman JH, Kasapis C, Yale SA, Flaum M, Gorman JM. 1996. Suicidal behavior in schizophrenia and its relationship to awareness of illness. American Journal of Psychiatry, 153(9): 1185-1188.
Ames A, Molinari V. 1994. Prevalence of personality disorders in community-living elderly. Journal of Geriatric Psychiatry and Neurology, 7(3): 189-194.
Amir M, Kaplan Z, Efroni R, Kotler M. 1999. Suicide risk and coping styles in posttraumatic stress disorder patients. Psychotherapy and Psychosomatics, 68(2): 76-81.
Antoni MH, Cruess S, Cruess DG, Kumar M, Lutgendorf S, Ironson G, Dettmer E, Williams J, Klimas N, Fletcher MA, Schneiderman N. 2000. Cognitive-behavioral stress management reduces distress and 24-hour urinary free cortisol output among symptomatic HIV-infected gay men. Annals of Behavioral Medicine, 22(1): 29-37.
Antoni MH, Lehman JM, Klibourn KM, Boyers AE, Culver JL, Alferi SM, Yount SE, McGregor BA, Arena PL, Harris SD, Price AA, Carver CS. 2001. Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychology , 20(1): 20-32.
APA (American Psychiatric Association). 1994. The Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC.
Appels A. 1997. Depression and coronary heart disease: Observations and questions. Journal of Psychosomatic Research, 43(5): 443-452.
Appleby L. 2000. Prevention of suicide in psychiatric patients. In: Hawton K, van Heeringen K, Editors. The International Handbook of Suicide and Attempted Suicide. (pp. 617-630). Chichester, UK: John Wiley and Sons.
Apter A, Gothelf D, Orbach I, Weizman R, Ratzoni G, Har-Even D, Tyano S. 1995. Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. Journal of American Academy of Child and Adolescent Psychiatry, 34(7): 912-918.
Apter A, Kotler M, Sevy S, Plutchik R, Brown SL, Foster H, Hillbrand M, Korn ML, van Praag HM. 1991. Correlates of risk of suicide in violent and nonviolent psychiatric patients. American Journal of Psychiatry, 148(7): 883-887.
Asarnow JR, Carlson GA, Guthrie D. 1987. Coping strategies, self-perceptions, hopelessness, and perceived family environments in depressed and suicidal children. Journal of Consulting and Clinical Psychology, 55(3): 361-366.
Bailer J, Brauer W, Rey ER. 1996. Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study. Acta Psychiatrica Scandinavica, 93(5): 368-377.
Bandura A. 1982. Self-efficacy mechanism in human agency. American Psychologist, 37(2): 122-147.
Bandura A. 1988. Self-efficacy conception of anxiety. Anxiety Research, 1(2): 77-98.
Bandura A. 1991. Social cognitive theory of self-regulation. Organizational Behavior and Human Decision Processes, 50(2): 248-287.
Bandura A. 1992. Self-efficacy mechanism in psychobiologic functioning. In: Schwarzer R, Editor. Self-Efficacy: Thought Control of Action. (pp. 355-394). Washington, DC: Hemisphere Publishing Corp.
Bandura A, Cioffi D, Taylor C, Barr, Brouillard ME. 1988. Perceived self-efficacy in coping with cognitive stressors and opioid activation. Journal of Personality and Social Psychology, 55(3): 479-488.
Bandura A, Taylor CB, Williams SL, Mefford IN, Barchas JD. 1985. Catecholamine secretion as a function of perceived coping self-efficacy. Journal of Consulting and Clinical Psychology, 53(3): 406-414.
Bayley R. 1996. First person account: Schizophrenia. Schizophrenia Bulletin, 22: 727-729.
Beaton R, Murphy S, Johnson C, Pike K, Corneil W. 1999. Coping responses and posttraumatic stress symptomatology in urban fire service personnel. Journal of Traumatic Stress, 12(2): 293-308.
Bechtold DW. 1988. Cluster suicide in American Indian adolescents. American Indian and Alaska Native Mental Health Research, 1(3): 26-35.
Beck AT. 1986. Hopelessness as a predictor of eventual suicide. Annals of the New York Academy of Sciences, 487: 90-96.
Beck AT, Brown G, Berchick RJ, Stewart BL, Steer RA. 1990. Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. American Journal of Psychiatry, 147(2): 190-195.
Beck AT, Brown G, Steer RA. 1989. Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology, 57(2): 309-310.
Beck AT, Kovacs M, Weissman A. 1975. Hopelessness and suicidal behavior. An overview. Journal of the American Medical Association, 234(11): 1146-1149.
Beck AT, Lester D. 1973. Components of depression in attempted suicides. Journal of Psychology, 85: 257-260.
Beck AT, Lester D, Albert N. 1973. Suicidal wishes and symptoms of depression. Psychological Reports, 33(3): 770.
Beck AT, Steer RA, Beck JS, Newman CF. 1993. Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide and Life-Threatening Behavior, 23(2): 139-145.
Beck AT, Steer RA, Kovacs M, Garrison B. 1985. Hopelessness and eventual suicide: A 10-year prospective study of patients hospitalized with suicidal ideation. American Journal of Psychiatry, 142(5): 559-563.
Beck AT, Steer RA, McElroy MG. 1982. Relationships of hopelessness, depression and previous suicide attempts to suicidal ideation in alcoholics. Journal of Studies on Alcohol, 43(9): 1042-1046.
Beck AT, Weissman A, Kovacs M. 1976. Alcoholism, hopelessness and suicidal behavior. Journal of Studies on Alcohol, 37(1): 66-77.
Beck AT, Weissman A, Lester D, Trexler L. 1974. The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42(6): 861-865.
Beck AT, Weissman A, Lester D, Trexler L. 1976. Classification of suicidal behaviors. II. Dimensions of suicidal intent. Archives of General Psychiatry, 33(7): 835-837.
Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG. 2001. Treatment utilization by patients with personality disorders. American Journal of Psychiatry, 158(2): 295-302.
Benight CC, Antoni MH, Kilbourn K, Ironson G, Kumar MA, Fletcher MA, Redwine L, Baum A, Schneiderman N. 1997. Coping self-efficacy buffers psychological and physiological disturbances in HIV-infected men following a natural disaster. Health Psychology, 16(3): 248-255.
Benight CC, Flores J, Tashiro T. 2001. Bereavement coping self-efficacy in cancer widows. Death Studies, 25(2): 97-125.
Benight CC, Ironson G, Klebe K, Carver C, Wynings C, Burnett K, Greenwood D, Baum A, Scheiderman N. 1999a. Conservation of resources and coping self-efficacy predicting distress following a natural disaster: A causal model analysis where the environment meets the mind. Anxiety, Stress, and Coping, 12: 107-126.
Benight CC, Swift E, Sanger J, Smith A, Zeppelin D. 1999b. Coping self-efficacy as a mediator of distress following a natural disaster. Journal of Applied Social Psychology, 29(12): 2443-2464.
Berenson CK. 1998. Frequently missed diagnoses in adolescent psychiatry. Psychiatric Clinics of North America, 21(4): 917-926.
Beskow J, Kerkhof A, Kokkola A, Uutela A. 1999. Suicide Prevention in Finland 1986-1996: External Evaluation by an International Peer Group. Helsinki: Ministry of Social Affairs and Health.
Bhatia SC, Khan MH, Mediratta RP, Sharma A. 1987. High risk suicide factors across cultures. International Journal of Social Psychiatry, 33(3): 226-236.
Blackwood DH, Visscher PM, Muir WJ. 2001. Genetic studies of bipolar affective disorder in large families. British Journal of Psychiatry, 41 (Suppl): S134-S136.
Block J, Block JH, Keyes S. 1988. Longitudinally foretelling drug usage in adolescence: Early childhood personality and environmental precursors. Child Development, 59(2): 336-355.
Boeschen LE, Koss MP, Figueredo AJ, Coan JA. 2001. Experiential avoidance and post-traumatic stress disorder: A cognitive mediational model of rape recovery. Journal of Aggression, Maltreatment and Trauma, 4(2): 211-245.
Bonner RL, Rich AR. 1991. Predicting vulnerability to hopelessness. A longitudinal analysis. Journal of Nervous and Mental Disease, 179(1): 29-32.
