Associations Between Reasons for Living and Diminished Suicide Intent Among African-American Female Suicide Attempters

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DOI: 10.1097/NMD.0000000000000170 · Source: PubMed
Abstract
African-American women are at high risk for suicide ideation and suicide attempts and use emergency psychiatric services at disproportionately high rates relative to men and other ethnic groups. However, suicide death rates are low for this population. Cultural variables in the African-American community may promote resilience and prevent fatal suicidal behavior among African-American women. The present study evaluated self-reported reasons for living as a protective factor against suicidal intent and suicide attempt lethality in a sample of African-American female suicide attempters (n = 150). Regression analyses revealed that reasons for living were negatively associated with suicidal intent, even after controlling for spiritual well-being and symptoms of depression. These results indicate that the ability to generate and contemplate reasons for valuing life may serve as a protective characteristic against life-threatening suicidal behavior among African-American women. Implications for research and clinical practice are further discussed.
Associations Between Reasons for Living and Diminished Suicide
Intent Among African-American Female Suicide Attempters
Kelci C. Flowers, MS,* Rheeda L. Walker, PhD,ÞMartie P. Thompson, PhD,þ
and Nadine J. Kaslow, PhD, ABPP§
Abstract: African-American women are at high risk for suicide ideation and
suicide attempts and use emergency psychiatric services at disproportionately
high rates relative to men and other ethnic groups. However, suicide death rates
are low for this population. Cultural variables in the African-American com-
munity may promote resilience and prevent fatal suicidal behavior among
African-American women. The present study evaluated self-reported reasons for
living as a protective factor against suicidal intent and suicide attempt lethality in
a sample of African-American female suicide attempters (n= 150). Regression
analyses revealed that reasons for living were negatively associated with suicidal
intent, even after controlling for spiritual well-being and symptoms of depres-
sion. These results indicate that the ability to generate and contemplate reasons
for valuing life may serve as a protective characteristic against life-threatening
suicidal behavior among African-American women. Implications for research
and clinical practice are further discussed.
Key Words: African-American, women, suicide, reasons for living
(J Nerv Ment Dis 2014;202: 569Y575)
In the United States, suicide is one of the leading causes of death,
accounting for 12.02 per 100,000 deaths annually (Centers for
Disease Control and Prevention [CDC], 2009). Suicide deaths occur
less frequently among African-American women, who account for only
1.87 per 100,000 deaths (CDC, 2009). However, African-American
women use emergency psychological and psychiatric services at sig-
nificantly higher rates than do men, as well as women from other ethnic
groups (Compton et al., 2005; Doshi et al., 2005; Meadows et al.,
2005). Recent reports also suggest that young African-American adult
women are at high risk for suicidal ideation (Richardson-Vejlgaard
et al., 2009) and suicide attempts (Baca-Garcia et al., 2010). Individuals
who attempt suicide are markedly more vulnerable to future suicide
attempts and/or deaths than are those without a history of suicide at-
tempts (Brown et al., 2000; Mann et al., 2005). The pattern of elevated
suicide vulnerability among African-American women, despite the rela-
tively low suicide death rate within this population, represents a paradox that
warrants further examination. Given that many researchers have previously
noted that cultural variables seemingly ‘‘protect’’ African-Americans from
suicide death (e.g., Early and Akers, 1993; Fitzpatrick et al., 2008; Griffin-
Fennell and Williams, 2006; Kaslow et al., 2004; Meadows et al., 2005;
Walker, 2007), we suggest that having reasons for living may be a protective
factor associated with suicide processes (i.e., intent and lethality) that ulti-
mately affects suicide outcomes among African-American women.
