ArticleLiterature Review

Future Well-Being Among People Who Attempt Suicide and Survive: Research Recommendations

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Abstract

Over 48,000 people died by suicide in 2018 in the United States, and more than 25 times that number attempted suicide. Research on suicide has focused much more on risk factors and adverse outcomes than on protective factors and more healthy functioning. Consequently, little is known regarding relatively positive long-term psychological adaptation among people who attempt suicide and survive. We recommend inquiry into the phenomenon of long-term well-being after non-fatal suicide attempts, and we explain how this inquiry complements traditional risk research by (a) providing a more comprehensive understanding of the sequelae of suicide attempts, (b) identifying protective factors for potential use in interventions and prevention, and (c) contributing to knowledge and public education that reduces the stigma associated with suicide-related behaviors.

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... Twenty million people worldwide attempt suicide every year, and approximately 5% of these attempts are fatal. In part because suicide is so tragic, scientific study of suiciderelated phenomena has overlooked the possibility that some people who try to kill themselves not only recover from these urges, but also eventually emerge with greater psychological well-being (Tong et al., 2021). ...
Article
If one struggles with depression, anxiety, or suicidal impulses, what is the best outcome that one can hope for? Can psychopathology be a bridge to a better place where people operate with autonomy and self-mastery, enjoy healthy relationships, experience frequent positive emotions, and view life as meaningful and purposeful? Studies of national samples have revealed that a substantial number of people with depression, panic disorder, and suicidal impulses go on to achieve high levels of psychological well-being. We consider the practical and theoretical implications of these findings and call for a transformational mental-health agenda that focuses on good outcomes.
... Understanding the motivations for suicide and whether a suicide attempt may be instrumental in attaining personal and interpersonal goals will aid efforts in designing interventions to prevent subsequent attempts. A recent study raised whether some individuals who attempted suicide and survived achieved good psychological adaptation (Tong et al., 2021). "Good psychological adaptation" may be defined as an improvement of personal well-being and interpersonal relationships after a suicide attempt. ...
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This study focused on the well-being of the survivors of suicide attempts and the well-being of their interpersonal relationships after the attempt. The data came from a sample of 392 college students from ten Muslim majority countries who reported having attempted suicide in the last four years. Suicide was conceptualized as a goal-directed behavior embedded in a sociocultural context and motivated by personal or interpersonal goals. We tested a process that linked culturally shaped self-construal to the post-suicidal personal and interpersonal well-being. We posited that this process would operate through the attitudes towards suicide, motives for suicide, the strength of the intention to die. Our model indicated that the acceptability of suicide was positively associated with escape motives, and this association was even stronger for the individuals with interdependent self-construals. Escape motives were negatively associated with post-suicidal personal and interpersonal well-being, but communication motives were not associated with these outcomes. We also found evidence that having an interdependent self-construal might be beneficial for post-suicidal personal and interpersonal well-being. Our results further suggested that the post-suicidal personal and interpersonal well-being of highly interdependent individuals may depend on the interpretation of their act of suicide by their close others.
... The relative neglect of well-being and functioning assessments in psychopathology research motivated our team to consider long-term well-being after psychopathology. Because few studies have considered the prevalence of high functioning after psychopathology, including OWB, we developed rigorous criteria to operationalize OWB (Rottenberg et al., 2018;Tong et al., 2021), informed by prior work on self-determination theory, well-being, and quality of life (Keyes, 2002;Ryff, 1989). Research from these interrelated literatures suggest that a set of psychological needs must be satisfied for effective functioning and psychological health. ...
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Optimal functioning after psychopathology is understudied. We report the prevalence of optimal well-being (OWB) following recovery after depression, suicidal ideation, generalized anxiety disorder, bipolar disorder, and substance use disorders. Using a national Canadian sample (N = 23,491), we operationalized OWB as absence of 12-month psychopathology and scoring above the 25th national percentile on psychological well-being and functioning measures. Compared with 24.1% of participants without a history of psychopathology, 9.8% of participants with a lifetime history of psychopathology met OWB. Adults with a history of substance use disorders (10.2%) and depression (7.1%) were the most likely to report OWB. Persons with anxiety (5.7%), suicidal ideation (5.0%), bipolar 1 (3.3%), and bipolar 2 (3.2%) were less likely to report OWB. Having just one lifetime disorder increased the odds of OWB by 4.2 times relative to multiple lifetime disorders. While psychopathology substantially reduces the probability of OWB, many individuals with psychopathology attain OWB.