Bornstein RF, Klein DN, Mallon JC, Slater JF. 1988. Schizotypal personality disorder in an outpatient population: Incidence and clinical characteristics. Journal of Clinical Psychology, 44(3): 322-325.
Borst SR, Noam GG. 1989. Suicidality and psychopathology in hospitalized children and adolescents. Acta Paedopsychiatrica, 52(3): 165-175.
Bostwick JM, Pankratz VS. 2000. Affective disorders and suicide risk: A reexamination. American Journal of Psychiatry, 157(12): 1925-1932.
Brady KT, Sonne SC. 1995. The relationship between substance abuse and bipolar disorder. Journal of Clinical Psychiatry, 56 (Supp 13): 19-24.
Breier A, Astrachan BM. 1984. Characterization of schizophrenic patients who commit suicide. American Journal of Psychiatry, 141(2): 206-209.
Brent DA, Holder D, Kolko D, Birmaher B, Baugher M, Roth C, Iyengar S, Johnson BA. 1997. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry, 54(9): 877-885.
Brent DA, Johnson BA, Perper J, Connolly J, Bridge J, Bartle S, Rather C. 1994. Personality disorder, personality traits, impulsive violence, and completed suicide in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 33(8): 1080-1086.
Brent DA, Kolko DJ. 1990. The assessment and treatment of children and adolescents at risk for suicide. In: Blumenthal SJ, Kupfer DJ, Editors. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. (pp. 253-302). Washington, DC: American Psychiatric Press.
Brent DA, Kolko DJ, Allan MJ, Brown RV. 1990. Suicidality in affectively disordered adolescent inpatients. Journal of the American Academy of Child and Adolescent Psychiatry, 29(4): 586-593.
Brent DA, Kolko DJ, Birmaher B, Baugher M, Bridge J. 1999. A clinical trial for adolescent depression: Predictors of additional treatment in the acute and follow-up phases of the trial. Journal of the American Academy of Child and Adolescent Psychiatry, 38(3): 263-270; discussion 270-271.
Brent DA, Kolko DJ, Birmaher B, Baugher M, Bridge J, Roth C, Holder D. 1998. Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. Journal of the American Academy of Child and Adolescent Psychiatry, 37(9): 906-914.
Brent DA, Perper JA, Allman CJ. 1987. Alcohol, firearms, and suicide among youth: Temporal trends in Allegheny County, Pennsylvania, 1960 to 1983. Journal of the American Medical Association, 257(24): 3369-3372.
Brent DA, Perper JA, Moritz G, Allman C, Friend A, Roth C, Schweers J, Balach L, Baugher M. 1993. Psychiatric risk factors for adolescent suicide: A case-control study. Journal of the American Academy of Child and Adolescent Psychiatry, 32(3): 521-529.
Brissette I, Scheier MF, Carver CS. 2002. The role of optimism in social network development, coping, and psychological adjustment during a life transition. Journal of Personality and Social Psychology, 82(1): 102-111.
Brodsky BS, Malone KM, Ellis SP, Dulit RA, Mann JJ. 1997. Characteristics of borderline personality disorder associated with suicidal behavior. American Journal of Psychiatry, 154(12): 1715-1719.
Bromet EJ, Schwartz JE, Fennig S, Geller L, Jandorf L, Kovasznay B, Lavelle J, Miller A, Pato C, Ram R, et al. 1992. The epidemiology of psychosis: The Suffolk County Mental Health Project. Schizophrenia Bulletin, 18(2): 243-255.
Brown GR, Anderson B. 1991. Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse. American Journal of Psychiatry, 148(1): 55-61.
Caldwell CB, Gottesman II. 1990. Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin, 16(4): 571-589.
Caldwell CB, Gottesman II. 1992. Schizophrenia—a high-risk factor for suicide: Clues to risk reduction. Suicide and Life-Threatening Behavior, 22(4): 479-493.
Catanzaro SJ. 2000. Mood regulation and suicidal behavior. In: Joiner TE, Rudd DM, Editors. Suicide Science: Expanding the Boundaries. (pp. 81-103). Norwell, MA: Kluwer Academic Publishers.
Catanzaro SJ, Mearns J. 1999. Mood-related expectancy, emotional experience, and coping behavior. Kirsch I, Editor. How Expectancies Shape Experience. (pp. 67-91). Washington, DC: American Psychological Association.
Chochinov HM, Wilson KG, Enns M, Lander S. 1998. Depression, hopelessness, and suicidal ideation in the terminally ill. Psychosomatics, 39(4): 366-370.
Chu J. 1999. Trauma and suicide. In: Jacobs DG, Editor. The Harvard Medical School Guide to Suicide Assessment and Intervention. (pp. 332-354). San Francisco: Jossey-Bass Publishers.
Cohen BJ, Nestadt G, Samuels JF, Romanoski AJ, McHugh PR, Rabins PV. 1994. Personality disorder in later life: A community study. British Journal of Psychiatry, 165(4): 493-499.
Cole DA. 1989. Psychopathology of adolescent suicide: Hopelessness, coping beliefs, and depression. Journal of Abnormal Psychology, 98(3): 248-255.
Comings DE, Johnson JP, Gonzalez NS, Huss M, Saucier G, McGue M, MacMurray J. 2000. Association between the adrenergic alpha 2A receptor gene (ADRA2A) and measures of irritability, hostility, impulsivity and memory in normal subjects. Psychiatric Genetics, 10(1): 39-42.
Conwell Y, Brent D. 1995. Suicide and aging. I: Patterns of psychiatric diagnosis. International Psychogeriatrics, 7(2): 149-164.
Conwell Y, Duberstein PR, Cox C, Herrmann JH, Forbes NT, Caine ED. 1996. Relationships of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry, 153(8): 1001-1008.
Corbitt EM, Malone KM, Haas GL, Mann JJ. 1996. Suicidal behavior in patients with major depression and comorbid personality disorders. Journal of Affective Disorders, 39(1): 61-72.
Cruess DG, Antoni MH, Kumar M, Schneiderman N. 2000a. Reductions in salivary cortisol are associated with mood improvement during relaxation training among HIV-seropositive men. Journal of Behavioral Medicine, 23(2): 107-122.
Cruess DG, Antoni MH, McGregor BA, Kilbourn KM, Boyers AE, Alferi SM, Carver CS, Kumar M. 2000b. Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer. Psychosomatic Medicine, 62(3): 304-308.
Davis T, Gunderson JG, Myers M. 1999. Borderline personality disorder. In: Jacobs DG, Editor. The Harvard Medical School Guide to Suicide Assessment and Intervention. (pp. 311-331). San Francisco: Jossey-Bass Publishers.
De Hert M, Peuskens J. 2000. Psychiatric aspects of suicidal behaviour: Schizophrenia. In: Hawton K, van Heeringen K, Editors. The International Handbook of Suicide and Attempted Suicide. (pp. 121-134). Chichester, UK: John Wiley and Sons.
Dieserud G, Roysamb E, Ekeberg O, Kraft P. 2001. Toward an integrative model of suicide attempt: A cognitive psychological approach. Suicide and Life-Threatening Behavior, 31(2): 153-168.
Dingman CW, McGlashan TH. 1986. Discriminating characteristics of suicides. Chestnut Lodge follow-up sample including patients with affective disorder, schizophrenia and schizoaffective disorder. Acta Psychiatrica Scandinavica, 74(1): 91-97.
Drake RE, Gates C, Cotton PG, Whitaker A. 1984. Suicide among schizophrenics. Who is at risk? Journal of Nervous and Mental Disease, 172(10): 613-617.
Drake RE, Gates C, Whitaker A, Cotton PG. 1985. Suicide among schizophrenics: A review. Comprehensive Psychiatry, 26(1): 90-100.
Duberstein PR, Conwell Y, Caine ED. 1993. Interpersonal stressors, substance abuse, and suicide. Journal of Nervous and Mental Disease, 181(2): 80-85.
Dubo ED, Zanarini MC, Lewis RE, Williams AA. 1997. Childhood antecedents of self-destructiveness in borderline personality disorder. Canadian Journal of Psychiatry, 42(1): 63-69.
