The Internal Struggle Between the Wish to Die and the Wish to Live: A Risk Factor for Suicide
A study group of 5,814 patients, including 44 who committed suicide (0.8%), were recruited from a psychiatric outpatient clinic. Structured diagnostic interviews and clinician ratings of the wish to live and wish to die were conducted. The outcome variable was the occurrence of suicide, as indicated on death certificates.
A dichotomized index score of the difference between the wish to live and the wish to die yielded a hazard ratio of 6.51 for suicide. This index contributed a unique risk for suicide after the authors controlled for age, psychiatric hospitalization, suicide attempts, bipolar disorder, major depressive disorder, and unemployment status.
The difference between the wish to die versus the wish to live is a unique risk factor for suicide.
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Article: The Internal Struggle Between the Wish to Die and the Wish to Live: A Risk Factor for Suicide
[Show abstract] [Hide abstract] ABSTRACT: Adolescents comprise a unique and often challenging group of patients with diverse presentations to the Mental Health Services; suicidal behavior being one of them. The main aim of this naturalistic project was to investigate demographic and clinical correlates of adolescent suicidal and self-harm events, which may be of value to decision-making in clinical practice. All adolescents (n = 149) registered and actively managed by a specialist community mental health service in South London were included in the study. Clinical information from their files was used to determine suicidality/self-harm events. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) was utilised for classification purposes. Logistic regression was used to explore the effects of age, sex, diagnosis, medication, substance use (alcohol and/or cannabis) and ethnicity on suicidality/self-harming behaviors. Age, sex and use of psychotropic medication were identified to play a significant role in determining the risk of engaging in self-harming behavior. The risk was higher with increasing age and female sex. Medication seemed to have a protective effect. Reporting a 20% prevalence of non-suicidal self-injury (NSSI) in our population, we highlight the importance of NSSI as a distinct diagnostic category. Our findings have implications for risk assessment and appropriate decision-making in clinical settings. Results are translatable and relevant to other metropolitan areas.
- "Furthermore, our results imply increased severity and probably lethality in the self-harming behavior, with increasing age as highlighted by increased likelihood of suicide intent and attempting suicide. This is of particular importance, as the intent to die portends a risk for future suicide and repeated attempts (Oquendo et al., 2004) and can be reliably ascertained (Brown et al., 2005). "
- "When intent and ideation are not distinguished, ideation not characterized by intent to act is unrecognized. Current classification systems distinguish intent to act from suicidal ideation, and thoughts or plans about suicide without any intent to act are still considered suicidal ideation (Brown et al., 2005), though a less severe form (Posner et al., 2011; Silverman et al., 2007). It is important to note that intent to act and intent to die are different concepts. "
[Show abstract] [Hide abstract] ABSTRACT: Major depression occurs at high prevalence in the general population, often starts in juvenile years, recurs over a lifetime, and is strongly associated with disability and suicide. Searches for biological markers in depression may have been hindered by assuming that depression is a unitary and relatively homogeneous disorder, mainly of mood, rather than addressing particular, clinically crucial features or diagnostic subtypes. Many studies have implicated quantitative alterations of motility rhythms in depressed human subjects. Since a candidate feature of great public-health significance is the unusually high risk of suicidal behavior in depressive disorders, we studied correlations between a measure (vulnerability index [VI]) derived from multi-scale characteristics of daily-motility rhythms in depressed subjects (n = 36) monitored with noninvasive, wrist-worn, electronic actigraphs and their self-assessed level of suicidal thinking operationalized as a wish to die. Patient-subjects had a stable clinical diagnosis of bipolar-I, bipolar-II, or unipolar major depression (n = 12 of each type). VI was associated inversely with suicidal thinking (r = -0.61 with all subjects and r = -0.73 with bipolar disorder subjects; both p<0.0001) and distinguished patients with bipolar versus unipolar major depression with a sensitivity of 91.7% and a specificity of 79.2%. VI may be a useful biomarker of characteristic features of major depression, contribute to differentiating bipolar and unipolar depression, and help to detect risk of suicide. An objective biomarker of suicide-risk could be advantageous when patients are unwilling or unable to share suicidal thinking with clinicians.
- "The strong negative association between VI and self-rated suicidal thinking or wish to die, and its positive association with self-rated vital drive or wish to live suggest that VI may be associated specifically with contrasting forces that often confront one other in mood disorder patients–the wish to die and the wish to live . The lack of correlations between VI and other subjective phenomenological measures, including depressed mood, dysphoria, anxiety, unusual body-perception experiences (cœnesthesias), and autonomic-neurovegetative symptoms suggests at least two levels of subjective psychopathology in depression: [a] experiences of decreased fundamental vitality rooted in psychomotor activity (reflected in VI scores), and [b] more cognitive experiences of hopelessness-helplessness (self-rated depression) or of anguish, fear, anger and distress (self-rated anxiety and dysphoria) associated with abnormal somatic experiences (self-rated autonomic-cœnesthetic symptoms). "