The ability to adaptively generate and consider reasons for
valuing life may potentially protect African-American women from
engaging in fatal suicidal behaviors. African-Americans report more
reasons for living than do European Americans, especially moral
objections and survival and coping beliefs (Bender, 2000; Morrison
and Downey, 2000; Richardson-Vejlgaard et al., 2009). The available
literature examining reasons for living among African-Americans
indicates that the ability to generate reasons for living is associated
with strong cultural values, racial identity, religiosity, and social support
(June et al., 2009; Street et al., 2012; Walker et al., 2010). Furthermore,
higher levels of optimism, spiritual well-being, and family social sup-
port predict reasons for living among suicidal African-American
women; spiritual well-being is a uniquely predictive variable in this
population (West et al., 2011).
The fact that self-generated reasons for living may promote re-
silience and are embedded in the cultural milieu in the African-
American community is particularly meaningful given the breadth of
scientific evidence that suggests that reasons for living reliably differ-
entiate suicidal and nonsuicidal individuals (e.g., Dervic et al., 2004;
Linehan et al., 1983; Lizardi et al., 2007; 2008; Malone et al., 2000;
Oquendo et al., 2004, 2007; Osman et al., 1999). Previous empirical
investigations have found that reasons for living are inversely related to
suicide risk, suicidal ideation, and suicidal behavior in nonclinical and
clinical samples (e.g., Dean and Range, 1999; Ellis and Jones, 1996;
Osman et al., 1993; Wang et al., 2007). Among psychiatric inpatients,
individuals without a history of suicide attempts report significantly
more reasons for living than do their counterparts who have attempted
suicide in the past, especially moral objections to suicide (Dervic et al.,
2004; Lizardi et al., 2008; Malone et al., 2000; Mann et al., 1999;
Osman et al., 1999). In addition, having more reasons for living de-
creases the risk of future suicidal behavior among female psychiatric
inpatients with major depressive disorder (Lizardi et al., 2007;
Oquendo et al., 2004, 2007).
The significance of these results is further amplified by evidence
that self-reported reasons for living may be associated with suicidal
intent and lethality. In a study of psychiatric inpatients, Kovacs and
Beck (1977) found that women who were more ambivalent toward life
versus death endorsed less suicidal intent after a suicide attempt than
did women with a unidirectional motivation to die. The available lit-
erature consistently emphasizes that individuals who contemplate sui-
cide often experience an ‘‘internal suicide debate,’’ whereby they
consider reasons for dying as well as reasons for living (e.g.,Brown
et al., 2005; Harris et al., 2010; Jobes and Mann, 1999; O’Connor et al.,
2012). As such, the results of Kovacs and Beck (1977) suggest that
vulnerable individuals may experience less suicidal intent if they are
able to generate and contemplate an abundance of reasons for living.
Similarly, other research indicates that reasons for living may be asso-
ciated with decreased medical lethality of suicide attempts, even after
controlling for religious affiliation, education level, hopelessness, and
anxiety (Jobes and Mann, 1999; Lizardi et al., 2009). Although all of
the known studies examining the relation between reasons for living
and suicidal behavior were conducted using entirely or predominantly
European American samples, these findings suggest that self-generated
reasons for living may be associated with nonfatal suicidal behavior
among African-Americans as well. Moreover, the capacity to generate
and effectively contemplate reasons to value one’s life may explain the
ORIGINAL ARTICLE
The Journal of Nervous and Mental Disease &Volume 202, Number 8, August 2014 www.jonmd.com 569
*Department of Psychology, The University of Georgia, Athens, GA; Department
of Psychology, The University of Houston, Houston, TX; Department of
Public Health Sciences, Clemson University, Clemson, SC; and §Department
of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA.
Send reprint requests to Rheeda L. Walker, PhD, The University of Houston, 126
Heyne Building, Houston, TX 77204-5502. E-mail: rlwo@uh.edu.
Copyright *2014 by Lippincott Williams & Wilkins
ISSN: 0022-3018/14/20208Y0569
DOI: 10.1097/NMD.0000000000000170
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
disproportionately low rate of suicide-related deaths among African-
American women, despite their continued risk for suicide attempts.