Dunner DL, Gershon ES, Goodwin FK. 1976. Heritable factors in the severity of affective illness. Biological Psychiatry, 11(1): 31-42.
Durlak JA. 1997. Primary prevention programs in schools. Advances in Clinical Child Psychology, 283-318.
Durlak JA, Wells AM. 1997. Primary prevention mental health programs for children and adolescents: A meta-analytic review. American Journal of Community Psychology, 25(2): 115-152.
Eaves L, Rutter M, Silberg JL, Shillady L, Maes H, Pickles A. 2000. Genetic and environmental causes of covariation in interview assessments of disruptive behavior in child and adolescent twins. Behavior Genetics, 30(4): 321-334.
Ellis JB, Smith PC. 1991. Spiritual well-being, social desirability and reasons for living: Is there a connection? International Journal of Social Psychiatry, 37(1): 57-63.
Evans J, Williams JM, O’Loughlin S, Howells K. 1992. Autobiographical memory and problem-solving strategies of parasuicide patients. Psychological Medicine, 22(2): 399-405.
Falloon IR, Talbot RE. 1981. Persistent auditory hallucinations: Coping mechanisms and implications for management. Psychological Medicine, 11(2): 329-339.
Feehan M, McGee R, Williams SM. 1993. Mental health disorders from age 15 to age 18 years. Journal of the American Academy of Child and Adolescent Psychiatry, 32(6): 1118-1126.
Felsman JK, Vaillant GE. 1987. Resilient children as adults: A 40-year study. In: James AE, Cohler BJ, Editors. The Invulnerable Child. (pp. 289-314). New York: Guilford Press.
Fennig S, Putnam K, Bromet EJ, Galambos N. 1995. Gender, premorbid characteristics and negative symptoms in schizophrenia . Acta Psychiatrica Scandinavica, 92(3): 173-177.
Fenton WS, McGlashan TH, Victor BJ, Blyler CR. 1997. Symptoms, subtype, and suicidality in patients with schizophrenia spectrum disorders. American Journal of Psychiatry, 154(2): 199-204.
Fergusson DM, Lynskey MT. 1996. Adolescent resiliency to family adversity. Journal of Child Psychology and Psychiatry and Allied Disciplines, 37(3): 281-292.
Fergusson DM, Woodward LJ, Horwood LJ. 2000. Risk factors and life processes associated with the onset of suicidal behaviour during adolescence and early adulthood. Psychological Medicine, 30(1): 23-39.
Figueroa E, Silk KR. 1997. Biological implications of childhood sexual abuse in borderline personality disorder. Journal of Personality Disorders, 11(1): 71-92.
Flavin DK, Franklin JE, Frances RJ. 1990. Substance abuse and suicidal behavior. In: Blumenthal SJ, Kupfer DJ, Editors. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. (pp. 177-204). Washington, DC: American Psychiatric Press.
Ford AB, Rushforth NB, Rushforth N, Hirsch CS, Adelson L. 1979. Violent death in a metropolitan county: II. Changing patterns in suicides (1959-1974). American Journal of Public Health, 69(5): 459-464.
Foster T, Gillespie K, McClelland R. 1997. Mental disorders and suicide in Northern Ireland. British Journal of Psychiatry, 170: 447-452.
Fowler RC, Rich CL, Young D. 1986. San Diego Suicide Study. II. Substance abuse in young cases. Archives of General Psychiatry, 43(10): 962-965.
Frances A, Fyer M, Clarkin J. 1986. Personality and suicide. Annals of the New York Academy of Sciences, 487: 281-293.
Frankenhaeuser M. 1982. Challenge-control interaction as reflected in sympathetic-adrenal and pituitary-adrenal activity: Comparison between the sexes. Scandinavian Journal of Psychology, Suppl 1: 158-164.
Friedman RC, Aronoff MS, Clarkin JF, Corn R, Hurt SW. 1983. History of suicidal behavior in depressed borderline inpatients . American Journal of Psychiatry, 140(8): 1023-1026.
Funahashi T, Ibuki Y, Domon Y, Nishimura T, Akehashi D, Sugiura H. 2000. A clinical study on suicide among schizophrenics. Psychiatry and Clinical Neurosciences, 54(2): 173-179.
Fyer MR, Frances AJ, Sullivan T, Hurt SW, Clarkin J. 1988. Suicide attempts in patients with borderline personality disorder. American Journal of Psychiatry, 145(6): 737-739.
Gardner DL, Cowdry RW. 1985. Suicidal and parasuicidal behavior in borderline personality disorder. Psychiatric Clinics of North America, 8(2): 389-403.
Garland M, Hickey D, Corvin A, Golden J, Fitzpatrick P, Cunningham S, Walsh N. 2000. Total serum cholesterol in relation to psychological correlates in parasuicide. British Journal of Psychiatry, 177: 77-83.
Garvey MJ, Spoden F. 1980. Suicide attempts in antisocial personality disorder. Comprehensive Psychiatry, 21(2): 146-149.
Ge X, Conger RD. 1999. Adjustment problems and emerging personality characteristics from early to late adolescence. American Journal of Community Psychology, 27(3): 429-459.
Gillham JE, Reivich KJ. 1999. Prevention of depressive symptoms in school children: A research update. Psychological Science, 10(5): 461-462.
Gillham JE, Reivich KJ, Jaycox LH, Seligman MEP. 1995. Prevention of depressive symptoms in schoolchildren: Two-year follow-up. Psychological Science, 6(6): 343-351.
Gladstone TR, Kaslow NJ. 1995. Depression and attributions in children and adolescents: A meta-analytic review. Journal of Abnormal Child Psychology, 23(5): 597-606.
Glantz MD, Sloboda Z. 1999. Analysis and reconceptualization of resilience. In: Glantz MD, Johnson JL, Editors. Resilience and Development: Positive Life Adaptations. (pp. 109-128). New York: Kluwer Academic/Plenum Publishers.
Goldberg DP, Lecrubier Y. 1996. Form and frequency of mental disorders across centres. In: Ustun TN, Sartorius N, Editors. Mental Illness in General Health Care: An International Study. (pp. 323-334).: John Wiley and Sons.
Goldman S, Beardslee WR. 1999. Suicide in children and adolescents. In: Jacobs DG, Editor. The Harvard Medical School Guide to Suicide Assessment and Intervention. (pp. 417-442). San Francisco: Jossey-Bass Publishers.
Goldsmith HH, Lemery KS. 2000. Linking temperamental fearfulness and anxiety symptoms: A behavior-genetic perspective. Biological Psychiatry, 48(12): 1199-1209.
Goldsmith SJ, Fryer M, Frances A. 1990. Personality and suicide. In: Blumenthal SJ, Kupfer DJ, Editors. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. (pp. 155-176). Washington, DC: American Psychiatric Press.
Goldston DB. 2001. Issues in measurement of suicide risk factors in youth. Workshop presentation at the Institute of Medicine’s Workshop on Risk Factors for Suicide, March 14, 2001. Summary available in: Institute of Medicine. Risk Factors for Suicide: Summary of a Workshop. (pp. 5-7). Washington, DC: National Academy Press.
Goldston DB, Daniel SS, Reboussin BA, Reboussin DM, Frazier PH, Harris AE. 2001. Cognitive risk factors and suicide attempts among formerly hospitalized adolescents: A prospective naturalistic study. Journal of the American Academy of Child and Adolescent Psychiatry, 40(1): 91-99.
Goodman RA, Istre GR, Jordan FB, Herndon JL, Kelaghan J. 1991. Alcohol and fatal injuries in Oklahoma. Journal of Studies on Alcohol, 52(2): 156-161.
Goodwin FK, Jamison KR. 1990. Manic-Depressive Illness. New York: Oxford University Press.
Gorman JM, Coplan JD. 1996. Comorbidity of depression and panic disorder. Journal of Clinical Psychiatry, 57 (Suppl 10): 34-41; discussion 42-43.
Green BL, Rodgers A. 2001. Determinants of social support among low-income mothers: A longitudinal analysis. American Journal of Community Psychology, 29(3): 419-441.
Green MA, Curtis GC. 1988. Personality disorders in panic patients: Response to termination of antipanic medication. Journal of Personality Disorders, 2: 303-314.
