The international handbook of suicide prevention [2nd Edition] 9781118903223, 1118903226, 9781118903230, 1118903234, 9781118903247, 1118903242, 9781118903278, 1118903277

Citation preview

The International Handbook of Suicide Prevention

For two people who made me a better person. Dr Clare Cassidy (1968–2008) I continue to be inspired by Clare’s memory daily. An amazing friend and colleague. “But then with autumn upon us, so breezy and cruel, Clare left us in Paris, heartbroken and cool. But we remember Clare’s grace, her beauty, her light; Her kindness, her smile and sadness, its might.” (RO’C, 2008) Professor Noel Sheehy (1955–2011) One day in the summer of 1994 Noel asked me whether I might be interested in undertaking a PhD on suicide—without hesitation I jumped at the chance. Without him, I would never have embarked on a career in suicide research. He took a chance on me. For this (and many other things besides) I will always be grateful. So kind and generous. In my thoughts Rory C. O’Connor

The International Handbook of Suicide Prevention Second Edition Edited by

Rory C. O’Connor and Jane Pirkis

This second edition first published 2016 © 2016 John Wiley & Sons, Ltd Edition history: John Wiley & Sons, Ltd (1e, 2011) Registered Office John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Offices 350 Main Street, Malden, MA 02148‐5020, USA 9600 Garsington Road, Oxford, OX4 2DQ, UK The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley‐blackwell. The right of Rory C. O’Connor and Jane Pirkis to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Limit of Liability/Disclaimer of Warranty: While the publisher and authors have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. It is sold on the understanding that the publisher is not engaged in rendering professional services and neither the publisher nor the author shall be liable for damages arising herefrom. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloging‐in‐Publication Data Names: O’Connor, Rory C., editor. | Pirkis, Jane, editor. Title: The international handbook of suicide prevention / edited by Rory C. O’Connor and Jane Pirkis. Description: 2nd Edition. | Hoboken : Wiley, 2016. | Revised edition of International handbook of suicide prevention research, policy and practice, 2011. | Includes bibliographical references and index. Identifiers: LCCN 2016021173 (print) | LCCN 2016022004 (ebook) | ISBN 9781118903278 (cloth) | ISBN 9781118903230 (pdf) | ISBN 9781118903247 (epub) Subjects: LCSH: Suicide–Prevention–Research. | Suicidal behavior–Research. Classification: LCC HV6545 .I594 2016 (print) | LCC HV6545 (ebook) | DDC 616.85/8445–dc23 LC record available at https://lccn.loc.gov/2016021173 A catalogue record for this book is available from the British Library. Cover image: Gettyimages/Kenichi Sotozaki / EyeEm Set in 10/12pt Galliard by SPi Global, Pondicherry, India

1 2016

To all those who have been affected by suicide and to those who struggle daily to stay alive.

To Suzy, Poppy, and Oisin for all their continued support

Contents

Notes on Contributors

xi

Introduction1 Rory C. O’Connor and Jane Pirkis Part I  Suicidal Determinants and Frameworks   1 Challenges to Defining and Classifying Suicide and Suicidal Behaviors Morton M. Silverman

9 11

  2 International Perspectives on the Epidemiology and Etiology of Suicide and Self‐Harm36 Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur   3 Self‐Harm: Extent of the Problem and Prediction of Repetition Ella Arensman, Eve Griffin, and Paul Corcoran

61

  4 Major Mood Disorders and Suicidal Behavior Zoltán Rihmer and Peter Döme

74

  5 Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior Antoine Desîlets, Myriam Labossière, Alexander McGirr, and Gustavo Turecki

93

  6 Substance Use Disorders and Suicidal Behavior: A Conceptual Model Kenneth R. Conner and Mark A. Ilgen

110

  7 Personality Disorders and Suicidality Joel Paris

124

  8 The Association Between Physical Illness/Medical Conditions and Suicide Risk Maurizio Pompili, Alberto Forte, Alan L. Berman, and Dorian A. Lamis

133

  9 Relationships of Genes and Early‐Life Experience to the Neurobiology of Suicidal Behavior149 J. John Mann and Dianne Currier 10 Understanding the Suicidal Brain: A Review of Neuropsychological Studies of Suicidal Ideation and Behavior Kees van Heeringen and Stijn Bijttebier

170

viii Contents 11 Visualizing the Suicidal Brain: Neuroimaging and Suicide Prevention Katherin Sudol and Maria A. Oquendo 12 Present Status and Future Prospects of the Interpersonal–Psychological Theory of Suicidal Behavior Christopher R. Hagan, Jessica D. Ribeiro, and Thomas E. Joiner 13 The Integrated Motivational‐Volitional Model of Suicidal Behavior: An Update Rory C. O’Connor, Seonaid Cleare, Sarah Eschle, Karen Wetherall, and Olivia J. Kirtley 14 Sociological Perspectives on Suicide: A Review and Analysis of Marital and Religious Integration Steven Stack and Augustine J. Kposowa

188

206

220

241

15 Inequalities and Suicidal Behavior Stephen Platt

258

16 Economic Recession, Unemployment, and Suicide David Gunnell and Shu‐Sen Chang

284

Part II  Intervention, Treatment, and Care

301

17 Evidence‐Based Prevention and Treatment of Suicidal Behavior in Children and Adolescents Yari Gvion and Alan Apter

303

18 Prevention and Treatment of Suicidality in Older Adults Diego De Leo and Urška Arnautovska

323

19 Therapeutic Alliance and the Therapist Konrad Michel

346

20 Clinical Care of Self‐Harm Patients: An Evidence‐Based Approach Keith Hawton and Kate E. A. Saunders

362

21 After the Suicide Attempt—The Need for Continuity and Quality of Care Lars Mehlum and Erlend Mork

387

22 Management of Suicidal Risk in Emergency Departments: A Clinical Perspective403 Simon Hatcher 23 Treating the Suicidal Patient: Cognitive Therapy and Dialectical Behavior Therapy416 Nadine A. Chang, Shari Jager‐Hyman, Gregory K. Brown, Amy Cunningham, and Barbara Stanley 24 Lessons Learned from Clinical Trials of the Collaborative Assessment and Management of Suicidality (CAMS) David A. Jobes, Katherine Anne Comtois, Lisa A. Brenner, Peter M. Gutierrez, and Stephen S. O’Connor

431

Contents ix 25 Modes of Mind and Suicidal Processes J. Mark G. Williams, Danielle S. Duggan, Catherine Crane, Silvia R. Hepburn, Emily Hargus, and Bergljot Gjelsvik

450

26 Brief Contact Interventions: Current Evidence and Future Research Directions466 Allison J. Milner and Gregory L. Carter 27 Delivering Online Cognitive Behavioral Therapy Interventions to Reduce Suicide Risk Ad Kerkhof and Bregje van Spijker 28 Helplines, Tele‐Web Support Services, and Suicide Prevention Alan Woodward and Clare Wyllie Part III  Suicide Prevention: Bringing Together Evidence, Policy, and Practice

480 490

505

29 Suicide Prevention in Low‐ and Middle‐Income Countries Lakshmi Vijayakumar and Michael Phillips

507

30 Suicide in Asia: Epidemiology, Risk Factors, and Prevention Murad M. Khan, Nargis Asad, and Ehsanullah Syed 

524

31 Cultural Factors in Suicide Prevention Lai Fong Chan and Maniam Thambu

541

32 Suicide Prevention Strategies: Case Studies from Across the Globe Gergö Hadlaczky, Danuta Wasserman, Christina W. Hoven, Donald J. Mandell, and Camilla Wasserman

556

33 Rurality and Suicide Cameron R. Stark, Vincent Riordan, and Nadine Dougall

569

34 Why Mental Illness is a Risk Factor for Suicide: Implications for Suicide Prevention Brian L. Mishara and François Chagnon 35 Suicide Prevention Through Restricting Access to Suicide Means and Hotspots Ying‐Yeh Chen, Kevin Chien‐Chang Wu,Yun Wang, and Paul S. F. Yip

594

609

36 Reducing Suicide Without Affecting Underlying Mental Health: Theoretical Underpinnings and a Review of the Evidence Base Linking the Availability of Lethal Means and Suicide637 Deborah Azrael and Matthew J. Miller 37 Surviving the Legacy of Suicide Onja T. Grad and Karl Andriessen

663

38 Suicide Prevention Through Personal Experience DeQuincy A. Lezine

681

x Contents 39 Time to Change Direction in Suicide Research Heidi Hjelmeland and Birthe Loa Knizek

696

40 Suicide Research Methods and Designs Catherine R. Glenn, Joseph C. Franklin, Jaclyn C. Kearns, Elizabeth C. Lanzillo, and Matthew K. Nock

710

41 School‐Based Suicide Prevention Programs Lynda Kong, Jitender Sareen, and Laurence Y. Katz

725

42 Media Influences on Suicidal Thoughts and Behaviors Jane Pirkis, Katherine Mok, Jo Robinson, and Merete Nordentoft

743

43 Suicide Clusters Jo Robinson, Jane Pirkis, and Rory C. O’Connor

758

44 Making an Economic Case for Investing in Suicide Prevention: Quo Vadis? David McDaid

775

Index 791

Notes on Contributors

Karl Andriessen School of Psychiatry University of New South Wales Randwick NSW Australia

Nargis Asad Department of Psychiatry Aga Khan University Karachi Pakistan

Alan Apter Feinberg Child Study Center Schneider’s Children’s Medical Center of Israel Petach Tikvah and Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel

Deborah Azrael Harvard Injury Control Research Center Harvard T.H. Chan School of Public Health Boston, Massachusetts USA

Ella Arensman National Suicide Research Foundation Department of Epidemiology and Public Health WHO Collaborating Centre for Surveillance and Research in Suicide Prevention University College Cork Cork Ireland Urška Arnautovska Australian Institute for Suicide Research and Prevention WHO Collaborating Centre on Research and Training in Suicide Prevention Griffith University Australia

Alan L. Berman Department of Psychiatry Johns Hopkins School of Medicine Baltimore, Maryland USA Stijn Bijttebier Unit for Suicide Research Ghent University Ghent Belgium Lisa A. Brenner VA Veteran Integrated Service Network 19 – Mental Illness Research Education, & Clinical Center Denver Colorado USA

xii

Notes on Contributors

Gregory K. Brown Department of Psychiatry University of Pennsylvania Pennsylvania USA Gregory L. Carter Centre for Translational Neuroscience and Mental Health Faculty of Health and Medicine University of Newcastle, Callaghan Australia François Chagnon Centre for Research and Intervention on Suicide and Euthanasia and Psychology Department Université du Québec à Montréal Montréal, Québec Canada Lai Fong Chan Department of Psychiatry Universiti Kebangsaan Malaysia [National University of Malaysia] Kuala Lumpur Malaysia Nadine A. Chang Department of Psychiatry Mount Sinai St. Luke’s Hospital New York USA

Seonaid Cleare Suicidal Behaviour Research Laboratory Institute of Health & Wellbeing University of Glasgow Glasgow Scotland UK Katherine Anne Comtois Department of Psychiatry and Behavioral Sciences and Department of Psychology Harborview Medical Center University of Washington Seattle Washington USA Kenneth R. Conner University of Rochester Medical Center Rochester New York USA VA VISN 2 Center of Excellence Canandaigua New York USA

Shu‐Sen Chang Institute of Health Behaviors and Community Sciences and Department of Public Health College of Public Health National Taiwan University Taiwan

Paul Corcoran National Suicide Research Foundation Department of Epidemiology and Public Health National Perinatal Epidemiology Centre WHO Collaborating Centre for Surveillance and Research in Suicide Prevention University College Cork Cork Ireland

Ying‐Yeh Chen Taipei City Psychiatric Center Taipei City Hospital & National Yang‐Ming University Taipei Taiwan

Catherine Crane Oxford Mindfulness Centre Department of Psychiatry University of Oxford England UK



Notes on Contributors

Amy Cunningham Centre for Acceptance and Change Pennsylvania USA Dianne Currier Centre for Epidemiology and Biostatistics Melbourne School of Population and Global Health University of Melbourne Melbourne Australia Diego De Leo Australian Institute for Suicide Research and Prevention WHO Collaborating Centre on Research and Training in Suicide Prevention and Life Promotion Clinic Griffith University Australia

Danielle S. Duggan Oxford Mindfulness Centre Department of Psychiatry University of Oxford England UK Sarah Eschle Suicidal Behaviour Research Laboratory Institute of Health & Wellbeing University of Glasgow Glasgow Scotland UK Alberto Forte Department of Neurosciences, Mental Health and Sensory Organs Suicide Prevention Center Sant’Andrea Hospital Sapienza University of Rome Italy

Antoine Desîlets McGill Group for Suicide Studies Douglas Mental Health University Institute McGill University Montreal Canada

Joseph C. Franklin Department of Psychology Vanderbilt University Nashville Tennessee USA

Peter Döme Laboratory for Suicide Research and Prevention National Institute of Psychiatry and Addictions Budapest Hungary

Bergljot Gjelsvik Oxford Mindfulness Centre Department of Psychiatry University of Oxford Oxford England UK

Nadine Dougall NMAHP Research Unit School of Health Sciences University of Stirling Stirling Scotland UK

Catherine R. Glenn Department of Clinical and Social Sciences in Psychology University of Rochester Rochester New York USA

xiii

xiv

Notes on Contributors

Onja T. Grad Centre for Mental Health University Psychiatric Hospital Ljubljana Slovenia Eve Griffin National Suicide Research Foundation WHO Collaborating Centre for Surveillance and Research in Suicide Prevention University College Cork Cork Ireland

Emily Hargus Oxford Mindfulness Centre Department of Psychiatry University of Oxford Oxford England UK Simon Hatcher Department of Psychiatry University of Ottawa Ottawa Canada

David Gunnell School of Social and Community Medicine University of Bristol England UK

Keith Hawton Centre for Suicide Research Department of Psychiatry University of Oxford England UK

Peter M. Gutierrez VA Veteran Integrated Service Network 19 – Mental Illness Research, Education and Clinical Center Denver Colorado USA

Silvia R. Hepburn Department of Clinical Health Psychology St Mary’s Hospital England UK

Yari Gvion Department of Psychology Bar Ilan University Ramat Gan Israel Gergö Hadlaczky National Centre for Suicide Research and Prevention of Mental lll‐Health (NASP) Karolinska Institutet Stockholm Sweden Christopher R. Hagan Laboratory for the Study and Prevention of Suicide‐Related Conditions and Behaviors Department of Psychology Florida State University USA

Heidi Hjelmeland Department of Social Work and Health Science Norwegian University of Science and Technology Trondheim Norway Christina W. Hoven Department of Epidemiology and Division of Child Psychiatry Child Psychiatric Epidemiology Group, College of Physicians and Surgeons and Mailman School of Public Health, Columbia University New York State Psychiatric Institute New York USA



Notes on Contributors

Isabelle M. Hunt Centre for Suicide Prevention Centre for Mental Health and Safety University of Manchester Manchester England UK Shari Jager‐Hyman Aaron T. Beck Psychopathology Research Center University of Pennsylvania Pennsylvania USA Mark A. Ilgen VA Serious Mental Illness Treatment Research and Evaluation Center & University of Michigan Department of Psychiatry Ann Arbor Michigan USA David A. Jobes Suicide Prevention Lab Department of Psychology The Catholic University of America Department of Psychology Washington, DC USA Thomas E. Joiner Laboratory for the Study and Prevention of Suicide‐Related Conditions and Behaviors Department of Psychology Florida State University USA Navneet Kapur Centre for Suicide Prevention Centre for Mental Health and Safety University of Manchester Manchester England UK

xv

Laurence Y. Katz Department of Psychiatry University of Manitoba Winnipeg Canada Jaclyn C. Kearns National Center for PTSD VA Boston Healthcare System Boston Massachusetts USA Ad Kerkhof Department of Clinical, Neuro, and Developmental Psychology and the EMGO Institute for Health and Care Research Faculty of Behavioural and Movement Sciences VU University Amsterdam The Netherlands Murad M. Khan Department of Psychiatry Aga Khan University Karachi Pakistan Olivia J. Kirtley Suicidal Behaviour Research Laboratory Institute of Health & Wellbeing University of Glasgow Glasgow Scotland UK Birthe Loa Knizek Department of Applied Social Sciences Department of Social Work and Health Science Norwegian University of Science and Technology Trondheim Norway Lynda Kong Department of Psychiatry University of Manitoba Winnipeg Canada

xvi

Notes on Contributors

Augustine J. Kposowa Department of Sociology University of California Riverside USA Myriam Labossière McGill Group for Suicide Studies Douglas Mental Health University Institute McGill University Montreal Canada Dorian A. Lamis Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Atlanta Georgia USA Elizabeth C. Lanzillo Department of Psychology Brown University Rhode Island USA DeQuincy A. Lezine Prevention Communities Fresno California USA Donald J. Mandell International Center for Child Mental Health National Center for Disaster Preparedness Mailman School of Public Health Columbia University New York State Psychiatric Institute New York USA Maniam Thambu Department of Psychiatry Universiti Kebangsaan Malaysia [National University of Malaysia] Kuala Lumpur Malaysia

J. John Mann Division of Molecular Imaging & Neuropathology Department of Psychiatry College of Physicians and Surgeons Columbia University New York State Psychiatric Institute USA David McDaid Personal Social Services Research Unit LSE Health and Social Care London School of Economics and Political Science London UK Alexander McGirr Department of Psychiatry University of British Columbia Vancouver Canada Lars Mehlum National Centre for Suicide Research and Prevention Institute of Clinical Medicine University of Oslo Oslo Norway Konrad Michel University Hospital of Psychiatry University of Bern Bern Switzerland Matthew J. Miller Department of Health Sciences Northeastern University Boston Massachusetts USA Allison J. Milner Melbourne School of Population and Global Health University of Melbourne Melbourne Australia



Notes on Contributors

Centre for Mental Health Research School of Population and Global Health The University of Melbourne Melbourne Australia Brian L. Mishara Centre for Research and Intervention on Suicide and Euthanasia and Psychology Department Université du Québec à Montréal Montréal Québec Canada Erlend Mork National Centre for Suicide Research and Prevention Institute of Clinical Medicine University of Oslo Oslo Norway Katherine Mok Centre for Mental Health Melbourne School of Population and Global Health University of Melbourne Melbourne Australia Matthew K. Nock Department of Psychology Harvard University Cambridge Massachusetts USA

xvii

Stephen S. O’Connor Department of Psychiatry and Behavioral Sciences University of Louisville Louisville Kentucky USA Maria A. Oquendo Molecular Imaging & Neuropathology Division (MIND) Department of Psychiatry College of Physicians and Surgeons Columbia University New York State Psychiatric Institute USA Joel Paris Institute of Community and Family Psychiatry McGill University Montreal Quebec Canada Michael Phillips Suicide Research and Prevention Centre Shanghai Jiaotong University School of Medicine and Emory University School of Medicine Shanghai China

Merete Nordentoft Psychiatric Center Copenhagen University of Copenhagen Copenhagen Denmark

Jane Pirkis Centre for Mental Health Melbourne School of Population and Global Health University of Melbourne Melbourne Australia

Rory C. O’Connor Suicidal Behaviour Research Laboratory Institute of Health & Wellbeing University of Glasgow Glasgow Scotland UK

Stephen Platt Usher Institute of Population Health Sciences & Informatics University of Edinburgh Scotland UK

xviii

Notes on Contributors

Maurizio Pompili Department of Neurosciences, Mental Health and Sensory Organs Suicide Prevention Center Sant’Andrea Hospital Sapienza University of Rome Italy Zoltán Rihmer Laboratory for Suicide Research and Prevention National Institute of Psychiatry and Addictions Budapest Hungary Jessica D. Ribeiro Vanderbilt University Nashville Tennessee USA Vincent Riordan West Cork Mental Health Services, Cork, Ireland and Centre for Rural Health Research and Policy Inverness Scotland UK Jo Robinson Orygen, The National Centre of Excellence in Youth Mental Health Melbourne Victoria Australia

Morton M. Silverman Department of Psychiatry School of Medicine University of Colorado Denver USA Steven Stack Departments of Criminology, and Psychiatry & Behavioral Neuroscience Wayne State University Detroit USA Barbara Stanley Division of Molecular Imaging & Neuropathology Department of Psychiatry College of Physicians and Surgeons Columbia University New York State Psychiatric Institute USA Cameron R. Stark Department of Public Health NHS Highland, Inverness Centre for Rural Health University of Aberdeen Aberdeen Scotland UK

Jitender Sareen Department of Psychiatry University of Manitoba Winnipeg Canada

Sarah Steeg Centre for Suicide Prevention Centre for Mental Health and Safety University of Manchester Manchester England UK

Kate E. A. Saunders Department of Psychiatry University of Oxford Warneford Hospital England UK

Katherin Sudol Frank H. Netter, M.D. School of Medicine Quinnipiac University North Haven, Connecticut USA



Notes on Contributors

Ehsanullah Syed Department of Psychiatry Penn State Milton S Hershey Medical Center Penn State College Of Medicine Hershey Pennsylvania USA Gustavo Turecki McGill Group for Suicide Studies Douglas Mental Health University Institute McGill University Montreal Canada Kees van Heeringen Unit of Suicide Research and Flemish Suicide Prevention Centre Ghent University Ghent Belgium

Columbia University New York State Psychiatric Institute New York USA Danuta Wasserman National Centre for Suicide Research and Prevention of Mental lll‐Health (NASP) Karolinska Institutet Stockholm Sweden Karen Wetherall Suicidal Behaviour Research Laboratory Institute of Health & Wellbeing University of Glasgow Glasgow Scotland UK

Bregje van Spijker National Institute for Mental Health Research Research School of Population Health The Australian National University Australia Capital Territory Australia

J. Mark G. Williams Oxford Mindfulness Centre Department of Psychiatry University of Oxford Oxford England UK

Lakshmi Vijayakumar Voluntary Health Services SNEHA Suicide Prevention Centre India & University of Melbourne Chennai India

Kirsten Windfuhr Centre for Suicide Prevention Centre for Mental Health and Safety University of Manchester Manchester England UK

Yun Wang Hong Kong Jockey Club Centre for Suicide Research and Prevention University of Hong Kong Hong Kong Camilla Wasserman Child Psychiatric Epidemiology Department of Child and Adolescent Psychiatry

Alan Woodward Lifeline Research Foundation Lifeline Australia Canberra Australian Capital Territory Australia

xix

xx

Notes on Contributors

Kevin Chien‐Chang Wu Department and Graduate Institute of Medical Education and Bioethics National Taiwan University College of Medicine Department of Psychiatry National Taiwan University Hospital Taiwan Clare Wyllie Research & Evaluation Samaritans UK

Paul S. F. Yip Centre for Suicide Research and Prevention & Department of Social Work and Social Administration University of Hong Kong Hong Kong

Introduction Rory C. O’Connor and Jane Pirkis

Since the publication of the first edition of the International Handbook of Suicide Prevention in 2011 (O’Connor, Platt, & Gordon, 2011), Preventing Suicide: A Global Imperative has been published by the World Health Organization (World Health Organization [WHO], 2014). This landmark publication, the first ever world suicide prevention report, highlighted the scale of the task of suicide prevention. At least 804,000 people take their own lives each year across the globe, which translates into a death every 40 seconds. The report also touches on many of the issues that we examine in detail herein, including the epidemiology of suicide and how best to inter­ vene to prevent it. We are delighted that many of those who contributed to the WHO report have authored chapters for the second edition of this Handbook. There are a number of changes in this edition of the Handbook. First, there is a change in editorship. Rory C. O’Connor has been joined by Jane Pirkis from University of Melbourne as coeditor, and Jane takes the place of Stephen Platt and Jacki Gordon, who were coeditors of the first edition. Second, we have expanded the Handbook; in terms of chapters, it is now 20% longer, which has allowed us to include more hot topics in suicide research and prevention. Third, given that the majority of the world’s suicides occur in Asia and low‐ and middle‐income countries, additional chapters have been dedicated to better understand suicide across different countries and cultures. Fourth, the majority of chapters end with a section describing up to 10 key resources. These resources include a selection of journal articles, books, reports, or online resources that the authors believe the reader would benefit from reading. As in the first edition of the Handbook, we have tried to understand why people attempt suicide and what can be done to reduce suicide by harnessing the expertise of more than 110 suicidologists from across the world. The Handbook offers kaleido­ scopic views on the complex multitude of factors that may explain suicidal behavior and the array of approaches to suicide prevention. It should appeal to anyone with an interest in trying to comprehend suicide and, ultimately, prevent it. To this end, one of the guiding principles of this volume is to improve our understanding of the r­elationship between attempted suicide and deaths by suicide. A more comprehensive understanding of this relationship is important not only for theoretical and conceptual reasons but also because secondary prevention interventions are frequently directed at  those who attempt suicide. Any national or international suicide prevention strategy, to be effective, must be able to engage those who have attempted suicide. The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

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Rory C. O’Connor and Jane Pirkis

Although this may seem self‐evident, it is crucial, given the universal recognition that maintaining patients who have attempted suicide in treatment is fraught with diffi­ culties. Further, it is sobering to note that the best predictor of future suicidal behavior (and suicide) is past suicidal behavior. Therefore, if we can intervene with those who have previously tried to take their own lives, we should be able to prevent at least some of the future deaths by suicide. Consequently, nonfatal suicidal behavior and suicide receive equal attention in this Handbook. As suicide attempt and self‐harm are often used interchangeably in the research literature (also see the following text), where we use the term suicide attempt/suicidal behavior in this Introduction, we are referring to self‐injurious behavior with evidence of suicidal intent. Self‐harm is used to describe all self‐harming behaviors where suicidal intent is not explicitly ascertained. The overarching aim of this Handbook is to bring together the different exponents of suicide research and prevention irrespective of country of origin or professional background, because only through learning and working together internationally and across disciplines will we rise to the challenge of reducing suicidal behavior in every country. Suicidology, defined as the science of suicide and suicide prevention (Maris, 1993), is little over 55 years old, and embraces researchers, practitioners, and policy planners whose disciplinary backgrounds include psychology, psychiatry, epidemi­ ology, sociology, social work, health economics, nursing, emergency medicine, ethics, law, and public health. This heterogeneity is a major strength, as the whole (i.e., the discipline of suicidology) is much greater than the sum of its constituent disciplines. We continue to learn from each other’s difficulties and successes, and to exchange a broad range of theoretical and methodological perspectives. However, one of the challenges of working in an interdisciplinary manner is that there are inevitable differ­ ences in emphasis, which can lead to difficulties in how we communicate about self‐ injurious behavior across countries and professions. Although there have been several efforts to reach consensus on definitions and nomenclature (see Chapter  1 by Silverman), as a discipline we have yet to agree on a common definition of suicidal behavior. This renders the comparison of studies difficult. One study may include a heterogeneous sample of patients, some of whom are reporting suicidal intent and some of whom are not, whereas another may include only individuals who have engaged in potentially lethal suicide attempts, with explicit and high suicidal intent. Despite our best efforts, we are unlikely to achieve an agreed definition of suicidal behavior for some considerable time. Indeed, an inspection of the international liter­ ature still yields a myriad of different terms to describe the broad spectrum of self‐ injurious thoughts and behaviors (e.g., self‐harm, attempted suicide, suicidal behavior, nonsuicidal self‐injury; see Chapter  1 by Silverman). Consequently, we asked each contributing author to make explicit early in their chapter how they operationalized and defined suicidal behavior therein. Additional aims of the book are to showcase the state of the science in terms of research, policy, and practice, to share insights and expertise, and to enhance mutual learning. In this Handbook, we present the latest research on determinants of suicidal behaviors and the most promising interventions, treatments, and ways of caring for those at risk. We also describe the challenges of translating research, policy, and prac­ tice into saving lives. The extent to which suicidologists meet this latter challenge will determine, in large part, whether or not the universal goal of reducing suicide rates across the globe is attained. In short, this Handbook addresses the key questions of

Introduction

3

why people attempt suicide, what the best interventions are for those at risk, and what the key international challenges are in our pursuit of suicide prevention. In addressing these questions, it is important to recognize that the evidence base is, by and large, limited and that it must be understood in terms of the specific characteristics of a study population or the particular context of an intervention. Encouragingly, though, there have been major advances in our understanding of how best to treat and prevent suicidal behavior since the publication of the first edition. As before, this edition of the Handbook is organized into three parts. Part I is concerned with the determinants and frameworks that inform our understanding of suicide and attempted suicide. Part II focuses on treatment, intervention, and care, and Part III reviews a range of suicide prevention issues that span research, policy, and practice. Chapters 1 to 3 provide the foundations for many of the subsequent chapters. In Chapter 1, for example, Silverman provides an overview of how the international community defines, classifies, and communicates about self‐injury with and without suicidal intent. As noted earlier, these remain contested issues within the field with much of the recent debate stimulated by the inclusion of nonsuicidal self‐injury and suicidal behavior disorder in DSM 5 as areas requiring further research (e.g., Kapur, Cooper, O’Connor, & Hawton, 2013; Oquendo & Baca‐Garcia, 2014). In Chapter 2, Windfuhr, Steeg, Hunt, and Kapur endeavor to bring together the research literature on the factors associated with suicidal behavior from different disciplines, and in Chapter 3, Arensman, Griffin, and Corcoran consider the specific challenge of pre­ dicting repetition of self‐harm. These are followed by four chapters (Chapters 4–7) that summarize the research and clinical literature on the relationship between sui­ cidal behavior and psychiatric illness (depression [Chapter 4 by Rihmer and Dome], schizophrenia and other psychotic disorders [Chapter  5 by Desîlets, Labossière, McGirr, & Turecki), substance user disorders [Chapter 6 by Conner and Ilgen], and personality disorders [Chapter 7 by Paris]). The Handbook also considers the extent to which the treatment of these disorders can reduce suicide and attempted suicide. The risk of suicide in medical conditions is described in Chapter 8 (by Pompili, Forte, Berman, and Lamis). The neurobiological and neuropsychological substrates that underpin suicidal behavior are considered in Chapters 9 and 10. In Chapter  9, Mann and Currier review the role of the serotonergic and noradrenergic neurotransmitter systems and the hypothalamic–pituitary–adrenal axis. They highlight the importance of study­ ing the interaction between genetic vulnerability and environmental adversity in early life as a means of understanding how the effects of developmental changes in neurobiological systems can persist into adulthood and affect suicide risk. Chapter  10 by van Heeringen and Bijttebier investigates how changes in brain function are mediated by neuropsychological factors to increase the risk of suicide in response to stressors. In a new addition to this edition, the research findings and clinical implications of magnetic resonance imaging (MRI), diffusion tensor imaging, functional MRI (fMRI), positron emission tomography, and single photon emission computed tomography studies in suicide attempters are reviewed in Chapter 11 by Sudol and Oquendo. The central role of psychology in understanding suicide risk is highlighted in Chapters 12 and 13. For example, the interpersonal‐psychological theory of suicidal behavior is described by Hagan, Ribeiro, and Joiner in Chapter 12, together with its history, its current status, as well as suggestions for further directions. The integrated

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Rory C. O’Connor and Jane Pirkis

motivational‐volitional model of suicidal behavior, a tripartite model that maps the relationship between background factors and trigger events and the development of suicidal ideation/intent into suicidal behavior is outlined by O’Connor, Cleare, Eschle, Wetherall, and Kirtley in Chapter 13. In the final three chapters (Chapters 14–16) of Part I, the focus shifts to the social context of suicide. In Chapter 14, Stack and Kposowa consider sociological perspectives, including the role of marital and religious integration. The powerful effects of inequalities, economic recession, and unemploy­ ment on suicide rates across the globe receive detailed analyses in Chapters 15 and 16. Lower socioeconomic status (at an individual level) and socioeconomic deprivation (at an area level) are both risk factors, although the evidence presented by Platt in Chapter 15 suggests that the “area effect” is compositional (rather than c­ontextual). The complicated relationship between an economic recession and suicide risk is emphasized by Gunnell and Chang in Chapter 16: levels of debt, house repossession, relationship difficulties, alcohol misuse, pressures on those remaining in work and job insecurity, and cuts in mental health services ought to be considered in addition to unemployment. Part II begins with two chapters that review the evidence‐based treatment and care of suicidal children and adolescents (Chapter 17 by Gvion and Apter) and older adults (Chapter  18 by De Leo and Arnautovska). In the former, the interplay b­etween biological, genetic, environmental, social, and psychological factors in the etiology and course of suicidal behavior is considered alongside the effectiveness of  prevention and treatment among children and adolescents. Chapter  18 high­ lights the age‐specific and gender‐specific risk and protective factors in old age as well as  reviewing the efficacy of existing treatment and preventative strategies. The fundamental role of the therapist and the importance of the therapeutic alliance are considered in Chapter 19 by Michel. The subsequent six chapters (Chapter 20–25) also address clinical issues concerning treatment of patients who have attempted suicide, are actively suicidal, or who have presented to hospital following self‐harm. Recent systematic reviews of studies of attitudes of self‐harm patients toward clinical services and staff attitudes toward self‐harm patients are included in Chapter  20 (by Hawton and Saunders), as is a study of service provision with recommendations for the clinical management of self‐harm patients. Results of a systematic review of aftercare interventions are also summarized in Chapter 20. The authors conclude that there is now robust evidence that short‐term psychological therapy should be routinely offered to patients following self‐harm. After reviewing the l­iterature, with a particular focus on clinical practice, Mehlum and Mork’s Chapter 21 suggests a set of requirements to ensure the continuity of care of suicide attempters, and makes recommendations for policy and clinical practice. In another new chapter, Hatcher presents a systems approach (adopted elsewhere in medicine and in other industries) applied to the management of suicide risk in emergency departments (Chapter 22). Chapters 23–25 focus on key psychological processes in suicidality and emphasize how a better understanding of such processes is integral to a range of psychotherapeutic treatments. Cognitive Therapy, Dialectical Behavior Therapy, and the Collaborative Assessment and Management of Suicidality are reviewed in Chapters 23 (by Chang, Jager‐Hyman, Brown, Cunningham, and Stanley) and 24 (by Jobes, Comtois, Brenner, Gutierrez, and O’Connor). Chapter  25 (by Williams, Duggan, Crane, Hepburn, Hargus, and Gjelsvik) explores the conditions under which suicidal ideas may persist

Introduction

5

and escalate. It also describes mindfulness training and presents preliminary evidence that such training may be beneficial to those at risk of suicidal ideation and behavior. In the final three chapters of Part II (Chapters 26–28), different types of interven­ tions adopting alternative modes of delivery are examined. Because it is often difficult to engage suicidal patients in treatment, interest in brief contact interventions has grown in recent years, with studies yielding promising findings in some subgroups (Chapter 26 by Milner and Carter). The role of online interventions to reduce suicide risk is considered by Kerkhof and van Spijker in Chapter 27. The authors ask whether the high expectations around online interventions have been met and highlight a number of challenges for future research. The significance of helplines in suicide p­ revention is explored by Woodward and Wyllie in Chapter  28. Although crisis helplines have been a mainstay of many national suicide prevention activities for decades, the authors review the evidence for their efficacy, noting the difficulties of evaluating their benefits. Part III of the Handbook comprises 16 chapters directed at a selection of hot topics in suicide prevention. These topics bring together the different domains of research evidence, policy, and practice and highlight many of the challenges and successes in suicide prevention internationally. Part III begins with a chapter on suicide preven­ tion in low‐ and middle‐income countries by Vijayakumar and Phillips (Chapter 29). This chapter stresses the importance of understanding suicide within the global context, recognizing that three-quarters of the world’s suicides occur in low‐ and m­iddle‐income countries. The international theme continues in Chapters 30 and 31. In  Chapter  30, Khan, Asad, and Syed discuss suicide in Asia (the world’s largest continent, where approximately 60% of the globe’s total deaths by suicide occur). In Chapter 31, Chan and Maniam discuss the cultural factors in suicide prevention. In both chapters, research gaps are identified, and consideration is given to the establishment of culturally relevant suicide prevention programs. In Chapter 31, the authors call for stronger collaborations between the disciplines of mental health, sociology, and anthropology to facilitate better translational research. In Chapter 32, Hadlaczky, Wasserman, Hoven, Mandell, and Wasserman use case studies to compare the widely used primary, secondary, and tertiary model of suicide prevention with the U.S. Institute of Medicine model oriented toward universal, selective, and indicated approaches. In  Chapter  33, drawing on evidence from across the globe, Stark, Riordan, and Dougall disentangle the relationship between the nature of rurality and suicide, following a critical dissection of the potential influence of other recognized suicide risk factors in the rural context. In Chapter  34, Mishara and Chagnon tackle the difficult issue of why a minority of people with mental health problems die by suicide. The authors argue that a better understanding of the mechanisms that may explain why mental disorder is so closely associated with suicide will improve our knowledge of why only a minority of people with mental health problems die by suicide. The next two chapters (Chapter 35 by Chen, Wu, Wang, and Yip and Chapter 36 by Azrael and Miller) shift the focus away from factors that contribute to the development of suicidal distress to understanding how restricting access to the means of suicide can reduce suicide deaths. Although there is some overlap between the two chapters, they have a different focus, and each contributes a unique pers­ pective to understanding the relationship between means restriction and suicide prevention.

