Lifestyle Interventions and Prevention of Suicide

Abstract

Over the past years, there has been a growing interest in the association between lifestyle psychosocial interventions, severe mental illness, and suicide risk. Patients with severe mental disorders have higher mortality rates, poor health states, and higher suicide risk compared to the general population. Lifestyle behaviors are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. The current article provides a comprehensive review of the literature on lifestyle interventions, mental health, and suicide risk in the general population and in patients with psychiatric disorders. For this purpose, we investigated lifestyle behaviors and lifestyle interventions in three different age groups: adolescents, young adults, and the elderly. Several lifestyle behaviors including cigarette smoking, alcohol use, and sedentary lifestyle are associated with suicide risk in all age groups. In adolescents, growing attention has emerged on the association between suicide risk and internet addiction, cyberbullying and scholastic and family difficulties. In adults, psychiatric symptoms, substance and alcohol abuse, weight, and occupational difficulties seems to have a significant role in suicide risk. Finally, in the elderly, the presence of an organic disease and poor social support are associated with an increased risk of suicide attempt. Several factors may explain the association between lifestyle behaviors and suicide. First, many studies have reported that some lifestyle behaviors and its consequences (sedentary lifestyle, cigarette smoking underweight, obesity) are associated with cardiometabolic risk factors and with poor mental health. Second, several lifestyle behaviors may encourage social isolation, limiting the development of social networks, and remove individuals from social interactions; increasing their risk of mental health problems and suicide.

Full text

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published: 06 November 2018
doi: 10.3389/fpsyt.2018.00567
Frontiers in Psychiatry | www.frontiersin.org 1November 2018 | Volume 9 | Article 567
Edited by:
Michael Noll-Hussong,
Universitätsklinikum des Saarlandes,
Germany
Reviewed by:
Giuseppe Carrà,
Università degli Studi di Milano
Bicocca, Italy
Serdar M. Dursun,
University of Alberta, Canada
Luigi Janiri,
Università Cattolica del Sacro Cuore,
Italy
*Correspondence:
Maurizio Pompili
maurizio.pompili@uniroma1.it
Specialty section:
This article was submitted to
Psychosomatic Medicine,
a section of the journal
Frontiers in Psychiatry
Received: 23 July 2018
Accepted: 18 October 2018
Published: 06 November 2018
Citation:
Berardelli I, Corigliano V, Hawkins M,
Comparelli A, Erbuto D and Pompili M
(2018) Lifestyle Interventions and
Prevention of Suicide.
Front. Psychiatry 9:567.
doi: 10.3389/fpsyt.2018.00567
Lifestyle Interventions and
Prevention of Suicide
Isabella Berardelli 1, Valentina Corigliano 1, Michael Hawkins 2, Anna Comparelli 1,
Denise Erbuto 1and Maurizio Pompili 1
*
1Department of Neurosciences, Mental Health and Sensory Organs, Suicide Prevention Center, Sant’Andrea Hospital,
Sapienza University of Rome, Rome, Italy, 2Department of Psychiatry, University of Toronto, Toronto, ON, Canada
Over the past years, there has been a growing interest in the association between lifestyle
psychosocial interventions, severe mental illness, and suicide risk. Patients with severe
mental disorders have higher mortality rates, poor health states, and higher suicide risk
compared to the general population. Lifestyle behaviors are amenable to change through
the adoption of specific psychosocial interventions, and several approaches have been
promoted. The current article provides a comprehensive review of the literature on lifestyle
interventions, mental health, and suicide risk in the general population and in patients
with psychiatric disorders. For this purpose, we investigated lifestyle behaviors and
lifestyle interventions in three different age groups: adolescents, young adults, and the
elderly. Several lifestyle behaviors including cigarette smoking, alcohol use, and sedentary
lifestyle are associated with suicide risk in all age groups. In adolescents, growing
attention has emerged on the association between suicide risk and internet addiction,
cyberbullying and scholastic and family difficulties. In adults, psychiatric symptoms,
substance and alcohol abuse, weight, and occupational difficulties seems to have a
significant role in suicide risk. Finally, in the elderly, the presence of an organic disease
and poor social support are associated with an increased risk of suicide attempt. Several
factors may explain the association between lifestyle behaviors and suicide. First, many
studies have reported that some lifestyle behaviors and its consequences (sedentary
lifestyle, cigarette smoking underweight, obesity) are associated with cardiometabolic risk
factors and with poor mental health. Second, several lifestyle behaviors may encourage
social isolation, limiting the development of social networks, and remove individuals from
social interactions; increasing their risk of mental health problems and suicide.