Grossi G, Ahs A, Lundberg U. 1998. Psychological correlates of salivary cortisol secretion among unemployed men and women. Integrative Physiological and Behavioral Science, 33(3): 249-263.
Gunderson JG, Sabo AN. 1993. The phenomenological and conceptual interface between borderline personality disorder and PTSD. American Journal of Psychiatry, 150(1): 19-27.
Guze SB, Robins E. 1970. Suicide and primary affective disorders. British Journal of Psychiatry, 117(539): 437-438.
Hagnell O, Lanke J, Rorsman B. 1981. Suicide rates in the Lundby study: Mental illness as a risk factor for suicide. Neuropsychobiology, 7(5): 248-253.
Hankin BL, Abramson LY, Siler M. 2001. A prospective test of the hopelessness theory of depression in adolescence. Cognitive Therapy and Research, 25(5): 607-632.
Harburg E, Gleibermann L, Gershowitz H, Ozgoren F, Kulik CL. 1982. Twelve blood markers and measures of temperament. British Journal of Psychiatry, 140: 401-409.
Harkavy-Friedman JM, Restifo K, Malaspina D, Kaufmann CA, Amador XF, Yale SA, Gorman JM. 1999. Suicidal behavior in schizophrenia: Characteristics of individuals who had and had not attempted suicide. American Journal of Psychiatry, 156(8): 1276-1278.
Harrington R, Kerfoot M, Dyer E, McNiven F, Gill J, Harrington V, Woodham A, Byford S. 1998. Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. Journal of the American Academy of Child and Adolescent Psychiatry, 37(5): 512-518.
Harris EC, Barraclough B. 1997. Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry, 170: 205-228.
Harris EC, Barraclough B. 1998. Excess mortality of mental disorder. British Journal of Psychiatry, 173: 11-53.
Hayward L, Zubrick SR, Silburn S. 1992. Blood alcohol levels in suicide cases. Journal of Epidemiology and Community Health, 46(3): 256-260.
Heila H, Isometsa ET, Henriksson MM, Heikkinen ME, Marttunen MJ, Lönnqvist JK. 1997. Suicide and schizophrenia: A nationwide psychological autopsy study on age- and sex-specific clinical characteristics of 92 suicide victims with schizophrenia. American Journal of Psychiatry, 154(9): 1235-1242.
Heila H, Isometsa ET, Henriksson MM, Heikkinen ME, Marttunen MJ, Lönnqvist JK. 1998. Antecedents of suicide in people with schizophrenia. British Journal of Psychiatry, 173: 330-333.
Heim C, Nemeroff CB. 2001. The role of childhood trauma in the neurobiology of mood and anxiety disorders: Preclinical and clinical studies. Biological Psychiatry, 49(12): 1023-1039.
Heim C, Owens MJ, Plotsky PM, Nemeroff CB. 1997. Persistent changes in corticotropin-releasing factor systems due to early life stress: Relationship to the pathophysiology of major depression and post-traumatic stress disorder. Psychopharmacology Bulletin, 33(2): 185-192.
Hellerstein D, Frosch W, Koenigsberg HW. 1987. The clinical significance of command hallucinations. American Journal of Psychiatry, 144(2): 219-221.
Henriksson MM, Aro HM, Marttunen MJ, Heikkinen ME, Isometsa ET, Kuoppasalmi KI, Lönnqvist JK. 1993. Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150(6): 935-940.
Hlady WG, Middaugh JP. 1988. Suicides in Alaska: Firearms and alcohol. American Journal of Public Health, 78(2): 179-180.
Holahan CJ, Moos RH. 1990. Life stressors, resistance factors, and improved psychological functioning: An extension of the stress resistance paradigm. Journal of Personality and Social Psychology, 58(5): 909-917.
Horesh N, Rolnick T, Iancu I, Dannon P, Lepkifker E, Apter A, Kotler M. 1996. Coping styles and suicide risk. Acta Psychiatrica Scandinavica, 93(6): 489-493.
Hur YM, Bouchard TJ Jr. 1997. The genetic correlation between impulsivity and sensation seeking traits. Behavioral Genetics, 27(5): 455-463.
Hyyppa MT. 1987. Psychoendocrine aspects of coping with distress. Annals of Clinical Research, 19(2): 78-82.
IOM (Institute of Medicine). 2001. Health and Behavior: The Interplay of Biological, Behavioral, and Societal Influences. Washington, DC: National Academy Press.
Isometsa ET, Henriksson MM, Aro HM, Lönnqvist JK. 1994. Suicide in bipolar disorder in Finland. American Journal of Psychiatry, 151(7): 1020-1024.
Isometsa ET, Henriksson MM, Heikkinen ME, Aro HM, Marttunen MJ, Kuoppasalmi KI, Lönnqvist JK. 1996. Suicide among subjects with personality disorders. Amreican Journal of Psychiatry, 153(5): 667-673.
Jaycox LH, Reivich KJ, Gillham J, Seligman ME. 1994. Prevention of depressive symptoms in school children. Behaviour Research and Therapy, 32(8): 801-816.
Jenike MA, Baer L, Minichiello WE, Schwartz CE, Carey RJ Jr. 1986. Concomitant obsessive-compulsive disorder and schizotypal personality disorder. American Journal of Psychiatry, 143(4): 530-532.
Joffe RT, Regan JJ. 1989. Personality and suicidal behavior in depressed patients. Comprehensive Psychiatry, 30(2): 157-160.
Joiner TE Jr, Rudd MD. 1995. Negative attributional style for interpersonal events and the occurrence of severe interpersonal disruptions as predictors of self-reported suicidal ideation. Suicide and Life-Threatening Behavior, 25(2): 297-304.
Joiner TE Jr, Steer RA, Abramson LY, Alloy LB, Metalsky GI, Schmidt NB. 2001a. Hopelessness depression as a distinct dimension of depressive symptoms among clinical and non-clinical samples. Behaviour Research and Therapy, 39(5): 523-536.
Joiner TE Jr, Voelz ZR, Rudd MD. 2001b. For suicidal young adults with comorbid depressive and anxiety disorders, probem-solving treatment may be better than treatment as usual. Professional Psychology—Research & Practice, 32(3): 278-282.
Joiner TE Jr, Wagner KD. 1995. Attribution style and depression in children and adolescents: A meta-analytic review. Clinical Psychology Review, 15(8): 777-798.
Josepho SA, Plutchik R. 1994. Stress, coping, and suicide risk in psychiatric inpatients. Suicide and Life-Threatening Behavior, 24(1): 48-57.
Joyce P, Beautrais A, Mulder R. 1994. The prevalence of mental disorder in individuals who suicide and attempt suicide. In: Kelleher M, Editor. Divergent Perspectives on Suicidal Behavior. Cork: Fifth European Symposium on Suicide.
Kaplan HB. 1999. Toward an understanding of resilience: A critical review of definitions and models. In: Glantz MD, Johnson JL, Editors. Resilience and Development: Positive Life Adaptations. (pp. 17-84). New York: Kluwer Academic/Plenum Publishers.
Keilp JG, Sackeim HA, Brodsky BS, Oquendo MA, Malone KM, Mann JJ. 2001. Neuropsychological dysfunction in depressed suicide attempters. American Journal of Psychiatry, 158(5): 735-741.
Keller MB, Hanks DL. 1995. Anxiety symptom relief in depression treatment outcomes. Journal of Clinical Psychiatry, 56 (Suppl 6): 22-29.
Kendall RE. 1983. Alcohol and suicide. Substance and Alcohol Actions/Misuse, 4(2-3): 121-127.
Kessler RC. 2000. Posttraumatic stress disorder: The burden to the individual and to society. Journal of Clinical Psychiatry, 61 (Suppl 5): 4-12; discussion 13-14.
Kessler RC, Borges G, Walters EE. 1999. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56(7): 617-626.
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, Wittchen HU, Kendler KS. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51(1): 8-19.
Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12): 1048-1060.
King CA, Hill EM, Naylor M, Evans T, Shain B. 1993. Alcohol consumption in relation to other predictors of suicidality among adolescent inpatient girls. Journal of the American Academy of Child and Adolescent Psychiatry, 32(1): 82-88.