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One of the most important developments in the field of suicidology in the past 10 years has been the greater inclusion of those with lived experience (those who have lost loved ones to suicide as well as those who have been suicidal themselves) in suicide research and prevention activities. To reflect this, in Chapters 37 and 38 (by Grad and Andriessen, and Lezine, respectively), the authors describe the complexity of the bereavement process and how it impacts upon family, friends, and professionals, as well as noting the insights that those with lived experience can provide. The whole field of suicidology can benefit from these insights. The barriers to speaking out and being a lived experience advocate are also described. In Chapter  39, Hjelmeland and Knizek critique mainstream suicidological research, and give consideration to the extent to which suicidology has dispropor­ tionately focused on explaining suicidality to the detriment of understanding it. This chapter also reviews the posited (im)balance between quantitative and qualitative methods used in international suicide research and calls for a change in direction in suicide research. Staying with the research methods focus, Chapter 40 (by Glenn, Franklin, Kearns, Lanzillo, and Nock) reviews the commonly used methods and designs for psychological studies of suicidal behavior. This chapter ends by high­ lighting major gaps in our knowledge that require future research. In the next three chapters (Chapters 41–43), the effect of social influences or social context on s­uicidal behavior is evaluated, albeit in very different contexts. In Chapter 41, Kong, Sareen, and Katz evaluate school‐based suicide prevention programs and present recommen­ dations for future policymaking. Chapter  42, by Pirkis, Mok, Robinson, and Nordentoft, reviews the evidence for and against the “Werther effect,” the p­resumed impact of media reporting on suicide, derived from the suicide of the p­rotagonist in Goethe’s (1774) novel The Sorrows of Young Werther following an ill‐fated love affair and subsequent so‐called “copycat” suicides following its publication. The emerging evidence for the positive effects of media reporting (“Papageno effect”) and the role of new media in suicide prevention are also evaluated. In the penultimate chapter (Chapter 43), Robinson, Pirkis, and O’Connor describe suicide clusters, posit var­ ious mechanisms to explain their effects, and explore approaches to prevent or reduce their impact on affected communities. In the final chapter of the Handbook (Chapter 44), McDaid makes the economic case for investing in suicide prevention. He acknowledges that every single death by suicide is a personal and social tragedy, and that placing a cost on a person’s life may seem unpalatable, but argues that if the economic case helps to shore up resources for suicide prevention (and it does help), then it is vital that this case be made. Indeed, McDaid ends Chapter 44 with the call to embed economic analyses into all evaluations of suicide prevention strategies. We are extremely grateful to the contributors to this Handbook, all of whom responded extremely positively to our requests and queries. We hope that the material contained herein from many of the world’s leading experts in suicide research and prevention will inform suicide prevention efforts across the globe. We are also extremely passionate about enthusing and training the next generation of suicidolo­ gists, so we very much hope that the exciting and innovative research, policy, and practice detailed within this volume will act as a catalyst for others to get involved in the fight against suicide.

Introduction

7

References Kapur, N., Cooper, J., O’Connor, R. C., & Hawton, K. (2013). Attempted suicide versus non‐suicidal self injury: New diagnosis, or false dichotomy? British Journal of Psychiatry, 202, 326–238. Maris, R. W. (1993). The evolution of suicidology. In A. A. Leenaars (Ed.), Suicidology: Essays in honor of Edwin Shneidman. Northvale, NJ: Jason Aronson. O’Connor, R. C., Platt, S., & Gordon, J. (Eds.). (2011). The International handbook of suicide prevention: Research, evidence and practice. Chichester, England: Wiley‐Blackwell. Oquendo, M. A., & Baca‐Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM‐5 classification system: Advantages outweigh limitations. World Psychiatry, 13, 128–130. World Health Organization (WHO). (2014). Preventing suicide: A global imperative. Geneva,  Switzerland: WHO. http://apps.who.int/iris/bitstream/10665/131056/1/ 9789241564779_eng.pdf

Part I

Suicidal Determinants and Frameworks

1

Challenges to Defining and Classifying Suicide and Suicidal Behaviors Morton M. Silverman Introduction After over a century of serious attention to the public health problem of suicide and suicidal behaviors, there have been many significant advances in suicidology; yet ­challenges remain. We now know a great deal about the epidemiology of suicide and suicidal behaviors. We are beginning to develop a body of knowledge about the biological underpinnings to suicidal behavior through research on the neurobiology and genetics of risk for suicide. However, we still know little about protective factors and what places an individual at acute risk for suicidal behavior. We need to bridge the gap between our expanding knowledge base of the incidence and prevalence of ­suicidal behaviors in different populations, the etiology, progression, and transmission of suicidal behaviors, and the development of effective clinical and population‐based protocols, practices, procedures, and policies. In order to achieve this goal, we need to translate what we have learned from epi­ demiological surveillance and research studies into practical clinical and population‐ based applications. Similarly, what is learned in clinical settings needs to be communicated to researchers and theoreticians so they can better investigate and understand these behaviors. However, the suicide literature remains replete with confusing (and sometimes derogatory or pejorative) terms, definitions, descriptors, and classifications that make it difficult, if not impossible, to compare and contrast different research studies, clinical reports, or epidemiological surveys (Crosby, Ortega, & Melanson, 2011; Jenkins & Singh, 2000; Rudd & Joiner, 1998; Shneidman, 1985; Silverman, 2006), or to make comparisons, generalizations, or extrapolations (Linehan, 1997; Westefeld et al., 2000). Hence, advances in suicidology are hindered by a lack of a standardized nomenclature and classification system. This remains a challenge. Most individuals who die by suicide are reported to have communicated their intent to others (usually next of kin or friends), and the majority have also visited or been treated by mental health professionals, primary care providers, or other physicians

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

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during the weeks or months preceding their death by suicide (Luoma, Martin, & Pearson, 2002). Why is this so? It may be that family members, significant others, or other supports do not recognize or respond to the conditions, contexts, or commu­ nications associated with escalating suicidal risk. A compelling answer is that suicidal behavior is often undiagnosed, undertreated, or mistreated in clinical settings because the signs and symptoms are misunderstood by the clinician, and, for the individual, truthfully answering questions about being suicidal can be influenced by stigma, denial, guilt, anger, and shame (Mann et  al., 2005; Malone, Szanto, Corbitt, & Mann, 1995). Determining that a suicide risk assessment has been completed after receiving a negative response to asking a single question (e.g., are you thinking about suicide?) is insufficient, because, in part, the question provides no context, parame­ ters, or time frame. One of the major difficulties in communicating about suicidal phenomena with our patients and within our disciplines (as well as across disciplines) is that we do not share a precise set of terms or speak the same scientific language. We also do not share the same conceptualizations of what constitutes self‐harm and the suicidal ­process. The terminology we use is often based on our training (Silverman & Berman, 2014b); theoretical, political, social, psychological, biological, and religious perspec­ tives; and the professional responsibilities to identify and count these behaviors in the first place (clinical, epidemiological, public health, research, etc.). Conceptual, methodological, and clinical challenges result from widely varying definitions and classification schemes for such terms as suicide attempt (Nock & Kessler, 2006). As a result, epidemiologists cannot consistently and accurately determine the incidence and prevalence of suicide‐related phenomena, researchers cannot easily compare their study populations or the effectiveness of their interventions, and clinicians have difficulty in translating research findings into practical applications when working with an individual at risk for suicidal behaviors. It is a known fact that there is inaccuracy in the reporting of suicidal deaths (Jobes & Berman, 1985; Shneidman, 1980). Estimates of underreporting have ranged from 10% to 50% (Jobes, Berman, & Josselson, 1987; Litman, 1980). Some have noted substantial underreporting and misclassification of childhood and adolescent suicides (Wekstein, 1979). Jobes and Berman reported that the majority (58%) of medical examiners they surveyed in the United States either agreed or strongly agreed that “the actual suicide rate is probably two times the reported rate.” It appears that there may be variations in both the death certification process and the manner of death determination. Jobes, Berman, and Josselson (1987) have identified over 20 possible sources of variability in the official reporting of suicide data. They suggest that perhaps the single most important source of variability and error in suicide statistics arises from the virtual absence of any standardized classification criteria that coroners and medical examiners might use more uniformly to evaluate cases of equivocal suicide. Although relatively small in number, the category of “undetermined manner of death” may ­represent a significant number of true suicides (Elnour & Harrison, 2009; O’Carroll, 1989; Rockett, Kapusta, & Coben, 2014; Tollefsen, Hem, & Ekeberg, 2012). If we cannot even agree upon what defines a suicide, how, then, are we to determine what is an attempt to die by suicide? There is considerable debate about the differential attributes of those who die by suicide, those who attempt suicide, and those who engage in deliberate self‐harm (DSH). The resolution of these controversies is hampered



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because studies have used dissimilar descriptive methods and definitions for what is a suicide attempt (Linehan, 1986; Maris, 1992). When the suicide attempts are medi­ cally serious (e.g., involving admission to an intensive care unit; requiring surgery under general anesthesia; needing extensive, specialized medical care), these two pop­ ulations overlap considerably (Beautrais, 2001). However, because most epidemio­ logical studies are based on self‐report of prior suicidal behavior without defining these terms for the population being surveyed, the profile of those engaging in non­ medically serious suicide attempts remains inconsistent and unreliable. Currently there is no international surveillance system for the primary purpose of estimating annual national rates of suicide attempts (Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007a). However, the International Association for Suicide Prevention and the International Association for Suicide Research have recently formed a task force to address this issue. Put simply, the absence of a universally accepted nomenclature and set of diagnostic criteria has limited our attempts to accu­ rately quantify the extent of the problem (incidence and prevalence), identify effective interventions, both clinical and preventive, as well as useful markers of vulnerability. The above problems, among others, make it difficult to • accurately count the number of suicides and suicide attempts that occur annually; • accurately differentiate suicide attempts from nonsuicidal self‐injuries; • conduct longitudinal studies of suicide ideators or suicide attempters; • communicate between and among clinicians, researchers, patients, and patients’ families; • establish suicide and suicide attempts as a major public health problem that w ­ arrants investment of resources at the local, regional, national, and international levels; • determine definitions for levels of risk; • develop, implement, and evaluate treatment approaches; and • develop, implement, and evaluate preventive interventions.

Challenges to Developing and Implementing a Standardized Nomenclature and Classification System Nomenclature for suicidal ideation and behavior has been the subject of considerable international attention and debate (De Leo, Burgis, Bertolote, Kerkhof, & Bille‐ Brahe, 2006; O’Carroll et  al., 1996; Silverman et  al., 2007a; Silverman, Berman, Sanddal, O’Carroll, & Joiner, 2007b). The need for clear and consistent use of terms to guide research and clinical practice has provided the impetus for efforts to develop standard operational definitions and nomenclature to classify suicide and self‐inju­ rious thoughts and behaviors (e.g., Crosby et al., 2011; De Leo et al., 2006; Posner, Oquendo, Gould, Stanley, & Davies, 2007; Silverman et  al., 2007a). However, as Heilbron, Compton, Daniel, and Goldston (2010) have noted, implementing a stan­ dard nomenclature for clinical and research purposes has long been recognized to be a complex task (Wakefield, 1992; Wilson, 1993). The ongoing debate concerning nomenclature has perpetuated the use of multiple terms to refer to the same behavior (Bille‐Brahe, Kerkhof, De Leo, & Schmidtke, 2004; O’Carroll et  al., 1996; Silverman, 2006). For example, the following are

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a ­sampling of terms that have all been used to refer to the act of self‐injury with the intent to die (i.e., suicide attempt): parasuicide, failed attempt, failed completion, nonfatal suicide, aborted suicide, self‐directed violence, near‐lethal attempt, death rehearsal, suicidal episode, courting death, and cry for help. The following are some terms used to describe thoughts with the wish to die (i.e., suicide ideation): suicidal flashes, suicidal preoccupations, morbid ruminations, fleeting thoughts of suicide, and suicidal contemplations. There is also a plethora of terms to describe death caused by a self‐injurious behavior with any intent to die as a result of the behavior (i.e., suicide): committed suicide, completed suicide, fatal suicide attempt, self‐murder, successful attempt, suicidal execution, lethal suicide attempt, hastened death, inten­ tional self‐murder, and rational suicide (Silverman, 2006). Such variability in termi­ nology and definitions not only contributes to imprecise communication, but also limits comparison of prevalence rates nationally and internationally, and hampers clinical and preventive interventions. There are currently several nomenclatures and/or classification systems that are being developed and tested in the United States (Brenner et  al., 2011; Posner et  al., 2007; Silverman et  al., 2007b), as well as internationally (De Leo et al., 2006). I argue elsewhere that not only must we use the same terminology and definitions, but that these terms must be easily understood, applied, and consis­ tent, and should relate to each other in a way that has utility, meaning, and rele­ vance to the real world of at‐risk individuals (Silverman, 2006). We must develop an accurate suicide‐related morbidity and mortality database in order to conduct meaningful research, better delineate risk and protective factors as well as media­ tors and modifiers of suicidal behaviors, develop and implement prevention efforts, and advance the general public health (Jobes, Berman, & Josselson, 1987; O’Carroll, 1989).

Clarifying Terminology The history of the evolution of terms, definitions, and classification systems can be found in a number of published articles (e.g., De Leo et al., 2004; O’Carroll et al., 1996; Silverman, 2006). Before I review some of the current attempts to develop and implement nomenclature and classification systems, it is pertinent to provide some generally accepted definitions for these constructs. Nomenclature: A set or system of names or terms, such as those used in a particular science or art; a system of words used technically to name things in a particular dis­ cipline. A nomenclature should be commonly understood, widely acceptable, and comprehensive. The terms should define the basic clinical phenomena and be based on a logical set of necessary component elements that can be easily applied. Hence, a nomenclature is simply establishing the words (and definitions) chosen for use in the development of a classification, using taxonomic principles. Classification: The act of distributing things into classes or categories of the same type; the act or method of distributing into a class or category according to characteristics. A classification system is built upon a nomenclature, a more exhaustive categoriza­ tion and breakdown of subtypes of related phenomena, and further differentiates among phenomena that appear to be similar by the use of modifiers. A classification



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system allows one to add “qualifiers” or subtypes to the main categories in order to  further differentiate certain subgroups of individuals who share the same characteristics. Taxonomy: The practice and science of classification as well as the laws or principles underlying such a classification; the science dealing with the description, identification, naming, and classification of organisms. Although grounded in a scientific understanding of disease, taxonomies such as The International Statistical Classification of Diseases and Related Health Problems (ICD), must address the needs of the varied and changing public health and health‐care delivery commu­ nities across the globe. The current practice of updating the ICD nomenclature periodically attempts to balance: (a) the need for a consistent terminology to permit clear communication about diseases that are defined by agreed‐upon criteria, with (b) the need to ensure that the classification system (i.e., the taxonomy) properly reflects advances in our understanding of biological pathways and environmental factors that contribute to disease origin and pathology. Hence, a formalized nomen­ clature is essential for clear communication and understanding. Currently used disease classifications have properties that limit their information content and usability. “Current disease taxonomies, including ICD‐10, are primarily based on symptoms, on microscopic examination of diseased tissues and cells, and on other forms of laboratory and imaging studies, and are not designed optimally to incorporate or exploit rapidly emerging molecular data, incidental patient characteristics, or socio‐environmental influences on disease” (Institute of Medicine, 2011, p. 14). Long before we construct a formal taxonomy for suicide and suicidal behaviors, we must first arrive at a set of uniform terms and definitions.

Terminology in Suicide Classification Systems In relation to suicide and suicidal behaviors, a classification system would help ­organize subtypes of behaviors, for example, via the use of modifiers that further differentiate subtypes of distinct behaviors. A classification system would categorize behavioral presentations into mutually exclusive “boxes” on the basis of the careful use of termi­ nology and definitions. In the ideal world, no behavioral presentation should “straddle” more than one established “box.” This, of course, is dependent upon ­gathering enough information about the behavioral presentation in order for it to be classified appropriately by identifying the characteristics that differentiate each classification “box” (Silverman, 2006). From my perspective, the following are some examples of subtype qualifiers for a suicide classification system: • • • • • • •

Timing: Imminent versus Short‐Term versus Long‐Term Duration: Acute versus Chronic Frequency: First Time versus Repetitive versus Chronic Intensity: Low versus Medium versus High Character: Unintentional versus Intentional Intent to die: Present versus Absent Context: Impulsive versus Planned

16 • • • • •

Morton M. Silverman Quality: Active versus Passive Dosage: Nonlethal versus Nearly Lethal versus Lethal Setting: Public versus Semiprivate versus Private Method: Firearm versus Hanging versus Jumping versus Overdose Outcome: Injury versus Noninjury versus Death

In the process of reducing the terminology of suicide to its “essential components,” we first need to agree on what constitutes the “full‐range” or continuum of suicide‐ related thoughts, communications, and actions. And what does “suicide‐related” really mean? Are there unique thoughts, communications, and actions that result in self‐destructive actions and outcomes? Or do they better identify cognitions, ­emotions, and actions that may lead to many different actions and outcomes? Rudd (2000, p. 19) suggested that what is needed is “an inclusive conceptual framework that allows for direct clinical application of empirical findings across specific areas of functioning (i.e., cognitive, emotional, biological, behavioral, and interper­ sonal domains).” Such a model would address the broad range of factors empirically validated as relevant, incorporating the diagnostic components of DSM‐5 and the forthcoming ICD‐11. Rudd suggested that cognitive theory and therapy offer a unique foundation for such integrative efforts (e.g., Alford & Beck, 1997). Although one can argue about the degree of specificity for describing suicidal behaviors, there is a set of commonly used terms that generally describes suicidal thoughts and behaviors. These suicide‐related generic terms are ideation (with or without a plan); intent; motivation; preparatory acts (toward imminent self‐harm); self‐harm or self‐injurious behaviors (with or without injury, or fatal); undetermined suicide‐related or self‐injurious behaviors (with or without injury, or fatal); suicide attempt (with or without injury); and suicide (Brenner et  al., 2011; Matarazzo, Clemans, Silverman, & Brenner, 2013). The definitions of terms such as suicide attempt or self‐harm are predicated on the definition of suicide. After all, a true suicide attempt is an action, the goal of which is to die by suicide. However, as noted elsewhere (Silverman, 2006), there are at least 15 definitions of suicide in our scientific literature, and at least 10 definitions of suicide attempt or nonfatal self‐injury. Until we establish a standardized nomencla­ ture, we will continue to have differences between and among official reporting sources (e.g., police, coroner, medical examiner death certificates), research studies, clinical population reports (e.g., hospital discharge summaries, emergency department reports, first‐responder reports), and epidemiological surveys (which are often dependent upon self‐report). A brief list of the challenges to resolving these conundrums is presented below: 1 Agreeing on which terms should be used and defining them as mutually exclusive. There remains confusion about when to apply and what exactly constitutes terms such as suicidality, intentional or deliberate self‐harm, suicide‐related behavior, parasuicide, and nonsuicidal self‐injury. 2 Developing a nomenclature that is free of bias—philosophical, theoretical, biological, sociological, political, religious, cultural, and so on. The current state of our knowledge suggests that suicidal thoughts and behaviors express them­ selves differently in different cultures, different age groups, different genders, and different ethno‐racial groups.



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3 Being sensitive to different needs. For example, the epidemiologist, medical examiner/coroner, public health officer, first responder, researcher, clinician, and emergency room physician often focus on different aspects of the suicidal continuum, and use different measures and sources in order to record their ­ findings and observations. Furthermore, they require different standards of ­ ­evidence, levels of certainty for such evidence, and they place different emphases on different aspects of evidence. 4 Defining those terms that are related to the act of death by suicide, such as suicide ideation, suicide intent, and suicide attempt, when there is not a clear or consistent definition of the term suicide. The nomenclature must be internally consistent, and all the terms must be based on, and relate to, a culturally sensitive, and ­consistent definition of suicide. 5 Deciding which terms are pejorative or dismissive. The use of certain terms to label self‐injurious behaviors may bias decisions about the level of clinical care needed, or color the perceptions of the urgency with which follow‐up care is needed after a crisis (Heilbron et al., 2010). Such terms include completed suicide, successful suicide, committed suicide, suicide gesture, failed attempt, suicide victim, nonfatal suicide, and nonfatal suicide attempt (Crosby et  al., 2011; Silverman, 2006). For example, the terms completed suicide and successful suicide imply achieving a desired outcome, whereas those involved in the mission of preventing deaths by suicide would view this event as undesirable. Furthermore, death by suicide is a final state, so the use of the adjective “completed” or “successful” is unnecessary and connotes a judgment. The term failed attempt gives a negative impression of the person’s action, implying an unsuccessful effort aimed at achiev­ ing death. The term nonfatal suicide portrays a contradiction in terms. A “suicide” indicates a death, while “nonfatal” indicates that no death occurred. Furthermore, “failed” or “nonfatal” suggests that the person somehow was not capable of accomplishing their apparent intent to die. The use of the adjective “committed” (e.g., committed suicide) suggests a legal connotation. The term gesture (e.g., suicide gesture) connotes a value judgment with a pejorative or negative impres­ sion of the person’s intent. 6 Remaining consistent with the terminologies and approaches used by public health agencies and by scientific fields that study other forms of violence (e.g., homicides and sexual assault) and unintentional injuries (e.g., motor vehicle crashes). 7 Resolving the distinctions between what we label a suicide attempt, deliberate (intentional or instrumental) self‐harm, or nonsuicidal self‐injury. 8 Developing a standardized nomenclature that is sufficiently adaptable to allow some alterations for specific uses within certain specialties or professions. However, there must be a clear crossover table to demonstrate equivalencies between and among terms currently used in existing nomenclatures, so that clinical, research, and epidemiological studies can be compared (Matarazzo, Clemans, Silverman, & Brenner, 2013). 9 Examining as many factors as possible that are involved in the behavior. To best assess these factors in a comprehensive manner, clinicians and researchers need an instrument or protocol that allows for reliable data collection across a wide range of settings, and one that can clearly distinguish between suicidal behaviors and nonsuicidal self‐injurious behaviors.

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10 Overcoming the factors that might affect the reliable self‐reporting of self‐ destructive behaviors, for example, fear of reprisal (involuntary hospitalization), or being judged by the researcher, care provider, or first responder as “crazy” or “mentally ill.” Until we destigmatize suicide and suicidal behaviors, and redefine them as self‐inflicted injuries that are mediated by biology or other external sociocultural factors, we will never be able to accurately count or acquire the data we need to improve our understanding of the suicidal process and the suicidal patient, develop interventions to address these components, and ultimately develop effective preventive interventions. Of note, a new term has entered our lexicon—lived experience—that has been created to self‐ identify those individuals who have engaged in nonfatal self‐injurious behavior with the intent to die. We remain dependent upon other scientific fields to educate us about how aspects of cognition, brain development (acquisition of reasoning, cognitive skills, executive functioning), social behavior, and risk‐taking behaviors impact the development of suicidal thinking and the unfolding of suicidal actions. For example, when does idea­ tion become clinically significant? And under what conditions? What are the essential elements that must contribute to an individual’s risk appraisal? At what age and under what contexts can an individual develop and access executive functioning, such as understanding the consequences of certain actions? We must go beyond our reliance on self‐report surveillance instruments for under­ standing such important components of the suicidal process as suicidal thoughts, intent, motivation, planning, significance of prior life events, appraisal of current stressors, history of prior self‐destructive behaviors, and so on. If we are to continue to be dependent upon self‐reports in our surveillance, research, and clinical studies, then we must provide the respondents with clear terms, definitions, and examples of what we are seeking to measure.

Examples of Definitional Obfuscation There remains confusion about what exactly constitutes suicidal behavior, deliberate self‐harm, suicidality, or suicide‐related behavior, and how to define suicide and suicide attempt (Silverman, 2006; Silverman et al., 2007a). Linehan, Comtois, Brown, Heard, and Wagner (2006) critiqued prior research studies using different definitions and terms, and determined that the following characteristics were assessed in varying degrees: whether or not a suicide attempt or self‐injury has occurred; whether the participant has injured himself or herself once or repeatedly; the exact number of ­suicidal or otherwise self‐injurious acts during a stated time period; the first and most recent act; existence of intent at the time of a self‐injurious act; instrumental intent or motivation for an act, other than suicide intent; method used and its lethality or medical severity; degree of impulsivity (resisting urges, degree of planning, warning others, drinking); likelihood of “rescue” from an act; and behavior or consequences after the suicidal act. The following terms and definitions illustrate the overlap or lack of clarity when describing suicide and suicidal behaviors.



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Parasuicide The World Health Organization (WHO)/EURO Multicentre Study on Parasuicide was a multinational, European study that covered two broad areas of research: ­monitoring trends in the epidemiology of parasuicide (epidemiological monitoring study); and follow‐up investigations of parasuicide populations, with a view to ­identifying the social and personal characteristics predictive of future suicidal behavior (repetition prediction project). Aitken, Buglass, and Kreitman (1969) combined all nonfatal suicidal behaviors into one category called “parasuicide,” without assessing the true motivation of the behavior, and at the same time preserving the link to ­completed suicide. As Linehan et al. (2006, p. 303) have pointed out, “Although parasuicide as a term has been widely accepted among researchers and was the defi­ nition selected for the WHO/EURO multinational study, the definition has not gained popularity both because the term is often interpreted as indicating no suicide intent (i.e., as mutually exclusive of suicide attempts instead of the intended larger category including suicide attempts) and because it does not translate well in other languages. The term deliberate self‐harm avoids this problem but fails to capture the relationship of the behaviour to suicide.” As a result, the WHO/EURO investiga­ tors  revised their nomenclature to replace “parasuicide” with “fatal or nonfatal ­suicidal behaviour with or without injuries” and also required that the behavior be “nonhabitual” to distinguish nonfatal suicidal behavior from the other repetitive self‐injurious behaviors (De Leo et  al., 2004; Schmidtke, Bille‐Brahe, De Leo, Kerkhof, & Wasserman, 2004).

Suicidality There is no definition of suicidality other than that it is the state of being suicidal. But what does that mean? Does it mean having the full constellation of suicidal ideations, intent, motivations, and plans? Does it mean having made a suicide attempt, or having been exposed to others who have been suicidal or rehearsed a suicidal act Is it the equivalent of being in a “suicidal condition” or “suicidal state of mind” (Litman, 1980)? The term suicidality has been used as a “catch‐all” term to represent a broad range of suicide‐related cognitions, emotions, and behaviors (Silverman, 2006). For the most part it has been used to categorize individuals who have expressed a combination or permutation of cognitions (ideation, intent, motivation, and planning), as well as behavior (“threats”, “gestures”, rehearsals, and attempts). It has also been used to categorize patients who are manifesting active mental illness and report thinking about or feeling suicidal, or even having engaged in recent self‐ injurious behaviors. Hence, it becomes nearly impossible to compare populations who are deemed to be expressing suicidality. Despite efforts to remove the term suicidality from the nomenclature, it remains a very common term in the clinical discourse and in the scientific literature. A leading group of international experts in suicide prevention, psychometrics, pharmacoepide­ miology, and genetics, as well as research psychiatrists involved in studies of psychi­ atric disorders associated with elevated suicide risk across the life cycle, concluded that the term suicidality is not as clinically useful as more specific terminology, such as ideation, attempts, and suicide (Meyer et al., 2010). I would argue strongly, along with others (Crosby et al., 2011; Meyer et al., 2010; Posner et al., 2007) that such

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a term be removed from the lexicon because it has no real utility other than to identify a situation or state where an individual expresses some ill‐defined form of suicide‐ related cognition, emotion, or behavior.

Suicide Ideation Besides thinking about dying by self‐injury, some clinicians and researchers include planning, motivation, and intent under the rubric of suicidal ideation. Some do not make the distinction between what is suicidal thinking and what are morbid thoughts (Rudd, 2006). Some believe that there is a clear distinction between fleeting, persistent, and chronic suicidal thinking. Others make distinctions between active and passive suicide ideation (Borges, Angst, Nock, Ruscio, & Kessler, 2008; Silverman & Berman, 2014a). Valtonen et al. (2009) explored whether the ways of defining and measuring suicidal ideation markedly influence which patients with bipolar disorder are classified as sui­ cidal. They also explored the extent to which the correlates for suicidal ideation differ as a consequence of different definitions, and investigated the predictive value of different measures of suicidal ideation for suicide attempts during a 6‐month follow‐up. They compared the predictive value of three different scales of suicidal ideation: Scale for Suicidal Ideation, Hamilton Depression Scale item 3, and Beck Depression Inventory item 9. Altogether 74% of patients had suicidal ideation as defined in at least one of the aforementioned ways, only 29% met the criteria for all three ways; agreement between definitions ranged from low to moderate. They concluded that who is classified as ­having suicidal ideation depends strongly on the definition and means of measurement among patients with bipolar disorder. Hence, different measures for ideation have the potential to cause inconsistency when correlates of suicidal ideation are investigated.

Intent to Die The presence or absence of intent to die, whether determined as subjective or objective, has generally been seen as a key factor in differentiating nonsuicidal from suicidal self‐harm behaviors (Beck, Beck, & Kovacs, 1975; Hjelmeland & Knizek, 1999; Silverman, 2006; Silverman et al. 2007a). Most would agree that engaging in a suicidal behavior (e.g., attempt) involves some degree of determination, desire, wish, and goal‐oriented planning. But is this “intent to die” a cognition, emotion, or behavior? And is it essential, or a defining element, for a thought/ideation or a self‐ injury to be labeled as “suicidal”? Many patients who self‐harm, when asked by clinicians at the time of the injury, will deny that they had an intent to die, despite the evidence to the contrary (e.g., high lethality of the act, prior history of near‐lethal suicide attempts, corroborating information from family, friends, or support network). Diffi­ culties in diagnosis can arise when the assessment of the intent to die is denied by the patient yet some ambivalence is present. As Rosenberg et al. (1988, p. 1446) stated, “with respect to intent, absence of evidence is not evidence of absence.” Nevertheless, it has long been recognized and debated that suicide intention is a multidimensional variable, characterized by different degrees of intensity/severity, and influenced by all possible aspects of human experiences (cultural, existential, spiritual, etc.). Reducing it to a dichotomic (yes/no) category may be pragmatic, but also a dangerous generalization, with potentially misleading implications, including the lowering of clinical attention and concern.