THE PRESENT STUDY
Accordingly, the present study examined the relations between
reasons for living and suicidal intent and suicide attempt lethality
among African-American women to highlight self-reported reasons for
living as a potential protective factor against continued suicidal be-
havior. Given the well-established association between suicidal behav-
ior and both spirituality/religiosity (Griffin-Fennell and Williams,
2006; Kaslow et al., 2006; Meadows et al., 2005) and symptoms of
depression (e.g., Harris and Barraclough, 1998, Joe et al., 2006;
Kaslowet al., 2004; 2006), the present study also sought to demonstrate
that the relations between reasons for living and both suicidal intent and
suicide attempt lethality exist above and beyond the effects of depres-
sive symptoms and spiritual well-being. We hypothesized that en-
dorsement of (1) more overall reasons for living would be associated
with less suicidal intent and lethality, (2) more dimensions of reasons
for living (Linehan et al., 1983; survival and coping, responsibility to
family, child-related concerns, fear of suicide, fear of social disap-
proval, and moral objectives) would be associated with less suicidal
intent and lethality, and (3) more overall reasons for living would be
associated with less suicidal intent and lethality, even after controlling
for spiritual well-being and depressive symptoms.
METHODS
Participants and Procedure
Participants were African-American women (n= 150) between
the ages of 18 and 61 years (mean [SD], 35.87 [11.04] years) who were
recruited for a larger study (see West et al., 2011) examining the ef-
fectiveness of a 10-week suicide intervention program at a large,
university- affiliated southern hospital. Accordingly, the present study
represents a secondary data analysis project. All participants had
attempted suicide within the previous year and were recruited after
presenting to either the hospital emergency department after a nonfatal
suicide attempt or an affiliated walk-in clinic for nonemergency ser-
vices. The principal investigator (PI) of the larger study or her designee
was available by pager at all times to ensure that she could be notified
immediately about any African-American woman who presented to the
hospital emergency department after a nonfatal suicide attempt. After
the PI determined if the woman’s behavior met criteria for a suicide
attempt (i.e., self-injurious act that required medical attention or in
which there was serious intent), a research team member recruited her
for participation in the study and interviewed her within 24 hours of
becoming medically stable. Exclusionary criteria were (1) diagnosis of
a life-threatening medical condition, (2) significant cognitive impair-
ment as indicated by scores 24 or lower of 30 on the Mini-Mental State
Exam (Folstein et al., 2001), and (3) presentation of acute psychosis.
Signed informed consent was obtained before participation in the study
and all measures were administered orally.
Measures
Demographics
The participants were asked comprehensive demographic ques-
tions including their age, relationship status, highest level of education,
and employment status.
Reasons for Living
To assess adaptive characteristics that might be diminished in
individuals who contemplate suicide, the Reasons for Living Inventory
(RFL; Linehan et al., 1983) was used. The RFL is a 48-item ques-
tionnaire with six subscales to assess six components of this construct:
positive expectancies about the ability to cope with the future (Survival
and Coping Beliefs), responsibility to family (Responsibility to Family),
concerns about children (Child-Related Concerns), fear of killing oneself
(Fear of Suicide), perceptions of social condemnation (Fear of Social
Disapproval), and personal, religious, and spiritual beliefs that discourage
and oppose suicidal acts (Moral Objections). All item responses are on a
6-point Likert scale ranging from 1 (extremely unimportant) to 6 (ex-
tremely important). Total scores can range from 48 to 288, with higher
scores indicating more reasons for living. This measure has moderately
high internal consistency reliability (alpha values range from 0.72 to
0.95) and construct, criterion, and predictive validity (rvalues range from
j0.16 to j0.76; Linehan et al., 1983; Osman et al., 1999) with pre-
dominantly European American samples of college undergraduates and
psychiatric inpatients. High internal consistency reliability of this mea-
sure has been demonstrated with African-American college students (>=
0.95; Walker et al., 2010) and older African-American adults (>=0.81;
June et al., 2009); however, studies that include clinical or community
samples of African-American women have not reported reliability esti-
mates. Cronbach’s alpha for the present study was 0.97.