Keywords: suicide, suicide attempts, suicidal thoughts, lifestyle behavior, lifestyle intervention, suicide prevention
INTRODUCTION
Several well-established psychosocial factors and lifestyle behaviors including life satisfaction,
economic adversities, family environment, major life and occupational stressor(s), substance and
alcohol abuse, medical conditions, cigarette smoking, being sedentary, underweight or obese,
and diet are considered prominent factors in the development of severe mental disorders and
suicide risk. Psychiatric patients, including patients affected by schizophrenia, bipolar disorder,
schizoaffective disorder and depressive disorder, have higher mortality rates and higher suicide
risk compared to the general population (1,2). Increased mortality is probably also due, besides
psychiatric impairment and psychotropic medication use, to unhealthy lifestyle behaviors including

Berardelli et al. Lifestyle and Suicide
poor diet, excessive smoking, alcohol use, and lack of exercise.
These unhealthy lifestyle behaviors can increase the development
of many physical diseases including overweight, obesity,
metabolic syndrome, diabetes, cardiovascular disease,
cerebrovascular disease, hepatitis, amongst other medical
conditions (3,4).
Suicide has been described as a multi-faceted construct
in relation to psychiatric symptoms, medical conditions, and
lifestyle risk factors (5–7). Moreover, lifestyle behaviors are
involved in the pathogenesis of medical and severe psychiatric
disorders such as depression and psychosis (8,9), increasing the
risk of suicide (10).
Recently, considerable attention has been paid to the
concept of life satisfaction and well-being as psychosocial
indicators of mental health (11). It has been hypothesized
(12,13) that life satisfaction and meaning in life can help
people overcome adversity. Factors associated with optimal
well-being and life satisfaction included prudent lifestyle
behaviors such as healthy eating, adequate sleep, physical
activity, avoiding tobacco, and limiting alcohol consumption
(14). Few studies have revealed that suicide ideation is related
to psychiatric symptomatology, lifestyle behavior, and lower
life satisfaction (15,16). Koivumaa-Honkanen et al. (17) in
a study of 29,067 Finnish adults found that unhappiness
was associated with an increased risk of suicide. This group
also reported that unhappiness was associated with older age,
male gender, sickness, living alone, smoking, heavy alcohol
consumption, physical inactivity, and belonging to intermediate
social class.
In the past few decades, a lot of progress has been made
to identify public health strategies for the prevention of mental
health and suicide. Although the approach to suicide has always
involved clinical aspects, especially the assessment and the
treatment of depression (18), it seems necessary to consider also
risk factors that can be identified and modified through specific
lifestyle interventions.
Based on data demonstrating how lifestyle behaviors may be
involved in both the genesis of severe psychiatric disorders and
in increasing suicide risk (19), we aimed to provide a narrative
review synthetizing existing published literature on lifestyle
interventions and suicide prevention in psychiatric patients
behavior. Additionally, we provide a review of the literature on
lifestyle interventions promoting mental health reducing suicide
risk in the general population and in patients with psychiatric
disorders.
Lifestyle behaviors and interventions may differ at different
life stages of life. Given this, we reviewed lifestyle behaviors and
interventions associated with suicide risk in three age group
categories: adolescents and young people (age 16–30), young
adults and adults (age 30–65), and older adults and elderly (age
>65).
MATERIALS AND METHODS
We searched the relevant databases including MEDLINE, ISI
Web of Knowledge – Web of Science Index, Cochrane Reviews
Library and PsychoINFO for papers published from January 2000
to March 2018.