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There remain a number of important unanswered and under‐researched questions relating to the relationship between intent and suicidal thoughts and behaviors, of which the following are the most salient: 1 2 3 4 5 6 7 8 9

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Is intent a component of suicide ideation? Is planning a component/essential ingredient of intent versus ideation? Is intent needed to classify a self‐injurious behavior as being “suicidal”? What role does the presence of intent have in determining level of risk? How do the motivations (rationales) for engaging in self‐injurious behaviors ­differ from the intent? Are motivations another component of suicide ideation? How do we measure intent? What are its defining characteristics? How explicit or implicit does the ideation or emotion need to be in order to label it as “suicide intent”? Are there defining degrees of implicitness or explicitness? Should the presence of intent be the defining characteristic that separates nonsui­ cidal self‐injury from suicidal self‐injury? If we know that a significant percentage of individuals labeled as expressing non‐ suicidal self‐injury do later engage in suicide attempts and/or eventually die by suicide, then does that negate the importance of including intent in our defini­ tions of suicide‐related ideations and behaviors? By defining deliberate self‐harm as being self‐injurious actions with or without the intent to die, are we lumping together different populations whose self‐harm behaviors may have different underlying etiologies and goals?

Suicide Gesture In a review of the history of the use of the term suicide gesture, Heilbron et al. (2010, p. 222) state: “Building on an earlier collaborative effort sponsored by the National Institute of Mental Health, the Center for Mental Health Services, and the American Association of Suicidology (O’Carroll et al., 1996), Silverman et al. (2007a) referred to the term suicide gesture as akin to a behavioral form of suicide threat, and they did not include the term in their recommended nomenclatures because of its imprecision and arguably dismissive connotations. Posner et al. (2007) cited similar reasons for deciding against use of the term ‘suicide gesture’ in the Columbia‐Classification Algorithm for Suicide Assessment (C‐CASA).” In a recent publication of the Centers for Disease Control and Prevention (CDC) (Crosby et al., 2011), describing uniform definitions to be used in suicide surveillance, the term suicide gesture similarly is not recommended because of the subjective and often negative nature of the term. As Heilbron et al. (2010, p. 222) indicate, the term suicide gesture has been used incon­ sistently and may negatively impact the quality of care provided to patients. Furthermore, “Despite the fact that many current or proposed systems for describing self‐harm behav­ iours do not recommend the use of suicide gesture as a label, the term has continued to be used widely in clinical practice and in research, as well as in training settings.”

Suicide Attempt Two lines of evidence suggest that suicidal behaviors are repetitive: many of those who die by suicide have made a previous suicide attempt; and many of those who have engaged in a suicide attempt will make subsequent attempts (Beautrais, 2004; Conner,

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Langley, Tomaszewski, & Conwell, 2003). In a 5‐year follow‐up study of a consecu­ tive series of 302 individuals admitted to hospital for medically serious suicide attempts, Beautrais found that 37% made at least one further attempt and 6.7% died by suicide. In a larger study of all patients admitted for any degree of attempted suicide during the 10‐year period, 1993–2002, Gibb, Beautrais, and Fergusson (2005) found that within 10 years, 28.1% of those who had been admitted for an index suicide attempt were readmitted for a further suicide attempt, and 4.6% died by suicide. We know that approximately 25% of those who engage in medically serious suicide attempts do so within 5 min of deciding to end their lives, and are often labeled as “impulsive” suicidal individuals (Simon et al., 2001). Furthermore, approx­ imately 50% engaged in near‐lethal suicide attempts within 1 hour of the thought entering their awareness. It is important to recognize that intent and lethality are not unitary or even neces­ sarily highly correlated constructs, for it has been observed that most suicidal behavior is associated with mixed motives and varying degrees of ambivalence about life and death (Shneidman, 1996), making it difficult to neatly categorize self‐injurious behav­ iors on the basis of the presence or absence of intent and degree of lethality. Furthermore, there is no simple relationship between intention, preparation, lethality, and outcome. It follows that concerted efforts need to be made to identify those at most risk of an index suicide attempt, as well as providing services to those who have engaged in an index suicide attempt, irrespective of its level of lethality. A prior suicide attempt is statistically the best predictor of future suicide attempts and death by suicide, and a history of repeated attempts further increases the risk of death by suicide. To that end, it is imperative to have a clear and consistent definition of what is a suicide attempt. Such a standardized definition does not presently exist.

Deliberate Self‐Harm and Nonsuicidal Self‐Injury The concept of deliberate self‐harm arose out of Kreitman’s original creation of the term parasuicide to label all suicide‐related self‐injury that did not result in death by suicide (Kreitman, 1977). As a result, the term gained much favor in Europe broadly, but not so in the United States. In fact, as mentioned above, the WHO used the term to describe a number of large‐scale epidemiological studies that were undertaken in multiple sites in Europe (Schmidtke et al., 1996, 2004). Over time, the term deliberate self‐harm replaced parasuicide, but this term may have a potentially pejorative connotation, depending upon whether the word “deliberate” is understood to mean the intent to die, or whether it refers to the self‐harm itself (i.e., the person harmed themselves of their own volition). Hence, the current term being used in Europe to describe self‐injury that does not lead to death is self‐harm (with or without intent). In the United States, the term nonsuicidal self‐injury is becoming popular to describe similar behaviors. However, non­ suicidal self‐injury excludes those individuals who overdose (self‐poisoning), even when as many as 25%–50% of those who self‐poison may report no suicidal intent (O’Connor et al., 2007). Another criticism of nonsuicidal self‐injury as a diagnostic term is that the prefix “nonsuicidal” is misleading, because many studies have reported nonsuicidal behaviors, such as self‐cutting, as being associated with greater risk for subsequent suicide attempts and/or death by suicide (Kapur, Cooper, O’Connor, & Hawton, 2013). A related complication is that the term suicide



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gesture remains in the lexicon in the United States, despite well‐developed reasons to replace it with more precise descriptions of suicidal behaviors and the functional assessment of suicide‐related behaviors (Heilbron et al., 2010). The original definition of deliberate self‐harm included all self‐injurious behaviors, regardless of whether the individual had intended to die. Deliberate self‐harm has been identified as a behavior that carries considerable risk of subsequent self‐harm, including suicide attempt and death by suicide, and may be a more accurate descrip­ tion of these behaviors than nonsuicidal self‐injury (Kapur, Cooper, O’Connor, & Hawton, 2013). An early study by Hawton and Fagg (1988) found that at least 1% of patients referred to general hospitals in the United Kingdom for deliberate self‐harm died by suicide within a year of an episode of deliberate self‐harm, and 3%–5% within 5–10 years. Other studies found that 1%–2% of patients die by suicide in the year fol­ lowing being seen in a hospital emergency department or being admitted for treatment (Owens, Horrocks, & House, 2002), with an estimated 7%–10% of individuals even­ tually dying by suicide (Nordentoft et  al., 1993). Of note is that, until recently, researchers have almost totally ignored studying nonhospital‐treated self‐harm. As a result, we are only now learning about the incidence and prevalence of deliberate self‐harm that occurs in the community (Klonsky & Olino, 2008). The deliberate self‐harm literature as well as the suicide attempt literature rarely dis­ tinguishes the populations by method (self‐poisoning, cutting, etc.), location of the injury (wrists, arms, legs, head, etc.), physical location at the time of self‐injury, time of day, day of week, and so on. Without such a classification system, it is more difficult to differentiate between the nonsuicidal deliberate self‐harm and suicide attempt behav­ iors. Deliberate self‐harm is more common among females (upward of 2/3 of patients in some studies). Similarly, in the United States, suicide attempts occur at a ratio of about 3–4:1 for females versus males. In both populations, the largest percentage of cases is among adolescents and young adults. In the hospital‐treated deliberate self‐ harm literature, the large majority of the patients have self‐poisoned (Hawton, 1997). Despite the foregoing definitional and classification issues inherent in differentiating these populations, some recent studies suggest that deliberate self‐harm differs from suicide attempts in clinically important ways (Brown, Henriques, Sosdjan, & Beck, 2004; Chapman & Dixon‐Gordon, 2007; Chapman, Gratz, & Brown, 2006). Reasons for suicide attempts are more likely to involve “making others better off” (reducing burdensomeness), whereas reasons for deliberate self‐harm include “anger expression” and “distraction” (Brown et al., 2004). Other studies highlight the differing emotional experiences associated with these behaviors, although emotional relief is a key motivation for both deliberate self‐harm and suicide attempts (Brown et al., 2004). Individuals who engage in deliberate self‐harm report that the behavior relieves unendurable anxiety or tension; temporarily reduces anger, anxiety, sadness, depression, and shame; or as a form of self‐punishment, relieves anger directed inward, self‐blame, and self‐loathing for perceived social transgressions (Chapman & Dixon‐Gordon, 2007; Kemperman, Russ,  & Shearin, 1997; Krasser, Rossmann, & Zapotoczky, 2003). Chapman and Dixon‐Gordon (2007) found that relief was the most common con­ sequence of deliberate self‐harm, whereas anger was the most common consequence of a suicide attempt. They suggest that deliberate self‐harm serves an emotion regulatory function. However, a significant proportion of individuals reported that their predominant emotional experience following deliberate self‐harm was negative, most notably including sadness. How these characteristics differ from those who

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engage in suicide attempts is yet to be well delineated. Linehan (1997) has sug­ gested that the presence or absence of the intent to die during self‐harm is a critical factor that can differentiate the two behaviors. However, it is important to note that multiple motives often underpin both suicide attempts and deliberate self‐harm (Hjelmeland & Knizek, 1999). Recent research has suggested that all forms of deliberate self‐harm (self‐cutting and overdose; regardless of the intent) may be a precursor to suicidal behaviors. The long‐term results of the multicentre study of self‐harm in the United Kingdom dem­ onstrated that those who self‐cut are actually at higher risk of suicide than those who overdose with medication, although both groups were found to be at increased risk (Hawton et al., 2015).

Relevance to the General Population’s Understanding and use of Terminology Concerns about correct labeling for purposes of clinical decision making are not unique to suicidology. There is a current controversy in the field of cancer regarding the labeling of certain pathological conditions that do not lead to death. For example, Esserman, Thompson, and Reid (2013) suggest reserving the term cancer for condi­ tions with natural histories ending in metastasis and death, in order to reduce screen­ ing and decrease rates of overtreatment for less aggressive forms of disease. They acknowledge that the term cancer has taken on a broad meaning within the cultural lexicon. The general public has adopted many medical terms and concepts that often represent a wide spectrum of illness and disease states. It has been pointed out that “for better or worse, cancer is no longer just a diagnosis, it is an ­identity” (Capurso, 2014). For example, the general public applies the term depression to intermittent, occa­ sional sadness and despair as well as to chronic, debilitating disease that can result in death. However, depression may not begin with sadness or a low mood. In an analo­ gous manner, being labeled “suicidal” or with “suicidality” is not a specific descriptor of suicide thoughts, symptoms, or behaviors, but rather an identity. What is meant by “He/she is no longer suicidal?” Does this mean he/she no longer has current idea­ tion, current intent, or access to lethal means? What about the motivations to end a life? Can they remain present and still label an individual as not being “suicidal”? The use of more precise descriptors is consistent with the overarching goals of performing more competent suicide risk assessments and more clearly communicating the results to inform treatment planning, which are critical components of effective and ethical care for suicidal individuals (e.g., Jobes, Rudd, Overholser, & Joiner, 2008; Heilbron et al., 2010).

The Need for Sensitivity and Consistency The measurement needs of epidemiologists differ from those of clinicians or researchers. Epidemiologists are interested in counting discrete outcomes (e.g., deaths). Primary care physicians do not need to know subtypes of self‐destructive behaviors or the nuances of suicidal intentions or plans. They do need to know the



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few screening questions to ask that will elicit an answer that broadly identifies the patient as requiring a referral to a mental health professional. The emergency department physician needs to know the criteria to determine whether the behavior being assessed will lead to further self‐injury. The clinical researcher needs to differentiate accurately among the population of persons who are engaged in self‐destructive behaviors, and to be able to compare populations across research sites. Given the multidimensional aspects of suicidal thoughts and behaviors, the researcher needs to have valid and reliable criteria for allocating the study samples into discrete groups. The mental health clinician needs to know the specifics of the current ideation, intent, plans and actions, as well as the ­history of prior self‐destructive behaviors (e.g., who, where, when, why, how much, how often) in order to determine which treatment approach has the best likelihood of ­succeeding. The mental health clinician also needs to determine what contribution a current mental disorder may add to the expression of self‐destructive behaviors.

The Role of Nomenclature in Screening One method of assessing the extent/degree of an individual’s suicidal state is by using screening instruments to elicit signs and symptoms found to be associated with sui­ cidal thoughts and actions. How the question is worded can determine the response, because the wording is a reflection of our understanding of the parameters, and cultural expression of the underlying construct that we are trying to measure. Take, for example, the commonly used question, “Have you seriously thought of killing yourself recently?” For this question, what does “seriously” mean? Does it matter to know whether the time frame is “recently,” “last 2 weeks,” “last month,” “last 6 months,” “last year,” or “lifetime”? Without a specific definition and context of the construct being screened for, it becomes very difficult to interpret the response. Rarely are definitions of “suicide ideation/thoughts” and “suicide attempt” provided on screening instruments. There are many assessment instruments to identify the presence of suicidal ­ideations and/or suicidal behaviors. However, they differ in terms of standard measures of validity, reliability, and clinical utility. They often lack clear definitions or assess for mutually exclusive behaviors. One striking limitation is that they do not all ask about all the multiple factors or characteristics that are considered to be suicide‐related behaviors (Linehan et al., 2006; Meyer et al., 2010).

Recent Efforts to Clarify Suicidal Behaviors The intent of this overview is not to present an exhaustive review of all the attempts to develop nomenclatures and classification systems for the study of suicide and suicide‐related thoughts and behaviors, but to highlight some recent examples.

WHO/EURO Parasuicide Multicentre Study (1996–2001) In the 1990s, the WHO embarked on the EURO/WHO Parasuicide Multicentre Study, which required a nomenclature to differentiate various suicidal behaviors (with a specific emphasis on the identification of parasuicidal behaviors) (De Leo et  al.,

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2004, 2006; Schmidtke et al., 2006). The use of the term parasuicide was based on Kreitman’s definition of parasuicide as “a nonfatal act in which an individual deliber­ ately causes self‐injury or ingests a substance in excess of any prescribed or generally recognised therapeutic dosage” (Kreitman, 1977). As is evident, Kreitman’s term avoids any reference to intent or motivation (Kreitman, 1977). In 1999, the study changed its original name (“Study on Parasuicide”) into “Suicidal Behaviour.” The study ended in 2001, after having involved 35 centers. The study methodology included a list of 14 possible “intentions” and was able to reliably demonstrate the simultaneous presence of multiple motivations in suicidal individuals (Hjelmeland et al., 2002). Thus, the degree of lethality depends upon intention, preparation, planning, knowledge of the lethality of the method, and, in some cases, upon purely coincidental factors. One of the main outcomes of the study was a strong push toward focusing on the person (the actor) and a recognition of the importance of identifying suicide intention at the primary health‐care level, including in emergency department settings (De Leo et  al., 2004, 2006; Schmidtke et  al., 2004). After the study ended, members of the multicenter study revised the initial WHO nomenclature on the basis of some of their observations from the study (De Leo et al., 2004). They established the key components of fatal and nonfatal suicidal behaviors: self‐initiated; with or without intent to die; and outcome. One criticism is that although they collapsed “parasuicide,” “deliberate self‐harm,” and “attempted suicide” under one term, (i.e., “non‐fatal suicidal behaviour”), this term can be applied with or without the presence of intent to die. Thus, intent to die is not a defining characteristic of suicidal behaviors. This system also does not account for the possibility of undetermined or uncertain behavioral states associated with intent to die.

Columbia University Suicidality Classification (2005) Suicidologists at Columbia University were approached by the U.S. Food and Drug Administration (FDA) to assist them in reviewing all of the adverse event reporting associated with drug trials involving children and adolescents. The FDA was concerned about whether some of the adverse events being reported were appropriately being labeled as “suicidality.” Under contract to the FDA, the Columbia team developed a “Classification Scheme”—which is a nomenclature of terms and definitions. These researchers reviewed all of the adverse events reports to determine how many actually were related to suicidal behaviors. The “Classification Scheme” was also used for the review of adverse event reporting for drug trials with adults (Posner et al., 2007). It was hoped that this classification scheme would ideally lead to a better systematic assessment of suicidality and improved identification of high‐risk groups for research protocols (clinical registries). Subsequent to conducting the FDA analysis, the Columbia group developed the Columbia Suicidality Severity Rating Scale (C‐SSRS). This measures the degree of suicidal ideation and the level of lethality. Suicidal ideation is measured on a 1–5 point scale (from “wish to die,” “active suicidal ideation,” “method,” “intent,” to “plan”). Hence, the assessment of intent, motivation, and plans are part of the measurement of suicidal ideation. Suicidal behavior is measured on five levels: (1) actual attempt; (2) interrupted attempt; (3) aborted attempt; (4) preparatory act or behavior; and



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(5) nonsuicidal self‐injury. Lethality is measured on a 0–4 scale with the level of severity defined as the frequency, duration, controllability, deterrents, and reasons for ideation.

CDC Self‐Directed Violence Surveillance System (2011) In the spring of 2003, the CDC began to develop surveillance definitions for self‐ directed violence, on the basis of their prior work in developing surveillance defini­ tions for other forms of violence. Over the ensuing years, this process included two major meetings of national experts in the field of suicidology and injury surveillance, as well as external (national and international) and internal review. The surveillance terms and definitions that were agreed upon are self‐directed violence (analogous to self‐injurious behavior), which can be categorized into nonsuicidal self‐directed ­violence or suicidal self‐directed violence; undetermined self‐directed violence; suicide attempt, interrupted self‐directed violence by self or other; suicide; and other suicidal behavior including preparatory acts. In 2011, Self‐Directed Violence Surveillance: Uniform Definitions and Recommended Data Elements (Crosby et  al., 2011) was ­published. When the training of surveillance personnel is completed, the Self‐Directed Violence Classification System will be able, for the first time ever, to collect consistent data on suicide attempts nationwide (Crosby et al., 2011).

Denver VA VISN 19 MIRECC Self‐Directed Violence Classification System (2012) Beginning with the Silverman et al. (2007b) nomenclature as a template, researchers at the Denver Veterans Administration’s Mental Illness Research, Education, and Clinical Care Center (MIRECC) collaborated with the CDC to develop a nomen­ clature and classification system that identifies both suicidal and nonsuicidal self‐ directed violence. The Self‐Directed Violence Classification System has clinical utility and can be used across the U.S. Department of Defense and the Veterans Administration Hospital system (Brenner et al., 2011). There are 22 mutually exclusive terms and definitions that describe the range of suicidal thoughts and behaviors. The Self‐ Directed Violence Classification System focuses on the final pathway of clinical behav­ iors and outcomes rather than a taxonomy that includes etiology. This system is currently being used in clinical trials and in clinical settings within the Veterans Administration Hospital system.

Key Questions Why do we need a classification system? How does it advance the identification, treatment, and prevention of suicide‐related phenomena? A public health approach affords a framework to determine the incidence and prevalence of a public health problem, and the risk and protective factors associated with the problem, and offers clues as to the transmission or progression of the problem. In order to approach sui­ cidal thoughts and actions from a public health perspective, we must first have the tools to conduct surveillance. One of the key tools is a classification system that accu­ rately identifies and measures the problem.

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I would argue that two of the most important goals in the field of suicidology are to prevent the onset and expression of suicide‐related thoughts and actions, and to provide timely and appropriate interventions and management for those who already have expressed suicide‐related thoughts and behaviors. Preventive interven­ tions can take many forms, including health promotion, “upstream prevention,” stress reduction, mental health literacy, stress reduction, and so on. Therapeutic inter­ ventions can include psychotherapy, medications, hospitalizations, safety plans, resil­ iency training, and so on. Therapeutic interventions can also be seen as preventive interventions for those deemed to be at future risk, including those who have already expressed suicide ideations and behaviors, the survivors of those who have lost a loved one to suicide, those who have witnessed a death by suicide, or those suffering from psychiatric disorders. We wish to know what characteristics and degrees of thoughts and actions (e.g., ­frequency, duration, timing, intensity) place an individual at continued risk in the present, near term, or future for similar thoughts and actions. We also wish to know which thoughts and/or actions are ones that require immediate, near‐term, or long‐term attention, and to what degree of intervention. For example, all suicidal ideations are not similar, suicide intent differs from suicide motivations, suicide ­ planning can take make different forms, and suicide attempts can be stratified by level of intent, frequency, and lethality of means. Hence, which types or forms of ideation require more investigation, attention, and intervention? Is suicide planning a more developed extension or serious evolution of suicide ideation, or is suicide planning a separate classification from suicide ideation?

Future Directions Variations in the way self‐injurious and self‐harm terms are defined and operational­ ized in relation to suicide ideation and behaviors have resulted in a diverse array of constructs, studies, and levels of analyses, few of which allow for satisfying systematic comparison. What is needed are studies that examine salient dimensions of suicidal thoughts and behaviors (subjective and structural) within and across contexts with an eye to contextual and demographic mediators, moderators, interactions, and group‐ level variations (Whitlock, Wyman, & Moore, 2014). Furthermore, a classification system that meets the needs of all interested parties— epidemiologists, statisticians, researchers, clinicians, public health practitioners, and so on—must adhere to a framework and set of criteria. In the process of meeting the following criteria, a number of challenges and questions must be addressed: Validation: No classification system has been fully tested to date in terms of deter­ mining whether the terms (and their definitions) actually accurately describe the phenomenology, and, in fact, separate out (e.g., distinctly classify) the range of thoughts, actions, and behaviors associated with the suicidal process. Reliability: Is a specific classification system consistent over time with the same indi­ viduals and with similar populations? Another aspect is whether different clinicians or researchers (sometimes with different theoretical or cultural orientations) can reach agreement on which categories should be assigned for a particular presentation (inter‐rater agreement or reliability; Sartorius et al., 1993).



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Utility: Are the guidelines accompanying the use of the classification system easily understood? Are the essential components of each definition clearly understood or defined? Can we arrive at a specific classification category quickly (i.e., by the least possible number of questions asked or inquiries made)? Is it easy to use? Does it have clinical utility in different settings (outpatient; inpatient; emergency department; research lab)? Generalizability: Does the classification system contain categories or terms suitable for dealing with the range of self‐injurious presentations seen in different cultural settings and countries with different populations (“goodness of fit”)? In short, is the classification culturally sensitive, without theoretical underpinnings, translat­ able to other languages, and so on. Comparability: None of the existing systems have been compared against each other using the same population of individuals with the range of suicide‐related thoughts and behaviors (e.g., suicidal ideation, intent, planning, or attempt). Predictability: What value does a classification system have in predicting or foreseeing further suicidal thoughts or behaviors? For example, does suicide ideation predict suicide attempts, or what types of suicide attempts predict eventual death by suicide? Levels of Risk: There has never been a study that uses a well‐defined and validated classification system to arrive at, or derive, levels of suicide risk. What combination of symptoms or behaviors, and to what degree (what are the essential characteristics of ideation, intent, planning, or attempt), are the essential elements for determining a level of risk (e.g., low, medium, high, acute)? Outcome: Of utmost importance is whether the classification of individuals results in meaningful outcomes. In other words, there has never been a study linking specific interventions with specific classifications (e.g., suicide ideation, intent, planning, or attempt), or determinations of levels of risk. In short, what specific interventions work best for individuals classified as exhibiting suicidal ideation, intent, planning, or attempt? What interventions work best for individuals determined to be at low, medium, high, or acute risk?

Conclusions Measures of suicide and nonfatal suicidal behavior continue to be hindered by the lack of a standard nomenclature and classification system (Brenner et  al., 2011; De Leo et al., 2006; Silverman et al., 2007a, 2007b), clear operational definitions (Garrison, McKeown, Valois, & Vincent, 1993; Silverman & Maris, 1995), and ­standardized lethality measures (Berman, Shepherd, & Silverman, 2003). Apart from the “traditional” difficulties in defining the range of nonfatal suicidal and self‐harm behaviors, there remains the need for uniformity in classifying “idea­ tion” (e.g., death wishes, morbid thoughts, suicide ideation, transient, chronic, intense). Standardization would be very useful in describing the attributes of: “­survivors” of the death of a loved one or peer by suicide (e.g., bereavement, grief, mourning, surviving); those who have engaged in suicide attempts (e.g., lived experi­ ence); and those involved in euthanasia and assisted suicide (e.g., voluntary, involuntary, active, passive, self‐euthanasia). From an international perspective, for theoretical and traditional reasons, countries have been very divided in their use of terminologies. Internationalization of research

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and the impact of electronic distribution of research findings and clinical observations have resulted in more pronounced difficulties in the comparability of research data and clinical guidelines in a cross‐cultural dimension. For example, the implementation of the WHO START Study worldwide has highlighted the wide range of choices and traditions in labeling suicide‐related phenomena. It is evident that cultural background, traditions, criminalization of suicide‐related behaviors, stigma embedded in suicidal behaviors, health-system practices, and official recording procedures all combine to create serious obstacles to a sharable platform for labeling suicide‐related ideations and behaviors in standardized ways. Current difficulties in communicating among professionals as well as their patients include: limitations of hindsight bias and informant bias regarding the reporting of suicidal thoughts, intent, and behaviors (Duberstein & Conwell, 1997); difficulty in comparing and contrasting epidemiological surveys or clinical research studies; incon­ sistency of scale development and validation when most measures assume that the respondent already possesses a definition and understanding of the suicidal behaviors being measured; and lack of specificity and consistency of definition for such terms as suicide attempt, self‐injurious behavior, and self‐harm (Silverman, 2006). Furthermore, each clinical specialty, research group, or surveillance team has developed their own reporting forms and systems to gather similar information. As a result, not only must we use the same terminology, but these terms must be easily understood, “user friendly,” easily applied, and internally consistent. The terms must relate to each other in a way that has utility, meaning, and relevance to the real world of at‐risk individuals. Unless, and until, all members in the field of suicidology speak the same language and approach the classification of suicidal behaviors in a clear, concise, and consistent manner, communications among all those who work for the goal of suicide preven­ tion will remain clouded. Consensus in the development, implementation, and evaluation of clinical and ­preventive interventions is required (Silverman, 2006). All the components of the suicidal process then must be identified, labeled, and classified if we are ever to reach the point where we all can share information and observations to help identify and treat suicidal individuals and develop interventions to prevent the onset, maintenance, duration, intensity, frequency, and recurrence of suicidal thoughts and behaviors. Although challenging, and at times quite difficult, classifying individuals on the basis of the intent of their self‐injury is a useful scientific and clinical endeavor (Nock & Kessler, 2006). Carefully defining key constructs, such as suicide attempts, will reduce variation in reporting and will enhance interpretation and communication of study results (Linehan, 1997; Meehan, Lamb, Saltzman, & O’Carroll, 1992). Even if we are able to differentiate a range of self‐destructive thoughts and ­behaviors into broad categories (such as suicide‐related ideations, communications, and behav­ iors) and subcategories (such as suicide ideation, suicide attempt, and suicide), not all suicide ideations and behaviors are identical across domains (e.g., time, duration, frequency, context, degree of lethality, degree of planning). It would be a goal to have as few categories and subcategories as possible to classify individuals accurately, so that finer differentiations can be made among individuals presenting with self‐destructive thoughts and behaviors. Within each subcategory we need to provide more levels of detail and depth, to fully describe the clinical presentations in as many domains as possible. We need



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to  recognize and establish criteria for finer differentiation within each subcategory that are believed to be critical to understanding and classifying suicidal behaviors: levels of lethality, time frames, levels of intent, types of methods used, degree of planning, motivations, and so on. In 2011, the National Academies of Science/Institute of Medicine released the report, Toward Precision Medicine: Building A Knowledge Network for Biomedical Research and a New Taxonomy of Disease (IOM, 2011). The report notes that a new taxonomy would integrate multiple parameters and “describe and define diseases based on their intrinsic biology in addition to traditional physical signs and symptoms; go beyond description and be directly linked to a deeper understanding of disease mechanisms, pathogenesis, and treatments; be highly dynamic, at least when used as a research tool, continuously incorporating newly emerging disease information”(p. 4). Although suicidal phenomena are not a disease, but a behavior (which may be influ­ enced by underlying disease processes), there is a palpable lack of progress in our field toward developing a taxonomy for suicidal thoughts and behaviors that mirrors the above level of sophistication. There remains a need for the establishment of an international task force to resolve differences among the existing nomenclatures, definitions, and classification systems. Such a Task Force on Nomenclature has been endorsed by the International Association for Suicide Prevention and the International Association for Suicide Research; how­ ever, it currently lacks funding to begin its work. The task force would try to generate an international nomenclature on all terms within the area of suicidology, inclusive of death wishes, assisted suicide, and bereavement. The aim is to obtain an international standardization of terminologies that may render research more comparable across the globe. Such a nomenclature must be compatible with DSM‐5 and ICD‐11, or at least provide a “crosswalk” between the agreed‐upon terminology and these two disease classification systems. This would be an important contribution toward ­ ­preventing suicide and suicidal behaviors. The ultimate goal is to significantly lower the rates of suicides and suicidal behav­ iors, and lighten the burden these actions impose at all levels of our societies. To do so, it is critical to develop, validate, and adopt the best taxonomy in an iterative fashion, recognizing that behavioral symptoms or disorders may arise from multiple etiologies, and that the expression of these behavioral disorders involves interactions of innate and extrinsic factors. Developing a comprehensive and uniform nomencla­ ture requires considerable collaborative effort on an international level.

References Aitken, R. C., Buglass, D., & Kreitman, N. (1969). The changing pattern of attempted suicide in Edinburgh, 1962–67. British Journal of Preventive and Social Medicine, 23, 111–115. Alford, B. A., & Beck, A. T. (1997). The integrative power of cognitive therapy. New York, NY: Guilford Press. Beautrais, A. L. (2001). Suicides and serious medical attempts: Two populations or one? Psychological Medicine, 5, 837–845. Beautrais, A. L. (2004). Further suicidal behaviour amongst medically serious suicide attempters. Suicide and Life‐Threatening Behavior, 34, 1–11. Beck, A. T., Beck, R., & Kovacs, M. (1975). Classification of suicidal behaviors: 1. Quantifying intent and medical lethality. American Journal of Psychiatry, 132, 285–287.

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Berman, A. L., Shepherd, G., & Silverman, M. M. (2003). The LSARS‐II: Lethality of suicide attempt rating scale—updated. Suicide and Life‐Threatening Behavior, 33, 261–276. Bille‐Brahe, U., Kerkhof, A., De Leo, D., & Schmidtke, A. (2004). Definitions and termina­ tion used in the World Health Organization/EURO Multicentre Study. In A. Schmidtke, U. Bille‐Brahe, D. De Leo, & A. Kerkhof (Eds.), Suicidal behaviour in Europe (pp. 11–14). Gottingen, Germany: Hogrefe and Huber. Borges, G., Angst, J., Nock, M. K., Ruscio, A. M., & Kessler, R. C. (2008). Risk factors for the incidence and persistence of suicide‐related outcomes: A 10‐year follow‐up study using the National Comorbidity Surveys. Journal of Affective Disorders, 105, 25–33. Brenner, L. A., Breshears, R. E., Betthauser, L. M., Bellon, K. K., Holman, E., Harwood, J. E. F., … Nagamoto, H. T. (2011). Implementation of a suicide nomenclature within 2 VA health­ care settings. Journal of Clinical Psychology in Medical Settings, 18, 116–128. Capurso, N. A. (2014). Changing the terminology of cancer (letter to the editor). Journal of the American Medical Association, 311, 202. Chapman, A. L., Gratz, K. L., & Brown, M. (2006). Solving the puzzle of deliberate self‐ injury: The experiential avoidance model. Behaviour Research and Therapy, 44, 371–394. Chapman, A. L., & Dixon‐Gordon, K. L. (2007). Emotional antecedents and consequences of deliberate self‐harm and suicide attempts. Suicide and Life‐Threatening Behavior, 37, 543–552. Conner, K. R., Langley, J., Tomaszewski, M. S., & Conwell, Y. (2003). Injury hospitalization and risks for subsequent self‐injury and suicide: A national study in New Zealand. American Journal of Public Health, 93, 1128–1131. Crosby, A. E., Ortega, L., & Melanson, C. (2011). Self‐directed violence surveillance: Uniform definitions and recommended data elements, Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. De Leo, D., Burgis, S., Bertolote, J., Kerkhof, A. D. M., & Bille‐Brahe, U. (2004). Definitions of suicidal behaviour. In D. De Leo, U. Bille‐Brahe, A. D. M. Kerkhof, & A. Schmidtke (Eds.), Suicidal behaviour: Theories and research findings (pp. 17–39). Cambridge, MA: Hogrefe & Huber. De Leo, D., Burgis, S., Bertolote, J. M., Kerkhof, A. D. M., & Bille‐Brahe, U. (2006). Definitions of suicidal behaviour: Lessons learned from the WHO/EURO multicentre study. Crisis, 27, 4–15. Duberstein, P. R., & Conwell, Y. (1997). Personality disorders and completed suicides: A meth­ odological and conceptual review. Clinical Psychology: Science and Practice, 4, 359–376. Elnour, A. A., & Harrison, J. (2009). Suicide decline in Australia: Where did the cases go? Australian and New Zealand Public Health, 33, 67–69. Esserman, L. J., Thompson, I. M., Jr., & Reid, B. (2013). Overdiagnosis and overtreatment in cancer: An opportunity for improvement. Journal of the American Medical Association, 310, 797–798. Garrison, C. Z., McKeown, R. E., Valois, R. F., & Vincent, M. L. (1993). Aggression, sub­ stance abuse, and suicidal behaviours in high school students. American Journal of Public Health, 83, 179–184. Gibb, S. J., Beautrais, A. L., & Fergusson, D. M. (2005). Mortality and further suicidal behav­ iour after an index suicide attempt: A 10‐year study. Australian and New Zealand Journal of Psychiatry, 39, 95–100. Hawton, K. (1997). Attempted suicide. In D. M. Clarke & C. G. Fairburn (Eds.), Science and practice of cognitive behaviour therapy (pp. 285–312). Oxford, England: Oxford University Press. Hawton, K., Bergen, H., Cooper, J., Turnbull, P., Waters, K., Ness, J., & Kapur, N. (2015). Suicide following self‐harm: Findings from the multicentre study of self‐harm in England, 2000–2012. Journal of Affective Disorders, 175, 147–151. Hawton, K., & Fagg, J. (1988). Suicide, and other causes of death, following attempted suicide. British Journal of Psychiatry, 152, 359–366.



