Researchers have identified the effects of individual and environmental risk factors for suicide over a person’s lifespan

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A review of studies into suicide risk factors at different stages of peoples’ lives, as well as of the effectiveness of assessment and treatment approaches, has found that while some factors such as genetics and family history play a part in suicide risk throughout life, other factors including clinical depression, substance misuse, lack of social support and economic factors become stronger after adolescence.

Publishing in the New England Journal of Medicine (NEJM), the researchers from the University of Oxford and the Karolinska Institutet, Stockholm, found that among individual risk factors for suicide, depression, bipolar disorder, schizophrenia-spectrum disorders, substance use disorders, epilepsy, and traumatic brain injury each increases the odds of completed suicide by a factor of more than 3 during the course of a lifetime.

The researchers looked at the effectiveness of interventions at a population level to target high-risk groups or individuals, such as restricting access to poisons or firearms, but found that these measures vary in effectiveness by country and culture.

Professor Seena Fazel of Oxford University’s Department of Psychiatry, said: ‘This is the first evidence synthesis to look at suicide at a population-wide level and through the course of peoples’ lives, which is particularly useful because many risk factors contribute differentially in childhood, adolescence, and adulthood, and we have attempted to identify both replicated factors and their strength.

The researchers looked at the effectiveness of interventions at a population level to target high-risk groups or individuals, such as restricting access to poisons or firearms, but found that these measures vary in effectiveness by country and culture.

‘Preventing suicide involves understanding the full picture of contributing factors throughout a lifetime, and there is no simple solution or fix. What we wanted to do in this review was to provide an overview of the latest evidence of how to identify higher risk individuals, and one that could be used in any country.’

The researchers concluded that when assessing and treating suicide risk: a person who presents with suicidal thoughts may be at risk for suicide even if there are few overt symptoms of a psychiatric disorder; suicide risk should be assessed by considering predisposing and precipitating factors; the risk of suicide should be managed through regular follow-up and brief psychological therapy; for persons with symptoms of mental illness, pharmacologic treatment should also be considered; the suicidal person, family members, and those who provide care should all take part in ensuring a safe environment, with removal of the means of suicide such as guns or certain medications; if the risk of suicide is considered to be high or uncertain, the person should be referred immediately to mental health services, and the use of risk-assessment tools should be considered to aid risk stratification and communication among services.


In recent decades, suicide prevention initiatives have increased substantially, yet the suicide rate has continued to rise, and suicide deaths are still generally perceived as unexpected. This study sought to identify factors that might account for this discrepancy by focusing on the exhibition of suicide warning signs.

Methods: Qualitative interviews were conducted with 15 adults [mean age = 36 (SD = 14), 93% female] who had attempted suicide at least once in their lifetime.

Results: A disconnect between participants and their environment emerged as a central theme. Many expressed ambivalence about whether they wanted others to intervene before their attempts, resulting in either expression or inhibition of warning signs.

Regardless of whether they wanted their attempt to be predictable, most participants expressed disappointment if they perceived a lack of intervention before their attempt. In some cases, this disappointment exacerbated distress and may have contributed to the attempt itself.

Participants also expressed difficulty disclosing their suicidal ideation to others. Thus, even if they wanted help, participants were unsure how to effectively attain it.

Conclusions: Findings underscore the complexity of predicting and preventing suicide; however, engaging individuals with lived experience in these efforts facilitates greater understanding toward outreach and intervention approaches.

Over the past twenty years, the rate of suicide fatalities has increased substantially; the age-adjusted suicide rate increased by 33% from 10.5 to 14.0 per 100,000 from 1999 through 2017. (Centers for Disease Control and Prevention [CDC], 2018). This increase, in addition to the general categorization of suicide as an unexpected form of dying (Bailley, Kral, & Dunham, 1999; Ellenbogen & Gratton, 2001), highlights a significant public health concern in need of extensive research attention.

Over the past several years, global suicide prevention initiatives have increased substantially to try and address this dilemma (Arensman, 2017). The World Health Organization (WHO), the International Association for Suicide Prevention, and the American Association of Suicidology (AAS) are just a few of the organizations that have created action plans, a World Suicide Prevention day, and websites listing common warning signs (i.e., specific signs that have the potential to be noticed by others and suggest imminent intent to die) and risk factors to spread suicide awareness (AAS, 2017; Arensman, 2017; Dedić, 2016; Rudd et al., 2006).

The “IS PATH WARM?” mnemonic is another example of an effort to ease public recognition and recollection of common warning signs (i.e., suicide ideation, substance abuse, purposelessness, anxiety, feeling trapped, hopelessness, withdrawal, anger, recklessness, and mood changes; AAS, 2017).