The following keywords were used: “lifestyle intervention,”
“life satisfaction”, “diet,” “physical activity,” “nutrition,”
“cholesterol,” “diabetes,” “lifestyle behaviors,” “cigarette
smoke” matched with “suicide risk,” “healthy population,”
“mental disorders,” “schizophrenia,” “psychotic disorders,”
“bipolar disorder,” “depression,” “adolescents,” “adults,” and
“elderly.” Inclusion criteria were: studies adopting psychosocial
interventions for promoting changes in lifestyle behaviors,
studies aiming to improve patients’ physical status (evaluated
in terms of body mass index – BMI, level of physical activity,
smoking status, etc.) and studies that assess the association
between lifestyle behaviors and psychiatric disorders and suicide
risk. Only papers written in English were included. Studies
included in this narrative review were those that examined
suicide and lifestyle interventions in adolescence, young adults
or adults and the elderly. Studies in which the age group
investigated was not clearly defined were excluded from this
review.
Randomized controlled trials, clinical controlled trials, pilot
studies, cohort studies and reviews were considered eligible for
the review process. In addition, the reference lists of all included
studies and of relevant existing systematic reviews were checked
for possible studies. Papers were screened by an independent
researcher (IB) and assessed for eligibility by a senior expert
(MP).
LIFESTYLE BEHAVIOR AND SUICIDE IN
ADOLESCENTS AND YOUNG PEOPLE
Suicidal ideation and suicide attempt are relatively common in
this phase of life; with completed suicide being the second most
common cause of death in adolescents (20).
It has been described that 10–20% of adolescents suffer
from a mental disorder (21). Adolescence is often associated
with elevated levels of anxiety, stress, and adverse life events,
which may lead to maladaptive feelings of hopelessness, personal
failure, and suicidal ideation (22). While positive coping
strategies, efficacious problem-solving skills, and general life
satisfaction are considered protective for suicide (23). Common
severe psychiatric disorders in adolescents include depression,
anxiety disorders, behavioral problems (e.g., oppositional defiant
disorder or conduct disorder), early psychosis, eating disorders
(e.g., anorexia nervosa and bulimia nervosa) and addictive
disorders (24), all risk factors for suicidal behavior in adolescents
(25,26).
Unhealthy lifestyle behaviors may impact mental health
and suicidal behavior by influencing emotions and judgement.
Studies have demonstrated that adolescents with first-episode
psychosis have a high prevalence of tobacco, alcohol and cannabis
use, selective dietary habits, lower physical activity, and lower
level of activity during leisure time (27–30). Other studies
have demonstrated a close relationship between cannabis use,
hypomania, mania, and suicide risk in adolescents (31,32).
Furthermore, a relationship between weight, social relations, and
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Berardelli et al. Lifestyle and Suicide
depressive symptoms has been described (33); stressing the link
between lifestyle behavior, mental health and suicide risk.
High symptom of any personality disorder in adolescence
have negative repercussions on functioning over the subsequent
10 to 20 years. For instance, elevated Borderline Personality
Disorder (BPD) symptoms in adolescence have been shown
to be an independent risk factor for substance-use disorders
during early adulthood, alcohol consumption, psychopathology,
health risk behaviors, and suicide risk (34–37). Prevention and
early intervention for BPD are necessary not only for reduction
on psychiatric symptoms but also for improving psychosocial
functioning and decreasing substance abuse, which are known
risk factors for suicide.
Im et al. (38) examined 370,568 students with the aim of
recognizing risk factors for suicidal ideation in adolescents found
that low sleep satisfaction, high stress, alcohol consumption,
smoking, and sexual activity, were significant lifestyle factors
associated with suicidal ideation. Lee et al. (39) in a sample
of 860 adolescents confirmed the relationship between several
lifestyle behaviors and suicide risk including sleep disturbance,
internet game addiction, and interpersonal factors (e.g., family
conflicts and peer problems). A recent systematic review of 17
studies recognized that, in adolescents, a diagnosis of binge eating
disorder was predictive of suicidality, while a high body mass
index (BMI) was not (40). Substance-use disorders, including
alcohol use disorder, are considered one of the most important
risk factors associated with suicide risk during adolescence (41,
42). Moreover, it has been reported that the more the number of
substances abused the higher the suicide risk (43). Borges et al.
(44) in a recent trial on 1,071 young Mexicans reported that
the use of cannabis before age 15, high frequency of cannabis
use and another recent substance-use disorder increased the
risk of suicide. Park et al. (45) collected data from 68,043
adolescents with the purpose of investigating the undesirable
effects of frequent use of caffeinated energy drinks. Their results
indicated that energy drink consumption was associated with
sleep dissatisfaction, severe stress, depressive mood, suicidal
ideation, suicide plan, and suicide attempt. Similarly, Kim et al.