Suicidal Intent
The Suicide Intent Scale (SIS; Beck et al., 1974) was used to
measure the intensity of participants’ wishes to die at the time of their
suicide attempt. The SIS uses 20 items to obtain information regarding
the circumstances related to the suicide attempt, the individual’s
thoughts and feelings at the time of the attempt, expectations regarding
the fatality of the suicidal act, and ambivalence toward living. Re-
spondents are asked to select one of three statements that most accu-
rately describes the intensity of their wish to die at the time of their
suicide attempt, where statements range from 0, indicating the absence
of suicide intent, to 2, indicating the presence of suicide intent. Total
scores can range from 0 to 30, with higher scores indicating more
suicide intent. Although additional unscored items are available to as-
sess current feelings about the attempt, previous number of suicide at-
tempts, and substance use at the time of the suicide attempt, those items
were not included in the current analyses. This measure has high in-
ternal consistency (alpha values range from 0.81 to 0.82) with samples
of European Americans (Beck et al., 1974) and African-Americans
(Kaslow et al., 2006) and moderate concurrent validity (rvalues
range from 0.26 to 0.69) with measures of depression, hopelessness,
and pessimism administered to primarily European American psychi-
atric inpatients (Beck et al., 1974). Internal consistency reliability for
the present study was adequate (>= 0.61).
Suicide Attempt Lethality
Lethality of suicide attempts was assessed via the Lethality
Scales (LS; Beck et al., 1975). This measure characterizes the degree of
medical injury resulting from a suicide attempt using eight separate
interviewer-administered scales that range from 0 (fully conscious and
alert) to 8 (death). Scales are labeled according to the method of suicide
attempt and include the following means: drug with sedative effects,
drug without sedative effects, shooting, immolation, drowning, cutting,
jumping, and hanging. Lethality ratings were assigned by trained in-
terviewers based on a thorough medical chart review and examination
of participants’ condition at the time of hospital admission. In accor-
dance with the available literature (Beck et al., 1975; Oquendo et al.,
2003; Zalsman et al., 2006), LS scores in the present study were used to
categorize suicide attempts as low-lethality attempts (LS score G4)
or high-lethality attempts (LS score Q4). An LS score of 4 or greater
is indicative of physical injury requiring immediate medical treatment
and, as a result, represents the threshold at which medical hospitalization
is necessary (Beck et al., 1975). For all analyses, the LS score for each
participant’s most medically severe suicide attempt across methods was
used. This measure has good interrater reliability (e.g.,r= 0.80; Lester
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and Beck; 1975). For the present study, lethality ratings for each partic-
ipant were determined by a single trained interviewer, and as a result,
reliability estimates are not available.
Depressive Symptoms
To assess depressive symptoms, the Beck Depression Inventory-
II (BDI-II; Beck et al., 1996) was administered. The BDI-II is a 21-item
questionnaire that measures symptoms of depression via statements
that are consistent with the Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition Text Revision (American Psychiatric
Association, 2000) diagnostic criteria for a major depressive episode.
Respondents are asked to select one of four statements that most ac-
curately describe their thoughts, emotions, and behaviors, where
statements range from 0, indicating absence of the symptom, to 3, in-
dicating presence of the symptom. Total possiblescores range from 0 to
63, such that higher scores are indicative of greater depressive symp-
toms. This assessment has excellent internal consistency (alpha values
range from 0.91 to 0.94) and adequate convergent and discriminant
validity (rvalues range from 0.66 to 0.93) with predominantly Euro-
pean American samples (Beck et al., 1996; Dozois et al., 1998), as well
as African-American samples (Joe et al., 2008). Cronbach’s alpha for
the present study was 0.93.