Klatsky AL, Friedman GD, Siegelaub AB. 1981. Alcohol and mortality. A ten-year Kaiser-Permanente experience. Annals of Internal Medicine, 95(2): 139-145.
Klerman GL, Weissman MM. 1989. Increasing rates of depression. Journal of the American Medical Association, 261(15): 2229-2235.
Koenig HG, Cohen HJ, George LK, Hays JC, Larson DB, Blazer DG. 1997. Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. International Journal of Psychiatry in Medicine, 27(3): 233-250.
Koerner K, Linehan MM. 2000. Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 23(1): 151-167.
Koivumaa-Honkanen H, Honkanen R, Viinamaki H, Heikkila K, Kaprio J, Koskenvuo M. 2001. Life satisfaction and suicide: A 20-year follow-up study. American Journal of Psychiatry, 158(3): 433-439.
Kotler M, Finkelstein G, Molcho A, Botsis AJ, Plutchik R, Brown SL, van Praag HM. 1993. Correlates of suicide and violence risk in an inpatient population: Coping styles and social support. Psychiatry Research, 47(3): 281-290.
Kotler M, Iancu I, Efroni R, Amir M. 2001. Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous and Mental Disease, 189(3): 162-167.
Kovacs M, Beck AT, Weissman A. 1975. The use of suicidal motives in the psychotherapy of attempted suicides. American Journal of Psychotherapy, 29(3): 363-368.
Kroll P, Ryan C. 1983. The schizotypal personality on an alcohol treatment unit. Comprehensive Psychiatry, 24(3): 262-270.
Kumpfer KL. 1999. Factors and processes contributing to resilience: The resilience framework. In: Glantz MD, Johnson JL, Editors. Resilience and Development: Positive Life Adaptations. (pp. 179-224). New York: Kluwer Academic/Plenum Publishers.
Landmark J, Cernovsky ZZ, Merskey H. 1987. Correlates of suicide attempts and ideation in schizophrenia. British Journal of Psychiatry, 151: 18-20.
Lazarus R, Folkman S. 1984. Stress, Appraisal and Coping. New York: Springer.
Lerner MS, Clum GA. 1990. Treatment of suicide ideators: A problem-solving approach. Behavior Therapy, 21(4): 403-411.
Lesage AD, Boyer R, Grunberg F, Vanier C, Morissette R, Menard-Buteau C, Loyer M. 1994. Suicide and mental disorders: A case-control study of young men. American Journal of Psychiatry, 151(7): 1063-1068.
Lesch KP, Merschdorf U. 2000. Impulsivity, aggression, and serotonin: A molecular psychobiological perspective. Behavioral Sciences and the Law, 18(5): 581-604.
Lesperance F, Frasure-Smith N. 2000. Depression in patients with cardiac disease: A practical review. Journal of Psychosomatic Research, 48(4-5): 379-391.
Lester D. 1995. The association between alcohol consumption and suicide and homicide rates: A study of 13 nations. Alcohol and Alcoholism, 30(4): 465-468.
Lester D, Beck AT. 1977. Suicidal wishes and depression in suicidal ideators: A comparison with attempted suicides. Journal of Clinical Psychology, 33(1): 92-94.
Levenson MR, Aldwin CM, Bosse R, Spiro A 3rd. 1988. Emotionality and mental health: Longitudinal findings from the normative aging study. Journal of Abnormal Psychology, 97(1): 94-96.
Liebowitz MR. 1993. Functional classification of anxiety-panic. International Clinical Psychopharmacology, 8 (Suppl 1): 47-52.
Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. 1991. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48(12): 1060-1064.
Linehan MM, Camper P, Chiles JA, Strosahl K, et al. 1987. Interpersonal problem solving and parasuicide. Cognitive Therapy and Research, 11(1): 1-12.
Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. 1983. Reasons for staying alive when you are thinking of killing yourself: The reasons for living inventory. Journal of Consulting and Clinical Psychology, 51(2): 276-286.
Linehan MM, Rizvi SL, Welch SS, Page B. 2000. Psychiatric aspects of suicidal behavior: Personality disorders. In: Hawton K, van Heeringen K, Editors. The International Handbook of Suicide and Attempted Suicide. (pp. 147-178). Chichester, UK: John Wiley and Sons.
Lönnqvist JK. 2000. Psychiatric aspects of suicidal behaviour: Depression. Hawton K, van Heeringen K, Editors. The International Handbook of Suicide and Attempted Suicide. (pp. 107-120). Chichester, UK: John Wiley and Sons.
Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. 1996. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Archives of General Psychiatry, 53(2): 159-168.
Maier SF, Seligman MEP. 1976. Learned helplessness: Theory and evidence. Journal of Experimental Psychology: General, 105: 3-46.
Makela P. 1996. Alcohol consumption and suicide mortality by age among Finnish men, 1950–1991 . Addiction, 91(1): 101-112.
Malone KM, Oquendo MA, Haas GL, Ellis SP, Li S, Mann JJ. 2000. Protective factors against suicidal acts in major depression: Reasons for living. American Journal of Psychiatry, 157(7): 1084-1088.
Mann JJ, Brent DA, Arango V. 2001. The neurobiology and genetics of suicide and attempted suicide: A focus on the serotonergic system. Neuropsychopharmacology, 24(5): 467-477.
Mann JJ, Waternaux C, Haas GL, Malone KM. 1999. Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2): 181-189.
Marcus SC, Olfson M, Pincus HA, Shear MK, Zarin DA. 1997. Self-reported anxiety, general medical conditions, and disability bed days. American Journal of Psychiatry, 154(12): 1766-1768.
May PA. 1995. Adolescent suicide in the West. Second Bi-Regional Adolescent Suicide Prevention Conference. Washington, DC: US DHHS, Health Resources and Services Administration, Maternal and Child Health Bureau.
May PA, Van Winkle NW, Williams MB, McFelley PJ, DeBruyn LM, Serna P. In press. Alcohol and suicide death among American Indians of New Mexico: 1980–1998. Suicide and Life-Threatening Behavior.
Mayfield DG, Montgomery D. 1972. Alcoholism, alcohol intoxication, and suicide attempts. Archives of General Psychiatry, 27(3): 349-353.
Medhus A. 1975. Mortality among female alcoholics. Scandanavian Journal of Social Medicine, 3(3): 111-115.
Merikangas KR, Mehta RL, Molnar BE, Walters EE, Swendsen JD, Aguilar-Gaziola S, Bijl R, Borges G, Caraveo-Anduaga JJ, DeWit DJ, Kolody B, Vega WA, Wittchen HU, Kessler RC. 1998. Comorbidity of substance use disorders with mood and anxiety disorders: Results of the International Consortium in Psychiatric Epidemiology. Addictive Behaviors, 23(6): 893-907.
Merrill J, Milner G, Owens J, Vale A. 1992. Alcohol and attempted suicide. British Journal of Addiction, 87(1): 83-89.
Miczek KA, Maxson SC, Fish EW, Faccidomo S. 2001. Aggressive behavioral phenotypes in mice. Behavioural Brain Research, 125(1-2): 167-181.
Miczek KA, Weerts E, Haney M, Tidey J. 1994. Neurobiological mechanisms controlling aggression: Preclinical developments for pharmacotherapeutic interventions. Neuroscience and Biobehavioral Reviews, 18(1): 97-110.
Miles CP. 1977. Conditions predisposing to suicide: A review. Journal of Nervous and Mental Disease, 164(4): 231-246.
Minkoff K, Bergman E, Beck AT, Beck R. 1973. Hopelessness, depression, and attempted suicide. American Journal of Psychiatry, 130(4): 455-459.
Mirin SM, Weiss RD. 1986. Affective illness in substance abusers. Psychiatric Clinics of North America, 9(3): 503-514.
Modestin J, Oberson B, Erni T. 1997. Possible correlates of DSM-III-R personality disorders. Acta Psychiatrica Scandinavica, 96(6): 424-430.
Mohr WK. 2001. Bipolar disorder in children. Journal of Psychosocial Nursing and Mental Health Services, 39(3): 12-23.