Additional studies have explored cognitive warning signs for suicide, including state hopelessness, conceptualizing suicide as a solution, fixation on suicide, focus on escape, and loneliness (e.g., Adler et al., 2016).

However, despite these organizational efforts to raise awareness, the general public may not understand what to look for as “warning signs” of suicide (Latakiene, Skruibis, Dadasev, Grizas, Dapseviciute, & Gailiene, 2016).

An analysis of suicide communication processes in a Lithuanian study supports this claim (Latakienė et al., 2016). Findings suggest that although suicide attempters tried to reach out to others prior to or after their attempt, only when the expression of warning signs was made during an actual attempt, did other people end up actively trying to prevent the attempt by going to the location of the act, calling an ambulance, or organizing help from a distance.

In fact, the most common reactions to disclosure prior to an attempt were disbelief and general unresponsiveness. It seems that individuals surrounding the attempters were not aware of the seriousness of intent (Latakienė et al., 2016) and thus, may have overlooked important warning signs. Consequently, this lack of support was a compelling contributing factor to heightened risk of suicide.

Therefore, increasing public awareness of common warning signs through active didactics has been a focus of suicide prevention efforts, instead of relying on a passive list of potential signs. Madson and Vas (2003) conducted an activity-based task including fictional vignettes in a college psychology course to assess the participants’ abilities to point out risk factors associated with suicide.

Importantly, after a discussion about the “correct” answers—which established which person was most likely to die by suicide—participants in the study demonstrated improved ability to recognize risk factors on a subsequent assessment. Several additional studies also indicate the potential effect of educational intervention on understanding signs of risk (Lamis, Underwood, & D’Amore, 2016; Pisano, Cross, Watts, & Conner, 2011; Tsai, Lin, Chang, Yu, & Chou, 2011). Although the public seems to benefit from learning about common warning signs in order to identify them more readily (e.g., Lamis et al., 2016; Madson & Vas, 2003; Pisani et al., 2011; Tsai et al., 2011), research suggests that the “IS PATH WARM?” model is not a valid way to predict who will attempt suicide (Lester, McSwain, & Gunn, 2011).

Similarly, other publicly available lists of warning signs are not evidence-based and do not appear to be situated within a theoretical framework. This is largely a reflection of the limitations in our ability to predict suicide attempts and deaths more generally. For instance, a recent meta-analysis of 50 years of research regarding risk factors of suicide has indicated that present risk factors for suicidal thoughts and behaviors are weak and erroneous (Franklin et al., 2017).

Despite substantial efforts, results also suggested that the predictive ability of recognizing individuals at risk of suicide has not improved over the past 50 years (Franklin et al., 2017).

Many warning signs require observing the suicidal individual and recognizing expressions or communications of potential risk (e.g., AAS, 2017); however, the rising suicide rates suggest this approach to recognizing risk may be insufficient.

Although there is research suggesting that the majority of people who attempt suicide communicate directly and/or indirectly about their ideation and intent prior to their attempt (Hawton, Houston, & Shepperd, 1999; Robins, Gassner, Kayes, Wilkinson, & Murphy, 1959; Rudestam, 1971), suicide remains difficult to predict.

Therefore, it is important to examine the discrepancy in reported rates of communication and the perception that suicide is unpredictable. At least three potential issues may be at play:

1) communication happens but is misinterpreted, unrecognized, and/or expressed in ambiguous ways,

2) communication happens but is invalidated (e.g., not taken seriously, lack of intervention), and

3) communication does not happen due to the anticipation of stigmatizing reactions and/or fears of placing burden on others.

The complexity of circumstances prior to suicide attempts are considerable (e.g., attempts may even be surprising to the attempter; Ghio et al., 2011); however, several theories may help to explain the discrepancies between displays or perceptions of suicide warning signs and prospective prediction of suicidal behaviors.

Specifically, the actor-observer bias, the biosocial theory, and the interpersonal-psychological theory of suicide provide potentially useful frameworks from which to view these multifaceted interpersonal dynamics.

Although it has been demonstrated that suicidal individuals may neither perceive a need for help nor want it (e.g., Bruffaerts et al., 2011; Czyz, Horwitz, Eisenberg, Kramer, & King, 2013), it is possible that some suicidal individuals are communicating about their risk, but signs are being misinterpreted or unrecognized.

Specifically, perhaps the warning signs that attempters believe they are exhibiting are not as salient to others as they are to the attempters themselves. This may indicate that perception or observer expectation plays an important role in recognizing the warning signs of suicide. Jones and Nisbett (1972) posited that there are different ways in which individuals understand an event based on whether they are actively participating in the event, or simply observing the event.