Article
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Optimal functioning after psychopathology is understudied. We report the prevalence of optimal well-being (OWB) following recovery after depression, suicidal ideation, generalized anxiety disorder, bipolar disorder, and substance use disorders. Using a national Canadian sample ( N = 23,491), we operationalized OWB as absence of 12-month psychopathology, coupled with scoring above the 25th national percentile on psychological well-being and below the 25th percentile on disability measures. Compared with 24.1% of participants without a history of psychopathology, 9.8% of participants with a lifetime history of psychopathology met OWB. Adults with a history of substance use disorders (10.2%) and depression (7.1%) were the most likely to report OWB. Persons with anxiety (5.7%), suicidal ideation (5.0%), bipolar I (3.3%), and bipolar II (3.2%) were less likely to report OWB. Having a lifetime history of just one disorder increased the odds of OWB by a factor of 4.2 relative to having a lifetime history of multiple disorders. Although psychopathology substantially reduces the probability of OWB, many individuals with psychopathology attain OWB.
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Background: Evidence indicates that repeat suicide attempters, as a group, may differ from 1st time attempters. The identification of repeat attempters is a powerful but underutilized clinical variable. Aims: In this research, we aimed to compare individuals with lifetime histories of multiple attempts with 1st time attempters to identify factors predictive of repeat attempts. Setting and Design: This was a retrospective record based study carried out at a teaching cum Tertiary Care Hospital in South India. Methods: Relevant data was extracted from the clinical records of 1st time attempters (n = 362) and repeat attempters (n = 61) presenting to a single Tertiary Care Center over a 4½ year period. They were compared on various sociodemographic and clinical parameters. The clinical measures included Presumptive Stressful Life Events Scale, Beck Hopelessness Scale, Coping Strategies Inventory – Short Form, and the Global Assessment of Functioning Scale. Statistical Analysis Used: First time attempters and repeaters were compared using appropriate inferential statistics. Logistic regression was used to identify independent predictors of repeat attempts. Results: The two groups did not significantly differ on sociodemographic characteristics. Repeat attempters were more likely to have given prior hints about their act (χ2 = 4.500, P = 0.034). In the final regression model, beck hopelessness score emerged as a significant predictor of repeat suicide attempts (odds ratio = 1.064, P = 0.020). Conclusion: Among suicide attempters presenting to the hospital, the presence of hopelessness is a predictor of repeat suicide attempts, independent of clinical depression. This highlights the importance of considering hopelessness in the assessment of suicidality with a view to minimize the risk of future attempts. Key words: Attempted suicide, cognition, depression, hopelessness, suicide
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The national cost of suicides and suicide attempts in the United States in 2013 was $58.4 billion based on reported numbers alone. Lost productivity (termed indirect costs) represents most (97.1%) of this cost. Adjustment for under-reporting increased the total cost to $93.5 billion or $298 per capita, 2.1-2.8 times that of previous studies. Previous research suggests that improved continuity of care would likely reduce the number of subsequent suicidal attempts following a previous nonfatal attempt. We estimate a highly favorable benefit-cost ratio of 6 to 1 for investments in additional medical, counseling, and linkage services for such patients.
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Research indicates that connection to mental health care services and treatment engagement remain challenges among suicide attempt survivors. One way to improve suicide attempt survivors' experiences with mental health care services is to elicit suggestions directly from attempt survivors regarding how to do so. This study aimed to identify and synthesize suicide attempt survivors' recommendations for how to enhance mental health treatment experiences for attempt survivors. A sample of 329 suicide attempt survivors (81.5% female, 86.0% White/Caucasian, mean age = 35.07 ± 12.18 years) provided responses to an open-ended self-report survey question probing how treatment might be improved for suicide attempt survivors. Responses were analyzed utilizing both qualitative and quantitative techniques. Analyses identified four broad areas in which mental health treatment experiences might be improved for attempt survivors: (a) provider interactions (e.g., by reducing stigma of suicidality, expressing empathy, and using active listening), (b) intake and treatment planning (e.g., by providing a range of treatment options, including nonmedication treatments, and conducting a thorough assessment), (c) treatment delivery (e.g., by addressing root problems, bolstering coping skills, and using trauma-informed care), and (d) structural issues (e.g., by improving access to care and continuity of care). Findings highlight numerous avenues by which health providers might be able to facilitate more positive mental health treatment experiences for suicide attempt survivors. Research is needed to test whether implementing the recommendations offered by attempt survivors in this study might lead to enhanced treatment engagement, retention, and outcomes among suicide attempt survivors at large. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
Article
Background: Although a history of a suicide attempt is the strongest predictor of future suicide attempts, not all adolescents who make an attempt engage in repetitive suicidal behavior. The present study sought to determine whether certain characteristics of a first suicide attempt (e.g., age of first attempt, method of attempt used, intent seriousness, medical lethality, and receipt of treatment after attempt) can distinguish between adolescents who make single versus multiple suicide attempts. Methods: Adolescents (N = 95) who were psychiatrically hospitalized and their guardian completed a diagnostic interview to gather information on all lifetime suicide attempts. A multivariate hierarchical logistic regression was conducted, predicting single attempt (SA) versus multiple attempt (MA) status. Results: Of the first-attempt characteristics examined, only age of first attempt, OR = 0.33, 95% CI [0.17-0.63], p = .001, and receipt of treatment following attempt, OR = 0.28, 95% CI [0.09-0.88], p = .028, significantly distinguished SA vs. MA status, even after controlling for current age and depression at the time of first attempt. Limitations: Female and White participants were overrepresented in this sample, which limits generalization to more heterogenous and diverse samples. The cross-sectional nature of data introduces the potential for retrospective recall bias. Conclusions: Younger age of first attempt and lack of receipt of mental health treatment following a first attempt were associated with MA status. These findings highlight the importance of early mental health screening, parental psychoeducation, and linkage to mental health care after a suicide attempt.