Molnar BE, Berkman LF, Buka SL. 2001. Psychopathology, childhood sexual abuse and other childhood adversities: Relative links to subsequent suicidal behaviour in the US. Psychological Medicine, 31(6): 965-977.
Mortensen PB, Juel K. 1993. Mortality and causes of death in first admitted schizophrenic patients. British Journal of Psychiatry, 163: 183-189.
Murphy GE. 1992. Suicide in Alcoholism. New York: Oxford University Press.
Murphy GE. 2000. Psychiatric aspects of suicidal behavior: Substance abuse. In: Hawton K., Van Heeringen K, Editors. International Handbook of Suicide and Attempted Suicide. (pp. 135-146). Chichester, UK: John Wiley and Sons.
Murphy GE, Armstrong JW Jr, Hermele SL, Fischer JR, Clendenin WW. 1979. Suicide and alcoholism. Interpersonal loss confirmed as a predictor. Archives of General Psychiatry, 36(1): 65-69.
Murphy GE, Robins E. 1967. Social factors in suicide. Journal of the American Medical Association, 199: 303-308.
Murphy SL, Rounsaville BJ, Eyre S, Kleber HD. 1983. Suicide attempts in treated opiate addicts. Comprehensive Psychiatry, 24(1): 79-89.
Nakamura MM, Overall JE, Hollister LE, Radcliffe E. 1983. Factors affecting outcome of depressive symptoms in alcoholics. Alcoholism, Clinical and Experimental Research, 7(2): 188-193.
Narrow WE. unpublished. One-Year Prevalence of Mental Disorders, Excluding Substance Use Disorders, in the U.S.: NIMH ECA Prospective Data. Population Estimates Based on U.S. Census Estimated Residential Population Age 18 and Over on July 1, 1998. Cited on NIMH website at: http://www.nimh.nih.gov/publicat/numbers.cfm [accessed December 20, 2001].
Neeleman J, Farrell M. 1997. Suicide and substance misuse. British Journal of Psychiatry, 171: 303-304.
Nelson FL, Farberow NL, Litman RE. 1988. Youth suicide in California: A comparative study of perceived causes and interventions. Community Mental Health Journal, 24(1): 31-42.
Nemeroff CB. 1996. The corticotropin-releasing factor (CRF) hypothesis of depression: New findings and new directions. Molecular Psychiatry, 1(4): 336-342.
NIAAA (National Institute on Alcohol Abuse and Alcoholism). 2001. Quick Facts. [Online]. Available: http://www.niaaa.nih.gov/databases/qf.htm [accessed December 20, 2001].
Nikulina EM, Hammer RP Jr, Miczek KA, Kream RM. 1999. Social defeat stress increases expression of mu-opioid receptor mRNA in rat ventral tegmental area. Neuroreport, 10(14): 3015-3019.
Nikulina EM, Marchand JE, Kream RM, Miczek KA. 1998. Behavioral sensitization to cocaine after a brief social stress is accompanied by changes in fos expression in the murine brainstem. Brain Research, 810(1-2): 200-210.
Nolen-Hoeksema S, Girgus JS, Seligman ME. 1992. Predictors and consequences of childhood depressive symptoms: A 5-year longitudinal study. Journal of Abnormal Psychology, 101(3): 405-422.
Norstrom T. 1988. Alcohol and suicide in Scandinavia. British Journal of Addiction, 83(5): 553-559.
NRC (National Research Council). 2002. Eccles J, Gootman JA, Editors. Community Programs to Promote Youth Development. Washington, DC: National Academy Press.
Nyman AK, Jonsson H. 1986. Patterns of self-destructive behaviour in schizophrenia. Acta Psychiatrica Scandinavica, 73(3): 252-262.
Ottoson H, Bodlund O, Ekselius L, Grann M, von Knorring L, Kullgren G, Lindstroem E, Soederberg S. 1998. DSM-IV and ICD-10 personality disorders: A comparison of a self-report questionnaire (DIP-Q) with a structured interview. European Psychiatry, 13: 246-253.
Page RM, Allen O, Moore L, Hewitt C. 1993. Co-occurrence of substance use and loneliness as a risk factor for adolescent hopelessness. Journal of School Health, 63(2): 104-108.
Paris J. 1998. Does childhood trauma cause personality disorders in adults? Canadian Journal of Psychiatry, 43(2): 148-153.
Paris J, Nowlis D, Brown R. 1989. Predictors of suicide in borderline personality disorder. Canadian Journal of Psychiatry, 34(1): 8-9.
Peuskens J, De Hert M, Cosyns P, Pieters G, Theys P, Vermote R. 1997. Suicide in young schizophrenic patients during and after inpatient treatment. International Journal of Mental Health, 25(4): 39-44.
Pfohl B, Stangl D, Zimmerman M. 1984. The implications of DSM-III personality disorders for patients with major depression. Journal of Affective Disorders, 7(3-4): 309-318.
PHS (Public Health Service). 2001. National Strategy for Suicide Prevention: Goals and Objectives for Action. Rockville, MD: U.S. Department of Health and Human Services.
Piazza PV, Deroche V, Deminiere JM, Maccari S, Le Moal M, Simon H. 1993. Corticosterone in the range of stress-induced levels possesses reinforcing properties: Implications for sensation-seeking behaviors. Proceedings of the National Academy of Sciences, 90(24): 11738-11742.
Piazza PV, Maccari S, Deminiere JM, Le Moal M, Mormede P, Simon H. 1991. Corticosterone levels determine individual vulnerability to amphetamine self-administration. Proceedings of the National Academy of Sciences, 88(6): 2088-2092.
Piazza PV, Rouge-Pont F, Deroche V, Maccari S, Simon H, Le Moal M. 1996. Glucocorticoids have state-dependent stimulant effects on the mesencephalic dopaminergic transmission. Proceedings of the National Academy of Sciences, 93(16): 8716-8720.
Pilkonis PA, Frank E. 1988. Personality pathology in recurrent depression: Nature, prevalence, and relationship to treatment response. American Journal of Psychiatry, 145(4): 435-441.
Plutchik R. 1995. Outward and inward directed aggressiveness: The interaction between violence and suicidality. Pharmacopsychiatry, 28 (Suppl 2): 47-57.
Poldrugo F, Forti B. 1988. Personality disorders and alcoholism treatment outcome. Drug and Alcohol Dependence, 21(3): 171-176.
Pollock LR, Williams J, Mark G. 2001. Effective problem solving in suicide attempters depends on specific autobiographical recall. Suicide and Life-Threatening Behavior, 31(4): 386-396.
Porsteinsson A, Duberstein PR, Conwell Y, Cox C, Forbes N, Caine ED. 1997. Suicide and alcoholism. Distinguishing alcoholic patients with and without comorbid drug abuse. American Journal on Addictions, 6(4): 304-310.
Poussaint AF, Alexander A. 2000. Lay My Burden Down: Unraveling Suicide and the Mental Health Crisis Among African-Americans. Boston: Beacon Press.
Proulx F, Lesage AD, Grunberg F. 1997. One hundred in-patient suicides. British Journal of Psychiatry, 171: 247-250.
Qin P, Agerbo E, Westergard-Nielsen N, Eriksson T, Mortensen PB. 2000. Gender differences in risk factors for suicide in Denmark. British Journal of Psychiatry, 177: 546-550.
Radomsky ED, Haas GL, Mann JJ, Sweeney JA. 1999. Suicidal behavior in patients with schizophrenia and other psychotic disorders. American Journal of Psychiatry, 156(10): 1590-1595.
Range LM, Penton SR. 1994. Hope, hopelessness, and suicidality in college students. Psychological Reports, 75(1, Part 2): 456-458.
Regier DA, Farmer ME, Rae DS, Myers JK, Kramer M, Robins LN, George LK, Karno M, Locke BZ. 1993a. One-month prevalence of mental disorders in the United States and sociodemographic characteristics: The Epidemiologic Catchment Area study. Acta Psychiatrica Scandinavica, 88(1): 35-47.
Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. 1993b. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 50(2): 85-94.
Regier DA, Rae DS, Narrow WE, Kaelber CT, Schatzberg AF. 1998. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry, Suppl(34): 24-28.