Spirituality
The Spiritual Well-Being Scale (SWBS; Ellison, 1983) was
used to assess spirituality. It is composed of two subscalesVreligious
well-being (RWB) and existential well-being (EWB); each subscale
consists of 10 items. The RWB subscale contains all items that spe-
cifically reference God, and the remaining items constitute the EWB
subscale. All item responses use a 6-point scale ranging from 1
(strongly disagree) to 6 (strongly agree), where total scores can range
from 20 to 120 and higher scores indicate more spirituality. This mea-
sure has excellent test-retest (rvalues range from 0.89 to 0.94) and
internal consistency (alpha values range from 0.92 to 0.93) reliability
with European American (Ellison, 1983) and African-American
(Brome et al., 2000; Kaslow et al., 2004) samples, as well as good
convergent validity with measures of similar constructs (rvalues range
from 0.83 to 0.91; Bufford et al., 1991; Ellison, 1983). Cronbachs al-
pha for the present study was 0.90.
RESULTS
As seen in Table 1, almost half of the women in the present
sample were single (n= 65, 43.3%). Most reported being homeless
(n= 77, 51.3%), being unemployed (n= 129, 86%), having three or
more children (n= 63, 52.5%), and having earned a 12th grade education/
general educational development diploma or less (n=113,76.4%).
Many also indicated that they had no health insurance (n= 88, 58.7%)
and a history of legal issues and incarceration (n= 86, 57.3%). More
than half also acknowledged being prescribed psychotropic medica-
tions, having a history of psychological or psychiatric treatment, having
a previous mental health diagnosis of depression, and having a history
of psychiatric hospitalizations.
The most common method of suicide attempt was ingesting
drugs with sedative effects, followed by ingesting drugs without seda-
tive effects and cutting (Table 2). Across all methods, more than two
thirds of suicide attempts (86.3%) were low-lethality attempts. In ad-
dition, more than half of participants (52.2%) were ‘‘fully conscious
and alert’’ or ‘‘conscious and sleepy’’ after the suicide attempt.
Reasons for Living and Suicidal Intent and Lethality
To test the hypothesis that more reasons for living would be
associated with less suicidal intent and lethality, simple linear regres-
sion and binary logistic regression analyses were conducted respec-
tively. These analyses revealed that RFL total scores predicted SIS
scores [F(1, 143) = 13.52, pG0.001], such that more reasons for living
were associated with less suicidal intent. However, RFL total scores
were not associated with LS scores [W
2
(1) = 0.04, p= 0.85].
To test the hypothesis that more endorsement of beliefs associ-
ated with dimensions of reasons for living would be associated with
less suicidal intent and lethality, bivariate correlations and multiple re-
gression models were evaluated. Bivariate correlations revealed that
SIS scores were significantly correlated with all of the RFL subscale
scores, such that more suicide intent was associated with less survival
and coping beliefs, less responsibility to family, fewer child-related
concerns, less fear of suicide, less fear of social disapproval, and fewer
moral objections (Table 3). Although the overall multiple linear regres-
sion model predicting suicide intent was also significant [F(6, 138) =
2.78, pG0.05], among the RFL subscales, only the regression coefficient
for Survival and Coping Beliefs was significant (A=j0.33, p=0.05)
TABLE 1. Psychiatric/Psychological History
Demographic Variable n%
History of psychological/psychiatric treatment 102 68.0
History of psychiatric hospitalization 81 55.1
Diagnosis of schizophrenia 27 18.0
Diagnosis of depression 86 57.3
Diagnosis of bipolar disorder 54 36.0
Diagnosis of anxiety disorder 35 23.3
Diagnosis of a personality disorder 9 6.0
Current medications: antipsychotic 62 41.3
Current medications: anticholinergics 12 8.0
Current medications: antidepressants 79 52.7
Current medications: mood stabilizers 11 7.3
Current medications: antianxiety 18 12.0
TABLE 2. Suicide Attempt Lethality by Method
Method n% Conscious % Low Lethality Mean (SD)
Drug with sedative effects 81 48.1 82.7 1.93 (1.65)
Drug without sedative effects 30 73.3 80.0 1.03 (1.87)
Shooting 1 100.0 100.0 0.00 (0.00)
Immolation 3 100.0 100.0 0.00 (0.00)
Drowning 1 100.0 100.0 0.00 (0.00)
Cutting 22 63.6 100.0 0.82 (1.14)
Jumping 7 71.4 85.7 1.57 (3.36)
Hanging 6 66.7 83.3 1.50 (2.01)
Scores on the LS are as follows: 0 = fully conscious/alert, 1 = conscious/sleepy, 2 = lethargic, 3 = asleep/easily aroused, 4 = coma/intact reflux, 5 = coma/no pain withdrawal, 6 = coma/no
reflex, 7 = coma/all reflexes absent, 8 = death.