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Can people achieve optimal well-being and thrive after major depression? Contemporary epidemiology dismisses this possibility, viewing depression as a recurrent, burdensome condition with a bleak prognosis. To estimate the prevalence of thriving after depression in United States adults, we used data from the Midlife Development in the United States study. To count as thriving after depression, a person had to exhibit no evidence of major depression and had to exceed cutoffs across nine facets of psychological well-being that characterize the top 25% of U.S. nondepressed adults. Overall, nearly 10% of adults with study-documented depression were thriving 10 years later. The phenomenon of thriving after depression has implications for how the prognosis of depression is conceptualized and for how mental health professionals communicate with patients. Knowing what makes thriving outcomes possible offers new leverage points to help reduce the global burden of depression.
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Recent standardized nomenclature has suggested distinctions among aborted, interrupted, and actual suicide attempts. This study examined differences in self-reported symptoms among individuals with a history of aborted, interrupted, and actual suicide attempts. 167 young adults with a history of suicidality completed self-report measures of suicide attempt history and current symptoms, a clinical interview assessing past suicidal behavior, and a pain tolerance task. Only 78.8% of participants who initially reported a suicide attempt history were classified as suicide attempters following the clinical interview. Individuals who reported only aborted attempts during the clinical interview reported less severe clinical symptoms than those reporting a history of at least one actual attempt. Individuals with a history of actual suicide attempts may represent a more clinically severe group than those with a history of aborted attempts only.
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We address a key issue at the intersection of emotion, psychopathology, and public health—the startling lack of attention to people who experience benign outcomes, and even flourish, after recovering from depression. A rereading of the epidemiological literature suggests that the orthodox view of depression as chronic, recurrent, and lifelong is overstated. A significant subset of people recover and thrive after depression, yet research on such individuals has been rare. To facilitate work on this topic, we present a generative research framework. This framework includes (a) a proposed definition of healthy end-state functioning that goes beyond a reduction in clinical symptoms, (b) recommendations for specific measures to assess high functioning, and (c) a road map for a research agenda aimed at discovering how and why people flourish after emotional disturbance. Given that depression remains the most burdensome health condition worldwide, focus on what makes these excellent outcomes possible has enormous significance for the public health.
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The world is complicated, and we hold a large number of beliefs about how it works. These beliefs are important because they shape how we interact with the world. One particularly impactful set of beliefs centers on emotion, and a small but growing literature has begun to document the links between emotion beliefs and a wide range of emotional, interpersonal, and clinical outcomes. Here we review the literature that has begun to examine beliefs about emotion, focusing on two fundamental beliefs, namely whether emotions are good versus bad and whether emotions are controllable versus uncontrollable. We then consider one underlying mechanism that we think may link these emotion beliefs with downstream outcomes, namely emotion regulation. Finally, we highlight the role of beliefs about emotion across various psychological disciplines and outline several promising directions for future research.