Reich JH. 1988. DSM-III personality disorders and the outcome of treated panic disorder. American Journal of Psychiatry, 145(9): 1149-1152.
Rich CL, Fowler RC, Fogarty LA, Young D. 1988. San Diego Suicide Study. III. Relationships between diagnoses and stressors. Archives of General Psychiatry, 45(6): 589-592.
Rich CL, Runeson BS. 1992. Similarities in diagnostic comorbidity between suicide among young people in Sweden and the United States. Acta Psychiatrica Scandinavica, 86(5): 335-339.
Rich CL, Young D, Fowler RC. 1986. San Diego suicide study. I. Young vs old subjects. Archives of General Psychiatry, 43(6): 577-582.
Rifai AH, George CJ, Stack JA, Mann JJ, Reynolds CF 3rd. 1994. Hopelessness in suicide attempters after acute treatment of major depression in late life. American Journal of Psychiatry, 151(11): 1687-1690.
Rihmer Z, Barsi J, Arato M, Demeter E. 1990. Suicide in subtypes of primary major depression. Journal of Affective Disorders, 18(3): 221-225.
Robins E, Murphy GE, Wilkinson RHJr, Gassner S, Kayes J. 1959. Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. American Journal of Public Health, 49: 888-899.
Robins L, Regier DA. 1991. Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. New York: The Free Press.
Roizen J. 1982. Estimating alcohol involvement in serious events. In: National Institute on Alcohol Abuse and Alcoholism. Alcohol Consumption and Related Problems. Alcohol and Health Monograph No. 1. (pp. 179-219). Washington, DC: U.S. Government Printing Office. DHHS Pub. No. (ADM) 82-1190.
Rossau CD, Mortensen PB. 1997. Risk factors for suicide in patients with schizophrenia: nested case-control study. British Journal of Psychiatry, 171: 355-359.
Roy A. 1982. Suicide in chronic schizophrenia. British Journal of Psychiatry, 141: 171-177.
Roy A. 1990. Relationship between depression and suicidal behaviour in schizophrenia. In: Delisi LE, Editor. Depression and Schizophrenia. Washington, DC: American Psychiatric Press.
Roy A, Draper R. 1995. Suicide among psychiatric hospital in-patients. Psychological Medicine, 25(1): 199-202.
Roy A, Linnoila M. 1986. Alcoholism and suicide. Suicide and Life-Threatening Behavior, 16(2): 244-273.
Roy A, Mazonson A, Pickar D. 1984. Attempted suicide in chronic schizophrenia. British Journal of Psychiatry, 144: 303-306.
Roy-Byrne PP, Post RM, Hambrick DD, Leverich GS, Rosoff AS. 1988. Suicide and course of illness in major affective disorder. Journal of Affective Disorders, 15(1): 1-8.
Rudd MD, Ellis TE, Rajab MH, Wehrly T. 2000. Personality types and suicidal behavior: An exploratory study. Suicide and Life-Threatening Behavior, 30(3): 199-212.
Rutter M, Quinton D. 1984. Parental psychiatric disorder: Effects on children. Psychological Medicine, 14(4): 853-880.
Saarinen PI, Lehtonen J, Lönnqvist J. 1999. Suicide risk in schizophrenia: An analysis of 17 consecutive suicides. Schizophrenia Bulletin, 25(3): 533-542.
SAMHSA (Substance Abuse and Mental Health Services Administration). 1999. National Household Survey on Drug Abuse. [Online]. Available: http://www.samhsa.gov/oas/nhsda.htm [accessed December 20, 2001].
Sandberg S, McGuinness D, Hillary C, Rutter M. 1998. Independence of childhood life events and chronic adversities: A comparison of two patient groups and controls. Journal of the American Academy of Child and Adolescent Psychiatry, 37(7): 728-735.
Sandler IN, Tein J, West SG. 1994. Coping, stress, and the psychological symptoms of children of divorce: A cross-sectional and longitudinal study. Child Development, 65(6): 1744-1763.
Scheier MF, Carver CS. 1992. Effects of optimism on psychological and physical well-being: Theoretical overview and empirical update. Cognitive Therapy and Research, 16(2): 201-228.
Scheier MF, Weintraub JK, Carver CS. 1986. Coping with stress: Divergent strategies of optimists and pessimists. Journal of Personality and Social Psychology, 51(6): 1257-1264.
Schmidt NB, Woolaway-Bickel K, Bates M. 2000. Suicide and panic disorder: Integration of
the literature and new findings. In: Joiner TE, Rudd MD, Editors. Suicide Science: Expanding the Boundaries. (pp. 117-136). Norwell, MA: Kluwer Academic Publishers.
Schnyder U, Moergeli H, Klaghofer R, Buddeberg C. 2001. Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. American Journal of Psychiatry, 158(4): 594-599.
Seligman ME. 1975. Helplessness. San Francisco: Freeman.
Shaffer D. 1988. The epidemiology of teen suicide: An examination of risk factors. Journal of Clinical Psychiatry, 49 (Suppl): 36-41.
Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab-Stone ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, Regier DA. 1996. The NIMH Diagnostic Interview Schedule for Children version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of American Academy of Child and Adolescent Psychiatry, 35(7): 865-877.
Shafii M, Carrigan S, Whittinghill JR, Derrick A. 1985. Psychological autopsy of completed suicide in children and adolescents. American Journal of Psychiatry, 142(9): 1061-1064.
Shen Y, Zhang W, Wang Y, Zhang A, et al. 1992. Epidemiological survey on alcohol dependence in populations of four occupations in nine cities of China: I. Methodology and prevalence. [Chinese]. Chinese Mental Health Journal, 6(3): 112-115.
Shneidman ES. 1971. Perturbation and lethality as precursors of suicide in a gifted group. Life-Threatening Behavior, 1(1): 23-45.
Shneidman ES. 1984. Aphorisms of suicide and some implications for psychotherapy. American Journal of Psychotherapy, 38(3): 319-328.
Shneidman ES. 1992. What do suicides have in common? Summary of the psychological approach. In: Bongar BM, Editor. Suicide: Guidelines for Assessment, Management, and Treatment. (pp. 3-15). New York: Oxford University Press.
Shneidman ES. 1993. Suicide as psychache. Journal of Nervous and Mental Disease, 181: 147-149.
Sidley GL, Whitaker K, Calam RM, Wells A. 1997. The relationship between problem-solving and autobiographical memory in parasuicide patients. Behavioural and Cognitive Psychotherapy, 25(2): 195-202.
Simon GE, Von Korff M. 1998. Suicide mortality among patients treated for depression in an insured population . American Journal of Epidemiology, 147(2): 155-160.
Smith SM, Goodman RA, Thacker SB, Burton AH, Parsons JE, Hudson P. 1989. Alcohol and fatal injuries: Temporal patterns. American Journal of Preventive Medicine, 5(5): 296-302.
Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. 1994a. Risk factors for suicidal behavior in borderline personality disorder. American Journal of Psychiatry, 151(9): 1316-1323.
Soloff PH, Lis JA, Kelly T, Cornelius J, Ulrich R. 1994b. Self-mutilation and suicidal behavior in borderline personality disorder. Journal of Personality Disorders, 8(4): 257-267.
Stallone F, Dunner DL, Ahearn J, Fieve RR. 1980. Statistical predictions of suicide in depressives. Comprehensive Psychiatry, 21(5): 381-387.
Startup M, Heard H, Swales M, Jones B, Williams JMG, Jones RSP. 2001. Autobiographical memory and parasuicide in borderline personality disorder. British Journal of Clinical Psychology, 40(2): 113-120.
Stone M, Hurt S, Stone D. 1987. The PI 500: Long-term follow-up of Borderline inpatients meeting DSM-III criteria I. Global Outcome. Journal of Personality Disorders, 1: 291-298.
Strosahl K, Chiles JA, Linehan M. 1992. Prediction of suicide intent in hospitalized parasuicides: Reasons for living, hopelessness, and depression. Comprehensive Psychiatry, 33(6): 366-373.
Styron W. 1990. Darkness Visible: A Memoir of Madness. New York: Random House.