The Journal of Nervous and Mental Disease &Volume 202, Number 8, August 2014 Reasons for Living and Suicide
*2014 Lippincott Williams & Wilkins www.jonmd.com 571
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(Table 4). With respect to suicide lethality, the results of point-biserial
correlations were not indicative of a significant relationship between
LS scores and any of the RFL subscale scores. Furthermore, neither the
overall multiple logistic regression model nor the beta weights for the
RFL subscales predicting LS scores [W
2
(6) = 1.90, p= 0.93] were sta-
tistically significant (Table 5).
To test the final hypothesis that more reasons for living would
be associated with less suicidal intent and lethality, even after con-
trolling for spiritual well-being and depressive symptoms, hierarchi-
cal regression analyses were conducted. As expected, the hierarchical
linear regression model predicting SIS scores was signif icant, such
that reasons for living predicted suicide intent above and beyond
spiritual well-being and symptoms of depression [F(3, 77) = 3.63,
pG0.05] (Table 6). However, the hierarchical logistic regression
model predicting lethality of suicide attempts was not statistically
significant [W
2
(3) = 5.48, p= 0.14] (Table 7).
DISCUSSION
The purpose of this study was to examine whether self-reported
reasons for living might be associated with diminished suicidal intent
and lethality among African-American female suicide attempters. The
current sample represented an economically marginalized and disad-
vantaged subgroup of African-American womenVwomen who use
emergency psychological and psychiatric services in the United States
at disproportionately high rates (e.g., Compton et al., 2005; Meadows
et al., 2005). The range of lethality of suicide attempts was limited. For
all methods, more than two thirds of suicide attempts were low-lethality
attempts. Furthermore, more than half of the sample presented to
the emergency department or psychiatric emergency services fully
conscious and alert or conscious and sleepy; less than 12% were in a
coma. This pattern of lethality is consistent with the available research
that suggests that low-lethality ratings are common among samples of
female suicide attempters of various ethnic backgrounds (e.g., Denning
et al., 2000; Kanchan et al., 2009; Rich et al., 1988).
Overall, the proposed hypotheses were partially supported. As
expected, self-reported reasons for living were associated with lower
levels of suicidal intent. However, contrary to prediction, reasons for
living were not significantly associated with lethality of suicide at-
tempts. The absence of a significant relation between reasons for living
and suicide lethality is especially surprising given that the capacity to
generate reasons for living is associated with fewer and less lethal
suicide attempts in predominately European American samples
(Lizardi et al., 2008, 2009). Nevertheless, it is possible that this lack of
finding may be attributed to limited variability in suicide attempt le-
thality in the current sample, with most of the women having attempts
that were very low in lethality.
Among the subscales of the RFL, endorsement of beliefs asso-
ciated with all of the dimensions of reasons for living was associated
with lower levels of suicidal intent at the bivariate level. However, only
survival and coping beliefs remained a significant predictor in the
multivariate model. These results are consistent with past findings that
individuals who report more dimensions of reasons for living across
also endorse less suicidal intent than do those who report fewer reasons
for living (Malone et al., 2000; Richardson-Vejlgaard et al., 2009).