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Suicide attempt survivors represent a high-risk group for death by suicide; however, few empirically supported, tailored interventions exist for this population. One intervention format that may be useful in reducing suicide risk among suicide attempt survivors is support groups co-led by a clinician and peer survivor. This study aimed to evaluate changes in suicidal symptoms and resilience appraisals following attempt survivors’ participation in the Survivors of Suicide Attempts (SOSA) support group. A sample of 92 suicide attempt survivors was recruited to participate in the 8-week SOSA support group. Individuals completed self-report measures of suicidal symptoms (i.e., suicidal ideation, hopelessness, suicidal desire, and suicidal intent) and resilience appraisals immediately prior to and following participation in the SOSA program. Paired t tests were utilized to examine pre-post symptom changes. Participants in this study reported significant reductions in suicidal ideation, hopelessness, suicidal desire, and suicidal intent after completing the SOSA program. Additionally, individuals reported significant increases in resilience appraisals following SOSA group participation. Of note, individuals engaged in concurrent mental health treatment did not demonstrate significantly greater reductions in suicidal symptoms than those not engaged in concurrent treatment, highlighting the potential utility of the SOSA intervention. Findings suggest that the SOSA support group model may be useful in therapeutically impacting suicidal symptoms and increasing resilience among suicide attempt survivors. However, to establish SOSA’s efficacy, further research is warranted to replicate these findings utilizing a randomized controlled trial design to compare outcomes from the SOSA support group to treatment as usual.
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Background Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain. Methods Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain‐related interference, and measures of psychological flexibility, including acceptance, cognitive defusion, committed action, and self‐as‐context. An item from the measure of depression was used to reflect ST. Results A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain‐related interference, and depression. Each component of psychological flexibility was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it. Conclusion This preliminary study suggests for the first time that component of PF are associated with part of a pattern of suicidal behavior in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioral options. This article is protected by copyright. All rights reserved.
Article
1 Background To examine whether there are subtypes of suicidal thinking using real‐time digital monitoring, which allows for the measurement of such thoughts with greater temporal granularity than ever before possible. 2 Methods We used smartphone‐based real‐time monitoring to assess suicidal thoughts four times per day in two samples: Adults who attempted suicide in the past year recruited from online forums (n = 51 participants with a total of 2,889 responses, surveyed over 28 days; ages ranged from 18 to 38 years) and psychiatric inpatients with recent suicidal ideation or attempts (n = 32 participants with a total of 640 responses, surveyed over the duration of inpatient treatment [mean stay = 8.79 days], ages ranged 23–68 years). Latent profile analyses were used to identify distinct phenotypes of suicidal thinking based on the frequency, intensity, and variability of such thoughts. 3 Results Across both samples, five distinct phenotypes of suicidal thinking emerged that differed primarily on the intensity and variability of suicidal thoughts. Participants whose profile was characterized by more severe, persistent suicidal thoughts (i.e., higher mean and lower variability around the mean) were most likely to have made a recent suicide attempt. 4 Conclusions Suicidal thinking has historically been studied as a homogeneous construct, but using newly available monitoring technology we discovered five profiles of suicidal thinking. Key questions for future research include how these phenotypes prospectively relate to future suicidal behaviors, and whether they represent remain stable or trait‐like over longer periods.
Article
Each year, approximately 1.3 million Americans survive a suicide attempt. While stigma has been reported by suicide attempt survivors, limited research has examined how suicide stigma may differ from the stigma of mental illness. U.S. adults (n=440) completed an online survey in which they were randomly assigned to one of four vignettes. Vignettes depicted a target individual with either past depression, past suicide attempt, death by suicide, or no information on suicide or mental illness (control). Participants completed a general measure of stigma, a suicide-specific stigma measure, and were surveyed on the recovery potential of individuals with mental illness and suicide attempt. While the general stigma measure failed to distinguish between groups, significant differences on the suicide stigma scale (SSAS-44) emerged between participants assigned in the depression and suicide conditions, especially for stereotype and prejudice subscales. Across conditions, participants believed that recovery was more realistic for someone described as having a mental illness than it was for someone described as having attempted suicide. These findings suggest that individuals who have attempted suicide are subject to differential stigma content from those with depression. Implications are discussed for combating stigma for suicide attempt survivors.