Challenges to Defining and Classifying Suicide and Suicidal Behaviors

33

Heilbron, N., Compton, J. S., Daniel, S. S., & Goldston, D. B. (2010). The problematic label of suicide gesture: Alternatives for clinical research and practice. Professional Psychology: Research and Practice, 41, 221–227. Hjelmeland, H., & Knizek, B. L. (1999). Conceptual confusion about intentions and motives of nonfatal suicidal behaviour: A discussion of terms employed in the literature of suicidology. Archives of Suicide Research, 5, 275–281. Hjelmeland, H., Hawton, K., Nordvik, H., Bille‐Brahe, U., De Leo, D., Fekete, S., … Wasserman, D. (2002). Why people engage in parasuicide: A cross‐cultural study of inten­ tions. Suicide and Life‐Threatening Behavior, 32, 380–393. Institute of Medicine (IOM). (2011). Toward precision medicine: Building a knowledge network for biomedical research and a new taxonomy of disease. Washington, DC: The National Academies Press. Jenkins, R., & Singh, B. (2000). General population strategies of suicide prevention. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide (pp. 597–615). Chichester, England: John Wiley. Jobes, D. A., & Berman, A. L. (1985). The numbers game: A critique of mortality stats. Paper presented at the 18th annual meeting of the American Association of Suicidology, Toronto. Jobes, D. A., Berman, A. L., & Josselson, A. R. (1987). Improving the validity and reliability of medical‐legal certifications of suicide. Suicide and Life‐Threatening Behavior, 17, 310–325. Jobes, D. A., Rudd, M. D., Overholser, J. C., & Joiner, T. E. (2008). Ethical and competent care of suicidal patients: Contemporary challenges, new developments, and considerations for clinical practice. Professional Psychology: Research and Practice, 39, 405–413. Kapur, N., Cooper, J., O’Connor, R. C., & Hawton, K. (2013). Attempted suicide versus non‐suicidal self injury: New directions or false dichotomy? British Journal of Psychiatry, 202, 326–328. Kemperman, I., Russ, M. J., & Shearin, E. (1997). Self‐injurious behaviour and mood regula­ tion in borderline patients. Journal of Personality Disorders, 11, 146–157. Klonsky, E. D., & Olino, T. M. (2008). Identifying clinically distinct subgroups of self‐injurers among young adults: A latent class analysis. Journal of Consulting and Clinical Psychology, 76, 22–27. Krasser, G., Rossmann, P., & Zapotoczky, H. G. (2003). Suicide and auto‐aggression, depres­ sion, hopelessness, self‐communication: A prospective study. Archives of Suicide Research, 7, 237–246. Kreitman, N. (1977). Parasucide. London, England: Wiley. Linehan, M. M. (1986). Suicidal people: One population or two? Annals of the New York Academy of Science, 487, 16–33. Linehan, M. M. (1997). Behavioral treatments of suicidal behavior: Definitional obfuscation and treatment outcomes. Annals of the New York Academy of Sciences, 836, 302–328. Linehan, M. M., Comtois, K. A., Brown, M. Z., Heard, H. I., & Wagner, A. (2006). Suicide Attempt Self‐Injury Interview (SASII): Development, reliability, and validity of a scale to assess suicide attempts and intentional self‐injury. Psychological Assessment, 1893, 303–312. Litman, R. E. (1980). Psychological aspects of suicide. In W. J. Curran, A. L. McGarry, & C. S. Petty, (Eds.), Modern legal medicine: Psychiatry and forensic science. Philadelphia, PA: F.A. Davis. Luoma, J. B., Martin, C. E., & Pearson, J. L. (2002). Contact with mental health and primary care providers before suicide: Review of the evidence. American Journal of Psychiatry, 159, 909–916. Malone, K. M., Szanto, K., Corbitt, E., & Mann, J. J. (1995). Clinical assessment versus research methods in the assessment of suicidal behaviour. American Journal of Psychiatry, 152, 1601–1607.

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Mann, J. J., Apter, A., Bertolote, J. M., Beautrais, A., Currier, D., Haas, A., … Hendin, H. (2005). Suicide prevention: A systematic review. Journal of the American Medical Association, 294, 2064–2074. Maris, R. W. (1992). The relationship of nonfatal suicide attempts to completed suicides. In R. W. Maris, A. L. Berman, J. T. Maltsberger, & R. I. Yufit, (Eds.), Assessment and prediction of suicide. New York, NY: The Guilford Press. Matarazzo, B. B., Clemans, T. A., Silverman, M. M., & Brenner, L. A. (2013). The self‐ directed violence classification system and the Columbia classification algorithm for suicide assessment: A crosswalk. Suicide and Life‐Threatening Behaviour, 43, 235–249. Meehan, P. J., Lamb, J. A., Saltzman, L. E., & O’Carroll, P. W. (1992). Attempted suicide among young adults: Progress toward a meaningful estimate of prevalence. American Journal of Psychiatry, 149, 41–44. Meyer, R. E., Salzman, C., Youngstrom, E. A., Clayton, P. J., Goodwin, F. K., Mann, J. J., … Sheehan, D. V. (2010). Suicidality and risk of suicide—definition, drug safety concerns, and a necessary target for drug development: A consensus statement. Journal of Clinical Psychiatry, 71, e1–e21. Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616–623. Nordentoft, M., Breum, L., Munck, L., Nordestgaard, A., Hunding, A., & Bjaedager, P. (1993). High mortality by natural and unnatural causes: A 10‐year follow‐up study of patients admitted to a poisoning treatment centre after suicide attempts. British Medical Journal, 306, 1637–1641. O’Carroll, P. W. (1989). A consideration of the validity and reliability of suicide mortality data. Suicide and Life‐Threatening Behavior, 19, 1–16. O’Carroll, P. W., Berman, A. L., Maris, R. W., Moscicki, E. K., Tanney, B. L., & Silverman, M. M. (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life‐ Threatening Behavior, 26, 237–252. O’Connor, R. C., Whyte, M. C., Fraser, L., Masterton, G., Miles, J., & MacHale, S. (2007). Predicting short‐term outcome in well‐being following suicidal behaviour: The conjoint effects of social perfectionism and positive future thinking. Behavior Research Therapy, 45, 1543–1555. Owens, D., Horrocks, J., & House, A. (2002). Fatal and non‐fatal repetition of self‐harm: Systematic review. British Journal of Psychiatry, 181, 193–199. Posner, K., Oquendo, M. A., Gould, M., Stanley, B., & Davies, M. (2007). Columbia classification algorithm of suicide assessment (C‐CASA): Classification of suicidal events in the FDA pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry, 164, 1035–1043. Rockett, I. R. H., Kapusta, N. D., & Coben, J. H. (2014). Beyond suicide: Action needed to improve self‐injury mortality accounting. Journal of the American Medical Association Psychiatry, 71, 231–232. Rosenberg, M. L., Davidson, L. E., Smith, J. C., Berman, A. L., Buzbee, H., Gantner, G., … Jobes, D. (1988). Operational criteria for determination of suicide. Journal of Forensic Sciences, 32, 1445–1455. Rudd, M. D. (2000). The suicidal mode: A cognitive‐behavioral model of suicidality. Suicide and Life‐Threatening Behavior, 30, 18–33. Rudd, M. D. (2006). The assessment and management of suicidality. Sarasota, FL: Professional Resource Press. Rudd, M. D., & Joiner, T. E., Jr. (1998). The assessment, management and treatment of ­suicidality: Towards clinically informed and balanced standards of care. Clinical Psychology: Science and Practice, 5, 135–150.



Challenges to Defining and Classifying Suicide and Suicidal Behaviors

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Sartorius, N., Kaelber, C. T., Cooper, J. E., Roper, M. T., Rae, D. S., Gulbinat, W., … Regier, D. A. (1993). Progress toward achieving a common language in psychiatry: Results from the field trial of the clinical guidelines accompanying the WHO classification of mental and behavioural disorders in ICD‐10. Archives of General Psychiatry, 50, 115–124. Schmidtke, A., Bille‐Brahe, U., De Leo, D., Kerkhof, A. D. M., Bjerke, T., Crepet, P., … Sampaio‐Faria, J. G. (1996). Attempted suicide in Europe: Rates, trends and sociodemo­ graphic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/Euro multicentre study on parasuicide. Acta Psychiatrica Scandinavia, 93, 327–338. Schmidtke, A., Bille‐Brahe, U., De Leo, D., Kerkhof, A. D. M., & Wasserman, D. (Eds.). (2004). Suicidal behaviour in Europe: Results from the WHO/Euro Multicentre study on suicidal behaviour. Gottingen, Germany: Hogrefe and Huber. Shneidman, E. S. (1980). The reliability of suicide statistics: A bomb burst. Suicide and Life‐ Threatening Behavior, 10, 67–69. Shneidman, E. S. (1985). Definition of suicide. Northvale, NJ: Jason Aronson. Shneidman, E. S. (1996). The suicidal mind. Oxford, England: Oxford University Press. Silverman, M. M. (2006). The language of suicidology. Suicide and Life‐Threatening Behavior, 36, 519–532. Silverman, M. M., & Berman, A. L. (2014a). Suicide risk assessment and suicide risk formula­ tion. Part I: Focus on suicide ideation in assessing suicide risk. Suicide and Life‐Threatening Behavior, 44, 420–431. Silverman, M. M., & Berman, A. L. (2014b). Training for suicide risk assessment and suicide risk formulation. Academic Psychiatry, 38, 526–537. Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007a). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and ­suicidal behaviors. Part I: Background, rationale, and methodology. Suicide and Life‐ Threatening Behavior, 37, 248–263. Silverman, M. M., Berman, A. L., Sanddal, N. D., O’Carroll, P. W., & Joiner, T. E. (2007b). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and ­suicidal behaviours. Part II: Suicide‐related ideations, communications and behaviors. Suicide and Life‐Threatening Behavior, 37, 264–277. Silverman, M. M., & Maris, R. W. (1995). The prevention of suicidal behaviors: An overview. Suicide and Life‐Threatening Behavior, 25, 10–21. Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M. J., & O’Carroll, P. W. (2001). Characteristics of impulsive suicide attempts and attempters. Suicide and Life‐ Threatening Behavior, 32, 49–59. Tollefsen, I. M., Hem, E., & Ekeberg, O. (2012). The reliability of suicide statistics: A systematic review. BMC Psychiatry, 12, 9. Valtonen, H. M., Suominen, K., Sokero, P., Mantere, O., Arvilommi, P., Leppämäki, S., & Isometsä, E. T. (2009). How suicidal bipolar patients are depends on how suicidal ideation is defined. Journal of Affective Disorders, 118, 48–54. Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47, 373–388. Wekstein, L. (1979). Handbook of suicidology. New York, NY: Brunner/Mazel. Westefeld, J. S., Range, L., Rogers, J. R., Maples, M. R., Bromley, J. L., & Alcorn, J. (2000). Suicide: An overview. The Counseling Psychologist, 28, 445–510. Whitlock, J., Wyman, P. A., & Moore, S. R. (2014). Connectedness and suicide prevention in adolescents: Pathways and implications. Suicide and Life‐Threatening Behavior, 44, 246–272. Wilson, M. (1993). DSM–III and the transformation of American psychiatry: A history. American Journal of Psychiatry, 150, 399–410.

2

International Perspectives on the Epidemiology and Etiology of Suicide and Self‐Harm Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur Introduction The global burden of suicide is considerable. It is the 15th leading cause of death worldwide (in 2012) and accounts for 1.4% of all deaths (World Health Organization [WHO], 2014). This translates into an estimated 804,000 suicide deaths worldwide each year (or one death every 40 s), and a global age‐standardized suicide rate of 11.4 per 100,000 population (WHO, 2014). Globally, suicides account for half of all violent deaths in men and 71% in women. The first ever WHO Mental Health Action Plan adopted by the 66th World Health Assembly recognizes suicide prevention as an important international priority, setting a global target of reducing the suicide rate in countries by 10% from a base rate in 2012 by the year 2020 (WHO, 2013). Suicide is a complex phenomenon, influenced by many different and often interacting factors. This chapter provides a broad overview of the current international literature on the rates and risk factors for suicide and self‐harm.

Suicide Definitions and Case Ascertainment The WHO defines suicide as “the act of deliberately killing oneself” (WHO, 2014, p. 12). Although there are over a dozen definitions of suicide, there is broad agreement as to what constitutes a death by suicide. In contrast, accurately recording a suicide death continues to be a barrier to obtaining accurate suicide statistics globally. The determination of death is made by the medical examiner or coroner in many countries, although police and physicians are also involved in some countries (Hawton & van Heeringen, 2009). The criteria used to determine a suicide death also vary ­between and within countries, as does the standard of proof required before a suicide verdict can be recorded (Hawton & van Heeringen, 2009). The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.



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The WHO reports that suicide deaths are most often misclassified (according to the International Classification of Disease and Related Health Conditions [ICD‐10]) as deaths of undetermined intent, accidents, homicides, and unknown cause (WHO, 2014). However, in some countries such as the United Kingdom, national sources of suicide statistics conventionally include deaths of undetermined intent and deaths with a suicide verdict to avoid underestimating suicide deaths (Linsley et al., 2001). Misclassification of deaths may occur to a greater degree in children and the elderly (Schmidtke et al., 2008; Windfuhr et al., 2008) and by method of suicide (Palmer et al., 2015). Suicide case ascertainment in children and adolescents, for example, can be impeded by the lack of clear intent, such as asphyxia from “choking games” (Crepeau‐Hobson, 2010). Older people have higher rates of suicide by self‐poisoning, one of the most common methods to be misclassified as accidental or unintentional (Rockett et al., 2014). Further, in countries where suicide remains illegal, where there is a recent legacy of suicide as a criminal act, or where the stigma of suicide forms part of social norms, determining accurate suicide rates can be difficult (WHO, 2014).

Cross‐National Rates and Trends in Suicide Rates  The WHO estimates country‐specific suicide rates for 172 member states with populations greater than 300,000 (WHO, 2014). On the basis of these regions, the worldwide suicide rate is estimated to be 11.4/100,000 persons per year. In general, Asian and eastern European countries have the highest rates, central/ south American and eastern Mediterranean countries have the lowest rates, with suicide rates in the United States, Western Europe, and Africa somewhere in between (Figure 2.1; Nock et al., 2008b; WHO, 2014). Suicide rates range from 0.4 to 44.2 per 100,000 population with the highest rates in the Southeast Asian region compared to other WHO regions (Figure 2.2). 80.0

Suicide rate per 100,000

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0.0

Figure  2.1  Age‐standardized suicide rates in 2012 for selected countries based on most recent data from the WHO. (From “Preventing suicide: A global imperative,” by World Health Organization [WHO] [2014]. Available at http://www.who.int/mental_health/suicide‐­ prevention/world_report_2014/en/, accessed September 26, 2014. Reproduced with permission of WHO.)

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Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur

World bank regions

All high income Member States LMICs in Western Pacific LMICs in South-East Asia LMICs in Europe LMICs in Eastern Mediterranean

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Figure 2.2  Age‐standardized suicide rates in 2012 in low‐ and middle‐income regions. (From “Preventing suicide: A global imperative,” by World Health Organization [WHO] [2014]. Available at http://www.who.int/mental_health/suicide‐prevention/world_report_2014/en/, accessed September 26, 2014. Reproduced with permission of WHO.)

Compared to low‐ and middle‐income countries, the rate of suicide in high‐income countries is slightly higher at 12.7 per 100,000 compared to 11.2 (WHO, 2014). However, these rates do not reflect the great variation in suicide rates within regions and smaller geographical areas. Although there are likely to be some genuine differences in cross‐national suicide rates, these should be interpreted with caution. Differences in case ascertainment, and availability and recency of reported data, may impact the comparability of suicide rates (WHO, 2014; De Leo, Milner, & Xiangdong, 2009). For example, some countries have not provided updated statistics to the WHO since the 1990s (Värnik, 2012). Differences in suicide rates between countries are also influenced by other factors such as the prevalence of known risk factors for suicide (e.g., mental illness, self‐harm) and the influence of broader societal factors (e.g., social deprivation, political change). Trends  Despite inconsistencies and variability in available suicide data, the WHO compared suicide rates among 172 member states between 2000 and 2012. The change in suicide rates ranged from a 69% fall to an increase of 270% (Figure 2.3a and Figure 2.3b; WHO, 2014). In nearly half (49%) of the countries, there had been a drop in suicide rates of over 10% between these time periods; 17% showed an increase of over 10%; and 34% showed changes of between −10% and 10%.

Methods of Suicide The most common methods of suicide in high‐income countries are hanging and firearms, accounting for 50% and 18% of all suicides, respectively (WHO, 2014). Other frequently used methods include self‐poisoning and jumping from a height, although the method of choice varies substantially by factors such as gender, country, and cultural and societal factors (Ajdacic‐Gross et  al., 2008). For example, hanging is more common among men than women (Figure 2.4a and 2.4b), and the substances used by women to self‐poison vary by country (Cook, Allcock, & Johnston, 2008).



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International Perspectives on the Epidemiology

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% decrease in suicide rate

(a)

Figure  2.3  (a) Increase (percentage change) in suicide rates between 2000 and 2012 in selected countries (from “Preventing suicide: A global imperative,” by World Health Organization [WHO]. [2014]. Available at http://www.who.int/mental_health/suicide‐prevention/world_ report_2014/en/, accessed September 26, 2014. Reproduced with permission of WHO); (b) Decrease (percentage change) in suicide rates between 2000 and 2012 in selected countries (from “Preventing suicide: A global imperative,” by World Health Organization [WHO]. [2014]. Available at http://www.who.int/mental_health/suicide‐prevention/world_report_2014/en/, accessed September 26, 2014. Reproduced with permission of WHO).

Availability of means is a key factor in the choice of a suicide attempt (Biddle et al., 2010). Pesticide poisoning accounts for 30% of suicides globally each year (Gunnell, Eddelston, Phillips, & Konradsen, 2007) and is a particular problem in developing or low‐ and middle‐income countries (WHO, 2014). Rates of firearm suicide are strongly associated with household firearm ownership (Miller, Lippmann, Azrael, & Hemenway, 2007). In the United Kingdom, higher rates of suicide by firearms are evident in rural areas, where gun ownership is higher (Stark, Riordan, & O’Connor, 2011). Jumping (e.g., from a height) as a means of suicide is more common in urban areas (e.g., Hong Kong), owing to the greater prevalence of high buildings, bridges, and access to train lines and underground train systems (Wong, Caine, Lee, Beautrais, & Yip, 2014). In some countries, emerging methods of suicide include mixing chemicals to create toxic gas (Morii, Miyagatani, Nakamae, Murao, & Kiyomi, 2010) and the use of helium (Office for National Statistics, 2013a).

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Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur (a) 11%

5% 9%

5% Other poisoning Pesticides Hanging

15%

Drowning Firearms Falls

2%

Other 53%

(b)

11%

15%

9%

Other poisoning 15%

5%

Pesticides Hanging Drowning Firearms

5%

Falls Other

40%

Figure 2.4  (a) Average percentage method of suicide for males across 56 countries. (From “Methods of suicide: International suicide patterns derived from the WHO mortality database,” by Ajdacic‐Gross et al., 2008, Bulletin of the World Health Organization, 86, 726–732. Reproduced with permission of WHO.) (b) Average percentage method of suicide for females across 56 countries. (From “Methods of suicide: International suicide patterns derived from the WHO mortality database,” by Ajdacic‐Gross et  al., 2008, Bulletin of the World Health Organization, 86, 726–732. Reproduced with permission of WHO.)

The method choice is also influenced by cognitive availability, that is, the knowledge and awareness of the possible ways to die by suicide (Thomas, Beech, & Gunnell, 2013). This has important implications for the media (both traditional media and the Internet) and how it portrays suicide, particularly if suicide methods are reported that individuals may not have previously considered (see Chapter 42 by Pirkis, Mok, Robinson, and Nordentoft). The evidence suggests that reducing the availability of certain methods can reduce suicide rates (Sarchiapone, Mandelli, Losue, Andrisano, & Roy, 2011). Yip et  al. (2010) demonstrated that removing charcoal packs from all supermarkets in a region of Hong Kong led to a significant fall (by 53.8%) in the suicide rate by charcoal burning



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in that area and an overall fall in the national suicide rate. However, it is difficult to establish any long‐term effectiveness of this intervention as the study was based on a one‐year follow‐up. Further, substitution of method may occur when availability of a particular suicide method is restricted (see Chapter 35 by Chen, Wu, Wang, and Yip and Chapter 36 by Azrael and Miller). To summarize, availability and lethality of method influence the choice of method, and this varies internationally. However, reducing access to means can reduce suicide rates. Effective monitoring and early identification of new suicide methods are essential to prevent epidemics and increases in overall suicide rates. The high rate of hanging in many countries is a particular public health challenge, and reducing cognitive availability via improved media portrayal may be more effective than focusing on physical access to means (NCISH, 2014). Overall, there remain important gaps in our existing knowledge about suicide means, particularly the psychology behind method selection.

Demographic Factors Sex  Across the globe, suicide rates are generally higher among males than females, with an average male‐to‐female ratio of 2.8:1 (WHO, 2014) but with wide variations across countries. An exception to this is China (excluding Hong Kong), where the male‐to‐female ratio is 0.8:1 (WHO, 2014). Gender differences are less pronounced in low‐ and middle‐income countries than in high‐income countries, where three times as many men as women die by suicide (WHO, 2014; Figure  2.5). Possible explanations include the availability of more lethal methods (e.g., agrochemical ­poisoning; Eddleston & Phillips, 2004) or political upheaval, gender, or religious beliefs (Sharma et al., 2007). Age  In almost all regions worldwide, suicide rates are highest in males and females aged 70 and above (WHO, 2014). In certain areas, higher suicide rates are seen in

High-income countries

Low- and middle-income countries

4

Male: Female ratio

3.5 3 2.5 2 1.5 1 0.5 0

5–14

15–29

30–49 Age-group

50–69

70+

Figure 2.5  Male:female ratio of suicide rates by age group and income level of country, 2012. (From “Preventing suicide: A global imperative,” by World Health Organization [WHO]. [2014]. Available at http://www.who.int/mental_health/suicide‐prevention/world_report_2014/ en/, accessed September 26, 2014. Reproduced with permission of WHO.)

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younger age groups. Globally, suicide accounts for 8.5% of all deaths in those aged 15–29, and represents the second leading cause of death in this age group after road traffic accidents (WHO, 2014). There have been significant changes in age‐specific suicide rates over the past ­several decades. Since the 1990s, there has been a decline in suicide rates among 15–24‐year‐olds (especially males) in many countries (Värnik et al., 2009), including England (Biddle, Brock, Brookes, & Gunnell, 2008), Scotland (Stark, Stockton, & Henderson, 2008), Australia (Morrell, Page, & Taylor, 2007), and Canada (Steele & Doey, 2007). This may, in part, be associated with the implementation of national suicide prevention programs or to treatment‐related factors such as increases in antidepressant prescribing and improved antidepressant efficacy (Gibbons, Hur, Bhaumik, & Mann, 2006). A cross‐national study of older adult suicide rates in 54 countries by Shah, Bhat, MacKenzie, and Koen (2008) showed a decline in many countries over 10 consecutive years. As a result of these age‐related changes, the age profile of suicide has altered considerably (Sharma et  al., 2007). Broadly speaking, suicide rates increase with advancing age in most countries (Conwell, van Orden, & Caine, 2011), although in some countries, there are greater absolute numbers of suicide among young adults. For example, in the United Kingdom in 2011, the highest suicide rate was in males aged 30–34 (Office for National Statistics, 2013b).

Socioeconomic and Cultural Factors Although a detailed review of sociological issues is beyond the scope of this chapter, some issues merit further discussion in a cross‐national context: marital status and children; ethnicity, culture, and religion; migration and social integration; and socioeconomic and wider societal factors. Each of these is discussed in the following subsections. Marital Status and Children  Suicide is generally more common among those who are single, divorced, and widowed (Wyder, Ward, & De Leo, 2009). Typically, marriage confers a protective effect (O’Reilly, Rosato, Connolly, & Cardwell, 2008), particularly for women, with widowhood increasing the risk in older individuals. However, there are international variations in the pattern of association between suicide and marital status, partly accounted for by differences in sociocultural norms. For example, in contrast to the international literature, Yeh, Xirasagar, Liu, Li, and Lin, (2008) found that young married women in Taiwan had an elevated risk of suicide while older widowed women had a decreased risk. The authors suggested that this could be explained by the changing roles of younger women in Taiwanese society and the greater familial ties and social networks for older women compared to some Western cultures. Children have also been found to confer a protective effect on their parents, particularly for mothers with two or more children (Qin, Agerbo, & Mortensen, 2003). However, there are few cross‐national studies on the link between children and suicide risk in parents, and it is likely that sociocultural norms will also affect any association. Ethnicity, Culture, and  Religion  The rate of suicide among African Americans has ­historically been lower than that of White Americans of European origin, although a rise in the suicide rate of African Americans in the 1980s and 1990s has resulted in an increasing convergence of rates between these two populations (Utsey, Hook, & Stanard, 2007). Indigenous populations (i.e., Alaska Native and American Indian communities), ­however,



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have higher rates of suicide than nonindigenous populations (Alcántara & Gone, 2007). Hispanic Americans and Asian Americans (Duarté‐Vélez & Bernal, 2007; Leong, Leach, Yeh, & Chou, 2007) also have comparatively high rates of suicide. In England and Wales, age‐standardized suicide rates are lower for South Asian men compared to White males, whereas women of South Asian origin show slightly elevated rates compared to their White peers (McKenzie, Bui, Nanchahal, & Blizard, 2008). Factors such as religiosity, spirituality, and familial and social ties have been proposed as contributory factors to lower suicide rates in some ethnic minority groups (Leong et al., 2007). However, factors associated with the risk of suicide, such as the stigma of mental health problems, less contact with mental health services, and substance misuse, are thought to disproportionately affect some ethnic groups (Utsey et al., 2007) and may contribute to higher suicide rates. One limitation of the research on ethnic minority groups and suicide is the selective focus on a small number of ethnic groups (e.g., African Americans, South Asians in the United Kingdom), with comparatively little research on other ethnic groups (e.g., Hispanic Americans, Asian Americans, indigenous populations). Further, the heterogeneity of ethnic minority groups has been largely overlooked in the research literature (Leong et al., 2007). Migration and Social Integration  There is evidence to suggest that the suicide rate among immigrants reflects that of their country of origin (Spallek et  al., 2014). However, assimilation (decline or disappearance of distinct ethnic features), acculturation (the transference of attitudes or behavior between cultures), immigration status (relocation of an individual from his or her country of birth to a new country), and social integration also play an important role in determining the risk of suicide among immigrants (Ratkowska & De Leo, 2013). For example, the experience of cultural differences and increased marginalization can lead to discrimination‐related stress and mental health problems (Panchanadeswaran & Dawson, 2011). Factors associated with the process of migration, such as the threat to family ties and social networks, may confer additional risk to some people (Ratkowska & De Leo, 2013). An elevated risk of suicide may also persist into the second generation of migrants, as attitudes toward help seeking or other culturally specific factors are transferred between generations (Hjern & Allebeck, 2002), although findings are inconsistent (Law, Kõlves, & De Leo, 2014). There remains, however, conflicting evidence as to whether an increased suicide risk is reflective of individuals having poorer health prior to migration or whether they have better health status prior to migration (i.e., the healthy migrant hypothesis; Lu, 2008). Socioeconomic and Wider Societal Factors  Evidence from the WHO indicates higher suicide rates among the richest countries (WHO, 2014). To date, fluctuations in the rate of suicide have been associated with fluctuations in macroeconomic indices such as financial loss (Reeves, McKee, & Stuckler, 2014) although there is wide variation between countries in the magnitude of these associations. Long‐term unemployment has generally been strongly associated with suicide (Milner, Page, & LaMontagne, 2013; see also Chapter 15 by Platt). The recent global economic recession of 2008–2010 has generated a number of empirical studies examining its effect on national suicide rates. Chang, Stuckler, Yip, and Gunnell (2013) examined the impact of the economic crisis on suicide rates in 54 European and American countries. They found 4,884 excess suicides in 2009 compared with the

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number expected on the basis of trends before the crisis. Other studies have reported that this economic crisis has ­contributed to an estimated 10,000 additional suicides in Europe, Canada, and the United States (Reeves et al., 2014). However, data from the Organisation for Economic Co‐operation and Development (OECD)‐affiliated countries have shown slight increases in suicide rates at the beginning of the recession but no sustained effect on overall suicide rates (OECD, 2014). The OECD report did, however, exclude deaths with verdicts of undetermined intent, which may underestimate the true effect of the financial crisis on suicide rates. Political regime and war have both been associated with suicide (Henderson, Stark, Humphry, & Selvaraj, 2006; Page, Morell, & Taylor, 2002), although evidence on the latter is mixed. Tomlinson (2012) reported a possible cohort effect in that those who grew up during the worst years of violence in the Northern Ireland conflict had the highest suicide rates in the decade after 1998 (following the signing of the Good Friday Agreement) and by 2010, Northern Ireland’s suicide rate had almost doubled compared to the rate in 1998. The Global Burden of Suicide  Estimations of the public health burden due to specific risk factors for suicide are often made in order to focus on preventive measures. Burden is usually quantified in terms of potential years of life lost from premature mortality. A further measurement takes into account the disability associated with living with a condition, including pain, physical dysfunction, and emotional distress encapsulated by the term disability adjusted life year. One disability adjusted life year equates to one healthy year of life lost. The Global Burden of Disease Study (GBD 2013) is a comprehensive assessment of mortality, disability, and disease burden covering 187 countries and 21 world regions for the years 1990, 2005, and 2010. Results have shown that mental health issues and substance misuse directly account for 7.4% of disability adjusted life years, making it the leading cause of years lived with disability and the fifth leading cause of disability adjusted life years lost (Whiteford et al., 2013). The additional risk of dying by suicide attributable to mental and substance use disorders was assessed by Ferrari and colleagues (2014), who found these factors were responsible for 62% of total suicide disability adjusted life years in 2010, with depressive illness accounting for the most disability adjusted life years (46.1%). This represented 22.5 million of the 36.2 million disability adjusted life years allocated to suicide.

Temporal Factors Temporal factors that have been associated with suicide include seasonality (e.g., suicide peaks in spring) and personally significant dates (e.g., birthday, anniversary). A recent review of the literature on suicide and seasonality confirmed that the evidence for a seasonal suicide effect remains inconclusive (Christodoulou et al., 2011). The evidence showing an elevated risk around birthdays and the impact of other temporal factors also remains ambiguous (Williams et al., 2011; Reulbach et al., 2007).

Psychological Factors The literature on the psychology of suicidal behavior and completed suicide has focused on the identification of personality traits and associated cognitive features (see O’Connor & Nock, 2014, for a detailed overview of psychological factors that can



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contribute to suicidal behavior; see also Chapters 12 [by Hagan, Ribeiro, and Joiner], 13 [by O’Connor, Cleare, Eschle, Wetherall, and Kirtley], and 25, [by Williams, Duggan, Crane, Hepburn, Hargus, and Gjelsvik], which describe psychological aspects of suicide research and prevention). Personality Traits  Two of the most widely studied personality traits in relation to suicidal behavior are impulsivity and perfectionism. Elevated impulsivity is known to increase aggression and risk‐taking behavior. Studies have found higher levels of impulsivity in those who attempt suicide compared to those with suicidal ideation only (Wang et  al., 2014). This trait has also been linked to more severe suicide attempts (Swann et al., 2005). Evidence suggests that impulsive individuals are more vulnerable to suicide when faced with triggers such as substance misuse, stress, and depression (Pompili et  al., 2010). However, abuse of alcohol or drugs can itself increase impulsivity, and therefore the contribution of impulsivity to suicidal behavior remains unclear (Anestis, Soberay, Gutierrez, Hernandez, & Joiner, 2014). In a systematic review, O’Connor (2007) identified 29 studies that investigated the association between perfectionism and suicidality and found some evidence of an association between self‐critical evaluative concerns (i.e., being excessively self‐ critical and concerned about other people’s expectations) and suicidality. Recently, Flett, Hewitt, and Heisel (2014) stated that the role of perfectionism as a risk factor for suicide has been underestimated and that clinical assessments should include perfectionism as a separate indicator for suicide risk. However, the interpretation and generalizability of this work are limited owing to methodological ­problems (e.g., lack of consistency in the measures of perfectionism) and the paucity of international research. Cognitive Variables  Cognitive variables that have been associated with suicidal behavior include hopelessness (Beck, Brown, Berchick, Stewart, & Steer, 2006), autobiographical memory (Pettersen, Rydningen, Christensen, & Walby, 2010), burdensomeness (Hill & Pettit, 2014), rumination (Miranda, Tsypes, Gallagher, & Rajappa, 2013), dichotomous thinking and cognitive rigidity (see Ellis & Rutherford, 2008 for a review), and problem‐solving skills (Gibbs et al., 2009). Again, however, the generalizability of the findings is limited because most studies have been carried out in Western or European countries.