(46) in a study of 121,106 Korean adolescents confirmed that
severe stress, inadequate sleep, and low school performance were
associated with more energy drink consumption and suicide
attempts.
Evidence suggests that sedentary lifestyle may impact
emotional and mental health in adolescents (47). A systematic
review on this topic found a strong relationship between
sedentarism, depressive symptomatology, psychological distress,
and suicide ideation in adolescents (48). In this regard, Lester
et al. (49) demonstrated that participation in sports reduced the
incidence of suicidal ideation.
Internet use has a mixed effect on children and young people’s
well-being. On one hand, internet users may develop a social
support that may be artificial. On the other hand, it exposes
adolescents to cyberbullying and meeting strangers online (50).
In recent years, there has been an increased interest in the
relationship between internet use, cyber-bullying, and suicide
(51). A recent systematic review of 51 articles investigated
the relationship between internet use and self-harm/suicidal
behavior. This review demonstrated that internet addiction and
elevated levels of internet use, were associated with a higher
suicide risk (52). John et al. (53) highlighted that compared
to non-victims of cyberbullying, victims of cyberbullying had a
greater risk of both self-harm and suicidal behaviors. Rodelli et al.
(54) evaluated the associations between physical activity, sport
participation, healthy diet, higher sleep duration and lower levels
of smoking and lower levels of alcohol use, and suicidal ideation
when faced to cyberbullying. Results showed that cyberbullying
victimization was associated with higher suicidal ideation while
increased physical activity, sleeping longer, healthy diet and lower
levels of smoking were associated with lower suicidal ideation.
Moreover, a systematic review on the role of web technologies,
mobile solutions, social networks, and machine learning in the
prevention of suicide risk highlighted that many of these methods
can help prevent suicide (55).
The potential role of family relationships (conflict, negative
relationship with parents, other) as a risk factor for suicide
was evaluated in 36,757 French adolescents (56). Results from
this study demonstrated that negative relationships with parents
and parental discord was significantly associated with suicide
risk and/or depression in adolescents regardless of gender. The
role of family interventions in the prevention of mental illness,
substance abuse, and suicide ideation and attempts have been
evaluated (57). The author suggested that family interventions
could be useful in the prevention of suicidal ideation and
behavior in both adolescents and parents.
LIFESTYLE BEHAVIOR AND SUICIDE IN
YOUNG ADULTS AND ADULTS
In adults, the relationship between lifestyle behavior, severe
psychiatric symptoms, and suicide risk is well documented
(58,59). Recent literature has demonstrated that behavioral
lifestyle interventions help patients with serious mental illnesses
lose weight and reduce cigarette smoking. Behavioral lifestyle
interventions also helped patients achieve changes in fasting
glucose levels in patients taking antipsychotic medications (60);
simultaneously reducing the possibility of developing medical
conditions; indirectly reducing the risk of suicide.
Studies have demonstrated that adult psychiatric inpatients
who had attempted suicide presented higher levels of sedentarism
and higher tobacco use compared to psychiatric patients who did
not attempt suicide (61,62).
Research reporting on the relationship between suicide,
obesity, total serum cholesterol, and dietary patterns is
controversial (63). Research examining the relationship between
lipid profile and suicide attempts have shown that compared
to non-attempters, suicide attempters had lower cholesterol
levels (64,65). More recently, a case control study of a
Mexican population found a positive association between lower
cholesterol levels and suicide attempt (66). Although the
mechanism behind hypocholesterolemia and suicide has not
been elucidated, it has been hypothesized that altered cholesterol
at synaptic lipid rafts cause a decrease in serotonin transmission,
neurotransmitter implicated in the pathophysiology of suicide
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Berardelli et al. Lifestyle and Suicide
(67,68). A recent systematic review and meta-analysis of 11
studies evaluating lipid profile in suicide attempters and non-
attempters in people with bipolar disorder failed to clarify the
relationship between LDL-cholesterol, triglycerides and suicide
in these patients. Shrivastava et al. (69) in a naturalistic cross-
sectional cohort study of 60 patients with early psychosis, found
that low levels of cholesterol were present only in the group of
patients with severe suicidality. Similarly, Messaoud et al. (70)
found a positive association between low plasma cholesterol level
and suicidal behavior in patients with major depressive disorder.