These findings indicate that survival and coping beliefs may be the
most relevant dimension of reasons for living for mental health care
professionals to reinforce among African-American women to decrease
the likelihood of continued suicidal behavior, as well suicide-related
deaths. These findings also suggest that outpatient mental health care
providers should consider taking the steps necessary to strengthen
TABLE 3. Correlations and Reliability Estimates (Presented on the Diagonal) for Scales
Scale 1 2 3 45678910
1 (0.94)
2 0.82*** (0.83)
3 0.69*** 0.75*** (0.61)
4 0.76*** 0.78*** 0.75*** (0.83)
5 0.80*** 0.76*** 0.75*** 0.79*** (0.78)
6 0.70*** 0.72*** 0.63*** 0.75*** 0.67*** (0.79)
7 0.96*** 0.90*** 0.80*** 0.88*** 0.87*** 0.81*** (0.96)
8j0.42*** j0.34*** j0.28** j0.29*** j0.42*** j0.23** j0.39*** (0.93)
9j0.53*** j0.50*** j0.56*** j0.47*** j0.54*** j0.31** j0.56*** 0.48*** (0.90)
10 j0.31*** j0.27** j0.25** j0.21* j0.21* j0.22** j0.29*** 0.09 0.25* (0.62)
1 = RFLYSurvival and Coping Beliefs; 2 = RFLYResponsibility to Family; 3 = RFLYChild-Related Concerns; 4 = RFLYFear of Suicide; 5 = RFLYFear of Social Disapproval; 6 =
RFLYMoral Objections; 7 = RFLYTotal; 8 = BDI-II; 9 = SWBS; 10 = SIS.
*pG0.05.
** pG0.01.
*** pG0.001.
TABLE 4. Linear Regression Predicting Suicide Intent as a Function of Dimensions of Reasons for Living
Predictor BSE BAtp
Survival and coping beliefs j1.28 0.64 j0.33 j2.01 0.05
Responsibility to family j0.28 0.57 j0.08 j0.50 0.62
Child related concerns j0.47 0.46 j0.14 j1.02 0.31
Moral objections 0.33 0.58 j0.02 0.57 0.57
Fear of suicide 0.51 0.51 0.09 1.00 0.31
Fear of social disapproval j0.06 0.40 0.16 j0.14 0.89
R
2
= 0.12; F(6, 138) = 2.78, pG0.05.
Flowers et al. The Journal of Nervous and Mental Disease &Volume 202, Number 8, August 2014
572 www.jonmd.com *2014 Lippincott Williams & Wilkins
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suicidal African-American women’s positive expectancies about their
ability to cope with future events as a means of preventing suicide
attempts.
Finally, the results indicate that reasons for living are associated
with suicidal intent above and beyond spiritual well-being and symp-
toms of depression, both of which have been previously demonstrated
as key factors in determining suicide risk (e.g., Griffin-Fennell and
Williams, 2006; Joe et al., 2006; Kaslow et al., 2004; 2006; Meadows et
al., 2005). This finding suggests that the capacity to generate and
contemplate adaptive reasons for valuing life may protect African-
American women from experiencing moderate to high levels of sui-
cidal intent, even more so than spirituality and religiosity do. Further-
more, reasons for living may serve as a valuable protective factor
against suicidal behavior, even in individuals who are depressed.
There were several limitations associated with the current study
that should be taken into account when considering the findings. First,
given that medical stabilization was required for all participants before
being enrolled in the study, there may be notable variations in the
amount of time that has elapsed between participants’ actual suicide
attempts and completion of the research study materials. Future studies
should document and control for this possible confound. Second, the
low degree of lethality of suicide attempts and subsequent low vari-
ability of lethality among participants may have limited the capacity to
find any significant relation between lethality and both reasons for
living and suicide intent. For all suicide attempt methods, over half of
the sample presented to the hospital fully conscious and alert or con-
scious and sleepy, and less than 12% were in a coma. This finding,
however, is consistent with the available literature (Denning et al.,
2000; Kanchan et al., 2009; Rich et al., 1988), which indicates that low
lethality ratings are common among female suicide attempters. Third,
the results of the current study may have restricted generalizability.