Biological and Genetic Factors There is growing evidence to suggest that a predisposition to suicide is at least partly heritable. Although the international literature on twin studies has mainly developed in Europe or North America, study findings converge in support of a g ­ enetic component to suicidality (Zai et al., 2012). Adoption studies show that suicide rates are higher in the biological relatives of adopted children who end their life compared to the biological relatives of adopted children who do not do so (Petersen, Sørensen, Andersen, Mortensen, & Hawton, 2013). Again, however, there is a dearth of international research—see Chapter 9 (by Mann and Currier), Chapter 10 (by van Heeringen and Bijttebier), and Chapter 11 (by Sudol and Oquendo). Molecular genetic studies have focused on the serotonergic system (Mann, 2013) and have indicated that candidate genes may include tryptophan hydroxylase, which is involved in the biosynthesis of serotonin (Bach‐Mizrachi et  al., 2008), and the serotonin 5‐HT2a receptor gene

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(Carlstrom et al., 2012). Migrant studies offer an alternative method of investigating the genetic component to suicide (see earlier section on migration and social integration in this chapter).

Suicide and Mental Illness Mental illness is a key contributory factor to suicide risk (Chesney, Goodwin, & Fazel, 2014). In a systematic review, Li, Page, Martin, and Taylor (2011) estimated the population attributable risk of suicide associated with mental disorders. Population attributable risks indicate the proportion of cases that would not occur in a given population if the feature under study was eliminated. The review found that the highest population attributable risks for suicide in males and females were affective disorders (26.3% and 31.6%, respectively) and ­substance use disorders (19.0% and 25.4%, respectively). However, there is variation in the prevalence of mental illness internationally, with higher rates found in Western countries and lower rates in Asian countries. Western studies have shown that approximately 90%–95% of suicide cases have a mental ­disorder (Cavanagh, Carson, Sharpe, & Lawrie, 2003; Nock et al., 2008b), whereas in Asia it is between 63% and 97% (Tong & Phillips, 2010; Vijayakumar, 2005). Although depressive ­illness is the most common mental disorder among suicide cases in both developed and low‐ and middle‐income countries (Tong & Phillips, 2010), the prevalence of the disorder differs widely. For example, in developed countries, more than two-thirds of suicide cases were reported to have a diagnosis of depressive disorder (Mann, 2002) compared to only 30%–45% in developing nations (Tong & Phillips, 2010). This may, in part, be a reflection of increased stigma and low rates of contact with mental health services in low‐ and middle‐income countries. Suicide Among People in Contact with Health Services  The U.K. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) is a unique national database of all suicide cases in contact with mental health services in the 12 months preceding suicide. Much of what we know about suicide in the mental health patient population in the United Kingdom is derived from the NCISH (see Windfuhr & Kapur, 2011, for a review). In the United Kingdom, between one-quarter and one-third of individuals who complete suicide have been in contact with mental health services in the year before death, equating to about 1,600 (28%) suicide cases annually (NCISH, 2015). The rates of recent contact with mental health services prior to death are broadly similar between nations within the United Kingdom, although proportions are lower in Wales (England: 28%; Northern Ireland: 27%; Scotland: 30%; Wales: 23%). However, studies investigating contact with mental health services prior to suicide have been carried out mainly in the United States, Nordic countries, and the United Kingdom. Reports from low‐ and middle‐income countries have shown much lower rates of contact with mental health services (Khan, Mahmud, Karim, Zaman, & Prince, 2008), in part owing to the lack of access to specialized mental health care as well as sociocultural factors (Chen & Yip, 2008). Rates and characteristics of suicide among patient suicide cases vary by demographic (e.g., age, sex) and clinical (e.g., patient group, diagnosis) characteristics. For example, psychiatric i­npatients are a particularly vulnerable patient group. In  England and Wales, 9% of suicide cases



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were inpatients (N = 1,367), whereas inpatients represented a smaller group in Northern Ireland (4%) and Scotland (7%; NCISH, 2015). It is worth noting, though, that the number of inpatient suicides in England and Wales fell between 2003 and 2012, particularly for those patients who die on the ward (NCISH, 2015). This may be attributable to guidance on the removal of specific ligature points (Department of Health, 2002) and continued vigilance regarding ward safety. Indeed, other improvements to aspects of service provision have been found to significantly reduce rates of patient suicide in England and Wales, p ­ articularly introducing 24‐hour crisis care, policies for patients with dual diagnosis, and multidisciplinary review after a suicide (While et al., 2012). Overall, comparison of U.K. inpatient suicide rates and trends with other countries is ­difficult given the paucity of robust international research in this patient population (Tishler & Reiss, 2009).

Self‐Harm Definitions and Terminology Self‐harm is a multifaceted and complex behavior that varies in both severity and intent. In the remainder of this chapter, the term self‐harm will be used to describe intentional acts irrespective of the intent, including self‐poisoning and self‐injury (Kapur, 2009). There are international differences in the nomenclature used, with some ­distinguishing between nonsuicidal self‐injury and suicide attempt (see Chapter 1 by  Silverman). There is continuing debate about the strength of the evidence that such a distinction is based on (Butler & Malone, 2013). Given the uncertainty, and the use of the broader definition in U.K. national guidance (NICE, 2011), here we use the term self‐harm.

The Relationship Between Suicide and Self‐Harm Self‐harm (and repeated self‐harm) is one of the strongest risk factors for subsequent suicide. On the basis of hospital‐admitted or treated populations, individuals who have self‐harmed have a 30–200‐fold increased risk of suicide in the year following an episode compared to individuals who have not self‐harmed (Cooper et  al., 2005). Individuals who repeat self‐harm are at even greater risk of subsequent suicide compared to individuals who have self‐harmed on only one occasion (Zahl & Hawton, 2004). Cross‐national risk factors for self‐harm are reasonably consistent and include female gender, younger age, fewer years of education, and mental disorder (Nock et  al., 2008a). Some risk factors for self‐harm overlap with risk factors for suicide (e.g., mental disorder), suggesting that the two behaviors are related, although their relationship is complex.

Rates and Trends of Self‐Harm For a comprehensive overview of the international literature on the epidemiology of self‐harm over the period 1970–2007, see Welch (2001) and more recent papers on suicidal ideation, plans, and attempts by Nock and colleagues (Nock et al., 2008a, 2008b). A summary of key studies is now presented.

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Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur

Rates As part of the WHO/EURO multicenter study of self‐harm, Schmidtke and c­ olleagues (2004) reported that self‐harm was more common among females than males, and higher rates were generally found among younger adults. In particular, young women aged 15–24 years and young men aged 25–29 years had the highest rates of self‐harm. There was also substantial variation, even among countries within one WHO region (i.e., the European region), with a ninefold difference between the highest and lowest self‐harm rates for males and a sixfold difference for females. Registration‐based studies (i.e., those using medical records as the main data source) such as the WHO/EURO study provide data on the rates of self‐harm behaviors that are treated within the health‐care system, usually hospital emergency departments. In recognition of the lack of standardized information about hospital‐ treated self‐harm from many low‐ and middle‐income countries, as well as the speculation that such countries have higher than average rates of suicide, the START (Suicide Trends in At‐Risk Territories) study (De Leo et  al., 2013), an ongoing project, was initiated by the WHO with the aim of addressing this gap. Participating countries include many that had no previous accounts of self‐harm prevalence. However, studies that focus on medically treated self‐harm underestimate the extent of the problem as not all episodes of self‐harm result in medical intervention (Kapur & Appleby, 2008). Bertolote et al. (2005) reported the findings from the WHO SUPRE‐MISS study of suicidal behavior, a population survey initiated to gain a better understanding of suicidal behavior in culturally diverse locations. The study yielded a lifetime prevalence of suicidal ideation ranging from 2.6% in Chennai, India, to 25.4% in Durban, South Africa. Lifetime prevalence of suicide attempts ranged from 0.4% in Hanoi, Vietnam, to 4.2% in both Brisbane (Australia) and Karaj (Islamic Republic of Iran). Nock and colleagues (2008a) reported the prevalence of suicidal behaviors from the WHO World Mental Health Survey initiative. Across 17 countries, the lifetime rate of suicide attempt was 2.7%, with a rate of 9.2% for ideation and 3.1% for suicide planning. There was substantial cross‐national variability, less so in respect of planned suicide attempts compared to other suicidal thoughts and behaviors (e.g., suicidal ideation, suicide planning). Countries in regions of the world with typically high suicide rates (e.g., Eastern Europe) did not necessarily have high rates of suicidal behavior (Nock et al., 2008b). More recently, 12‐month prevalence rates for suicidal behavior were found to be similar for males and females in high‐income (0.3% for both) and low‐income countries (0.4% for both) but higher for females (0.6%) than males (0.3%) in middle‐income countries (WHO, 2014). The WHO has estimated that the global annual rate of suicide attempt is around 4 per 1000 adults (or 0.4%; WHO, 2014). However, these results were from self‐report surveys with differing response rates across countries, somewhat limiting the strength of the evidence. School‐Based Studies of Self‐Harm  In an international school‐based survey of self‐ harm in adolescents (“Child and Adolescent Self‐Harm in Europe Study”; CASE), Madge and colleagues (2008) reported rates (for self‐harm in the previous year) of 8.9% for females and 2.6% for males, with lifetime rates of 13.5% for females and 4.3% for males. Many countries show similar rates of self‐harm in their adolescent



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populations, (e.g., Hawton et  al., 2002; O’Connor et  al., 2009), although recent studies have reported variation between countries. A study using self‐report data on over 45,000 15–16‐year‐olds from 17 countries participating in the European School Survey Project on Alcohol and Other Drugs found that the proportion reporting a lifetime suicide attempt varied from 4% in Armenia to 24% in Hungary, with a median of around 11% (Kokkevi et al., 2012). Female rates were consistently almost twice the rate of males. Although some U.K. nations have similar rates (O’Connor et al., 2009), the rate of adolescent self‐harm may be lower in Northern Ireland (O’Connor et al., 2014). Trends  There was a substantial increase in the rates of self‐harm during the 1960s and 1970s in the UK (Kapur & Gask, 2009). However, in their comprehensive review of suicide and suicidal behavior, Nock and colleagues report that, internationally, the prevalence of suicidal behavior appears to have remained relatively stable across time, with the most recent prevalence estimates similar to those reported in earlier studies (Nock et  al., 2008a). Recent data from England focusing on hospital‐treated self‐ harm, however, showed an increase in rates from 2008 to 2011 (Department of Health, 2013) in line with trends in suicide rates reported earlier in this chapter. With respect to adolescent self‐injury, both suicidal and nonsuicidal, a systematic review of rates across the world concluded that although rates were high relative to other age groups—a lifetime prevalence of around 18%—they did not seem to be increasing (Muehlenkamp et al., 2012). Interpreting Rates of Self‐Harm  Rates of self‐harm are difficult to ascertain, largely because the relevant data are not comprehensively and systematically collected within individual countries or cross‐nationally (Kapur & Appleby, 2008). Furthermore, where the data are collected, comparison between locations is difficult for several ­reasons. First, there are often methodological differences in how (e.g., inclusion criteria) and where the data are collected (e.g., hospital‐based studies, general ­ population surveys/interviews). A recent attempt to synthesize suicide and self‐harm data across “at‐risk” countries using the START study (De Leo et al., 2013) describes in detail the challenges encountered when combining data from diverse settings, and highlights the particular challenges in countries with more limited financial resources. Second, there are cultural differences in how self‐harming behavior is viewed by the medical profession that affect how data are recorded. Third, register‐based studies underestimate the prevalence of self‐harming behavior in the wider population as not all episodes of self‐harm present to health services (Kapur & Appleby, 2008). A recent estimate from an Irish study suggested that 6% of adolescent self‐harm episodes resulted in hospital presentation (McMahon et al., 2014). However, in general, the level of clinical need among people who present is likely to differ from those who do not seek help. Fourth, in population‐based studies, surveys can elicit different information as a result of differences in data collection approaches (e.g., interview, self‐reported) and question wording; response rates can also differ. However, both register‐based studies and population surveys generate important data, which can inform clinical services and public health initiatives to reduce the prevalence of self‐ harm. In short, further cross‐national studies, as well as those involving multiple sites within countries, are needed to give a comprehensive national and international view of the rates of self‐harming behavior (WHO, 2014).

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Methods of Self‐Harm In the United Kingdom, the majority of hospital‐treated self‐harm presentations are accounted for by self‐poisoning, with self‐injury—mainly self‐laceration—representing a minority (Kapur & Gask, 2009; Bergen et al., 2010). However, self‐injury is the most common method of self‐harm recorded in community studies of adolescent self‐harm (Hawton, Rodham, Evans, & Weatherall, 2002). Indeed, as outlined in the following section, it is possible that self‐injury is a distinct behavior, separate from other self‐harm and ­suicidal behaviors (Duffy, 2009). The following section discusses these two behaviors separately. Self‐Poisoning  Self‐poisoning can be described as “the self‐exposure of an individual … to an amount of substance associated with the significant potential to cause harm” (Camidge, Wood, & Bateman, 2003, p. 56). Self‐poisoning is one of the most common methods of self‐harming behavior seen by clinical services: upward of 80% of all hospital self‐harm presentations are self‐poisoning episodes (Hawton et  al., 2007). The rate of presentations to hospital following self‐harm in England has been shown to vary between 310/100,000 and 373/100,000 population for males and between 412/100,000 and 544/100,000 population for females (Bergen et  al., 2010). One of the most common means of self‐poisoning in the United Kingdom is  paracetamol ingestion, accounting for approximately 40% of all self‐poisoning ­episodes (Kapur & Gask, 2009). Generally, the substances used in self‐poisoning reflect ease of access or prescription patterns (Kapur & Gask, 2009). Agrochemicals are most commonly used in low‐ and middle‐income countries and in rural areas, with organophosphates accounting for the majority of fatalities (e.g., Sri Lanka, Thailand, Taiwan; Eddleston, 2000). In more urban areas of developing countries, medicines, particularly drugs ­acting on the central nervous system, are common (Eddleston, 2000). Self‐Injury  Self‐injury can be described as injury that is “intentionally self‐inflicted” (Lilley et  al., 2008). The majority of self‐injury episodes are lacerations, estimated to account for over 70% of self‐injury episodes (Duffy, 2009). Less common methods of self‐ injury include burning, stabbing, and self‐hitting (Duffy, 2009; Klonsky & Muehlenkamp, 2007). Cutting is a common method of self‐injury in the United Kingdom (Lilley et al., 2008), although methods of self‐injury differ cross‐nationally. Studies have noted that 4% of adults report a history of self‐injury (Klonsky & Muehlenkamp, 2007). Madge and colleagues (2008) found that the one‐year rate of self‐injurious behavior among an international community sample of young people (Europe and Australia) was around 9% for females and 3% for males aged 15–16‐year‐olds, markedly higher than rates of hospital‐treated adolescents in England (Hawton et al., 2012).

Outcomes Nonfatal repetition, suicide, and death from all causes are outcomes of particular interest. Nonfatal Repetition  On the basis of hospital‐treated samples, the rate of repetition within one year of an episode is approximately 15%–16%, rising to between 20% and



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25% in the years thereafter (Owens, D., Horrocks, J., & House, A. (2002)). Repetition often occurs within a short time. Both school‐based and hospital‐based studies have shown similar repetition rates among adolescent males and females (Madge et  al., 2008; Hawton et al., 2012). Much of the literature on the repetition of hospital‐treated self‐harm comes from the United Kingdom and Ireland, Nordic countries, and the rest of Europe, with fewer studies from North America, Australia, and New Zealand (Owens et al., 2002). There is evidence that repeat rates are lower in Asian countries compared to non‐Asian countries, probably owing to a combination of differences in hospital management, self‐ harm methods used, and patient characteristics (Carroll, Metcalfe, & Gunnell, 2014). Fatal Repetition of Self‐Harm  International reviews of the literature on repetition of individuals who self‐harmed and presented to hospital (Owens et al., 2002; Carroll et al., 2014) have found that approximately 2% of those who had self‐harmed had died by suicide at 1‐year follow‐up. In follow‐up studies of approximately 9 years or more, the proportion that ended their own life increased to approximately 7%. The median one‐year suicide rate was substantially lower in the United Kingdom than in other countries, suggesting geographical differences in outcome for self‐harm, or differences in ascertainment rates of self‐harm or suicide between countries (Owens et al., 2002). The risk of subsequent suicide appears to be elevated in those who self‐ injure compared to those who self‐poison (Cooper et al., 2005). Death From All Causes  People who self‐harm are also at higher risk than the general population of dying prematurely from causes other than suicide. Bergen and ­colleagues showed that among people who had presented to hospital with self‐harm, 6% had died after between 2 and 10 years of follow‐up. Those dying from natural causes lost an average of 26 years of life, increasing to 40 years for individuals dying from external causes (Bergen et al., 2012).

Socio‐Demographic Features of People Who Self‐Harm In a large cross‐national, self‐report study of adults from 17 countries, Nock and ­colleagues (2008a) reported that nonfatal suicidal behavior was associated with females and low educational achievement. Furthermore, the risk of suicide decreased ­substantially with increasing age. With the exception of gender distributions for suicide and self‐harm (i.e., suicidal behavior is more common among females; ­completed suicide is more common among males), the socio‐demographic characteristics of self‐ harm are consistent cross‐nationally and are broadly similar to those reported for suicide (see earlier sections in this chapter).

Cultural Features of People Who Self‐Harm As with suicide, the prevalence of self‐harm varies by ethnic group. Bhui, McKenzie, and Rasul (2007) carried out a systematic literature review of studies investigating self‐harm in U.K. ethnic minority groups. Important findings of that review included the higher rates of self‐harm among young Asian women and apparently increasing rates of self‐harm among young people of Caribbean origin. In another study of self‐ harm in three English cities, young Black women were found to have higher rates of self‐harm than White women of the same age (Cooper et al., 2010). However, in both

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studies, the prevalence of repetition was generally reported to be lower among adults from Black and Asian origins compared to nonethnic minority groups. There is evidence for a greater risk of attempted suicide among African American and Hispanic adolescents in the United States when compared to European American adolescents (U.S. Department of Health and Human Services, 2009). In the WHO/EURO Multicentre Study on Suicidal Behaviour, data were used to examine rates of suicide attempt in 56 immigrant groups across Europe (Lipsicas et al., 2012). Almost half of the groups were found to have higher rates compared to their host population; although most of these groups also had correspondingly higher suicide rates in their country of origin, some originated from countries with relatively low suicide rates. Despite these findings, more research is required to elucidate further the specific features of self‐harm in different ethnic minority groups internationally.

Temporal Features Self‐harm presentations may vary by season, time of week, and time of day. Another WHO study, the WHO/Euro Multicentre Study on Parasuicide, found broadly consistent temporal fluctuations across 13 European countries (Jessen et al., 1999). An examination of suicide attempts across public holidays (religious and nonreligious) revealed a decrease in suicide attempts prior to and during holidays, with an increase following holidays. However, it is unclear how well these findings generalize to non‐ Christian holidays and national holidays in non‐Western and developing countries. The majority of self‐harm presentations to hospital generally occur outside normal working hours, with females more likely to present at the weekend (Gunnell, Bennewith, Peters, House, & Hawton, 2005).

Clinical Features Many of the clinical features of hospital‐treated self‐harm are similar to those of suicide. A psychiatric diagnosis may be common among self‐harm patients, with some studies citing that as many as 90% of individuals who self‐harm have a psychiatric ­disorder (Kapur & Appleby, 2008). Psychiatric disorders are more likely to be identified in patients in Western countries (90% of adult patients) than non‐Western countries (71%; Hawton, Saunders, Topiwala, & Haw, 2013). In a systematic review of the self‐ harm literature, Fliege, Lee, Grimm, and Klapp (2009) reported that individuals who self‐harm without suicidal intent are heterogeneous diagnostically, presenting with personality disorders, affective ­disorders, substance abuse disorders, eating disorders, and schizophrenia. In a recent multinational self‐report survey study of the prevalence and risk factors for suicidal behavior, Nock and colleagues (2009) found a strong and consistent relationship ­between mental disorder and increased risk of suicidal behavior. The strongest associations were found between suicide attempts and mood disorders and suicide attempts and impulse‐control disorders. Mood disorders were a stronger predictor of suicidal behavior in high‐income countries, whereas impulse‐control disorders were a stronger predictor in low‐ and middle‐income countries. Psychological traits associated with self‐harming behavior include poor coping and problem‐solving skills, high levels of anxiety, impulsivity, aggression, and depression. The number of negative life events (e.g., sexual abuse) is also associated with self‐ harm, particularly in younger people (Fliege et al., 2009).



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Conclusion Despite variations in international rates and risk factors, it is clear that suicide and self‐harm are major public health issues contributing to substantial morbidity and mortality worldwide. Between 2000 and 2012, the global suicide rate has fallen by 26%—faster than the 18% decrease in overall mortality over this time period (WHO, 2014). If this fall in suicides can be maintained, the global target of reducing the suicide rate by 10% by 2020 (WHO, 2014) may be reached. A number of national suicide prevention objectives can help achieve this, as highlighted by the recent WHO (2014) report. It is important to: • • • • • •

enhance surveillance and research; identify and target vulnerable groups; improve the assessment and management of suicidal behavior; promote environmental and individual protective factors; increase awareness through public education; improve societal attitudes and beliefs and eliminate stigma toward people with mental disorders or who exhibit suicidal behaviors; • reduce access to means of suicide; • encourage the media to adopt better policies and practices toward reporting suicide; and • support individuals bereaved by suicide. Local suicide prevention strategies also have a key role to play in improving surveillance systems, particularly in low‐ and middle‐income countries, where 75% of all suicides occur. Perhaps one of the most consistent findings from the research literature is the well‐established association of mental illness with suicide and self‐harm suicidal behavior. There have also been positive signs of progress in governments within Europe, Canada, Australia, and the United States with regard to improving mental health and reducing stigma. However, despite the considerable advances made in recent years, there are still major gaps in our knowledge and a relatively shallow understanding of the factors associated with suicidal behavior. Better and more timely reporting of the rates of suicide and suicidal behavior can only improve our understanding of these complex phenomena. More international research using robust methodologies to investigate suicidal behavior is required. In particular, there is a dearth of research in, and published findings from, developing, low‐income, and non‐ Western countries. Truly international research will help to inform local, national, and international approaches to suicide prevention.

References Ajdacic‐Gross, V., Weiss, M. G., Ring, M., Hepp, U, Bopp, M., Gutzwiller, F., & Rössler, W. (2008). Methods of suicide: International suicide patterns derived from the WHO mortality database. Bulletin of the World Health Organization, 86, 726–732. Alcántara, C., & Gone, J. P. (2007). Reviewing suicide in Native American communities: Situating risk and protective factors within a transactional‐ecological framework. Death Studies, 31, 457–477.

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Anestis, M. D., Soberay, K. A., Gutierrez, P. M., Hernandez, T. D., & Joiner, T. E. (2014). Reconsidering the link between impulsivity and suicidal behavior. Personality and Social Psychology Review, 18(4), 366–386. doi: 10.1177/1088868314535988. Bach‐Mizrachi, H., Underwood, M. D., Tin, A., Ellis, S. P., Mann, J. J., & Arango, V. (2008). Elevated expression of tryptophan hydroxylase‐2 mRNA at the neuronal level in the dorsal and median raphe nuclei of depressed suicides. Molecular Psychiatry, 13, 507–513. Beck, A. T., Brown, G., Berchick, R. J., Stewart, B. L., & Steer, R. A. (2006). Relationship between hopelessness and ultimate suicide: A replication with psychiatric outpatients. FOCUS, 4, 291–296. Bergen, H., Hawton, K., Waters, K., Cooper, J., & Kapur, N. (2010). Epidemiology and trends in non‐fatal self‐harm in three centres in England: 2000–2007. British Journal of Psychiatry, 197, 493–498. Bergen, H., Hawton, K., Waters, K., Ness, J., Cooper, J., Steeg, S., & Kapur, N. (2012). Premature death after self‐harm: A multicentre cohort study. The Lancet, 380, 1568–1574. Bertolote, J. M., Fleischmann, A., De Leo, D., Bolhari, J., Botega, N., De Silva, D., … Wasserman, D. (2005). Suicide attempts, plans, and ideation in culturally diverse sites: The WHO SUPRE‐MISS community survey. Psychological Medicine, 35, 1457–1465. Bhui, K. S., McKenzie, K., & Rasul, F. (2007). Rates, risk factors & methods of self harm among minority ethnic groups in the UK: A systematic review. BMC Public Health, 7(336). Biddle, L., Brock, A., Brookes, S. T., & Gunnell, D. (2008). Suicide rates in young men in England and Wales in the 21st century: Time trend study. British Medical Journal, 336, 539–542. Biddle, L., Donovan, J., Owen‐Smith, A., Potokar, J., Longson, D., Hawton, K., … Gunnell, D. (2010). Factors influencing the decision to use hanging as a method of suicide: Qualitative study. British Journal of Psychiatry, 197, 320–325. Butler, A. M., & Malone, K. (2013). Attempted suicide v. non‐suicidal self‐injury: Behaviour, syndrome or diagnosis? British Journal of Psychiatry, 202, 324–325. Camidge, D. R., Wood, R. J., & Bateman, D. N. (2003). The epidemiology of self‐poisoning. British Journal of Clinical Pharmacology, 56, 613–619. Carlstrom, L., Saetre, P., Rosengren, A., Thygesen, J. H., Djurovic, S., Melle, I., … Jonsson, E. G. (2012). Association between a genetic variant in the serotonin transporter gene (SLC6A4) and suicidal behavior in patients with schizophrenia. Behavioral and Brain Functions, 8(24). doi: 10.1186./1744‐9081‐8‐24. Carroll, R., Metcalfe, C., & Gunnell, D. (2014). Hospital presenting self‐harm and risk of fatal and non‐fatal repetition: Systematic review and meta‐analysis. PLoS ONE, 9(2). Cavanagh, J. T. O., Carson, A. J., Sharpe, M., & Lawrie, S. M. (2003). Psychological autopsy studies of suicide: A systematic review. Psychological Medicine, 33, 395–405. Chang, S‐S., Stuckler, D., Yip, P., & Gunnell, D. (2013). Impact of 2008 global economic crisis on suicide: Time trend study in 54 countries. British Medical Journal, 347. doi:10.1136/bmmj.f5239. Chen, Y. Y., & Yip, P. S. (2008). Rethinking suicide prevention in Asian countries. The Lancet, 372, 1629–1630. Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all‐cause and suicide mortality in mental disorders: A meta‐review. World Psychiatry, 13, 153–160. Christodoulou, C., Douzenis, A., Papadopoulos, F. C., Papadopoulou, A., Bouras, G., Gournellis, R., & Lykouras, L. (2011). Suicide and seasonality. Acta Psychiatrica Scandinavica, 125, 127–146. Conwell, Y., van Orden, K., & Caine, E. D. (2011). Suicide in older adults. Psychiatric Clinics of North America, 34, 451–468. Cook, R., Allcock, R., & Johnston, M. (2008). Self‐poisoning: Current trends and practice in a UK teaching hospital. Clinical Medicine, 8, 37–40.



International Perspectives on the Epidemiology

55

Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E. Mackway‐Jones, K., & Appleby, L. (2005). Suicide after deliberate self‐harm: A 4‐year cohort study. American Journal of Psychiatry, 162, 297–303. Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H., Waters, K., & Kapur, N. (2010). Ethnic differences in self‐harm, rates, characteristics and service provision: Three‐city cohort study. British Journal of Psychiatry, 197, 212–218. Crepeau‐Hobson, F. (2010). The psychological autopsy and determination of child suicides: A survey of medical examiners. Archives of Suicide Research, 14, 24–34. Department of Health. (2002). NHSE SN (2002) 01: Cubicle rail suspension system with load release support systems. Available at http://www.dh.gov.uk/en/Publicationsandstatistics/ Lettersandcirculars/Estatesalerts/DH_4122863, accessed 15 September 2009. Department of Health. (2013). Annual report of the Chief Medical Officer 2013. Public mental health priorities: Investing in the evidence. Available at https://http://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/351629/Annual_ report_2013_1.pdf. De Leo, D., Milner, A., Fleischmann, A., Bertolote, J., Collings, S., Amadeo, S., … Wang, X. (2013). The WHO START study: Suicidal behaviors across different areas of the world. Crisis, 34, 156–163. De Leo, D., Milner, A., & Xiangdong, W. (2009). Suicidal behavior in the Western Pacific region: Characteristics and trends. Suicide and Life‐Threatening Behavior, 39, 72–81. Duarté‐Vélez, Y. M., & Bernal, G. (2007). Suicide behaviour among Latino and Latina adolescents: Conceptual and methodological issues. Death Studies, 31, 435–455. Duffy, D. F. (2009). Self‐injury. Psychiatry, 5, 263–265. Eddleston, M. (2000). Patterns and problems of deliberate self‐poisoning in the developing world. Quarterly Journal of Medicine, 93, 715–731. Eddleston, M., & Phillips, M. R. (2004). Self poisoning with pesticides. British Medical Journal, 328, 42–44. Ellis, T. E., & Rutherford, B. (2008). Cognition and suicide: Two decades of progress. International Journal of Cognitive Therapy, 1, 47–68. Ferrari, A. Z., Norman, R. E., Freedman, G., Baxter, A. J., Pirkis, J. E., Harris, M. G., … Whiteford, H. A. (2014). The burden attributable to mental and substance use disorders as risk factors for suicide: Findings from the Global Burden of Disease Study 2010. PLoS ONE, 9(4), e91936. doi: 10.1371/.pone.0091936. Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18, 156–172. Fliege, H., Lee, J.‐R., Grimm, A., & Klapp, B. F. (2009). Risk factors and correlates of deliberate self‐harm behavior: A systematic review. Journal of Psychosomatic Research, 66, 477–493. Gibbons, R. D., Hur, K., Bhaumik, D. K., & Mann, J. J. (2006). The relationship between antidepressant prescription rates and rate of early adolescent suicide. American Journal of Psychiatry, 163, 1898–1904. Gibbs, L. M., Dombrovski, A. Y., Morse, J., Siegle, G. J., Houck, P. R., & Szanto, K. (2009). When the solution is part of the problem: Problem solving in elderly suicide attempters. International Journal of Geriatric Psychiatry, 24, 1396–1404. Gunnell, D., Bennewith, O., Peters, T. J., House, A., & Hawton, K. (2005). The epidemiology and management of self‐harm amongst adults in England. Journal of Public Health, 27, 67–73. Gunnell, D., Eddelston, M., Phillips, M. R., & Konradsen, F. (2007). The global distribution of fatal pesticide self‐poisoning: Systematic review. BMC Public Health, 7, 357. doi:10.1186/1471‐2458‐7‐357. Hawton, K., Bergen, H., Casey, D., Simkin, S., Palmer, B., Cooper, J., … Owens, D. (2007). Self‐harm in England: A tale of three cities. Social Psychiatry and Psychiatric Epidemiology, 42, 513–521.