Studies on the associations between depression, suicidal
behavior, glucose levels or insulin resistance are scarce. Higher
glucose levels have been associated with dysthymia (71)
and higher HbA1c concentrations have been associated with
psychotic depression (72). Koponen et al. (73) in 448 patients
aged 35 years old found that patients with depression and suicidal
behavior had higher blood glucose concentrations at baseline and
at 2 h in the oral glucose tolerance test (OGTT).
Although dietary habits have been linked to depression,
only few studies have examined the association between dietary
patterns and suicide risk (74,75). Li et al. (75) found that
a dietary pattern comprise of vegetables, fruits, potatoes, soy
products, mushrooms, seaweed and fish was associated with
a decreased risk of suicide. Mukamal et al. (74) reviewed
retrospectively the dietary information of 6,803 adults describing
the differences in eating habits between suicide attempters
and non-attempters. Results indicated that male attempters
presented low consumption of vegetables and female attempters
presented insufficient fruit consumption. It was further observed
that female attempters ate significantly less fish and sea food
compared to female non-attempters. Finally, results showed that
fruits, vegetables, and meat were significantly under-consumed in
those individuals with a history of suicide attempt.
The relationship between body mass index (BMI) and suicide
risk in adult seems controversial. A study by Perera et al. (63)
supported the hypothesis of an inverse association between
BMI and completed suicide, where underweight was associated
with an increased risk of completed suicide while obesity and
overweight were associated with a decreased risk of suicide in
comparison to people of normal weight. Contrarily, Branco et al.
(76) stressed that obesity was associated with a higher prevalence
of suicide risk, especially in women. Kim et al. (77) on 6,022
nationally representative sample of Korean adults aged 18 to 74
found that being underweight was associated with higher suicide
risk and obesity was associated only with risk of suicide ideation
but not with suicide attempt. In the same study, underweight
individuals were more likely to report severe level of perceived
stress (OR, 1.7; 95% Cl, 1.26–2.17) and life dissatisfaction (OR,
1.3; 95% Cl, 1.07–1.68) compared to obese individuals.
A strong relationship exists between well-being and physical
activity, sports activities and level of fitness (78,79). Physical
activity and sports activities are considered protective lifestyle
behaviuors against stress, depression and other unhealthy
behaviors linked to medical illness. In particular, sport activities
improve coronary functioning and reduce obesity prevalence
(61,80). Physical activity could be effective in reducing mental
health disorders and suicidal behaviors through biological and
psychosocial mechanisms; for example, releasing endorphins,
increasing serotonin and norepinephrine synthesis, increasing
the sense of mastery, self-esteem and social interaction (81).
Vancampfort et al. (82) in a recent metanalysis showed that in
adults, low physical activity was associated with higher suicide
risk. Adams et al. (83) demonstrated that vigorous/moderate
physical activity was associated with a positive perceived health
and modestly associated with psychiatric symptoms and suicidal
ideation reduction; confirming the link between physical activity
and well-being.
In patients with schizophrenia, the evidence suggests that
increasing physical exercise promotes wellbeing, and improves
mental health in these patients (84). Dietary habits and
levels of physical activity were evaluated in 428 people
with schizophrenia spectrum disorders and increased waist
circumference demonstrating that in these patients the intake
of fiber, vegetables, fruit, and fish were insufficient and these
patients also had low levels of physical activity. Furthermore,
negative symptoms were associated with poor diet and less
physical activity (85).
The positive relationship between smoking and suicide risk
in adult patients with psychotic disorders has been evaluated
in a systematic-review and a meta-analysis of observational
studies on this topic (86). The same authors, in a randomized
study, investigated the effect of smoking reduction on suicidality
on 255 patients with a psychotic disorder. This author found
that smoking reduction, besides the positive effects on physical
health, had a protective effect on suicidal ideation in people
with psychosis (87). Bhatt et al. (88) characterized and identified
risk factors for suicide attempt in patients with psychiatric
disorders. Findings from this study indicated no significant
differences on demographic characteristics between psychiatric
inpatients who attempted suicide and psychiatric inpatients
who did not attempt suicide. The only risk factors for suicide
in psychiatric patients found in this study were the presence
of impulsivity and borderline personality symptoms. Howard
et al. (89) in a recent population-based cohort study on
12,888 subjects (6,456 men, 6,432 women) investigated the
relationship between chronic disease conditions, smoking habits,
alcohol consumption, depressive symptoms, personality type,
and other psychological parameters and suicide found that male
sex, obesity, smoking, and living alone were associated with
depression and with risk of suicide.