Article
Aims: To characterise and identify nationwide trends in suicide-related emergency department (ED) visits in the USA from 2006 to 2013. Methods: We used data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2013. E-codes were used to identify ED visits related to suicide attempts and self-inflicted injury. Visits were characterised by factors such as age, sex, US census region, calendar month, as well as injury severity and mechanism. Injury severity and mechanism were compared between age groups and sex by chi-square tests and Wilcoxon rank-sum tests. Population-based rates were computed using US Census data. Results: Between 2006 and 2013, a total of 3 567 084 suicide attempt-related ED visits were reported. The total number of visits was stable between 2006 and 2013, with a population-based rate ranging from 163.1 to 173.8 per 100 000 annually. The frequency of these visits peaks during ages 15-19 and plateaus during ages 35-45, with a mean age at presentation of 33.2 years. More visits were by females (57.4%) than by males (42.6%); however, the age patterns for males and females were similar. Visits peaked in late spring (8.9% of all visits occurred in May), with a smaller peak in the fall. The most common mechanism of injury was poisoning (66.5%), followed by cutting and piercing (22.1%). Males were 1.6 times more likely than females to use violent methods to attempt suicide (OR = 1.64; 95% CI = 1.60-1.68; p < 0.001). The vast majority of patients (82.7%) had a concurrent mental disorder. Mood disorders were the most common (42.1%), followed by substance-related disorders (12.1%), alcohol-related disorders (8.9%) and anxiety disorders (6.4%). Conclusions: The annual incidence of ED visits for attempted suicide and self-inflicted injury in the NEDS is comparable with figures previously reported from other national databases. We highlighted the value of the NEDS in allowing us to look in depth at age, sex, seasonal and mechanism patterns. Furthermore, using this large national database, we confirmed results from previous smaller studies, including a higher incidence of suicide attempts among women and individuals aged 15-19 years, a large seasonal peak in suicide attempts in the spring, a predominance of poisoning as the mechanism of injury for suicide attempts and a greater use of violent mechanisms in men, suggesting possible avenues for further research into strategies for prevention.
Article
Objectives: Stressful life events have been associated with high risk of suicidal behavior. The aim of this study was to examine whether persons who died by suicide in Denmark had more frequently been exposed to stressful life events, specifically divorce, death of a close relative, exposure to violence, and imprisonment, when compared to gender and age-matched controls. Methods: Data from Danish national registers were obtained for the period of 2000-2010 and a nested case-control design was applied. The association between exposure to stressful life events and suicide was examined using logistic regression analysis. Results: In all, 7,115 suicides were identified during the 11 years of follow-up. For each of these, 20 age- and gender-matched controls were randomly selected (n = 142,300). Cases who died by suicide had an odds ratio of 9.3 (CI-95%: 7.8-11.0) of having been exposed to imprisonment five or more times when compared to controls. People who died by suicide had 1.5-fold (CI-95%: 1.3-1.6) higher risk of having experienced a divorce. Stressful life events, such as divorce and imprisonment, were more frequent in temporal proximity to the date of death among the suicide cases than for end of exposure for controls (p < .001 and p < .001, respectively). Conclusion: Our findings confirm that, using nationwide data, stressful life events are positively associated to subsequent suicide. Causal pathways linking the two may, however, be indirect.
Article
Background: Past scholarly efforts to describe and measure the stigma surrounding suicide have largely viewed suicide stigma from the perspective of the general public. Aims: In the spirit of community-based participatory research (CBPR), the current study brought together a diverse stakeholder team to qualitatively investigate the suicide stigma as experienced by those most intimately affected by suicide. Method: Seven focus groups (n = 62) were conducted with suicide attempt survivors, family members of those who died by suicide, and suicide loss therapists. Results: Themes were derived for stereotypes (n = 30), prejudice (n = 3), and discrimination (n = 4). People who attempted suicide were seen as attention-seeking, selfish, incompetent, emotionally weak, and immoral. Participants described personal experiences of prejudice and discrimination, including those with health professionals. Conclusion: Participants experienced public stigma, self-stigma, and label avoidance. Analyses reveal that the stigma of suicide shares similarities with stereotypes of mental illness, but also includes some important differences. Attempt survivors may be subject to double stigma, which impedes recovery and access to care.
Book
The Book is the Italian Edition of M-M: Linehan DBT skills training manual pp.900
Article
Objective: The new Diagnostic Statistical Manual (DSM) requires the presence of fewer symptoms to make a diagnosis of adult ADHD while the criteria for diagnosis in childhood are unchanged as compared to previous editions. This study examines the prevalence of adults meeting the revised DSM-5 symptoms cutoff as compared to the previous DSM-IV symptoms cutoff. Method: This study is part of a larger nationwide study that evaluated the use of, and the attitudes toward, ADHD medications by university students. 445 students from four major university faculties were surveyed and filled out questionnaires for our study. Results: The proportion of participants that met the minimum threshold of six out of nine current symptoms in either of the two DSM-IV symptom domains (inattentive presentation and hyperactive/impulsive presentation) for ADHD was 12.7% while the proportion that met the minimum threshold of five symptoms in either of the DSM-5 symptom domains was 21%. Conclusion: Since the new DSM requires fewer current symptoms for a diagnosis of ADHD, a significant increase (65%) was observed in the number of participants meeting the new cutoff as compared to the old DSM-IV symptoms cutoff. This increase in the number of adults meeting symptoms cutoff may affect the rates of adults diagnosed with ADHD. Using the new criteria may identify more adults with ADHD and fewer diagnoses will be missed. However, meeting the new symptoms cutoff should be considered within the overall clinical context to prevent over-diagnosis.