56

Kirsten Windfuhr, Sarah Steeg, Isabelle M. Hunt, and Navneet Kapur

Hawton, K., Bergen, H., Waters, K., Ness, J., Cooper, J., Steeg, S., & Kapur, N. (2012). Epidemiology and nature of self‐harm in children and adolescents: Findings from the ­multicentre study of self‐harm in England. European Child & Adolescent Psychiatry, 21, 369–377. Hawton, K., & van Heeringen, K. (2009). Suicide. The Lancet, 373, 1372–1381. Hawton, K., Rodham, K., Evans, E., & Weatherall, R. (2002). Deliberate self harm in adolescents: Self report survey in schools in England. British Medical Journal, 325, 1207–1211. Hawton, K., Saunders, K., Topiwala, A., & Haw, C. (2013). Psychiatric disorders in patients presenting to hospital following self‐harm: A systematic review. Journal of Affective Disorders, 151, 821–830. Henderson, R., Stark, C., Humphry, R. W., & Selvaraj, S. (2006). Changes in Scottish suicide rates during the Second World War. BMC Public Health, 6, 167. doi: 10.1186/1471‐ 2458‐6‐167. Hill, R. M., & Pettit, J. W. (2014). Perceived burdensomeness and suicide‐related behaviors in clinical samples: Current evidence and future directions. Journal of Clinical Psychology, 70, 631–643. Hjern, A., & Allebeck, P. (2002). Suicide in first‐ and second‐generation immigrants in Sweden. A comparative study. Social Psychiatry and Psychiatric Epidemiology, 37, 423–429. Jessen, G., Jensen, B. F., Arensman, E., Bille‐Brahe, U., Crepet, P., De Leo, D., … Wasserman, D. (1999). Attempted suicide and major public holidays in Europe: Findings from the WHO/Euro Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 99, 412–418. Kapur, N. (2009). Suicide in the mentally ill. Psychiatry, 8(7), 257–260. Kapur, N., & Appleby, L. (2008). Suicide and self‐harm. In R. Murray, K. Kendelr, P. McGuffin, S. Wessely, & D. Castle (Eds.), Essential psychiatry (4th ed). Cambridge: Cambridge University Press. Kapur, N., Cooper, C., O’Connor, R. C., & Hawton, K. (2013). Non‐suicidal self‐injury v. attempted suicide: New diagnosis or false dichotomy? British Journal of Psychiatry, 202, 326–328. Kapur, N., & Gask, L. (2009). Introduction to suicide and self‐harm. Psychiatry, 8(7), 233–236. Khan, M. M., Mahmud, S., Karim, M. S., Zaman, M., & Prince, M. (2008). Case‐control study of suicide in Karachi, Pakistan. British Journal of Psychiatry, 193, 402–405. Klonsky, E. D., & Muehlenkamp, J. J. (2007). Self‐injury: A research review for the practitioner. Journal of Clinical Psychology, 63, 1045–1056. Kokkevi, A., Rotsika, V., Arapaki, A., & Richardson, C. (2012). Adolescents’ self‐reported suicide attempts, self‐harm thoughts and their correlates across 17 European countries. Journal of Child Psychology and Psychiatry, 53, 381–389. Law, C.‐K., Kõlves, K., & De Leo, D. (2014). Suicide mortality in second‐generation migrants, Australia, 2001–2008. Social Psychiatry and Psychiatric Epidemiology, 49, 601–608. Leong, F. T. L., Leach, M. M., Yeh, C., & Chou, E. (2007). Suicide among Asian Americans: What do we know? What do we need to know? Death Studies, 31, 417–434. Li, Z., Page, A., Martin, G., & Taylor, R. (2011). Attributable risk of psychiatric and socio‐ economic factors for suicide from individual‐level, population‐based studies: A systematic review. Social Science and Medicine, 72, 608–616. Lilley, R., Owens, D., Horrocks, J., House, A., Noble, R., Bergen, H., … Kapur, N. (2008). Hospital care and repetition following self‐harm: Multicentre comparison of self‐­poisoning and self‐injury. British Journal of Psychiatry, 192, 440–445. Linsely, K. R., Schapira, K., & Kelly, T. P. (2001). Open verdict vs. suicide—Importance to research. British Journal of Psychiatry, 178, 465–468. Lipsicas, C. B., Makinen, I. H., Apter, A., De Leo, D., Kerkhof, A., Lonnqvist, J., … Wasserman, D. (2012). Attempted suicide among immigrants in European countries: An international perspective. Social Psychiatry and Psychiatric Epidemiology, 47, 241–251.



International Perspectives on the Epidemiology

57

Lu, Y. (2008). A test of the “healthy migrant hypothesis”: A longitudinal analysis of health ­selectivity of internal migration in Indonesia. Social Science and Medicine, 67, 1331–1339. Madge, N., Hewitt, A., Hawton, K., de Wilde, E. J., Corcoran, P., Fekete, S., … Ystgaard, M. (2008). Deliberate self‐harm within an international community sample of young people: Comparative findings from the Child and Adolescent Self‐harm in Europe (CASE) Study. Journal of Child Psychology and Psychiatry, 49, 667–677. Mann, J. J. (2002). A current perspective of suicide and attempted suicide. Annals of Internal Medicine, 136, 302–311. Mann, J. J. (2013). The serotonergic system in mood disorders and suicidal behaviour. Philosophical Transactions of the Royal Society B, 368(1615), Available at http://dx.doi.org/ 10.1098/rstb.2012.0537. McKenzie, K., Bui, K., Nanchahal, K., & Blizard, B. (2008). Suicide rates in people of South Asian origin in England and Wales: 1993–2003. British Journal of Psychiatry, 193, 406–409. McMahon, E. M., Keeley, H., Cannon, M., Arensman, E., Perry, I. J., Clarke, M., … Corcoran, P. (2014). The iceberg of suicide and self‐harm in Irish adolescents: A population‐based study. Social Psychiatry and Psychiatric Epidemiology, 49, 1929–1935. Miller, M., Lippmann, S. J., Azrael, D., & Hemenway, D. (2007). Household firearm ownership and rates of suicide across the 50 United States. Journal of Trauma: Injury, Infection, and Critical Care, 62, 1029–1035. Milner, A., Page, A., & LaMontagne, A. D. (2013). Long‐term unemployment and suicide: A systematic review and meta‐analysis. PLoS ONE, 8(1), e51333. doi:10.1371/journal. pone.0051333. Miranda, R., Tsypes, A., Gallagher, M., & Rajappa, K. (2013). Rumination and hopelessness as mediators of the relation between perceived emotion dysregulation and suicidal ideation. Cognitive Therapy and Research, 37, 786–795. Morrell, S., Page, A. N., & Taylor, R. J. (2007). The decline in Australian young male suicide. Social Science and Medicine, 64, 747–754. Morii, D., Miyagatani, Y., Nakamae, N., Murao, M., & Kiyomi, T. (2010). Japanese experience of hydrogen sulphide: The suicide craze in 2008. Journal of Occupational Medicine and Toxicology, 5(28). doi: 10.1186/1745‐6673‐5‐28. Muehlenkamp, J. J., Claes, L., Havertape, L., & Plener, P. L. (2012). International prevalence of adolescent non‐suicidal self‐injury and deliberate self‐harm. Child and Adolescent Psychiatry and Mental Health, 6(10). National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) (2014). Annual report 2014: England, Northern Ireland, Scotland and Wales, July 2014. Manchester: University of Manchester. Available at www.manchester.ac.uk/nci. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) (2015). Annual report 2015: England, Northern Ireland, Scotland and Wales, July 2015. Manchester: University of Manchester. Available at www.manchester.ac.uk/nci. National Institute for Health and Clinical Excellence (NICE). (2011). The long term care and treatment of self‐harm. Clinical Guideline, 133. Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., … William, D. (2008a). Cross‐national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192, 98–105. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008b). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133–154. Nock, M. K., Hwang, I., Sampson, N., Kessler, R. C., Angermeyer, M., Beautrais, A., … Williams, D. R. (2009). Cross‐national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. PLoS Medicine, 6(8), 1–17. O’Connor, R. C. (2007). The relations between perfectionism and suicidality: A systematic review. Suicide and Life‐Threatening Behavior, 37(6), 698–714. O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. Lancet Psychiatry, 1, 73–85.

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O’Connor, R. C., Rasmussen, S., & Hawton, K. (2014). Adolescent self‐harm: A school‐based study in Northern Ireland. Journal of Affective Disorders, 159, 46–52. O’Connor, R. C., Rasmussen, S., Miles, J., & Hawton, K. (2009). Self‐harm in adolescents: Self‐report survey in schools in Scotland. British Journal of Psychiatry, 194, 68–72. Office for National Statistics. (2013a). Deaths related to drug poisoning in England and Wales, 2012. London, England: Office for National Statistics. Office for National Statistics. (2013b). Suicides in the United Kingdom, 2011. London, England: Office for National Statistics. O’Reilly, D., Rosato, M., Connolly, S., & Cardwell, C. (2008). Area factors and suicide: 5‐years follow‐up of the Northern Ireland population. British Journal of Psychiatry, 192, 106–111. Organisation for Economic Co‐operation and Development (OECD). (2014). Suicide. In Society at a glance: OECD social indicators. OECD Publishing. Available at http://dx.doi.org/ 10.1787/soc_glance‐2014‐24‐en, accessed October 1, 2014. Owens, D., Horrocks, J., & House, A. (2002). Fatal and non‐fatal repetition of self‐harm: Systematic review. British Journal of Psychiatry, 181, 193–199. doi: 10.1192/bjp.181.3.193. Page, A., Morell, S., & Taylor, R. (2002). Suicide and political regime in New South Wales and Australia during the 20th century. Journal of Epidemiology and Community Health, 56, 766–772. Palmer, B. S., Bennewith, O., Simkin, S., Cooper, J., Hawton, K., Kapur, N., & Gunnell, D. (2015). Factors influencing coroners’ verdicts: An analysis of verdicts given in 12 coroners’ districts to researcher‐defined suicides in England in 2005. Journal of Public Health, 37, 157–165. doi: 10.1093/pubmed/fdu024. Panchanadeswaran, S., & Dawson, B. A. (2011). How discrimination and stress affects self‐ esteem among Dominican immigrant woman: An exploratory study. Social Work in Public Health, 26, 60–77. Petersen, L., Sørensen, T. I. A., Andersen, P. K., Mortensen, P. B., & Hawton, K. (2013). Genetic and familial environmental effects on suicide—An adoption study of siblings. PLoS ONE, 8(10), e77973. doi:10.1371/journal.pone.0077973. Pettersen, K., Rydningen, N. N., Christensen, T. B., & Walby, F. A. (2010). Autobiographical memory and suicide attempts in schizophrenia. Suicide and Life‐Threatening Behavior, 40, 369–375. Pompili, M., Serafini, G., Innamorati, M., Dominici, G., Ferracuti, S., Kotzalidis, G. D., … Lester, D. (2010). Suicidal behaviour and alcohol abuse. International Journal of Environmental Research and Public Health, 7, 1392–1431. Qin, P., Agerbo, E., & Mortensen, P. B. (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: A national register‐based study of all ­suicides in Denmark, 1981–1997. American Journal of Psychiatry, 160, 765–772. Ratkowska, K. A., & De Leo, L. (2013). Suicide in immigrants: An overview. Open Journal of Medical Psychology, 2, 124–133. Reeves, A., McKee, M., & Stuckler, D. (2014). Economic suicides in the Great Recession in Europe and North America. British Journal of Psychiatry, 205, 246–247. doi: 10.1192/ bjp.bp.114.144766. Reulbach, U., Biermann, T., Markovic, K., Kornhuber, J., & Bleich, S. (2007). The myth of the birthday blues: A population‐based study about the association between birthday and suicide. Comprehensive Psychiatry, 48, 554–557. Rockett, I. R. H., Smith, G. S., Caine, E. D., Kapusta, N. D., Hanzlick, R. L., Larkin, G. L., … Fraser, D. W. (2014). Confronting death from drug self‐intoxication (DDSI): Prevention through a better definition. American Journal of Public Health, 104, e49–e55. Sarchiapone, M., Mandelli, L., Losue, M., Andrisano, C., & Roy, A. (2011). Controlling access to suicide means. International Journal of Environmental Research and Public Health, 8, 4550–4562.



International Perspectives on the Epidemiology

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Schmidtke, A., Sell, R., & Loehr, C. (2008). Epidemiology of suicide in older persons. Zeitschrift fűr Gerontologie and Geriatrie, 41(1), 3–13. Schmidtke, A., Weinacker, B., Loehr, C., Bille‐Brahe, U., De Leo, D., Kerkhof, A., … Rutz, W. (2004). Suicide and suicide attempts in Europe: An overview. In A Schmidtke, U. Bille‐ Brahe, D. De Leo, & A Kerkhof (Eds.), Suicidal behavior in Europe: Results from the WHO/EURO Multicentre Study on suicidal behavior (pp. 15–28). Cambridge, MA: Hogrefe & Huber. Shah, A., Bhat, R., MacKenzie, S., & Koen, C. (2008). Elderly suicide rates: Cross‐national comparisons of trends over a 10‐year period. International Psychogeriatrics, 20(4), 673–686. Sharma, B. R., Gupta, M., Sharma, A. K., Sharma, S., Gupta, H., Relhan, N., & Singh, H. (2007). Suicide in Northern India: Comparison of trends and review of literature. Journal of Forensic and Legal Medicine, 14, 318–326. Spallek, J., Reeske, A., Norredam, M., Nielson, S. S., Lehnhardt, J., & Razum, O. (2014). Suicide among immigrants in Europe—A systematic literature review. European Journal of Public Health, 1–9. doi:10.1093/eurpub/cku1221. Stark, C., Stockton, D., & Henderson, R. (2008). Reduction in young male suicide in Scotland. BMC Public Health, 8, 80. Stark, C. R., Riordan, V., & O’Connor, R. (2011). A conceptual model of suicide in rural areas. Rural and Remote Health, 11, 1622. (Online). Accessed October 3, 2014. Steele, M. M., & Doey, T. (2007). Suicidal behavior in children and adolescents. Part 1: Etiology and risk factors. Canadian Journal of Psychiatry, 52, 21S–33S. Swann, A. C., Dougherty, D. M., Pazzaglia, P. J., Pham, M., Steinberg, J. L., & Moeller, F. G. (2005). Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder. American Journal of Psychiatry, 162(9), 1680–1687. Thomas, K. H., Beech, E., & Gunnell, D. (2013). Changes in commonly used methods of suicide in England and Wales from 1901–1907 to 2001–2007. Journal of Affective Disorders, 144, 235–239. Tishler, C. L., & Reiss, N. S. (2009). Inpatient suicide: Preventing a common sentinel event. General Hospital Psychiatry, 31, 103–109. Tomlinson, M. W. (2012). War, peace and suicide: The case of Northern Ireland. International Sociology, 27, 464–482. Tong, Y., & Phillips, M. R. (2010). Cohort‐specific risk of suicide for different mental disorders in China. British Journal of Psychiatry, 196, 467–473. U.S. Department of Health and Human Services. (2009). Youth risk behavior surveillance— United States, 2009. Available at http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Utsey, S. O., Hook, J. N., & Stanard, P. (2007). A re‐examination of cultural factors that  ­mitigate risk and promote resilience in relation to African American Suicide: A review of the literature and recommendations for future research. Death Studies, 31, 399–416. Värnik, A., Kõlves, K., Allik, J., Arensman, E., Aromaa, E., van Audenhove, C., … Hegerl, U. (2009). Gender issues in suicide rates, trends and methods among youths aged 15–24 in 15 European countries. Journal of Affective Disorders, 113, 216–226. Värnik, P. (2012). Suicide in the world. International Journal of Environmental Research and Public Health, 9, 760–771. Vijayakumar, L. (2005). Suicide and mental disorders in Asia. International Review of Psychiatry, 17, 109–114. Wang, L., He, C. Z., Yu, Y. M., Qiu, X. H., Yang, X. X., Qiao, Z. X., … Yang, Y. J. (2014). Associations between impulsivity, aggression, and suicide in Chinese college students. BMC Public Health, 14, 551. doi:10.1186/1471‐2458‐14‐551. Welch, S. S. (2001). A review of the literature on the epidemiology of parasuicide in the general population. Psychiatric Services, 52, 368–375.

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While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., … Kapur, N. (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: A cross‐sectional and before‐and‐after observational study. The Lancet, 379, 1005–1012. doi: 10.1016/S0140‐6736(11)61712‐1. Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., Ferrari, A. J., Erskine, H. E., … Vos, T. (2013). Global burden of disease attributable to mental and substance use disorders: Findings from the global burden of disease study 2010. The Lancet, 382, 1575–1586. Williams, A., While, D., Windfuhr, K., Bickley, H., Hunt, I. M., Shaw, J., … Kapur, N. (2011). Birthday blues. Examining the association between birthday and suicide in a national sample. Crisis, 32, 134–142. Windfuhr, K., & Kapur, N. (2011). Suicide and mental illness: A clinical review of 15 years findings from the UK National Confidential Inquiry into Suicide. British Medical Bulletin, 100, 101–121. Windfuhr, K., While, D., Hunt, I., Turnbull, P., Lowe, R., Burns, J., … Kapur, N. (2008). Suicide in juveniles and adolescents in the United Kingdom. Journal of Child Psychology and Psychiatry, 49(11), 1155–1165. Wong, P. W. C., Caine, E. D., Lee, C. K. M., Beautrais, A., & Yip, P. S. F. (2014). Suicides by jumping from a height in Hong Kong: A review of coroner court files. Social Psychiatry and Psychiatric Epidemiology, 49, 211–219. World Health Organization (WHO). (2013). Mental Health Action Plan 2013–2020. Geneva, Switzerland: World Health Organization. World Health Organization (WHO). (2014). Preventing suicide: A global imperative. Available at http://www.who.int/mental_health/suicide‐prevention/world_report_2014/ en/, accessed September 26, 2014. Wyder, M., Ward, P., & De Leo, D. (2009). Separation as a suicide risk factor. Journal of Affective Disorders, 116(3), 208–213. Yeh, J. Y., Xirasagar, S., Liu, T. C., Li, C. Y., & Lin, H. C. (2008). Does marital status predict the odds of suicidal death in Taiwan? A seven‐year population based study. Suicide and Life Threatening Behavior, 38(3), 302–310. Yip, P. S. F., Law, C. K., Fu, K‐W., Law, Y. W., Wong, P. W. C., & Xu, Y. (2010). Restricting the means of suicide by charcoal burning. British Journal of Psychiatry, 196, 241–242. Zahl, D. L., & Hawton, K. (2004). Repetition of deliberate self‐harm and subsequent suicide risk: Long‐term follow‐up study of 11,583 patients. British Journal of Psychiatry, 185, 70–75. Zai, C. C., de Luca, V., Strauss, J., Tong, R. P., Sakinofsky, I., & Kennedy, J. L. (2012). Genetic factors and suicidal behavior. In Y. Dwivedi (Ed.), The neurobiological basis of suicide. Boca Raton, FL: CRC Press. Chapter  11. Available from: http://www.ncbi.nlm.nih.gov/ books/NBK107191/.

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Self‐Harm Extent of the Problem and Prediction of Repetition Ella Arensman, Eve Griffin, and Paul Corcoran Introduction Engaging in self‐harm is the strongest predictor of future suicidal behavior, both nonfatal and fatal (Gilbody, House, & Owens, 1997; Gunnell et al., 2008; Kerkhof & Arensman, 2001; Zahl & Hawton, 2004). Self‐harm frequently leads to nonfatal repetition with an estimated median risk of repetition of 16% within 1 year and 23% over 4 years, on the basis of the findings of systematic reviews (Carroll, Metcalfe, & Gunnell, 2014; Owens, Horrocks, & House, 2014). However, other estimates from a U.K. multicenter study suggest even higher rates of repeated self‐harm (33%) in the 12 months following an index case (Lilley et  al., 2008). Subsequent repeated self‐ harm often occurs within days and weeks of an index self‐harm act (Cedereke & Ojehagen, 2005; Kapur et al., 2006; Perry et al., 2012). Worldwide, few countries have reliable data on self‐harm. There is a broad spectrum of self‐harming behaviors, ranging from deliberate recklessness to highly lethal attempts at suicide, and only a minority of persons who self‐harm present to hospital (Skegg, 2005). However, hospital presentations due to self‐harm provide a potentially important indicator of the impact of psychiatric and psychological morbidity in the population. They also provide an important opportunity for the health and social care system to provide targeted interventions to reduce the risk of suicide in a well‐ delineated group of patients at high risk of suicide. An internationally agreed definition of self‐harm has been endorsed by the World Health Organization (WHO) and will be used to define self‐harm in this chapter: “an act with non‐fatal outcome in which an individual deliberately initiates a non‐habitual behaviour, that without intervention from others will cause self‐harm, or deliberately ingests a substance in excess of the prescribed or generally recognised therapeutic ­dosage, and which is aimed at realising changes that the person desires via the actual or expected physical consequences” (Platt et  al., 1992). This definition facilitated international comparisons of self‐harm incidence and trends in a European ­multicenter study (Schmidtke, Bille‐Brahe, Kerkhof, & De Leo, 2004) that demonstrated a more than 10‐fold variation in self‐harm rates across more than 20 regions. These rates were based on single centers as reliable estimates of national rates are not available. The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

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A National Self‐Harm Registry has been operating in the Republic of Ireland since 2002. The Irish Registry is a national system of population monitoring for the occurrence of self‐harm presenting to all hospital emergency departments in the country. The registry had near complete coverage of the country’s hospitals for the period 2002–2005. From 2006 onward, however, all general hospital and pediatric hospital emergency departments have contributed data to the registry (Griffin et al., 2015). The present chapter includes an overview of outcomes of the Irish self‐harm registry in terms of the incidence of self‐harm and repetition. In addition, a review of the international literature has been conducted on self‐harm, prediction of repetition, and assessment procedures to identify self‐harm patients at risk of future repetition.

Extent of the Problem of Self‐Harm and Repetition Extent of the Problem of Self‐Harm In Ireland, the National Self‐Harm Registry Ireland (NSHRI) records all self‐harm presentations made to hospital emergency departments. Over the period 2007–2013, 76,140 self‐harm presentations to hospital were made involving 51,240 individuals. The average annual total, male, and female rates of persons presenting with self‐harm were 207, 193, and 220 per 100,000 population, respectively. There was evidence of an increasing trend over the period 2007 to 2011 (+19%). This increase was most pronounced in the male rate, which increased by 30% during this period. Between 2011 and 2013, there have been annual decreases in the rate of self‐harm in Ireland (−4%, −2%, and −6%, respectively). However, the rate in 2013 was still 6% higher than the prerecession rate in 2007 (Griffin et al., 2015). Hawton et  al. (2007) conducted a multicenter study of self‐harm in the United Kingdom in which a similar methodology was used to obtain data on hospital presentations of self‐harm in Oxford, Manchester, and Leeds over an 18‐month period (March 2000–August 2001). Self‐harm rates for males ranged from 285 per 100,000 in Oxford to 460 in Manchester, and for females the rates ranged from 342 per 100,000 in Oxford to 587 in Manchester. These rates are higher than those found in  Ireland. However, between 2000 and 2007, the rates of self‐harm decreased in England, which was reflected mainly in a decline in emergency department presentations for self‐poisoning (Bergen, Hawton, Waters, Cooper, & Kapur, 2010a). The Northern Ireland Registry of Self‐Harm has been in operation in the Western Trust Area on a pilot basis since 2007 (Corcoran, Griffin, O’Carroll, Cassidy, & Bonner, 2015). In 2012, the registry was extended to all regions of Northern Ireland, using a similar methodology to that in the Republic of Ireland. In 2013, the total, male, and female rates of self‐harm were 327, 333, and 321 per 100,000, respectively (Public Health Agency [PHA], 2015). The Network for International Collaboration on Evidence in Suicide Prevention (NICE‐SP) conducted an international comparative study to examine the variation in self‐harm rates by gender in eight European regions between 1989 and 2003 (Arensman et al., 2008). Trends in self‐harm rates over time vary considerably across the different European regions and by gender. Self‐harm rates were consistently higher among women than men, with the highest rates in Manchester,

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United Kingdom (580); Oxford, United Kingdom (416); and Gent, Belgium (319), and the lowest rates in Sør‐Trøndelag, Norway (148); Umea, Sweden (128); and Ljubljana, Slovenia (72). The low self‐harm rates in Ljubljana are remarkable considering the high suicide rates at the national level. With the exception of Oxford, similar trends over time were found for female and male self‐harm rates. After 1995, an increasing trend for self‐harm was found in females in Oxford, whereas the rates for males remained stable. In Manchester, rates of self‐harm for both males and females were fairly stable. In the two Irish regions, Cork and Limerick, an increase in self‐harm was observed in both males and females after 1999. In the two Scandinavian regions, Sør‐Trøndelag and Umea, a decreasing trend for both males and females was observed over the period 1989–1995 followed by a stable pattern in the following years. In Gent, both male and female self‐harm rates showed a steep decline after 1995. Schmidtke et al. (2004) compared trends in self‐harm rates in 11 European regions over a maximum period of 10 years (1989–1999). In females, a decrease in self‐harm rates was observed in most regions from the mid‐1990s. In males, the self‐harm rates showed a less consistent pattern over time. The decreasing trend of self‐harm in women may be associated with the wider implementation of national suicide prevention programs and specific treatment programs such as cognitive behavioral therapy or dialectical behavior therapy aimed at reducing the risk of repeated self‐harm, which occurred during the same period.

Repetition of Self‐Harm Hospital‐Based Studies  The Irish NSHRI data over the period 2007–2013 show that 11,745 patients (22.3%) presented to the hospital emergency department on at least two occasions (at least one repetition), 5,190 (9.9%) presented at least three times (at least two repetitions), and 469 (0.9%) presented at least 10 times (Griffin et al., 2015). The risk of repetition was highest immediately after a self‐harm presentation, with half (47%) of all repeat events occurring in the first 3 months and almost two-thirds (64%) within the first 6 months. There was a clear association between repetition and the method of self‐harm: the highest rates were found among individuals who engaged in self‐cutting (either as the sole method or in combination with drug overdose). The risk of repetition within the first 12 months following the study index episode was 37.1% and 36.9% in individuals whose methods were cutting alone or cutting and overdose, respectively. The 12‐month risk of repetition was 25.2% for the overdose alone group. Among those who used highly lethal methods of self‐harm, such as attempted hanging, drowning, and poisoning by chemical substances, lower rates of repetition were found. The risk of repetition within the first 12 months increased from 19.1% among those under 15 years to 32.0% in those aged 25 to 44 years and then fell to 20.8% in those over 55. Repetition rates were similar in men and women (27.7% vs. 28.6%, respectively). Risk of repetition also varied according to the aftercare received for the index ­episode, with 12‐month risk of repetition highest among those admitted to a psychiatric ward (37.3%) and among those who left the emergency department without being seen or who refused admission (34.6% and 31.8%, respectively). The factor most strongly associated with predicting risk of repetition was a patient’s self‐harm history. Among those presenting for the first time, the risk of 12‐month

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repetition was just 14.8%. This increased to 33.6% for second presentations, 47.6% and 54.8% for fourth and fifth presentations, and 77.4% for fifth and subsequent presentations. A U.K. multicenter study reported a slightly lower overall repetition rate of 33% at 12 months following the study index self‐harm episode, but a higher repetition rate after self‐cutting (47%) and a lower repetition rate for the overdose alone group (15%; Lilley et al., 2008). On the basis of on the NICE‐SP study covering the period 1989–2003, the overall repetition rates at 12‐month follow‐up were lower, ranging from 10% in Limerick, Ireland, to 20% in Oxford, United Kingdom, among men, and from 7% in Limerick to 19% in Oxford among women (Arensman et al., 2008). Community‐Based Studies  A limited number of studies have addressed repetition of self‐harm in community‐based populations, and most studies focus on young people and do not include follow‐up measurements, limiting the capacity to determine prospective repetition. An international comparative school‐based cross‐sectional ­ study, known as the Child and Adolescent Self Harm in Europe (CASE) study, revealed relatively high levels of repeated self‐harm retrospectively (Madge et  al., 2008). Over 30,000, mainly 15‐ and 16‐year‐olds, completed anonymous self‐report questionnaires at school in six European countries and Australia. Just over half of adolescents who reported an act of self‐harm in the year prior to the study reported more than one self‐harm episode over their lifetime. Repetition rates ranged from 44.4% in Hungary to 62.4% in Norway. Repetition was more strongly associated with self‐harm acts involving multiple methods (63.0%) and self‐cutting only (58.8%) than drug overdose (44.9%) or other single methods (46.6%; Madge et al., 2008). Using the CASE study methodology, O’Connor et al. (2009) conducted a 6‐month follow‐up study among 500 school‐going adolescents, 6.2% reported an act of self‐harm during the follow‐up period. Factors associated with repeated self‐harm included worries about sexual orientation, history of sexual abuse, self‐harm by family members, anxiety, and low self‐esteem (O’Connor, Rasmussen, & Hawton, 2009). Chen et  al. (2010) conducted a population‐based prospective cohort study in Taiwan using a community‐based suicidal behavior registry. Of the 970 individuals who had engaged in an act of self‐harm, 5.7% repeated at 1‐year follow‐up, 7.8% after 2 years, and 9.5% after 4 years. Independent risk factors included female sex, self‐ cutting, and self‐poisoning.

Prediction of Repeated Self‐Harm Across the Lifespan In the following sections, we review prospective studies including self‐harm patients in different age groups who presented to emergency departments and who were ­followed up over different time periods.

Prediction of Repeated Self‐Harm in Young People Taking into account different follow‐up periods, repetition of self‐harm in adolescents aged 13–19 years varies from 15% at 6‐month follow‐up (Chitsabesan, Harrington, Harrington, & Tomenson, 2003) to 17.2% at 2‐year follow‐up (Hultén et al., 2001) and 42% at 9‐year follow‐up (Groholt, Ekeberg, & Haldorsen, 2006). These findings

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indicate that repeated self‐harm in young people is most likely to occur in the first few months ­following presentation to hospital. Across the different studies, several factors were found to be consistently associated with increased risk of repeated self‐harm. These included previous self‐harm, alcohol or drug misuse, depression, chronic psychosocial problems and behavior disturbance, developmental or personality disturbance, social isolation, disturbed family relationships, alcohol dependence in the family, and poor school record (Hawton & James, 2005; Portzky & Van Heeringen, 2007). More recently, self‐cutting and previous specialist assessment for self‐harm were shown to be positively associated with repetition of self‐harm (Hawton et al., 2012). Other, less frequently reported factors associated with self‐harm repetition were hopelessness (Goldston, Reboussin, & Daniel, 2006; Groholt et al., 2006), treatment history for mental or behavioral problems (Groholt et al., 2006), recent self‐harm by a friend (Lewinsohn, Rohde, & Seeley, 1994), and limited problem‐solving and effectiveness of problem‐solving (Hawton, Kingsbury, Steinhardt, James, & Fagg, 1999). Consequently, it is important to collect information on risk factors as part of screening procedures to assess the risk of repeated self‐harm in young people (Mann et al., 2005). Research in this area has mainly focused on school‐based screening programs in order to identify young people at risk of suicidal behavior (Scott, 2009; Shaffer et al., 2004). An example is the Columbia Suicide Screen (CSS), a brief self‐administered screening questionnaire intended to identify high school students at risk of ­suicidal behavior (suicidal ideation or suicide attempt; Shaffer et al., 2004). A study including over 1,700 students revealed good sensitivity (0.75) and reasonable specificity (0.83), and a positive predictive value of 16%. However, further research is required into the cost‐effectiveness of screening general populations versus at‐risk populations as well as the appropriateness of screening instruments across different cultures.

Prediction of Repeated Self‐Harm in Adults Various studies have addressed the prediction of repeated self‐harm in adults; h ­ owever, most studies have included a 1‐year follow‐up period. A systematic review covering 129 hospital‐based studies involving 329,001 self‐ harm patients identified a number of risk factors consistently associated with repeated self‐harm (Larkin, DiBlasi, & Arensman, 2014). These included previous self‐harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse, drug abuse, and living alone. Many risk factors for repetition of self‐ harm match risk factors for initiation of self‐harm. However, the most consistent evidence comes from long‐standing psychosocial vulnerabilities (Larkin et al., 2014). On the basis of a European multicenter study in which 836 adult self‐harm patients were followed up over a 12‐month period, McAuliffe et  al. (2006) found that the problem‐solving dimension “passive avoidance” was significantly associated with repeated self‐harm. Passive avoidance is characterized by preoccupation with problems, feeling unable to do anything, worrying about the past, and trying to avoid problems although its effect was attenuated by self‐esteem. In an Irish study by McAuliffe, Corcoran, Hickey, and McLeavey (2008) including 152 self‐harm patients who presented to an emergency department, a history of previous self‐harm was found to be predictive of prospective repetition. Poor optional thinking was significantly associated with

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increased risk of repetition among self‐harm patients who had engaged in a first‐ever self‐harm act at the time of the index episode. Sinclair, Hawton, & Gray (2010) conducted a 6‐year follow‐up study including 150 patients who had presented to hospital following an act of self‐harm. A relatively high proportion (57.4%) had engaged in repeated self‐harm acts. The presence of a psychiatric disorder and harmful use of alcohol were significantly associated with prospective repetition. In a 7‐year follow‐up study by Sinclair, JCaren, Hawton, and Williams (2007) among 68 self‐harm patients, evidence was found for a mediating effect of low autobiographical memory specificity between childhood sexual abuse and recent self‐harm and a partial mediating effect between affective disorders and recent self‐harm. Through the mechanism of low autobiographical memory specificity, abuse history and presence of an affective disorder increase an individual’s risk of further self‐harm.

Prediction of Repeated Self‐Harm in Older Adults A review of research on self‐harm in older adults by Chan, Draper, & Banerjee (2007) found that 4 out of 24 studies had addressed repetition prospectively. The 1‐year repetition rate ranged from 3.6% in a Chinese study by Chiu, Lam, Pang, Leung, and Wong (1996) to 11.1% in a European study by De Leo et al. (2002). According to Chiu et al., the relatively low repetition rate among Chinese older adults (age 65+) may reflect under-reporting owing to the strong stigma surrounding mental illness and suicidal behavior in Chinese societies. The U.K. multicenter study reported a 12.8% 12‐month repetition rate in older adults (60+) (Murphy et al., 2012). The research evidence for risk factors associated with repeated self‐harm in older adults is inconsistent across studies, which is largely due to differences in study design, variable selection, and instrument selection. De Leo et al. (2002) conducted a 12‐month prospective study among older adults (aged 60+) who had presented to a general hospital following an act of self‐harm. Individuals who repeated a self‐harm act at follow‐up had a lower score on the Beck Suicide Intent Scale compared to nonrepeaters, reflecting a lower level of suicidal intent associated with repeated self‐harm. Repeaters had also more often reported loss of their father during childhood. However, considering the relatively low number of repeaters (7 out of 55), these outcomes should be interpreted with caution. Hepple and Quinton (1997) followed 100 patients aged 65 and over who were referred to a liaison psychiatric service ­following self‐harm. At 3.5‐year (average) follow‐ up, 19% of the sample (all female), had engaged in further self‐harm acts. Compared to nonrepeaters, repeaters were significantly more likely (a) to have received a diagnosis of depression at the time of the index self‐harm act, (b) to have suffered from a persistent psychiatric disorder during follow‐up, and (c) to be receiving psychiatric treatment. Murphy et  al. (2012) found that previous self‐harm history, previous psychiatric treatment, and age 60–74 years were all associated with repeat self‐harm.