Several studies have focused on the role of occupation and
work stressors on suicide risk. Research on this topic has shown
that work characteristics and personal resources are linked to
depression and suicide attempts (90). A study on 2,855 employees
demonstrated that job autonomy, task variety, work-family
conflict, family-work conflict, and job dissatisfaction contributed
to suicide attempts (89). Furthermore, Kerr et al. (91) showed
that poor interpersonal relationships, unemployment, debt and
financial difficulties contribute to an increased risk of suicide in
the general population. A recent study of 2,027 employed patients
in primary care setting examined the association between
workplace and suicidal ideation (92). Suicidality was significantly
associated with work intensity in men and with work-related
emotional demands in women.
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Berardelli et al. Lifestyle and Suicide
Alcohol and substance abuse can worsen psychological well-
being and contribute to suicide risk (93). Consumption of
alcohol immediately prior to suicide is common (94,95),
with an estimated 37% of deaths from suicide having positive
blood alcohol concentrations on toxicology screening indicating
acute alcohol consumption before death (96). Bowden et al.
(97) in a large cohort study of 2,803,457 residents of Wales,
UK, highlighted the relationship between emergency alcohol-
related hospital admission and the increased risk of suicide. A
recent systematic review of 108 studies explored the associations
between substance use and suicide risk in low- and middle-
income countries (98) demonstrated an association between
alcohol use, intoxication and pathological use of alcohol, tobacco,
cannabis, illicit drugs and non-medical use of prescription drugs
and suicide risk. Furthermore, Choi et al. (99) examined blood
alcohol concentration (BAC) among suicide decedents aged
50 years or older. This study showed that alcohol problems
prior to suicide, relationship problems and death/suicide of
family/friends were associated with greater odds of having a
positive BAC. This study also found that alcohol intoxication was
linked to more violent means of suicide.
LIFESTYLE BEHAVIOR AND SUICIDE IN
OLDER ADULTS
Over 20% of adults aged 60 and over suffer from a psychiatric
or neurological disorder. In the elderly, severe mental disorders
present differently than in younger adults. The most common
mental and neurological disorders in this age group are
TABLE 1 | Lifestyle behaviors implicated in suicide risk (alphabetical order).
Lifestyle behaviors
• Difficulties in interpersonal relations
• Internet addiction
• Nutrition, dietary patterns
• Occupation and work stressor
• Sedentary
• Substance and alcohol abuse
• Tobacco’s smoke
• Underweight, Obesity
TABLE 2 | Common Lifestyle behaviors implicated in suicide risk in different age
ranges (based on results of studies included in this review).
Age range Lifestyle behavior and suicide risk
Adolescents and young
people
(age 16–30)
Difficulties in interpersonal relations, substance and
alcohol abuse, internet addiction.
Young adults and
adults
(age 30–65)
Substance and alcohol abuse, occupation and work
stressor.
Older adults and elderly
(age >65)
Difficulties in interpersonal relations, nutrition, dietary
patterns.
depression and dementia. However, anxiety disorders,
schizophrenia and psychotic disorders, and substance use
problems are also prevalent (100). A body of literature supports
the association between late-life suicide ideation and various risk
factors including depression and hopelessness (101,102), while
subjective well-being and meaning in life have been identified as
protective factors for suicide in older adults (101). Innamorati
et al. (103) in a study using psychological autopsy interviews
studied 117 old-old adults who died by suicide and compared
them to 97 young-old adults (6,574 years), 98 middle aged (50–64
years) suicide victims, and 117 psychiatric outpatients 75 years
and older without a history of suicidal behaviors. They found
that, in the elderly, unlike others stages of life, loneliness and lack
of social support, were associated with risk of suicide. Physical
illness, chronic severe pain, debilitating disease, and diagnosis
of a terminal illness are common antecedents to suicide in older
adults (104). Lee et al. (39) after analyzing age and sex-related
features and suicide risk in the elderly stressed that the only
stable risk factor for suicide in this age group was the negative
perception of one’s own health status.