Article
Most suicide ideators do not attempt suicide. Thus, it is useful to understand what differentiates attempters from ideators. We meta-analyzed 27 studies comparing sociodemographic and clinical variables between attempters and ideators. When comparing ideators to nonsuicidal individuals, there were several large effects. For example, depression and PTSD were markedly elevated among ideators (d = .85–.90). In contrast, when comparing attempters to ideators, all 12 variables had negligible to moderate effects. Specifically, depression, alcohol use disorders, hopelessness, gender, race, marital status, and education all were similar in attempters and ideators (d = −.05 to .31). Anxiety disorders, PTSD, drug use disorders, and sexual abuse history were moderately elevated in attempters compared to ideators (d = .48–.52). Implications for theory and practice are discussed.
Article
Empirically informed suicide risk assessment frameworks are useful in guiding the evaluation and treatment of individuals presenting with suicidal symptoms. Joiner et al. (1999) formulated one such framework, which has provided a concise heuristic for the assessment of suicide risk. The purpose of this review is to ensure compatibility of this suicide risk assessment framework with the growing literature on suicide-related behaviors. This review integrates recent literature on suicide risk factors and clinical applications into the existing model. Further, we present a review of risk factors not previously included in the Joiner et al. (1999) framework, such as the interpersonal theory of suicide variables of perceived burdensomeness, thwarted belongingness, and capability for suicide (Joiner, 2005; Van Orden et al., 2010) and acute symptoms of suicidality (i.e., agitation, irritability, weight loss, sleep disturbances, severe affective states, and social withdrawal). These additional indicators of suicide risk further facilitate the classification of patients into standardized categories of suicide risk severity and the critical clinical decision making needed for the management of such risk. To increase the accessibility of empirically informed risk assessment protocols for suicide prevention and treatment, an updated suicide risk assessment form and decision tree are provided. © 2015 Wiley Periodicals, Inc.
Article
This article describes the concept of posttraumatic growth, its conceptual foundations, and supporting empirical evidence. Posttraumatic growth is the experience of positive change that occurs as a result of the struggle with highly challenging life crises. It is manifested in a variety of ways, including an increased appreciation for life in general, more meaningful interpersonal relationships, an increased sense of personal strength, changed priorities, and a richer existential and spiritual life. Although the term is new, the idea that great good can come from great suffering is ancient. We propose a model for understanding the process of posttraumatic growth in which individual characteristics, support and disclosure, and more centrally, significant cognitive processing involving cognitive structures threatened or nullified by the traumatic events, play an important role. It is also suggested that posttraumatic growth mutually interacts with life wisdom and the development of the life narrative, and that it is an on-going process, not a static outcome.
Article
Existing literature has found a link between disclosure of a stigmatized identity and improved mental health; however, research on the impact of suicide disclosure to family members is scarce. Suicide attempt survivors (n = 74) in the United States were examined to assess whether family reaction moderates or mediates the relationship between suicide disclosure and subsequent depression symptoms. Family reaction did not moderate but did mediate the relationship between disclosure and depression symptoms while controlling for time since most recent attempt. Higher rates of disclosure predicted more positive family reactions, which in turn predicted less severe depression symptoms. Findings indicate that family members can play an essential role in the recovery process after an attempt occurs, which has important implications for both researchers and clinicians who seek to decrease stigma for attempt survivors while simultaneously decreasing the likelihood of future attempts. © 2015 The American Association of Suicidology.
Article
Terms such as risk, risk factors, and especially the term cause are inconsistently and imprecisely used, fostering scientific miscommunication and misleading research and policy. Clarifying such terms is the essential first step. We define risk and a risk factor (protective factor) and their potency, set out the conceptual basis of the methods by which risk factors are identified and potency demonstrated, and propose criteria for establishing the status of a risk factor as a fixed or variable marker or a causal risk factor. All definitions are based on the state of scientific knowledge (empirical documentation), rather than on hypotheses, speculations, or beliefs. We discuss common approaches and pitfalls and give a psychiatric research example. Imprecise reports can impede the search for understanding the cause and course of any disease and also may be a basis of inadequate clinical or policy decision-making. The issues in risk research are much too important to tolerate less than precise terminology or the less than rigorous research reporting that results from imprecise and inconsistent terminology.