Gender Differences For many years, studies addressing gender differences in relation to self‐harm and repetition reported consistently higher rates of self‐harm and repetition rates among females. However, recent findings from the NSHRI in Ireland show that males are

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now overrepresented among those who repeat self‐harm following an index episode at a hospital emergency department (Arensman, Larkin, Corcoran, Reulbach, & Perry, 2013; Griffin et al., 2015; Perry et al., 2012). This may be associated with the higher prevalence of self‐cutting among males compared to females in Ireland (Arensman et al., 2013). In a European multicenter study using a prospective design, no significant gender differences were found in 1,264 self‐harm patients with regard to 12‐month repetition rates (Hultén et  al., 2001). This was also true when comparing prospective ­repetition rates among self‐harm patients with a history of previous self‐harm and those without at the time of the index self‐harm episode. On the basis of a 23‐year follow‐up study among 11,583 self‐harm patients, Zahl and Hawton (2004) found that repetition of self‐harm was associated with an increased risk of suicide in both males and females. However, repetition of self‐harm was found to be a better predictor of suicide in females than males.

Ethnicity Research into the role of ethnicity in relation to repeated self‐harm is limited. It has previously been shown in England that young South Asian women (aged 16–24 years) are more likely to engage in self‐harm compared to White women, while lower rates of self‐ harm are observed among South Asian men across all age groups (Cooper et al., 2006b). In terms of risk of repeated self‐harm, South Asian men and women showed a lower risk compared to White men and women. A 5‐year prospective cohort study of 20,574 self‐ harm patients presenting to hospital emergency departments in Manchester, Oxford, and Derby (England) found that rates of self‐harm were highest among young Black females aged 16–34 years (risk ratio =1.56, 95% CI: 1.31–1.86 compared with White females; Cooper et al., 2010). In addition, Black and minority groups were less likely to receive a psychiatric assessment and to re‐present with self‐harm. More recently, alcohol use was found to be strongly associated with multiple repetitions among South Asian and Black men and women (Cooper et  al., 2013). These findings are consistent with Johnston, Cooper, Webb, and Kapur (2006), who conducted a study among 4,743 self‐harm patients to identify individual‐ and area‐level predictors of self‐harm repetition. The study showed that individual factors were more strongly associated with self‐harm repetition than area‐level factors. Previous self‐harm, previous psychiatric treatment, employment status, marital status, and White ethnicity were independently associated with repetition.

Assessment of Risk of Repeated Self‐Harm Assessing the risk of repeated self‐harm as well as the broader psychosocial needs of self‐ harm patients attending emergency departments is an important task (Tidemalm, Waern, Stefansson, Elofsson, & Runeson, 2008). Most suicide and self‐harm prevention strategies (e.g., Protect Life [DHSSPS, 2006]; Connecting for Life [Health Service Executive, 2015]) recognize the need for all self‐harm patients attending emergency departments to be given a comprehensive assessment by a suitably trained health professional, followed by appropriate referral and follow‐up, which is recommended by the U.K. Self‐ Harm Guideline of the National Institute for Health and Care Excellence in the United

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Kingdom (NICE, 2004, 2011). In addition, Bergen, Hawton, Waters, Cooper, and Kapur (2010b) found that ­psychosocial assessment was beneficial in reducing the risk of repetition, especially in the short term. However, the assessment procedures for self‐ harm patients presenting to emergency departments is inconsistent and patchy within and between countries (Bennewith, Peeters, Hawton, House, & Gunnell, 2005; Arensman et al., 2010). Indeed, a study in England found that almost half (45%) of self‐harm patients left the emergency department without being comprehensively assessed by a suitably qualified health professional. The fact that this percentage ranged from 18% to 64% across the 32 hospitals under study was a clear indication of a lack of standardized protocols (Bennewith, Gunnell, Peters, Hawton, & House, 2004). A similar study in Wales (Barr, Leitner, & Thomas, 2005) found that 45% of self‐harm patients left without a specialist psychosocial assessment. However, they found that this percentage had fallen from 52% to 42% over the 5‐year study period. There were indications of more frequently conducted specialist assessments among high‐risk patient groups. More recently, an English observational study of trends of clinical management of self‐harm found little improvement in levels of ­specialist psychosocial assessment of self‐harm between 2001 and 2011. Although there was an increase in hospital general admission, there was a decline in referrals for specialist mental‐health follow‐ups during this period (Cooper et al., 2013). On the basis of data from the NSHRI, there appeared to be widespread variation across health service regions in the management of self‐harm patients following ­presentation to the emergency department (Griffin et al., 2015). When explored by hospital groups (regional grouping of acute hospitals), the percentage admitted to a general ward ranged from 11% to 54%, psychiatric admission direct from emergency departments ranged from 3% to 17%, whereas the total percentage of patients who either refused to allow themselves to be admitted, left against medical advice, or who were discharged from the emergency departments was 61% nationally and ranged from 38% to 81% across hospital groups. It is likely that the vast majority of this group of self‐harm patients was not adequately assessed. Although those who used lethal methods, such as hanging and drowning, were more often referred for inpatient ­psychiatric treatment, nonetheless, a relatively high percentage were not admitted at all, involving 44% for highly lethal self‐harm methods. The consequences of nonstandardized procedures for the assessment and aftercare of self‐harm patients include increased risk of repeated self‐harm (nonfatal and fatal), undiagnosed problems such as alcohol dependence and depression, inadequate treatment plans, and poor compliance with treatment (Hickey, Hawton, Fagg, & Weitzel, 2001; Kapur et al., 2004). Psychosocial assessment appeared to be beneficial in reducing the risk ­ roduced of repetition, especially in the short term. Different sets of guidelines have been p in recent years (Australasian College for Emergency Medicine, 2000; National Institute for Clinical Excellence, 2004, 2011). According to Kapur (2005), these guidelines include elements of accepted good practice, but they are generally not evidence based. Cooper et al. (2006a) developed a four‐question tool, known as the Manchester Self‐Harm (MASH) rule, in order to improve assessment of repeated self‐harm, both nonfatal and fatal, by emergency department clinical staff. The four questions address (a) history of self‐harm; (b) previous psychiatric treatment; (c) benzodiazepine use in current self‐harm; and; (d) any current psychiatric treatment. On the basis of a study including over 9,000 patients who presented with self‐harm at emergency departments in Manchester and Salford, England, the MASH rule successfully predicted

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94% of all self‐harm patients who engaged in a repeated self‐harm act within 6 months of their hospital index self‐harm act, reflecting high sensitivity. The MASH rule also successfully identified all 22 suicides that occurred during the study period. The specificity was lower at 25%, indicating that one-quarter of all self‐harm patients were identified as nonrepeaters. The MASH rule performed slightly better for women than men (sensitivity: 96% versus 93%) and for patients aged 35 years and older versus those younger than 35 years (sensitivity: 96% versus 93%). A slightly higher sensitivity for the MASH rule was found when comparing self‐harm episodes assessed by emergency department staff (97%) versus those assessed by psychiatric staff (94%). Taking into account the objectives of the MASH rule and the target group involved, high sensitivity is more important than specificity, because a highly sensitive tool has few false negatives. Considering the absence of accurate screening tools in identifying risk of repeated self‐harm and suicide, the evidence obtained in the study by Cooper et al. (2006a) supports wider implementation of the MASH rule in emergency departments. Previously developed methods to predict repetition have shown similar levels of sensitivity (Corcoran et al., 1997; Kreitman & Foster, 1991). However, the MASH rule has proved to be effective in predicting both repeated nonfatal self‐harm and suicide. See also Chapter 20 (by Hawton and Saunders), Chapter 22 (by Hatcher), and Chapter 26 (by Milner and Carter) in this volume, each of which provides additional information on the treatment of patients who present to hospital following self‐harm.

Conclusions Self‐harm and predicting its repetition are still major challenges for professionals in health care and community‐based services, both in terms of the extent of the problem and the heterogeneity in terms of risk factors associated with repetition. There is increasing evidence supporting the need to address age‐ and gender‐specific factors in predicting repetition. The research clearly underlines the need to develop and implement uniform guidelines for the assessment of self‐harm patients in order to prevent repeated suicidal behavior (nonfatal and fatal). A recommendation is made for wider implementation of an evidence‐based screening tool identifying the risk of suicidal behavior.

References Arensman, E. Corcoran, P., Reulbach, U., Fitzgerald, T., Daly, C., & Perry, I. J. (2010). Deliberate self harm in Ireland 2003–2008: Incidence, repetition and aftercare. Cork, Ireland: National Suicide Research Foundation. Arensman, E., Fitzgerald, T., Bjerke, T., Cooper, J., Corcoran, P., Grad, O., … Van Heeringen, K. (2008). Deliberate self‐harm and suicide: Gender‐specific trend in eight European regions—preliminary findings. Abstract—Journal of Epidemiology & Community Health, 62(Suppl. 1). Arensman, E., Larkin, C., Corcoran, P., Reulbach, U., & Perry, I. J. (2013). Factors associated with self‐cutting as a method of self‐harm: Findings from the Irish National Registry of Deliberate Self‐Harm. European Journal of Public Health, 24(2), 292–297. Australasian College for Emergency Medicine. (2000). Guidelines for the management of deliberate self‐harm in young people. Retrieved from: http://www.acem.org.au/media/ publications/youthsuicide.pdf.

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Barr, W., Leitner, M., & Thomas, J. (2005). Psychosocial assessment of patients who attend an Accident and Emergency Department with self‐harm. Journal of Psychiatric and Mental Health Nursing, 12(2), 130–138. Bennewith, O., Gunnell, D., Peters, T., Hawton, K., & House, A. (2004). Variations in the hospital management of self‐harm in adults in England: Observational study. British Medical Journal, 328(7448), 1108–1109. Bennewith, O., Peeters, T. J., Hawton, K., House, A., & Gunnell, D. (2005). Factors associated with the non‐assessment of self‐harm patients attending an Accident and Emergency Department: Results of a national study. Journal of Affective Disorders, 89(1–3), 91–97. Bergen, H., Hawton, K., Waters, K., Cooper, J., & Kapur, N. (2010a). Epidemiology and trends in non‐fatal self‐harm in three centres in England, 2000 to 2007. British Journal of Psychiatry, 197, 493–498. Bergen, H., Hawton, K., Waters, K., Cooper, J., & Kapur, N. (2010b). Psychosocial assessment and repetition of self‐harm: The significance of single and multiple repeat episode analyses. Journal of Affective Disorders, 127, 257–265. Carroll, R., Metcalfe, C., & Gunnell, D. (2014). Hospital presenting self‐harm and risk of fatal and non‐fatal repetition: Systematic review and meta‐analysis. PLoS ONE, e89944. Cedereke, M., & Ojehagen, A. (2005). Prediction of repeated parasuicide after 1–12 months. European Psychiatry, 20(2), 101–109. Chan, J., Draper, B., & Banerjee, S. (2007). Deliberate self‐harm in older adults: A review of the literature from 1995 to 2004. International Journal of Geriatric Psychiatry, 22(8), 720–732. Chen, V. C., Tan, H. K., Cheng, A. T., Chen, C. Y., Liao, L. R., & Stewart, R. (2010). Non‐ fatal repetition of self‐harm: Population based prospective cohort study in Taiwan. British Journal of Psychiatry, 196(1), 31–35. Chitsabesan, P., Harrington, R., Harrington, V., & Tomenson, B. (2003). Predicting repeat self‐harm in children—how accurate can we expect to be?. European Child and Adolescent Psychiatry, 12(1), 23–29. Chiu, H. F., Lam, L. C., Pang, A. H., Leung, C. M., & Wong, C. K. (1996). Attempted suicide by Chinese elderly in Hong Kong. General Hospital Psychiatry, 18(6), 444–447. Cooper, J., Husain, N., Webb, R., Waheed, W., Kapur, N., Guthrie, E., & Appleby, L. (2006b). Self‐harm in the UK: Differences between South Asians and Whites in rates, characteristics, provision of service and repetition. Social Psychiatry and Psychiatric Epidemiology, 41(10), 782–788. Cooper, J., Kapur, N., Dunning, J., Guthrie, E., Appleby, L., & Mackway‐Jones, K. (2006a). A clinical tool for assessing risk after self‐harm. Annals of Emergency Medicine, 48(4), 459–466. Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H., Waters, K., & Kapur, N. (2010). Ethnic differences in self‐harm, rates, characteristics and service provision: Three‐city cohort study. British Journal of Psychiatry, 197(3), 212–218. Cooper, J., Steeg, S., Bennewith, O., Lowe, M., Gunnell, D., House, A., Hawton, K., & Kapur, N. (2013). Are  hospital services for self‐harm getting better? An observational study examining management, service provision and temporal trends in England. British Medical Journal Open, 3(11), e003444. Cooper, J., Steeg, S., Webb, R., Stewart, S. L. K., Applegate, E., Hawton, K., … Kapur, N. 2012). Risk factors associated with repetition of self‐harm in Black and Minority Ethnic (BME) groups: A multi‐centre cohort study. Journal of Affective Disorders, 148(2–3), 435–439. Corcoran, P., Griffin, E., O’Carroll, A., Cassidy, L., & Bonner, B. (2015). Hospital‐treated deliberate self‐harm in the Western Area of Northern Ireland. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 36, 83–90. doi:10.1027/0227‐5910/a000301

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Corcoran, P., Kelleher, M. J., Keeley, H. S., Byrne, S., Burke, U., & Williamson, E. (1997). A preliminary statistical model for identifying repeaters of parasuicide. Archives of Suicide Research, 3(1), 65–74. De Leo, D., Padoani, W., Lonnqvist, J., Kerkhof, A. J., Bille‐Brahe, U., Michel, K., … Scocco, P. (2002). Repetition of suicidal behaviour in elderly Europeans: A prospective longitudinal study. Journal of Affective Disorders, 72(3), 291–295. DHSSPS. (2006). Protect life. Northern Ireland suicide prevention strategy. Belfast, Northern Ireland: Northern Ireland Executive. Gilbody, S., House, A., & Owens, D. (1997). The early repetition of deliberate self‐harm. Journal of the Royal College of Physicians in London, 31(2), 171–172. Goldston, D. B., Reboussin, B. A., & Daniel, S. S. (2006). Predictors of suicide attempts: State and trait components. Journal of Abnormal Psychiatry, 115(4), 842–849. Griffin, E., Arensman, E., Corcoran, P., Dillon, C. B., Williamson, E., & Perry, I. J. (2015). National Self‐Harm Registry Ireland Annual Report 2014. Cork, Ireland: National Suicide Research Foundation. Groholt, B., Ekeberg, Ø., & Haldorsen, T. (2006). Adolescent suicide attempters: What ­predicts future suicidal acts? Suicide & Life‐Threatening Behaviour, 36(6), 638–650. Gunnell, D., Hawton, K., Ho, D., Evans, J., O’Connor, S., Potokar, J., … Kapur, N. (2008). Hospital admissions for self harm after discharge from psychiatric inpatient care: Cohort study. The British Medical Journal, 337, a2278. Hawton, K., Bergen, H., Casey, D., Simkin, S., Palmer, B., Cooper, J., … Owens, D. (2007). Self‐harm in England: A tale of three cities. Multicentre study of self‐harm. Social Psychiatry and Psychiatric Epidemiology, 42(7), 513–521. Hawton, K., Bergen, H., Kapur, N., Cooper, J., Steeg, S., Ness, J., & Waters, K. (2012). Repetition of self‐harm and suicide following self‐harm in children and adolescents: Findings from the Multicentre Study of Self‐harm in England. Journal of Child Psychology and Psychiatry, 53(12), 1212–1219. Hawton, K., & James, A. (2005). Suicide and deliberate self harm in young people. The British Medical Journal, 330(7496), 891–894. Hawton, K., Kingsbury, S., Steinhardt, K., James, A., & Fagg, J. (1999). Repetition of deliberate self‐harm by adolescents: The role of psychological factors. Journal of Adolescents, 22(3), 369–378. Health Service Executive. (2015). Connecting for life: Ireland’s national strategy to reduce suicide 2015–2020. Dublin, Ireland: Health Service Executive. Hepple, J., & Quinton, C. (1997). One hundred cases of attempted suicide in the elderly. The British Journal of Psychiatry, 171, 42–46. Hickey, L., Hawton, K., Fagg, J., & Weitzel, H. (2001). Deliberate self‐harm patients who leave the accident and emergency department without a psychiatric assessment: A neglected population at risk of suicide. Journal of Psychosomatic Research, 50(2), 87–93. Hultén, A., Jiang, G. X., Wasserman, D., Hawton, K., Hjelmeland, H., De Leo, D., … Schmidtke, A. (2001). Repetition of attempted suicide among teenagers in Europe: Frequency, timing and risk factors. European Child and Adolescent Psychiatry, 10(3), 161–169. Johnston, A., Cooper, J., Webb, R., & Kapur, N. (2006). Individual‐ and area‐level predictors of self‐harm repetition. British Journal of Psychiatry, 189, 416–421. Kapur, N. (2005). Management of self‐harm in adults: Which way now?. The British Journal of Psychiatry, 187, 497–499. Kapur, N., Cooper, J., Hiroeh, U., May, C., Appleby, L., & House, A. (2004). Emergency department management and outcome for self‐poisoning: A cohort study. General Hospital Psychiatry, 26(1), 36–41. Kapur, N., Turnbull, P., Hawton, K., Simkin, S., Mackway‐Jones, K., & Gunnell, D. (2006). The hospital management of fatal self‐poisoning in industrialized countries: An opportunity for suicide prevention?. Suicide and Life‐threatening Behavior, 36(3), 302–312.

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Kerkhof, A. J., & Arensman, E. (2001). Pathways to suicide. In K. Van Heeringen (Ed.), Understanding suicidal behaviour: The suicidal process approach to research, treatment and prevention (pp. 15–39). Chichester, England: John Wiley & Sons. Kreitman, N., & Foster, J. (1991). The construction and selection of predictive scales, with special reference to parasuicide. British Journal of Psychiatry, 159, 185–192. Larkin, C., DiBlasi, Z., & Arensman, E. (2014). Risk factors for repetition of self‐harm: A systematic review of hospital‐based studies. PLoS ONE, 9(1). Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1994). Psychosocial risk factors for future adolescent suicide attempts. Journal of Consulting and Clinical Psychology, 62(2), 297–305. Lilley, R., Owens, D., Horrocks, J., Noble, R., Bergen, H., Hawton, K., … Kapur, N. (2008). Hospital care and repetition following self‐harm: Multicentre comparison of self‐­poisoning and self‐injury. The British Journal of Psychiatry, 192(6), 440–445. Madge, N., Hewitt, A., Hawton, K., de Wilde, E. J., Corcoran, P., Fekete, S., … Ystgaard, M. (2008). Deliberate self‐harm within an international community sample of young people: Comparative findings from the Child & Adolescent Self‐harm in Europe (CASE) Study. Journal of Child Psychology & Psychiatry, 49(6), 667–677. Mann, J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A., … Hendin, H. (2005). Suicide prevention strategies: A systematic review. The Journal of the American Medical Association, 294(16), 2064–2074. McAuliffe, C., Corcoran, P., Hickey, P., & McLeavey, B. C. (2008). Optional thinking ability among hospital‐treated deliberate self‐harm patients: A 1‐year follow‐up study. British Journal of Clinical Psychology, 47(Pt. 1), 43–58. McAuliffe, C., Corcoran, P., Keeley, H. S., Arensman, E., Bille‐Brahe, U., De Leo, D., … Wasserman, D. (2006). Problem‐solving ability and repetition of deliberate self‐harm: A multicentre study. Psychological Medicine, 36(1), 45–55. Murphy, E., Kapur, N., Webb, R., Purandare, N., Hawton, K., Bergen, H., … Cooper, J. (2012). Risk factors for repetition and suicide following self‐harm in older adults: A multicentre cohort study. British Journal of Psychiatry, 200, 399–404. National Institute for Health and Care Clinical Excellence (NICE) UK. (2004). Self‐harm: The short‐term physical and psychological management and secondary prevention of self‐harm in pri­mary and secondary care. Retrieved from: https://www.nice.org.uk/guidance/cg16 National Institute for Health and Care Excellence (NICE) UK. (2011). Self‐harm in over 8s: Long‐term management. Retrieved from https://www.nice.org.uk/guidance/cg133. O’Connor, R. C., Rasmussen, S., & Hawton, K. (2009). Predicting deliberate self‐harm in adolescents: A six month prospective study. Suicide and Life‐Threatening Behavior, 39(4), 364–375. Owens, D., Horrocks, J., & House, A. (2002). Fatal and non‐fatal repetition of self‐harm: Systematic review. The British Journal of Psychiatry, 181, 193–199. Perry, I. J., Corcoran, P., Fitzgerald, A. P., Keeley, H. S., Reulbach, U., & Arensman, E. (2012). The incidence and repetition of hospital‐treated deliberate self harm: Findings from the world’s first national registry. PLoS ONE, 7(2), e31663. Platt, S., Bille‐Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., Crepet, P., … Sampaio Faria, J. (1992). Parasuicide in Europe: The WHO/EURO Multicentre Study on parasuicide. I.  Introduction and preliminary analysis for 1989. Acta Psychiatrica Scandinavica, 85, 97–104. Public Health Agency (PHA) (2015). Northern Ireland Registry of Self‐Harm Annual Report 2013/14. Belfast, Northern Ireland: DHSSPS. Portzky, G., & van Heeringen, K. (2007). Deliberate self‐harm in adolescents. Current Opinion in Psychiatry, 20(4), 337–342.

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Schmidtke, A., Bille‐Brahe, U., Kerkhof, A. J. F. M., & De Leo, D. (2004). Suicidal behaviour in Europe—Results from the WHO/EURO Multicentre Study on Suicidal Behaviour. Göttingen, Germany: Hogrefe & Huber. Scott, A. (2009). Cognitive behavioural therapy and young people: An introduction. The Journal of Family Health Care, 19(3), 80–82. Shaffer, D., Scott, M., Wilcox, H., Maslow, C., Hicks, R., Lucas, C. P., … Greenwald, S. (2004). The Columbia suicide screen: Validity and reliability of a screen for youth suicide and depression. Journal of the American Academy of Child and Adolescent Psychiatry, 43(1), 71–79. Sinclair, J. M., Caren, C., Hawton, K., & Williams, J. M. (2007). The role of autobiographical memory specificity in deliberate self‐harm: Correlates and consequences. Journal of Affective Disorders, 102(1–3), 11–18. Sinclair, J. M., Hawton, K., & Gray, A. (2010). Six year follow‐up of a clinical sample of self‐ harm patients. Journal of Affective Disorders, 121(3), 247–252. Skegg, K. (2005). Self‐harm. The Lancet, 366(9495), 1471–1483. Tidemalm, D., Waern, M., Stefansson, C. G., Elofsson, S., & Runeson, B. (2008). Excess mortality in persons with severe mental disorder in Sweden: A cohort study of 12,103 individuals with and without contact with psychiatric services. Clinical Practice & Epidemiology in Mental Health, 14(4), 23–32. Zahl, D. L., & Hawton, K. (2004). Repetition of deliberate self‐harm and subsequent suicide risk: Long‐term follow‐up study of 11,583 patients. The British Journal of Psychiatry, 185, 70–75.

4

Major Mood Disorders and Suicidal Behavior Zoltán Rihmer and Peter Döme

Introduction Major mood disorders (both unipolar major depression and bipolar disorder) are associated with a substantial burden of illness‐related health and economic ­problems. Given the 12–17% lifetime prevalence of unipolar major depressive episode and 1.3%–5.0% lifetime prevalence of bipolar I and bipolar II disorders (Rihmer & Angst, 2009), they are among the most frequent and also the potentially most life‐ threatening psychiatric illnesses (Angst, Angst, Gerber‐Werder, & Gamma, 2005; Goodwin & Jamison, 2007; Hawton, Sutton, Haw, Sinclair, & Harris, 2005; Rihmer, 2005). In spite of the great clinical and public health significance of major mood disorders, people with these disorders are still under‐referred, underdiagnosed, and undertreated (Dunner, 2003; Rihmer & Angst, 2005). This is particularly true for those who die by suicide and for those who attempt suicide and receive medical attention: more than 90% of them have at least one Axis I (mostly untreated) major mental disorder, most frequently a major depressive episode (56–87%), ­substance‐use disorders (26–55%), and/or schizophrenia (6–13%). Comorbid anxiety and personality disorders are also frequently present, but they are rare as principal (or sole) diagnoses (Balázs, Lecrubier, Csiszér, Koszták, & Bitter, 2003; Goodwin & Jamison, 2007; Hawton, Saunders, Topiwala, & Haw, 2013; Hawton et al., 2005; Rihmer, 2007; Rihmer, Benazzi, & Gonda, 2007; Rihmer, Rózsa, Rihmer, & Gonda, 2009; Tondo, Isacsson, & Baldessarini, 2003). Although suicidal behavior (suicide and suicide attempts) is very rare in the absence of current major mental disorders, it is not their linear/direct consequence. It is a very complex and multicausal human behavior, involving some personality characteristics as well as several psychosocial and cultural components that play an important role not only in the development of suicidal processes but also in the recognition and management of suicidal risk.

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.



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Although the ratio of attempted to completed suicides in the general population is about 20:1, it is much lower (5–10:1) among patients with major mood disorders, suggesting that these patients use more lethal (or more violent) suicide methods (Goodwin & Jamison, 2007; Tondo et  al., 2003; Tondo, Lepri, & Baldessarini, 2007). Suicide (an act of deliberately taking one’s life) and suicide attempts (a self‐ injurious act with intent to end one’s life) are two different, but greatly overlapping, phenomena: More than one-third of those who complete suicide have attempted suicide at least once previously, and the first attempt (even if the method used is nonviolent or nonlethal) significantly increases the risk of future suicide. This is partly because those who repeatedly attempt suicide frequently switch their method from nonviolent to violent or from nonlethal to lethal (Giner et  al., 2014; Goodwin & Jamison, 2007; Rihmer, 2007; Rihmer et al., 2007). As the risk factors for attempted and completed suicide in patients with mood ­disorder show only few differences and a prior suicide attempt is the most powerful predictor of death by suicide in this patient population (Goodwin & Jamison, 2007; Hawton et al., 2005; Pompili et al., 2013; Rihmer, 2007; Simon, Hunkeler, Fireman, Lee, & Savarino, 2007), the risk factors for attempted and completed suicide are not discussed separately in this chapter. For the present purposes, this chapter summarizes the most relevant and clinically modifiable suicide risk and protective factors in mood disorders and highlights the most effective preventive strategies. It focuses on suicide and suicide attempt, both of which are commonly referred to as “suicidal behavior,” but it does not cover self‐harm (or nonsuicidal self‐injury, defined as an intentional injuring of one’s body without apparent suicidal intent).

Suicidal Behavior in People With Mood Disorders Harris and Barraclough (1997) analyzed separately the risk of suicide in patients with an index diagnosis of unipolar major depression or bipolar disorder (37 reports and more than 11,000 patients). On the basis of long‐term cohort studies (with some patients followed for many decades), they reported standardized mortality ratios (SMRs) for suicide of about 20‐fold for patients with index diagnoses of unipolar major depression and 15‐fold for patients with bipolar disorders. Similar figures were reported by a recently published meta‐review: SMRs for suicide were 19.7 and 17.1 for depression and bipolar disorder, respectively (Chesney, Goodwin, & Fazel, 2014). The meta‐analyses that included studies performed before the 1990s could not provide a precise estimate of separate suicide risk in unipolar and bipolar disorder (i.e., they overestimated the suicide risk for unipolar depression and underestimated the same risk for bipolar illness). The main sources of this is that the index diagnosis ­frequently changes during the follow‐up from unipolar depression to bipolar disorder, and in the majority of these studies, the category of bipolar II disorder (depression with hypomania, but without mania) has not been considered separately, and such patients have been considered as having unipolar depression. A meta‐analysis of 28 reports, published between 1945 and 2001 (including only patients with an index diagnosis of bipolar disorder without long‐term lithium treatment) by Tondo et al. (2003), found that during an average 10 years of follow‐ up the SMR for suicide in bipolar patients was as high as 22 (15 for males and 21 for

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females). These authors also calculated that suicide rates in patients with bipolar ­ isorder average 0.4% per year, which is more than 25 times higher than the same rate d in the general population. In a 40–44 year prospective study of 406 formerly hospitalized (186 unipolar and 220 bipolar) patients with a major mood disorder, in which the unipolar–bipolar conversion was carefully considered during the follow‐up, Angst et al. (2005) found that 14.5% of unipolar and 8.2% of bipolar (I and II) patients died by suicide; the SMRs for suicide in unipolar and bipolar patients were 26 and 12, respectively. On the other hand, in their long‐term prospective follow‐up study (average 11 years) of 1,983 patients with unipolar major depression and 843 patients with bipolar disorder (I and II), Tondo et al. (2007) found a five‐times higher rate of suicide in bipolar (I and II) than in unipolar patients (0.25% of patients/year versus 0.05% of patients/ year). This study also found that the ratio of attempted suicide to completed suicide in bipolar II, bipolar I, and unipolar depression was 5, 11, and 10, respectively, indicating that the lethality of suicide attempts was highest in patients with bipolar II. In an impressive long‐term (up to 35 years) follow‐up study of 4,441 formerly hospitalized psychiatric patients, individuals with bipolar disorder (particularly bipolar II) had the highest risk for suicide; 4.2% of 602 bipolar II and 2.8% of 1,163 bipolar I patients died by suicide, whereas the comparable rate of 1,142 patients with unipolar major depression was 1.9% (Sani et al., 2011). In contrast to a major depressive episode, minor depression and pure dysthymic disorder (dysthymia without “comorbid” major depression) do not markedly increase the risk of suicide (Goodwin & Jamison, 2007; Rihmer, 2007). In a national long‐term follow‐up study of suicide risk in Denmark, the absolute lifetime risk for suicide in bipolar disorder was 7.8% for males and 4.8% for females, and the same figures for patients with unipolar depression were 6.7% and 3.8%, respectively (Nordentoft, Mortensen, & Pedersen, 2011). In patients with major mood disorders, previous suicide attempt is the most powerful single predictor of future suicide (Goodwin & Jamison, 2007; Harris & Barraclough, 1997; Hawton et al., 2005; Pompili et al., 2013; Rihmer, 2007). On the basis of only the 10 clinical studies (including more than 3,100 patients) in which unipolar and bipolar (I and II) patients were analyzed separately, the lifetime rate of prior suicide attempts was much higher in bipolar (I and II) patients (mean: 28%, range: 10–61%) than in patients with unipolar depression (mean: 13%, range: 9–30%; [Rihmer, 2005]). A recent long‐term prospective study also found that the rate of suicide attempts during follow‐up was more than double in bipolar (I and II) than in unipolar patients (Tondo et  al., 2007). Community‐based epidemiological studies (Chen & Dilsaver, 1996; Kessler Borges, & Walters, 1999; Szádóczky, Vitrai, Rihmer, & Füredi, 2000) showed that the lifetime rate of prior suicide attempts was 1.5 to 2.5 times higher in patients with bipolar (I and II) than in unipolar patients. The higher risk of suicidality in bipolar than in unipolar depression has been supported by epidemiological research showing that current suicidal ideation was significantly more common in bipolar I depression (72%, n = 1,154) than in unipolar depression (39%, n = 11,904 [Weinstock, Strong, Uebelacker, & Miller, 2009]). Comparing ­completed and attempted suicide between bipolar I and bipolar II disorder, most studies have found that suicidal behavior is more frequent in bipolar II than in bipolar I patients, but meta‐analyses have found this difference to be nonsignificant (Schaffer, Isometsä, & Tondo, 2015).



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Clinically Detectable Suicide Risk Factors in People With Mood Disorders Retrospective and prospective follow‐up clinical studies consistently show that suicidal behavior (suicide and suicide attempts) and suicidal ideation in patients with mood disorders occurs almost exclusively during a severe (mostly agitated or mixed) major depressive episode, less frequently in dysphoric mania, and very rarely during euphoric mania, hypomania, and euthymia (Hawton et al., 2005; Pompili et al., 2013; Rihmer, 2007; Sokero et al., 2006; Tondo, Lepri, & Baldessarini, 2008; Valtonen et al., 2005; Valtonen et al., 2008). This indicates that suicidal behavior in patients with unipolar and bipolar major depression is a state‐ and severity‐dependent phenomenon. However, because the majority of unipolar and bipolar depressed patients never end their lives (and up to 50% of them never attempt suicide; Goodwin & Jamison, 2007; Rihmer, 2007; Sokero et al., 2006; Tondo et al., 2003), other risk factors, in addition to an acute major mood episode, such as special clinical characteristics and some ­personality, familial, and psychosocial factors, may also play a significant contributory role (Balázs et al., 2006; Hawton et al., 2005; Mann, Waternaux, Haas, & Malone, 1999; O’Connor & Nock, 2014; Rihmer, 2007; Tondo et al., 2003). Most of the suicide risk factors in patients with mood disorders are related to acute (mostly major) depressive episodes, but several personality characteristics and historical data that can help clinicians identify highly suicidal patients.