Difficulties in interpersonal relations, social interactions, and
social participation have been also linked to suicidal ideation
and suicidal intent in the elderly (105). Mogensen et al. (106)
reported that in the elderly, suicide risk appeared highest during
the 6 months following the loss of a close relative and McLaren
et al. (107) observed that widowhood was associated with suicidal
ideation both in men and women. A longitudinal study on the
importance of social support while adjusting to loneliness in
bereaving elderly persons (108) and other studies examining
on the importance of social supports reported that primary
prevention programs designed specifically to increase social
relations could decrease suicide risk (109). Older people are at
risk for health decline and loss of independence that can affect
social interactions negatively. Clark et al. (110) evaluated the
effectiveness of lifestyle interventions in promoting well-being
in independently living older people and Lapierre et al. (111) in
a systematic review of 19 studies focusing on lifestyle programs
for older adults, highlighted that psychoeducational programs
and decreasing social isolation in this age group are effective
interventions in the prevention of suicide. More recently, Okolie
et al. (112) considered telephone counseling for vulnerable older
adults and community-based programs incorporating education,
gatekeeper training, depression screening, and group activities, as
valid therapeutic options in preventing suicidal ideation. Lifestyle
interventions in the areas of social interaction (113), personal
goals (114), coping, and adaptive behavior (113), emotional
TABLE 3 | Common Lifestyle behaviors implicated in suicide risk in psychiatric
disorders (based on results of studies included in this review).
Psychiatric disorders Lifestyle behavior and suicide risk
Psychotic
disorders
Substance and alcohol abuse, difficulties in
interpersonal relations, tobacco’s smoke.
Depressive
disorders
Substance and alcohol abuse, occupation and
work stressor.
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Berardelli et al. Lifestyle and Suicide
flexibility (115), social skills (116), self-esteem (117), sense of
belonging (118), reasons for living (119), hope (120), meaning
in life (101,121), religion or spirituality (122) could became
promising directions to prevent suicide in older adults.
Several studies have demonstrated the importance of a
balanced diet to prevent depression (123,124) and of sleep-
based interventions to prevent suicide (125). Considering that
hypnotics use in the elderly has been associated with an increased
risk of suicide (126), behavioral treatment of insomnia represents
an efficacious alternative to pharmacotherapy in this age group
(127). O’ Rourke et al. (128) studied specific predictors of suicide
in a sample of 220 older adults affected by Bipolar Disorder
(BD). Alcohol misuse, medication non-adherence, and cognitive
impairment were found to be direct predictors of suicide in these
patients, while sleep disturbances acts as a risk factor on suicide
ideation via depressive symptoms. Contrary to what happens in
other age groups, a link between smoking prevalence and suicide
rates in the elderly has not been observed (129).
DISCUSSION
In this article, we reviewed a growing body of literature
demonstrating a relationship between lifestyle behaviors,
mental health, and suicide risk (Table 1) in differing
stages of life (Table 2) and in severe psychiatric disorders
(Table 3). Our review suggests that enhancing protective
factors and reducing risk factors known to increase suicidal
behaviors (75,130–132) could help prevent suicide in
some individuals. Given the high comorbidity between
psychiatric disorders and medical illnesses that result
from unhealthy lifestyle behaviors, lifestyle interventions to
reduce medical diseases, and increase patient’s well-being are
urgently needed.
The relationship between lifestyle behavior and suicide is
complex and multifactorial. Unhealthy lifestyle behaviors can
directly increase the risk of suicide; at the same time increasing
the risk for many medical diseases. It is well known that medical
illnesses are associated with disability, social isolation and
associated with an increased risk of suicide. Sedentary behaviors,
underweight, obesity, cigarette smoking, and alcohol abuse are
associated with cardiometabolic risk factors, poor mental health,
and severe psychiatric disorders. These factors contribute to
an increased risk of suicide. Sedentary behaviors, weight issues
and fewer social supports contribute to social isolation, limiting
the development of social relationships, which increase the risk
of developing mental health problems and suicide. Adopting
healthy lifestyle behaviors are indispensable for both, improving
health and for the prevention of suicide at any stage in life.