Article
Importance Older adults have high rates of sleep disturbance, die by suicide at disproportionately higher rates compared with other age groups, and tend to visit their physician in the weeks preceding suicide death. To our knowledge, to date, no study has examined disturbed sleep as an independent risk factor for late-life suicide.Objective To examine the relative independent risk for suicide associated with poor subjective sleep quality in a population-based study of older adults during a 10-year observation period.Design, Setting, and Participants A longitudinal case-control cohort study of late-life suicide among a multisite, population-based community sample of older adults participating in the Established Populations for Epidemiologic Studies of the Elderly. Of 14 456 community older adults sampled, 400 control subjects were matched (on age, sex, and study site) to 20 suicide decedents.Main Outcomes and Measures Primary measures included the Sleep Quality Index, the Center for Epidemiologic Studies–Depression Scale, and vital statistics.Results Hierarchical logistic regressions revealed that poor sleep quality at baseline was significantly associated with increased risk for suicide (odds ratio [OR], 1.39; 95% CI, 1.14-1.69; P < .001) by 10 follow-up years. In addition, 2 sleep items were individually associated with elevated risk for suicide at 10-year follow-up: difficulty falling asleep (OR, 2.24; 95% CI, 1.27-3.93; P < .01) and nonrestorative sleep (OR, 2.17; 95% CI, 1.28-3.67; P < .01). Controlling for depressive symptoms, baseline self-reported sleep quality was associated with increased risk for death by suicide (OR, 1.30; 95% CI, 1.04-1.63; P < .05)Conclusions and Relevance Our results indicate that poor subjective sleep quality is associated with increased risk for death by suicide 10 years later, even after adjustment for depressive symptoms. Disturbed sleep appears to confer considerable risk, independent of depressed mood, for the most severe suicidal behaviors and may warrant inclusion in suicide risk assessment frameworks to enhance detection of risk and intervention opportunity in late life.
Article
IMPORTANCE The suicide rate among US Army soldiers has increased substantially in recent years. OBJECTIVES To estimate the lifetime prevalence and sociodemographic, Army career, and psychiatric predictors of suicidal behaviors among nondeployed US Army soldiers. DESIGN, SETTING, AND PARTICIPANTS A representative cross-sectional survey of 5428 nondeployed soldiers participating in a group self-administered survey. MAIN OUTCOMES AND MEASURES Lifetime suicidal ideation, suicide plans, and suicide attempts. RESULTS The lifetime prevalence estimates of suicidal ideation, suicide plans, and suicide attempts are 13.9%, 5.3%, and 2.4%. Most reported cases (47.0%-58.2%) had pre-enlistment onsets. Pre-enlistment onset rates were lower than in a prior national civilian survey (with imputed/simulated age at enlistment), whereas post-enlistment onsets of ideation and plans were higher, and post-enlistment first attempts were equivalent to civilian rates. Most reported onsets of plans and attempts among ideators (58.3%-63.3%) occur within the year of onset of ideation. Post-enlistment attempts are positively related to being a woman (with an odds ratio [OR] of 3.3 [95% CI, 1.5-7.5]), lower rank (OR = 5.8 [95% CI, 1.8-18.1]), and previously deployed (OR = 2.4-3.7) and are negatively related to being unmarried (OR = 0.1-0.8) and assigned to Special Operations Command (OR = 0.0 [95% CI, 0.0-0.0]). Five mental disorders predict post-enlistment first suicide attempts in multivariate analysis: pre-enlistment panic disorder (OR = 0.1 [95% CI, 0.0-0.8]), pre-enlistment posttraumatic stress disorder (OR = 0.1 [95% CI, 0.0-0.7]), post-enlistment depression (OR = 3.8 [95% CI, 1.2-11.6]), and both pre- and post-enlistment intermittent explosive disorder (OR = 3.7-3.8). Four of these 5 ORs (posttraumatic stress disorder is the exception) predict ideation, whereas only post-enlistment intermittent explosive disorder predicts attempts among ideators. The population- attributable risk proportions of lifetime mental disorders predicting post-enlistment suicide attempts are 31.3% for pre-enlistment onset disorders, 41.2% for post-enlistment onset disorders, and 59.9% for all disorders. CONCLUSIONS AND RELEVANCE The fact that approximately one-third of post-enlistment suicide attempts are associated with pre-enlistment mental disorders suggests that pre-enlistment mental disorders might be targets for early screening and intervention. The possibility of higher fatality rates among Army suicide attempts than among civilian suicide attempts highlights the potential importance of means control (ie, restricting access to lethal means [such as firearms]) as a suicide prevention strategy.