This actor-observer bias suggests that actors tend to attribute causes to situational factors (e.g., I fell because the road was icy), while observers tend to attribute causes to personal factors (e.g., she fell because she is clumsy). Although substantial research has been dedicated to exploring this effect, results are inconsistent (Aronson, 2002; Fiske & Taylor, 1991; Jones, 1976; Malle, 2006; Watson, 1982) and more research in different contexts is needed.

For instance, applying this theory to the experience of a suicide attempter, it is possible that the suicide attempter (actor) might believe they are expressing warning signs and are yearning for their environment to aid them in feeling better, yet those in their environment (observers) may think the expression of possible warning signs are simply characteristics of their personality, not realizing that the suicide attempters may be trying to elicit help from those around them.

As a result, it is possible that suicidal individuals believe they are directly communicating about their risk, yet might be expressing ambiguous signs (Robins et al., 1959); if this is the case, a discrepancy between the attempter and observers may result in missed opportunities for intervention.

Few studies to date have explored this concept within suicide-specific contexts and the few that have, are over three decades old, leaving several unanswered questions. One study investigated responses from hospital physicians regarding, among other things, circumstances under which they would kill themselves.

Results demonstrated that the primary drive for participants’ hypothetical suicides was the presence of an incurable disease, supporting the importance of personal factors when “actors” are evaluating possible causes for events; factors associated with relationships (situational factors) were assigned a secondary causal role (Reimer & Doenges, 1981). Another study sought to explore differences in perceptions of why individuals might attempt suicide (Goggin, Range, & Brandt, 1986).

Participants were randomly divided into two groups, each reading a one-paragraph vignette about a female that died by suicide and her sister. The two groups differed only in that one group was asked to imagine that they were the suicidal female in the story (actor role) and the other was told the story was about a female named Jeanne (observer role). The “actor” group attributed the cause of their suicide to be the psychological disturbance of their “sister” (situational factor).

Although these results provide promising support for this actor-observer paradigm in relation to perceptions of suicide, in both studies, participants had no history of suicide attempts and were asked to complete self-report questionnaires/vignettes about hypothetical situations that included suicidal individuals and their environmental circumstances (Goggin et al., 1986; Reimer & Doenges, 1981).

Participants also imagined themselves as suicide attempters to create the “actor” bias, rather than having personal lived experience. Importantly, a third study of the actor-observer bias did include suicide attempters (Hawton, Cole, O’Grady, & Osborn, 1982) and demonstrated promising results by comparing adolescent suicide attempters’ reported motivations for overdosing with the perceptions of their clinical assessors. Hawton et al. (1982) found that clinical assessors (observers) were more likely to perceive a suicide attempt as “manipulative” (personal attribution), while the suicide attempters (actors) reported the urge to rid themselves of unpleasant feelings and/or to demonstrate distress as a result of relationship stressors (situation attribution).

Although these findings support the potential actor-observer bias in suicidal populations, additional research is needed to replicate these results, further research this potential dynamic in lived experience samples, and explore whether the actor-observer bias can explain why suicide is still generally seen as an unexpected cause of death (Bailley et al., 1999; Ellenbogen & Gratton, 2001) to loved ones left behind (observers). Specifically, warning signs exhibited by suicide attempters (actors) may be overlooked or misinterpreted as a result of differing perceptions of the same situation.

This possible inconsistency between the perception of those suffering—who think their suffering is clear and obvious to others—and the individuals around them—who do not notice the suffering or do not take it seriously—may result in the perception of an invalidating environment for suicidal individuals.

It is also possible that individuals observing warning signs, recognize them and understand them to be serious, but for some reason (e.g., not knowing what to do) do not act on them (e.g., Wolk‐Wasserman, 1986). In either case, the way others respond to communication may affect the likelihood of communication occurring again in the future. The biosocial theory suggests that a combination of biological factors and a dysfunctional or invalidating environment can result in the development of psychopathology and dysfunctional behaviors (Linehan, 1993).

Therefore, it is possible that invalidating responses to the expression of warning signs can increase urges to die by suicide. Consequently, suicidal individuals may intentionally begin to suppress or obscure the expression of warning signs because they believe they won’t be met with favorable reactions. One study, involving Turkish and Swedish adolescents, provides support for this hypothesis; results demonstrated that many suicidal individuals did not disclose their suicidal urges because they believed they couldn’t tell anyone in their life, believed no one could help them, and were fearful of judgmental reactions (Eskin, 2003).

Veiel, Brill, Hafner, and Welz (1988) provided further evidence to support the claim that anticipated reactions from others might greatly impact whether or not suicidal individuals disclose their urges to die by suicide. Researchers found that although daily positive interactions were important for suicidal individuals to feel socially integrated, they were not the most important aspect of social interaction.