Suominen K, Henriksson M, Suokas J, Isometsa E, Ostamo A, Lönnqvist J. 1996. Mental disorders and comorbidity in attempted suicide. Acta Psychiatrica Scandinavica, 94(4): 234-240.
Swartz M, Blazer D, George L, Winfield I. 1990. Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 4(3): 257-272.
Sweeney PD, Anderson K, Bailey S. 1986. Attributional style in depression: A meta-analytic review. Journal of Personality and Social Psychology, 50(5): 974-991.
Tamerin JS, Mendelson JH. 1969. The psychodynamics of chronic inebriation: Observations of alcoholics during the process of drinking in an experimental group setting. American Journal of Psychiatry, 125(7): 886-899.
Taylor SE, Kemeny ME, Reed GM, Bower JE, Gruenewald TL. 2000. Psychological resources, positive illusions, and health. American Psychologist, 55(1): 99-109.
The Gallup Organization. 2001. Percent Who Drink Beverage Alcohol by Gender, 1939-1999. [Online]. Available: http://www.niaaa.nih.gov/databases/dkpat1.txt [accessed December 20, 2001].
Tsuang MT, Woolson RF, Fleming JA. 1980. Premature deaths in schizophrenia and affective disorders. An analysis of survival curves and variables affecting the shortened survival. Archives of General Psychiatry, 37(9): 979-983.
Turner RM. 1987. The effect of personality disorder diagnosis on the outcome of social anxiety symptom reduction. Journal of Personality Disorders, 1: 136-143.
Ucok A, Karaveli D, Kundakci T, Yazici O. 1998. Comorbidity of personality disorders with bipolar mood disorders. Comprehensive Psychiatry, 39(2): 72-74.
United Nations. 1996. Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies. New York: United Nations.
Vaillant GE. 1966. A twelve-year follow-up of New York narcotic addicts. I. The relation of treatment to outcome. American Journal of Psychiatry, 122(7): 727-737.
Vaillant GE, Blumenthal SJ. 1990. Introduction—Suicide over the life cycle: Risk factors and life-span development. In: Blumenthal SJ, Kupfer DJ, Editors. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. (pp. 1-14). Washington, DC: American Psychiatric Press.
van der Kolk BA. 1996. The body keeps score: Approaches to the psychobiology of post-traumatic stress disorder. In: van der Kolk BA, McFarlane AC, Weisaeth L, Editors. Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. (pp. 214-241). New York: Guilford Press.
van der Kolk BA, Perry JC, Herman JL. 1991. Childhood origins of self-destructive behavior. American Journal Psychiatry, 148(12): 1665-1671.
van Erp AM, Miczek KA. 2000. Aggressive behavior, increased accumbal dopamine, and decreased cortical serotonin in rats. Journal of Neuroscience, 20(24): 9320-9325.
Van Gastel A, Schotte C, Maes M. 1997. The prediction of suicidal intent in depressed patients. Acta Psychiatrica Scandinavica, 96(4): 254-259.
Verona E, Patrick CJ. 2000. Suicide risk in externalizing syndromes: Temperamental and neurobiological underpinnings. In: Joiner TE, Rudd DM, Editors. Suicide Science: Expanding the Boundaries. (pp. 137-173). Norwell, MA: Kluwer Academic Publishing.
Ward JA. 1984. Preventive implications of a Native Indian mental health program: Focus on suicide and violent death. Journal of Preventive Psychiatry, 2(4): 371-385.
Wasserman D, Varnik A. 2001. Perestroika in the former USSR: History’s most effective suicide-preventive programme for men. In: Wasserman D, Editor. Suicide: An Unnecessary Death. (pp. 253-257). London: Martin Dunitz Ltd.
Wasserman D, Varnik A, Dankowicz M. 1998. Regional differences in the distribution of suicide in the former Soviet Union during perestroika, 1984–1990. Acta Psychiatrica Scandinavica Supplement, 394: 5-12.
Wasserman IM. 1992. The impact of epidemic, war, prohibition and media on suicide: United States, 1910–1920. Suicide and Life-Threatening Behavior, 22(2): 240-254.
Weeke A. 1979. Causes of death in manic-depressives. In: Schou M, Strömgren E, Editors. Origin, Prevention and Treatment of Affective Disorders. (pp. 289-299). London: Academic Press.
Weishaar ME, Beck AT. 1990. Cognitive approaches to understanding and treating suicidal behavior. In: Blumenthal SJ, Kupfer DJ, Editors. Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. (pp. 469-498). Washington, DC: American Psychiatric Press.
Weiss RD, Hufford MR. 1999. Substance abuse and suicide. In: Jacobs DG, Editor. The Harvard Medical School Guide to Suicide Assessment and Intervention. (pp. 300-310). San Francisco: Jossey-Bass Publishers.
Weissman MM. 1993. The epidemiology of personality disorders: A 1990 update. Journal of Personality Disorders, Supplement, Spring: 44-62.
Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Oakley-Browne MA, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen HU, Yeh EK. 1997. The cross-national epidemiology of panic disorder. Archives of General Psychiatry, 54(4): 305-309.
Weissman MM, Klerman GL, Markowitz JS, Ouellette R. 1989. Suicidal ideation and suicide attempts in panic disorder and attacks. New England Journal of Medicine, 321(18): 1209-1214.
Weissman MM, Leaf PJ, Tischler GL, Blazer DG, Karno M, Bruce ML, Florio LP. 1988. Affective disorders in five United States communities. Psychological Medicine, 18(1): 141-153.
Welte JW, Abel EL, Wieczorek W. 1988. The role of alcohol in suicides in Erie County, NY, 1972–84. Public Health Reports, 103(6): 648-652.
Werner EE. 1995. Resilience in development. Current Directions in Psychological Science, 4(3): 81-85.
Werner EE. 1996. Vulnerable but invincible: High risk children from birth to adulthood. European Child and Adolescent Psychiatry, 5 (Suppl 1): 47-51.
Werner EE, Smith RS. Journeys from Childhood to Midlife: Risk, Resilience, and Recovery. 2001. Ithaca, NY: Cornell University Press.
Westermeyer JF, Harrow M, Marengo JT. 1991. Risk for suicide in schizophrenia and other psychotic and nonpsychotic disorders. Journal of Nervous and Mental Disease, 179(5): 259-266.
WHO (World Health Organization). 1999. Violence Prevention: An Important Element of a Health-Promoting School. WHO/SCHOOLS/98.3, WHO/HPR/HEP/98.2. Geneva: World Health Organization WHO Information Series on School Health.
Wiersma D, Nienhuis FJ, Slooff CJ, Giel R. 1998. Natural course of schizophrenic disorders: A 15-year followup of a Dutch incidence cohort. Schizophrenia Bulletin, 24(1): 75-85.
Winokur G, Tsuang M. 1975. The Iowa 500: Suicide in mania, depression, and schizophrenia. American Journal of Psychiatry, 132(6): 650-651.
Wyman PA, Sandler I, Wolchik S, Nelson K. 2000. Resilience as cumulative competence promotion and stress protection: Theory and intervention. In: Cicchetti D, Rappaport J, Sandler I, Weissberg RP, Editors. The Promotion of Wellness in Children and Adolescents. (pp. 133-184). Washington, DC: Child Welfare League of America.
Wyman PA, Cowen EL, Work WC, Kerley JH. 1993. The role of children’s future expectations in self-esteem functioning and adjustment to life stress: A prospective study of urban at-risk children. Development and Psychopathology, 5(4): 649-661.
Yang B, Clum GA. 2000. Childhood stress leads to later suicidality via its effect on cognitive functioning. Suicide and Life-Threatening Behavior, 30(3): 183-198.
Yufit RI, Bongar B. 1992. Suicide, stress, and coping with life cycle events. In: Maris RW, Berman AL, Editors. Assessment and Prediction of Suicide. New York: Guilford Press.
Zanarini MC, Frankenburg FR, Khera GS, Bleichmar J. 2001. Treatment histories of borderline inpatients. Comprehensive Psychiatry, 42(2): 144-150.
Zheng D, Macera CA, Croft JB, Giles WH, Davis D, Scott WK. 1997. Major depression and all-cause mortality among white adults in the United States. Annals of Epidemiology, 7(3): 213-218.
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.
Darkness Visible: A Memoir of Madness