Studies included in this article showed different lifestyle
behaviors in different lifestages. In adolescent and young
adults there are multiple important risk factors for suicide
including psychosis, depression, low sleep satisfaction, high
stress, substance abuse, alcohol consumption, smoking, sexual
activity, internet addiction, interpersonal factors, personality
disorders, anxiety or conduct disorders, eating disorders,
and aggressive, irritable and antisocial tendencies (38,39).
Though it has been demonstrated that school-based suicide
prevention programs increase knowledge on suicide without
really preventing suicidal behaviors (133), it seems necessary
to consider prevention programs that identify substance
abuse, educational competencies (literacy, study skills, time
management), educational environment, school programs,
social interactions, academic attainment, cognitive progress,
emotional control, behavioral expectations, physical and moral
development, and encouragement of active engagement in
sports.
In adults, lifestyle interventions on smoking, heavy alcohol
consumption, physical inactivity, BMI, sedentarism, and eating
habits should play a significant role in suicide prevention
(17,65). Effective lifestyle prevention programs in adults can
be developed through screening programs identifying and
assessing at-risk groups. These programs should include lifestyle
training, psychoeducation, support/skills training and crisis
response and referral resources (134). In patients with severe
psychiatric disease, strategies that promote exercise and sport
activities, that reduce caffeine consumption and other health-
adverse behaviors are particularly important for the reduction
of psychotic symptoms, depression, anxiety, low self-esteem,
and life dissatisfaction, factors that increase suicide risk. Gallego
et al. (135) suggested that in patients with either schizophrenia
spectrum disorders or affective disorders, physicians should
be alert for the presence of a previous suicidal attempts and
financial or relationship losses, factors that can increase suicidal
risk. Furthermore, psychiatric hospitalization, a close psychiatric
follow up, collaboration with family would be important
strategies in reducing the risk of suicidal behavior in patients
affected by severe psychiatric disorders.
Finally, in the elderly, difficulties in interpersonal relations,
social isolation and the consequences of physical disability can
represent targeted and specific points for intervention. The
concomitant presence of depressive symptoms and stressing
life events including loneliness and physical illness should be
considered warning signs for suicidal risk (136). In the elderly,
innovative strategies should promote positive aging, involve
family and community gatekeepers, and use telecommunications
to identify older adult at risk of suicide (112). Psychosocial
interventions influence depressive symptoms and considering
that mental illness is one of the most significant factors in suicide;
psychosocial interventions should be part of suicide prevention
programs in the elderly. Further trials are warranted, especially
for the most promising type of interventions for preventing
suicide, that is, social activities (137,138).
LIMITATIONS
When interpreting the results of this review, several limitations
should be considered. First, this is a narrative review, therefore,
studies were subjectively selected, which could have led to
selection bias. Second, we only selected articles in English leaving
relevant articles in other languages out of our review. Finally, we
did not draw a distinction between gender and risk factors for
suicide.
Frontiers in Psychiatry | www.frontiersin.org 6November 2018 | Volume 9 | Article 567

Berardelli et al. Lifestyle and Suicide
CONCLUSIONS
Lifestyle behavior is of paramount importance for suicide
prevention as maladaptive maneuvers (such as drinking or drug
abuse) as to face increased psychological pain and distress
consistently reduce cognitive skill to solve source of suffering.
Furthermore, reduced quality of life as observed by impairment
of some psychiatric disorders can be worsened by low exercise,
excessive smoking, poor diet, and determinants associated
with pharmacological treatment. Community mental health
with proper programs such as assertive community treatment,
psychoeducational family treatment, social skills training, and
psychosocial therapies are important interventions that can
incorporate education on lifestyle and ultimately reduce suicide
risk.
AUTHOR CONTRIBUTIONS
IB and VC searched the literature and provided first draft.
MH, AC, and DE independently reviewed the paper and added
relevant information. MP provided the intellectual impetuous
and supervised the entire process of development of the paper.
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Conflict of Interest Statement: The authors declare that the research was
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be construed as a potential conflict of interest.
Copyright © 2018 Berardelli, Corigliano, Hawkins, Comparelli, Erbuto and Pompili.
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