Article
The current study explored the relationship between stigma and suicide warning signs using a case vignette methodology. Three comparable vignettes were used varying only the essential warning signs, including heart attack, suicidality without specific mention of suicidal thinking, and suicidality with specific mention of suicidal thoughts and associated intent to die. After reading the vignette, participants responded to questions gauging urgency of response, along with their appraisal of the situation across six domains including: seriousness, time (how quickly should they respond), comfort 1 (how comfortable they were with the situation in general), sureness (how sure they were in their response), comfort 2 (how comfortable they were in implementing their response), and hopefulness (how hopeful they were that their response would be helpful). Consistent with study hypotheses, results indicated that participants were significantly less comfortable, less sure, and less hopeful when responding to a suicidal crisis when compared to a heart attack. In addition, participants were significantly less likely to access emergency services for a seriously suicidal individual in comparison to someone suffering a heart attack, instead choosing to talk with family and friends first. The potential moderating effects of family and individual history of psychiatric illness and treatment, along with current individual psychological symptoms, were also explored and discussed, with no significant impact uncovered. The importance of more targeted efforts to train individuals to not just recognize suicide warning signs, but on how to specifically respond, is emphasized.
Article
This article presents a methodological critique of the predominant research paradigms in modern social psychology, particularly social cognition, taking the approach of Solomon Asch as a more appropriate model. The critique has 2 parts. First, the dominant model of science in the field is appropriate only for a well-developed science, in which basic, real-world phenomena have been identified, important invariances in these phenomena have been documented, and appropriate model systems that capture the essence of these phenomena have been developed. These requirements are not met for most of the phenomena under study in social psychology. Second, the model of science in use is a caricature of the actual scientific process in well-developed sciences such as biology. Such research is often not model or even hypothesis driven, but rather relies on “informed curiosity” to motivate research. Descriptive studies are considered important and make up a substantial part of the literature, and there is less exclusive reliance on experiment. The two parts of the critique are documented by analysis of articles in appropriate psychology and biology journals. The author acknowledges that important and high quality work is currently being done in social psychology, but believes that the field has maladaptively narrowed the range of the phenomena and methodological approaches that it deems acceptable or optimal.
Article
Knowledge of psychological well-being persistently lags behind knowledge of psychological dysfunction. The imbalance is evident in magnitude of research-studies of psychological problems dwarf the literature on positive psychological functioning-and in the meaning of basic terms (e.g., typical usage equates health with the absence of illness). A person is viewed as mentally sound if he or she does not suffer from anxiety, depression, or other forms of psychological symptomatology. This prevailing formulation never gets to the heart of wellness; to do so, we must define mental health as the presence of the positive. To explicate the positive is, however, to grapple with basic values and ideals of the human experience. These values are no less evident in definitions of human suffering, although consensus in identification of the negative is somehow easier to achieve. Despite these challenges, much has been written, within the field of psychology and outside it, regarding the contours of positive psychological functioning.
Article
Psychological science has usually approached the treatment of disorder through research on individual combinations of risk and protective factors (including life experiences, thinking styles, behaviors, social relationships and genes) and the application of interventions that focus on improvements in the individual. However, we can do better than this. Not only should we be aiming to enhance well-being rather than merely reducing disorder, but we should also be doing so for the majority of people rather than the few who have a disorder. In this article, I focus on the mental health spectrum and make the case for a broad population-based approach. I argue that a very small shift in the population mean of the underlying symptoms or risk factors can do more to enhance well-being and reduce disorder than would any amount of intervention with individuals who need help. Examples from research on alcohol abuse and psychological distress are presented to illustrate the value of a population-based approach. © 2009 Association for Psychological Science.
Article
Development of a composite index for use in treatment outcome research with social phobia is described. The index consists of a number of individual outcome measures, and the cutoff scores are based on the performance of a normal control group. Treatment sensitivity of the index was assessed, and the change in classification of social phobics treated with behavioral or drug treatment was determined. At posttreatment, outcome measures revealed significant changes over treatment, and distribution of social phobics on the composite index was more similar to that of normals than at pretreatment. The results are discussed in terms of the usefulness of composite indexes in treatment outcome research and the necessity for such measures to be based on normative data.
Article
Reviews the literature since 1967 on subjective well-being (SWB [including happiness, life satisfaction, and positive affect]) in 3 areas: measurement, causal factors, and theory. Most measures of SWB correlate moderately with each other and have adequate temporal reliability and internal consistency; the global concept of happiness is being replaced with more specific and well-defined concepts, and measuring instruments are being developed with theoretical advances; multi-item scales are promising but need adequate testing. SWB is probably determined by a large number of factors that can be conceptualized at several levels of analysis, and it may be unrealistic to hope that a few variables will be of overwhelming importance. Several psychological theories related to happiness have been proposed; they include telic, pleasure and pain, activity, top–down vs bottom–up, associanistic, and judgment theories. It is suggested that there is a great need to more closely connect theory and research. (7 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)