Notably, crisis support was found to reduce the impact of stressful effects in suicidal populations. This suggests that perceived validation during a crisis (i.e., taking the crisis seriously, offering support, responding in a validating manner), rather than simply having an available social network, may play a particularly important role for suicidal individuals.

The number of individuals who can provide this crisis support may be small and thus, potential attempters may only express warning signs to certain people, leaving others unaware of their circumstances.

Myriad research has also shown that negative attitudes and stigma toward suicide attempters are pervasive across community and clinical settings (Binnix, Rambo, Abrutyn, & Mueller, 2018; Lester & Walker, 2006; Pompili, Girardi, Ruberto, Kotzalidis, & Tatarelli, 2005). In order to avoid stigmatization, it is probable that suicidal individuals choose not to communicate warning signs. In fact, suicide attempt survivors experience self-stigma in addition to stigma from others (Sheehan, Corrigan, & Al-Khouja, 2016).

In one study, an attempter believed he was “weak” and another thought “something was wrong with him” (Sheehan et al., 2016). Sheehan et al. (2016) also found non-fatal suicide attempters were commonly seen as attention-seeking, selfish, incompetent, emotionally weak, and immoral. Additionally, attempters in another study indicated feelings of stigma related to overgeneralization about the severity of their attempt, creating feelings of hopelessness regarding their recovery (Rimkeviciene, Hawgood, O’Gorman, & De Leo, 2015). It is apparent that feelings of stigma experienced by suicide attempters may even further increase risk of subsequent suicidal behaviors (Oexle et al., 2018).

In addition to the anticipation of unfavorable responses (e.g., invalidation, lack of intervention, stigma), feelings of burdensomeness may also contribute to suppression of warning signs by suicidal individuals. Joiner’s interpersonal-psychological theory of suicide (2005) posits that the presence of thwarted belongingness (the belief that one does not belong) and perceived burdensomeness (the belief that one’s existence creates a burden on loved ones) leads to the desire for suicide. In combination with the acquired capability to make the attempt, these experiences lead to an increased probability of attempting suicide.

A recent comprehensive review of twenty-seven research studies involving clinical samples supports this theory, demonstrating consistent associations between perceived burdensomeness and both suicidal ideation and suicide attempts (Hill & Pettit, 2014). Taking this theory into account, it is possible that suicidal individuals, who often might already feel like they are a resource liability, struggle to communicate their suicidal thoughts and/or behaviors because they do not want to worry others or put pressure upon others to intervene.

Thus, suicidal individuals may suppress signs that they are contemplating suicide to prevent further feelings of being a burden on others. Findings from a recent qualitative study exploring the motivation behind choosing to disclose suicidal urges has supported this hypothesis (Fulginiti & Frey, 2018).

Specifically, results indicated that individuals with lived experience that reported increased tendencies to disclose their suicidal urges also reported lower levels of burdensomeness prior to disclosure (Fulginiti & Frey, 2018).

In summary, there are several possible explanations for the discrepancy between increased suicide prevention initiatives alongside the continued perception of suicide as unexpected to loved ones left behind. It is possible that attempters do exhibit warning signs; however, others don’t recognize, understand, and/or validate them, creating an invalidating environment.

It is also possible that attempters gradually begin to suppress signs because of feared stigma from others and/or feelings of burdensomeness. This in turn may lead to increased difficulty for potential observers to recognize warning signs and suicide risk.

It is also possible that attempters try to suppress their suffering from the start, resulting in loved ones not being given the opportunity to realize individuals are at imminent risk.

The WHO has estimated that more than 800,000 individuals die by suicide each year (Dedić, 2016); thus, past approaches to identify and understand the warning signs of suicide may be insufficient.

Past research has indicated that the majority of individuals who attempt suicide communicate directly and/or indirectly about their ideation and intent prior to their attempt (Hawton et al., 1999; Robins et al., 1959; Rudestam, 1971), yet suicide remains difficult to predict. Therefore, investigating relevant factors associated with risk by speaking directly to suicide attempters may be most enlightening.

These individuals are best suited to provide information about their exhibition of warning signs prior to an attempt and may provide insight as to why deaths by suicide are still seen as predominantly unexpected. Speaking directly to suicide attempters also provides an important opportunity to understand the “actor’s” point of view which enables us to evaluate the presence of the actor-observer bias without having to use hypothetical vignettes and participants’ imaginations.

Guided by the prior literature, the aim of the current study was to understand what factors contribute to the discrepancy between known warning signs and suicide predictability using qualitative interviews with adults with lived experience of suicide attempts. Conducting qualitative research is vital within this population (Cutcliffe, 2003) and allows attempters to discuss their unique perceptions of the warning signs that they may or may not have exhibited to others, what led to their decisions to disclose or withhold, and the reactions they received.


Source:
Oxford University

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