Although this sample is representative of the African-American women
who frequently and disproportionately use emergency psychological
and psychiatric services in the United States, it may not accurately
characterize all African-American women. For instance, given that the
sample included only suicide attempters who came to the attention of
medical professionals, it does not include women whose injuries were
not recognized as suicide attempts or those who did not seek medical
attention. Furthermore, because all data were collected at one time
point, causality and the temporal relation for reasons of living and
suicidality could not be assessed and might be addressed in future
studies via longitudinal methodology. Future studies should also ex-
amine a more diverse sample of African-American women, as well as
women from other racial/ethnic backgrounds. Given the increasingly
heterogeneous black US population that includes black Caribbean and
other African immigrants, cross-cultural studies that assess reasons for
living and suicide behavior in the context of immigration and accul-
turation status are warranted.
CONCLUSIONS
In summary, the results of the current study demonstrate that
reasons for living may serve as a culturally relevant protective factor
against suicidal intent among African-American women who attempt
suicide. These findings highlight the need for more research to be
conducted with this population to better understand the use of reasons
for living as a potential buffer against suicidal ideation and behavior
and fatal suicide attempts among African-American women, as well as
other vulnerable populations that may be reticent to disclose suicidal
urges. These findings also illuminate the need for researchers to both
develop interventions for suicidal behavior that focus on strengthening
reasons for living and conduct randomized controlled trials to evaluate
the effectiveness of these interventions for decreasing nonfatal and fatal
TABLE 5. Logistic Regression Predicting Lethality of Suicide Attempt
Predictor BSE BWald pe
B
Survival and coping beliefs 0.06 0.41 0.02 0.89 1.06
Responsibility to family 0.08 0.37 0.05 0.83 1.08
Child-related concerns j0.02 0.30 0.01 0.94 0.98
Fear of suicide j0.41 0.40 1.08 0.30 0.66
Fear of social disapproval 0.32 0.34 0.91 0.34 1.38
Moral objections j0.02 0.26 0.01 0.94 0.98
Test W
2
df p % Correctly Classified
Overall model evaluation 1.90 6 0.93 86.10
LS score is coded as 1 for high lethality and 0 for low lethality. W
2
(6) = 1.90, p= 0.93.
TABLE 6. Hierarchical Linear Regression Predicting Suicide Intent as a Function of Reasons for Living
Predictor $R
2
df F SE At
Step 1 0.06
a
2, 78 2.39
a
Depression 0.04 0.03 0.27
Spiritual well-being 0.03 0.22* 1.78*
Step 2 0.07* 3, 77 3.63*
Depression 0.04 j0.04 j0.29
Spiritual well-being 0.04 0.07 0.53
Total reasons for living 0.53 j0.32** j2.41**
F(3, 77) = 3.63, pG0.05.
*pG0.10.
** pG0.05.
The Journal of Nervous and Mental Disease &Volume 202, Number 8, August 2014 Reasons for Living and Suicide
*2014 Lippincott Williams & Wilkins www.jonmd.com 573
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suicide attempts among vulnerable individuals. Furthermore, future
research should seek to examine and further understand the etiology
of and expand the available literature on suicidal behavioral within
underrepresented ethnic groups including subgroups of black
Americans. Advancing this research is important for addressing the
public health burden of suicide attempts and deaths worldwide and
improving health care providers’ ability to predict suicidal behavior
and prevent unnecessary deaths.
DISCLOSURES
This research was supported by a grant from the Centers for
Disease Control and Prevention National Center for Injury Prevention
and Control (R49 CCR421767-01) entitled Group interventions with
suicidal African-American women awarded to Nadine Kaslow, PhD,
ABPP. The funding sources had no role in study design; in the collec-
tion, analysis, and interpretation of data; in the writing of the report; or
in the decision to submit the paper for publication. The authors declare
no conflict of interest.
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    • "One way reasons for living may impact impulsive suicidal urges is by increasing positive expectations for the future (decreased hopelessness) (see [39]) which may in turn decrease levels of impulsivity [39]. Moreover, previous research has noted that African Americans who report higher levels of reasons for living also report greater levels of social support, and stronger ties to cultural values and racial identity40414243. Therefore, reasons for living may serve as a culturally salient buffer against suicidality among African Americans. "
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