Suicide Risk Factors During Acute Mood Episodes The clinical condition that is the most alarming in patients with mood disorders is a recent suicide attempt and a severe (melancholic) major depressive episode, frequently accompanied by hopelessness, guilt, few reasons for living, and suicidal ideation, as well as accompanied by agitation, insomnia, appetite and weight loss, and psychotic features (Akiskal, Benazzi, Perugi, & Rihmer, 2005; Angst et al., 2005; Goodwin & Jamison, 2007; Hawton et al., 2005; McGirr et al., 2007; Oquendo et al., 2004; Pompili et al., 2013; Rihmer, 2005, 2007; Valtonen et al., 2005). Recent results also suggest that mixed depressive episodes (major depression plus three or more co‐ occurring intradepressive hypomanic symptoms, which corresponds highly to the category of “agitated depression”), that are present in between 30% and 60% of patients with major unipolar and bipolar depression (Akiskal et  al., 2005; Benazzi, 2006; Goldberg et  al., 2009), substantially increase the risk of both attempted and completed suicide (Akiskal et  al., 2005; Balázs et  al., 2006; Benazzi, 2005; Goldberg et al., 2009; Rihmer et al., 2007; Pompili et al., 2013; Sato, Bottlender, Kleindienst, & Möller, 2005; Valtonen et al., 2008). These results can explain, at least in part, rare “antidepressant‐induced” suicidal behavior: antidepressant monotherapy, unprotected by mood stabilizers or atypical antipsychotics, particularly in bipolar and bipolar spectrum disorder (including “unipolar” depressive mixed state), can not only lead to hypomanic/manic switches and rapid cycling, but can also worsen the pre-existing mixed state or generate de novo mixed conditions, making the clinical picture more serious and ultimately leading to self‐destructive behavior (Akiskal, 2007; Benazzi, 2005; Rihmer, 2007; Rihmer & Akiskal, 2006; Takeshima & Oka, 2013). Suicidal behavior in patients with bipolar disorder, however, does not exclusively occur during depressive episodes. In contrast to classical (euphoric) mania, where

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s­uicidal tendencies are extremely rare, suicidal thoughts and attempts are relatively common in patients with a DSM‐IV mixed affective episode (simultaneous occurrence of mania and major depression) and dysphoric mania. This supports the common clinical sense that suicidal behavior in bipolar patients is linked to depressive symptomatology even during a manic episode (Angst et al., 2005; Goodwin & Jamison, 2007; Valtonen et al., 2005, 2008). Comorbid anxiety/anxiety disorders, substance‐use disorders, personality disorders (mainly borderline personality disorders), and serious medical illnesses, particularly in the case of multiple comorbidities, increase the risk of all forms of suicidal behavior (Balázs et al., 2003; Goodwin & Jamison, 2007; Hawton et al., 2005, 2013; Leverich et al., 2003; Rihmer, 2005, 2007; Simon et al., 2007; Valtonen et al., 2005). Acute alcohol use is also an important risk factor for attempted and completed suicide even in nonalcoholic depressives, because it increases both the risk and the lethality of suicidal acts (Sher et al., 2009; see also Chapter 6 by Conner and Ilgen in this volume). Strong evidence suggests that smoking is closely (positively) related to suicidal behavior in the general population (Döme, Gonda, & Rihmer, 2012) and—according to some studies—also in samples of patients with a current depressive episode. For instance, in a retrospective study, current smokers with a major depressive disorder had a greater number of depressive symptoms and higher levels of suicidality (suicide attempts; suicidal ideation) during their most severe depressive episode than never‐ smokers with a major depressive disorder. In addition, smoker patients have higher rates of alcohol/drug‐use disorders and subthreshold hypomania (Baek, Eisner, & Nierenberg, 2013a). Similar findings were reported by the same authors for patients with bipolar disorder (i.e., current smokers with bipolar disorder had higher levels of suicidality [suicide attempts; suicidal ideation] during their most severe depressive episode than never‐smokers with bipolar disorder [Baek, Eisner, & Nierenberg, 2013b]). At the same time, we cannot say with certainty that smoking is an independent risk factor for suicidal behavior in bipolar or in major depressive disorders (Döme et al., 2012; Holma, Melartin, Ketokivi, & Isometsä, 2013). As successful acute and long‐term treatment of unipolar depression and bipolar disorders substantially reduces the risk of both completed and attempted suicide (Baldessarini et  al., 2006; Guzzetta, Tondo, Centorrino, & Baldessarini, 2007; Rihmer & Gonda, 2013; Tondo et al., 2003), lack of medical and family support and the first few days or weeks of the therapy, when antidepressants usually do not work (Akiskal, 2007; Rihmer & Akiskal, 2006; Valenstein et al., 2009), should also be considered as important suicide risk factors. Suicide risk among patients with mood disorders is extremely high during the first few months of the mood disorder, soon after hospital admission, and also shortly after discharge from the hospital. Accordingly, a more intensive observation of patients in the early days of admission and a more intensive care of them during the early postdischarge period are required (Hawton & van Heeringen, 2009; Høyer, Olesen, & Mortensen, 2004; Isometsä, Sund, & Pirkola, 2014; Randall, Walld, & Finlayson, 2014).

Suicide Risk Factors Related to Prior Course of the Mood Disorder For suicide risk factors related to prior course of mood disorders, previous suicide attempts, particularly in the case of violent or more lethal methods, is the most powerful single predictor of future fatal and nonfatal suicide attempts in patients



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with depressive disorders (Goodwin & Jamison, 2007; Hawton et al., 2005; Pompili et al., 2013; Rihmer, 2007; Tondo et al., 2003). Other historical variables, such as early onset of the illness and early stage of the mood disorder (Angst et al., 2005; Goodwin & Jamison, 2007; Rihmer, 2007; Simon et al., 2007; Tondo et al., 2007), rapid cycling course, predominant depressive or mixed polarity, and more prior ­hospitalizations for depression (Azorin et al., 2009; Hawton et al., 2005; Leverich et al., 2003; Tondo et al., 2003; Valtonen et al., 2005, 2008), as well as recent hospital discharge (Oquendo et  al., 2004; Pompili et  al., 2013; Valenstein et  al., 2009), have also been shown to increase the chance of both attempted and completed suicide markedly in this patient population.

Suicide Risk Factors Related to Specific Personality Features Several studies show that some personality features also play a significant role in suicidal behavior: aggressive/impulsive personality traits appear to be especially potent in combination with current hopelessness and pessimism (MacKinnon et al., 2005; Mann et al., 1999; Oquendo et al., 2004; Sarchiapone et al., 2009; Swann et al., 2007; Zalsman et al., 2006). The interaction between personality features and illness characteristics in the suicidal process is best formulated by Mann et al. (1999) in their “stress‐diathesis model,” which proposes that suicidal behavior is determined not only by the stressor (acute major psychiatric illness), but also by a diathesis or predisposition (impulsive, aggressive, pessimistic personality traits). Most recent studies have demonstrated a strong relationship between some specific types of affective temperament and suicidal behavior. In patients with major depression, cyclothymia/cyclothymic temperament (a chronic condition characterized by numerous hypomanic episodes and many periods of depressive symptoms) was ­significantly related to lifetime and current suicidal behavior (attempts) and ideation both in adult and in pediatric samples (Akiskal, Hantouche, & Allilare, 2003; Kochman et  al., 2005). Depressive, anxious, cyclothymic, and irritable affective ­temperaments were markedly overrepresented, and hyperthymic temperament was under-represented among (nonviolent) suicide attempters, the majority of whom have experienced a current major depressive episode (Pompili et al., 2008; Rihmer et al., 2009). Although the vast majority of suicide cases in the general population are accounted for by males and the opposite is true for those who attempt suicide (Goodwin & Jamison, 2007; Harris & Barraclough, 1997; Rihmer & Akiskal, 2006), this gender difference is much smaller among suicidal patients with mood disorders (Angst et al., 2005; Hawton et al., 2005; Pompili et al., 2013; Simon et al., 2007; Tondo et al., 2003). This suggests that gender is not a significant, clinically useful predictor for completed and attempted suicide in this otherwise high‐risk population.

Suicide Risk Factors Related to Personal and Family History Early negative life events (e.g., parental loss, isolation, emotional, physical and particularly sexual abuse; Hawton et al., 2005; Leverich et al., 2003; Mann et al., 1999; Pompili et al., 2013; Sarchiapone et al., 2009), permanent adverse life situations (e.g., unemployment, isolation, separation), and acute psychosocial stressors (e.g., loss

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events, financial disasters; Hawton et al., 2005; Isometsä, Heikkinen, Henriksson, Aro, & Lönqvist, 1995; Leverich et  al., 2003; Rihmer, 2005, 2007) are the most important and clinically useful indicators of possible suicidality in patients with depressive disorders, primarily if other known risk factors are also present. However, a recent prospective study by Oquendo et al. (2014) found that current life events in patients with major mood disorders—in contrast to current major depressive episodes—were not predictors of suicidal behavior (and life events did not predict the recurrence of a major depressive episode). When subgroups (major mood disorder without borderline personality disorder and major mood disorder with borderline personality ­disorder) of the entire sample were investigated separately, current life events were found to be much weaker—but significant—predictors of suicidal behavior than current major depressive episode in the subgroup of patients with major mood ­disorder without borderline personality disorder. In contrast, in the subgroup of patients with major mood disorder and borderline personality disorder, current major depressive episode was a weaker predictor of suicidal behavior than it was in patients without comorbid borderline personality disorder, whereas current life events were rather protective against suicide. In sum, a current major depressive episode was a much stronger predictor of suicidal behavior than current life events in patients with a major mood disorder irrespective of the existence of a comorbid borderline personality ­disorder. The authors remarked that the suicide provoking effect of life events was also questioned by some other prospective studies (Oquendo et al., 2014). The unexpected finding of Oquendo et al. (2014) that life events do not predict recurrence of major depressive episodes is somewhat surprising because other studies have found negative life events to be predictors of both unipolar and bipolar depression (Koenders et al., 2014; Miklowitz & Johnson, 2006). However, acute psychosocial stressors are commonly dependent on the individual’s own behavior, particularly in the case of bipolar I disorder (Isometsä et al., 1995). Hypomanic and particularly manic episodes can easily lead to aggressive‐impulsive behavior, financial extravagance, or episodic promiscuity, thus generating several interpersonal conflicts, marital breakdown, and new negative life events, all of which have a deleterious impact on the further course of the illness. Family history of suicidal behavior and/or major mood disorders in first‐ and ­second‐degree relatives is also a strong risk factor for both attempted and completed suicide (Hawton et al., 2005; Leverich et al., 2003; MacKinnon et al., 2005; Mann et  al., 1999; Pompili et  al., 2013; Rihmer, 2007; Sánchez‐Gistau et  al., 2009). However, the familial component of suicidality seems to be independent, at least in part, of ­psychiatric disorders: relatives of those who die by suicide are over 10 times more likely than relatives of comparison subjects to attempt or complete suicide after controlling for psychopathology (Kim et al., 2005). Similarly, a recent longitudinal study found that suicide attempts of parents with mood disorders conveyed a nearly five‐times‐higher odds of suicide attempts among offspring even after controlling for some other offspring risk factors for suicidal behavior, such as previous suicide attempt and history of mood disorder (both assessed at baseline) or mood disorder at the time point before the suicide attempt (Brent et al., 2015). There is a complex relationship between the three main groups of suicide risk factors (illness‐related, personality‐ related, and historical data) that are, in general, additive in their nature: the more risk factors that are present, the higher the risk of suicidal behavior. The clinically ­detectable suicide risk factors in mood disorders are listed in Box 4.1.



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Box 4.1  Clinically Detectable Suicide Risk Factors in Depressive Disorders 1 Risk factors related to current mood episodes (a)  Severe major depressive episode Current suicide attempt, plan, ideation Hopelessness, guilt, pessimism, few reasons for living Agitation, depressive mixed state, insomnia, appetite and/or weight loss Psychotic features Past mania or hypomania (Bipolar I or II diagnosis) Comorbid Axis I (substance—including nicotine—use and anxiety) disorders, acute alcohol use Comorbid Axis II and disabling Axis III disorders Lacking medical care and family/social support First few days/weeks of the treatment (particularly if appropriate care and co‐medication is lacking) Recent discharge from the psychiatric ward (b)  Mixed affective episode (simultaneously occurring manic and major depressive episode) (c)  Dysphoric mania (mania and three or more intramanic depressive symptoms) 2 Risk factors related to prior course of the depressive disorder Previous suicide attempt/ideation (particularly in the case of violent/ highly lethal methods) Early onset/early stage of the illness/predominantly depressive course Rapid cycling course 3 Risk factors related to personality features Aggressive/impulsive/pessimistic personality traits, few reasons for living Cyclothymic, depressive, irritable, anxious temperament 4 Risk factors related to personal history and/or family history Early childhood traumas (parental loss, separation, neglect, and emotional, physical, and sexual abuse) Permanent adverse life situations (unemployment, financial problems, isolation, chronic/disabling medical disorders) Acute psychosocial stressors (loss events, acute financial catastrophe) Family history of depressive or bipolar disorders (first‐ and second‐degree relatives) Family history of suicide and/or suicide attempt (first‐ and second‐degree relatives).

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Suicide Protective Factors in People With Mood Disorders In contrast to the myriad of research studies on suicide risk factors, much less is known about what protects against suicidal behavior. Higher scores on the “reasons for living” scale are inversely associated with suicide attempt history among patients with major depression or bipolar disorder and also with lower levels of current suicide ideation among patients with major depression (Chaudhury et  al., 2007; Malone et al., 2000). Good family and social support, pregnancy and the postpartum period, having a (large number of) child(ren), holding strong religious beliefs, and restricting access to lethal suicide methods (e.g., reducing domestic and car exhaust gas toxicity, introducing stricter laws on gun control, or prescribing antidepressants that are less toxic in cases of overdose), whenever possible, seem to have some protective effect (Berecz et al., 2005; Dervic et al., 2004; Driver & Abed, 2004; Godwin & Jamison, 2007; Isometsä, 2014; Marzuk et al., 1997; Müller et al., 2005; Rihmer, 2005, 2007). As for the specific symptoms of depression, only appetite and weight gain, and hypersomnia seem to be associated with a decreased risk of suicide in patients with a current major depressive disorder (McGirr et  al., 2007). Recent studies of suicide attempters show that hyperthymic temperament might have a protective role against suicide attempts in patients with major depressive episode (Pompili et  al., 2008, 2013; Rihmer et  al., 2009). One of the most extensively studied suicide protective factors in major mood disorders is acute and long‐term pharmacological treatment that results in a marked decline in all forms of suicidal behavior in this high‐risk patient population (Angst et al., 2005; Baldessarini et al., 2006; Guzzetta et al., 2007; Rihmer, 2005, 2007; Rihmer & Gonda, 2013; Tondo et al., 2003, 2008). Although suicide is a statistically rare event in the community, it is more common among patients with mood disorder, most of whom have had some level of health‐ care contact in the weeks before their death (Goodwin & Jamison, 2007; Rihmer, 2005, 2007; Tondo et al., 2003). This underlines the potentially key role of health‐ care workers in suicide prevention. Indeed, GP‐based depression training programs show promising results. Following the pioneering Swedish Gotland Study, several studies (The Nuremberg Alliance Against Depression, the Swedish Jamtland Study, and the recent Hungarian Kiskunhalas GP‐Suicide Prevention Study) have demonstrated that the education of GPs in the diagnosis and treatment of depression, particularly in combination with public education and gatekeeper training (i.e., the education of individuals in the community who act as gatekeepers, such as members of the clergy, the police, teachers, social workers, peer helpers, and so on, who have primary contact with those at heightened risk for suicidal behavior) improves the identification and treatment of depressive disorders and, consequently, there are fewer suicide attempts and suicides in the areas served by trained GPs (Hegerl et al., 2006; Henriksson & Isacsson, 2006; Isaac et al., 2009; Rutz, Walinder, von Knorring, Rihmer & Pihlgren, 1997; Szántó, Kalmár, Hendin, Rihmer, & Mann, 2007). However, as health- and social-care workers can only help those who contact them, public education media campaigns on symptoms, dangers, treatability, and referral pathways are vitally important. In short, careful consideration of all suicide risk factors should improve the early detection of risk and facilitate more timely intervention prior to an individual engaging in a first suicidal act (see Box 4.1).



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Key Achievements in Suicide Prevention: Interventions to Decrease Suicide in Patients With Mood Disorders Prevention of suicide in patients with depressive disorder is a great challenge for everyone who cares for, or has contact with, them. The role of the health‐care system in suicide prevention varies as a function of the setting (e.g., psychiatric settings versus primary care practice), with specialized suicide prevention centers (where they exist) playing a most important role. As suicidal behavior in patients with depressive disorders is strongly related to severe major depressive episode and initially suicidal patients with depression become nonsuicidal with antidepressant treatment (Rihmer, 2007; Sokero et al., 2006; Tondo et al., 2008), it is logical to assume that successful acute and long‐term pharmacotherapy of depression markedly reduces the risk of ­suicidal behavior. Indeed, large‐scale, long‐term, observational (retrospective and prospective) clinical studies, which included severely ill, frequently suicidal depressed patients (usually inpatients), have shown that, compared to no treatment, the risk of completed and attempted suicide among unipolar and bipolar patients on long‐term ­pharmacotherapy (antidepressants and/or mood stabilizers) is reduced by 56–93% (Angst et al., 2005; Baldessarini et al., 2006; Guzzetta et al., 2007; Leon et al., 1999; Rihmer & Gonda, 2013; Yerevanian, Koek, Feusner, Hwang, & Mintz, 2004). The well‐documented marked antisuicidal effect of lithium in patients with bipolar and unipolar major mood disorder has also been supported recently by results derived from the general population: investigating the lithium levels in tap water in 18 municipalities in Japan in relation to the suicide mortality in each municipality, the authors found that lithium levels were significantly and negatively associated with suicide rate averages for 2002–2006 (Ohgami, Tearao, Shiotsuke, Ishii, & Iwata, 2009). Similar findings have been recently reported also from Austria, Greece, Japan (again), and Texas, United States (Vita, De Peri, & Sacchetti, 2015). Register‐ based observational cohort studies also show that former inpatients with unipolar major depression who continued treatment with antidepressants (Sondergard, Lopez, Andersen, & Kessin, 2007) and former inpatients with bipolar disorder who continuously took mood ­stabilizers (Sondergard, Lopez, Andersen, & Kessin, 2008) had a markedly decreased rate of death by suicide compared with those who stopped taking antidepressants and mood stabilizers. The evidence that suicide rates among depressed patients have ­progressively and significantly lowered through the “pretreatment era” (1900–1939), “ECT era” (1940–1959), and “antidepressant era” (1960–1992; 63, 57, and 33 per 100 patients per year, respectively) also supports the suicide preventive effect of antidepressants in depressed patients (O’Leary, Paykel, Todd, & Vardulaki, 2001). The marked decline in national suicide rates in countries where antidepressant ­utilization has increased threefold to tenfold in the past two decades also suggests that the beneficial effect of better and more widespread treatment of depression nowadays (or recently) can be detected also at the general population level (Gusmao et  al., 2013; Ludwig, Marcotte, & Norberg, 2009; Rihmer & Akiskal, 2006). However, the increase in antidepressant usage, at the level of the general population, is only a proxy marker for greater access of patients to appropriate care; and the decrease in national or regional suicide rates could reflect a general improvement in mental health care rather than an increase in antidepressant sales alone (Kapusta et  al., 2009; Pirkola,

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Sund, Sailas, & Wahlbeck, 2009; Rihmer, Rutz, & Barsi, 1993). The significant role of more widespread pharmacotherapy for depression in reducing suicide mortality has also been supported by the following findings. A recent marked decline in the use of antidepressants after the Food and Drug Administration (FDA) Black Box Warning in children and adolescents in the United States and the Netherlands has been accompanied by a sharp increase in suicide mortality in that age group, whereas there has been a further decrease in the suicide rate among older people where the utilization of ­antidepressants increased or declined only slightly (Gibbons et  al., 2007). Similar observations were reported in Canada (Katz et al., 2008) and Sweden (Isacsson & Ahlner, 2014) as well as for suicide attempts in the United States (Lu et al., 2014). However, a study from England and Wales could not detect this relationship in young people (12–19 years old) between 1993 and 2005 (Wheeler et al., 2008). Furthermore, some authors criticized the Gibbons’ study for drawing false conclusions from their raw dataset from the United States (see, for example, Stone, 2014). On the other hand, the slightly elevated (but, in an absolute sense, quite low) risk of suicidal behavior among (primarily young) patients taking antidepressants compared to those taking placebo in phase II/III randomized controlled antidepressant trials of unipolar major depression might be the consequence of the rarely occurring, depression‐worsening potential of antidepressant monotherapy (unprotected by mood stabilizers) in unrecognized bipolar depressed patients (misdiagnosed as having unipolar depression) as well as in subthreshold and mixed bipolar depressed patients. It may be that these latter patients were included into these trials but were falsely ­diagnosed with unipolar depression (Akiskal, 2007; Rihmer, 2007; Rihmer et  al., 2007; Rihmer & Akiskal, 2006). In other words, antidepressant pharmacotherapy (as one component of appropriate treatment of depression) decreases and extinguishes ­suicidal behavior in the vast majority of depressed patients but can exacerbate depression (and consequently can “induce” suicidality) in a small but vulnerable subpopulation. Antidepressant monotherapy in patients with threshold and subthreshold bipolar depression can result in a high rate of antidepressant resistance and sometimes can worsen the cross‐sectional picture of depression (particularly in adolescents and young adults) not only by causing (hypo)manic switch, but also by inducing or aggravating depressive mixed state/agitation, known as “activation syndrome,” which is the major substrate of suicidal behavior. The concomitant use of mood stabilizers and/or atypical antipsychotics, as well as anxiolytics in people with overt or covert bipolar depression, might prevent or minimize the chance of this “iatrogenesis” (Akiskal, 2007; Rihmer & Akiskal, 2006; Rihmer & Gonda, 2013; Takeshima & Oka, 2013). It should also be noted that in the only clinical psychotherapy trial (Bridge, Barbe, Birmaher, Kolko, & Brent, 2005) that enrolled adolescent outpatients with major depression, similar to those antidepressant clinical trials of adolescents (Whittington et  al., 2004), the rate of newly emerging suicidality in patients receiving psychotherapy only was much higher (12.5%; Bridge et al., 2005) than among those receiving antidepressants (4.7%; Whittington et al., 2004). Pharmacotherapy, however, is a necessary but not sufficient method of reducing suicidal behavior in depressed patients. There is some recent evidence that concurrent depression‐focused psychotherapies, in combination with pharmacotherapy, also improve the adherence of patients and increase the effectiveness of pharmacotherapy, and may therefore contribute to suicide prevention for patients with severe recurrent unipolar or bipolar disorders (Fountoulakis, Gonda, Siamouli, & Rihmer, 2009;



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Michalak, Yatham, & Lam, 2004; Rucci et al., 2002). The role of psychosocial interventions in suicide prevention is also supported by a recent World Health Organization (WHO) study of 1,867 suicide attempters (many of whom are expected to suffer from a current major depressive episode) seen in emergency departments. A brief individual intervention before discharge and regular contact thereafter (eight contacts during the 18‐month follow‐up) resulted in significantly fewer suicides (0.2%) in the intervention group (n = 872) than in the treatment as usual (TAU) group (n = 827, 2.2%; Fleischmann et al., 2008). However, as for suicidal depressed patients, psychotherapy for depression alone is not enough. A recent systematic review and meta‐analysis shows that there is little evidence for the assumption that suicidality in depressed patients can be reduced with psychotherapy for depression (Cuijpers, de Beurs, van Spijker Berking, Andersson, & Kerkhof, 2013) indicating that among those who are suicidally depressed, psychotherapy and psychosocial interventions should always be combined with appropriate acute (and if necessary long‐term) pharmacotherapy. A recent large‐scale follow‐up study demonstrated that psychosocial therapy (i.e., individually tailored [single or combined] use of elements of problem solving, dialectical behavior therapy, psychodynamic approaches, and support from social workers) focused on suicide prevention was effective among those who had self‐harmed in reducing repetition of self‐harm and—but only in the long run—in reducing suicide as well (Erlangsen et al., 2015).

Challenges for the Future Although the recognition and management of depressive disorders, including the detection and reduction of suicide risk, has improved substantially in recent decades, the main problem in everyday clinical practice remains the same: the underdiagnosis and undertreatment of mood disorders both with pharmacotherapy and with psychotherapeutic interventions. The misdiagnosis of a depressive episode of bipolar disorder as unipolar depression, leading to inadequate acute and long‐term treatment, is still quite common. The accurate identification of the unipolar or bipolar nature of a depressive episode is crucial because antidepressant monotherapy (unprotected by mood stabilizers) can exacerbate the short‐term and long‐term course of the illness, including increasing the risk of suicidal behavior. In addition, more research focused on community‐based educational programs is required to determine whether these complex and resource‐consuming community interventions work and, if so, to what extent. However, it should also be noted that early recognition and effective treatment of mental illnesses, including depressive disorders, would be an ideal target, irrespective of their relationship with suicide as more widespread and effective treatment of nonsuicidal psychiatric patients has the same clinical importance.

Conclusions Unrecognized/untreated unipolar and bipolar major depressive episodes are the major causes of attempted and completed suicide in this patient population. However, suicidal behavior in these patients has a good chance of being predicted, and health‐ care workers play a key role in recognizing and managing suicidal risk. Doctors must

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always be vigilant for the risk of suicidality when prescribing antidepressants or i­mplementing psychotherapy for patients with depressive disorders where the risk of suicidality is inherently very high. Successful acute and long‐term care of depressed patients, using both pharmacological and non pharmacological methods, substantially improves patients’ quality of life and reduces the risk of suicidal behavior even in this high‐risk population.

Key Resources 1. Akiskal, H. S., Benazzi, F., Perugi, G., & Rihmer, Z. (2005). Agitated “unipolar” depression re‐conceptualized as a depressive mixed state: Implications for the antidepressant‐suicide controversy. Journal of Affective Disorders, 85, 245–258. 2. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., … Thanh, H. T. (2008). Effectiveness of a brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86, 703–709. 3. Fountoulakis, K. N., Gonda, X., Siamouli, M., & Rihmer, Z. (2009). Psychotherapeutic intervention and suicide risk reduction: A review of the evidence. Journal of Affective Disorders, 113, 21–29. 4. Hawton, K., Saunders, K., Topiwala, A., & Haw, C. (2014). Psychiatric disorders in patients presenting to hospital following self‐harm: A systematic review. Journal of Affective Disorders, 151, 821–830. 5. Hegerl, U., Althaus, D., Schmidtke, A., & Niklewski, G. (2006). The alliance against depression: 2‐year evaluation of a community‐based intervention to reduce suicidality. Psychological Medicine, 36, 1225–1233. 6. Ludwig, J., Marcotte, D. E., & Norberg, K. (2009). Anti‐depressants and suicide. Journal of Health Economics, 28, 659–676. 7. Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M., … Girardi, P. (2013). Epidemiology of suicide in bipolar disorders: A systematic review of the literature. Bipolar Disorders, 15, 457–490. 8. Rihmer, Z. (2007). Suicide risk in mood disorders. Current Opinion in Psychiatry, 20, 17–22. 9. Rihmer, Z., & Gonda, X. (2013). Pharmacological prevention of suicide in patients with major mood disorders. Neuroscience and Biobehavioral Reviews, 37, 2398–2403. 10. Sokero, P., Eerola, M., Rytsala, H., Melartin, T., Leskela, U., Lestela‐Mielonen, P., & Isometsä, E. (2006). Decline in suicidal ideation among patients with MDD is p ­ receded by decline in depression and hopelessness. Journal of Affective Disorders, 95, 95–102.

References Akiskal, H. S. (2007). Targeting suicide prevention to modifiable risk factors: Has bipolar II been overlooked? Acta Psychiatrica Scandinavica, 116, 395–402. Akiskal, H. S., Benazzi, F., Perugi, G., & Rihmer, Z. (2005). Agitated “unipolar” depression re‐conceptualized as a depressive mixed state: Implications for the antidepressant‐suicide controversy. Journal of Affective Disorders, 85, 245–258. Akiskal, H. S., Hantouche, E. G., & Allilare, J. F. (2003). Bipolar II with and without cyclothymic temperament: “Dark” and “sunny” expressions of soft bipolarity. Journal of Affective Disorders, 73, 49–57.



Major Mood Disorders and Suicidal Behavior

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Angst, J., Angst, F., Gerber‐Werder, R., & Gamma, A. (2005). Suicide in 406 mood‐disorder patients with and without long‐term medication: A 40 to 44 years’ follow‐up. Archives of Suicide Research, 9, 279–300. Azorin, J.‐M., Kaladjian, A., Adida, M., Hantouche, E., Hameg, A., Lancrenon, S., & Akiskal, H. S. (2009). Risk factors associated with lifetime suicide attempts in bipolar I patients: Findings from a French National Cohort. Comprehensive Psychiatry, 50, 115–120. Baek, J. H., Eisner, L. R., & Nierenberg, A. A. (2013a). Smoking and suicidality in subjects with major depressive disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Affective Disorders, 150, 1158–1166. Baek, J. H., Eisner, L. R., & Nierenberg, A. A. (2013b). Smoking and suicidality in subjects with bipolar disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Depress Anxiety, 30, 982–990. Balázs, J., Benazzi, F., Rihmer, Z., Rihmer, A., Akiskal, K. K., & Akiskal, H. S. (2006). The close link between suicide attempts and mixed (bipolar) depression: Implications for suicide prevention. Journal of Affective Disorders, 91, 133–138. Balázs, J., Lecrubier, Y., Csiszér, N., Koszták, J., & Bitter, I. (2003). Prevalence and comorbidity of affective disorders in persons making suicide attempts in Hungary: Importance of the first episode and of bipolar II diagnosis. Journal of Affective Disorders, 76, 113–119. Baldessarini, R. J., Tondo, L., Davis, P., Pompili, M., Goodwin, F. K., & Hennen, J. (2006). Decreased risk of suicides and attempts during long‐term lithium treatment: A meta‐ analytic review. Bipolar Disorders, 8, 625–639. Benazzi, F. (2005). Suicidal ideation and depressive mixed states. Psychotherapy and Psychosomatics, 74, 107–108. Benazzi, F. (2006). Mood patterns and classification in bipolar disorder. Current Opinion in Psychiatry, 19, 1–8. Berecz, R., Cáceres, M., Szlivka, A., Dorado, P., Bartók, E., Peñas‐LLedó, E., … Degrell, I. (2005). Reduced completed suicide rate in Hungary from 1990 to 2001: Relation to suicide methods. Journal of Affective Disorders, 88, 235–238. Brent, D. A., Melhem, N. M., Oquendo, M., Burke, A., Birmaher, B., Stanley, B., … Mann, J. J. (2015). Familial pathways to early‐onset suicide attempt: A 5.6‐year prospective study. JAMA Psychiatry, 72, 160–168. Bridge, J. A., Barbe, R. P., Birmaher, B., Kolko, D. J., & Brent, D. A. (2005). Emergent ­suicidality in a clinical psychotherapy trial for adolescent depression. American Journal of Psychiatry, 162, 2173–2175. Chaudhury, S. R., Grunebaum, M. F., Galfalvy, H. C., Burke, A. K., Sher, L., Parsey, R. V., … Oquendo, M. A. (2007). Does first episode polarity predict risk for suicide attempt in bipolar disorder? Journal of Affective Disorders, 104, 245–250. Chen, Y. W., & Dilsaver, S. C. (1996). Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other axis I disorders. Biological Psychiatry, 39, 896–899. Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all‐cause and suicide mortality in mental disorders: A meta‐review. World Psychiatry, 13, 153–160. Cuijpers, P., de Beurs, D. P., van Spijker, B. A, Berking, M., Andersson, G., & Kerkhof, A. J. (2013). The effects of psychotherapy for adult depression on suicidality and hopelessness: A systematic review and meta‐analysis. Journal of Affective Disorders, 144, 183–190. Dervic, K., Oquendo, M. A., Grunebaum, M. F., Ellis, S., Burke, A. K., & Mann, J. J. (2004). Religious affiliation and suicide attempt. American Journal of Psychiatry, 161, 2303–2308. Döme, P., Gonda, X., & Rihmer, Z. (2012). Effects of smoking on health outcomes in bipolar disorder with a special focus on suicidal behavior. Neuropsychiatry, 2, 429–441. Driver, K., & Abed, R (2004). Does having offspring reduce the risk of suicide in women? International Journal of Psychiatry in Clinical Practice, 8, 25–29. Dunner, D. L. (2003). Clinical consequences of under‐recognized bipolar spectrum disorder. Bipolar Disorders, 5, 456–463.

88

Zoltán Rihmer and Peter Döme

Erlangsen, A., Lind, B. D., Stuart, E. A., Qin, P., Stenager, E., Larsen, K. J., … Nordentoft, M. (2015). Short‐term and long‐term effects of psychosocial therapy for people after deliberate self‐harm: A register‐based, nationwide multicentre study using propensity score matching. Lancet Psychiatry, 2, 49–58. Fleischmann, A., Bertolote, J. M., Wasserman, D., De Leo, D., Bolhari, J., Botega, N. J., … Thanh, H. T. (2008). Effectiveness of a brief intervention and contact for suicide attempters: A randomized controlled trial in five countries. Bulletin of the World Health Organization, 86, 703–709. Fountoulakis, K. N., Gonda, X., Siamouli, M., & Rihmer, Z. (2009). Psychotherapeutic intervention and suicide risk reduction: A review of the evidence. Journal of Affective Disorders, 113, 21–29. Gibbons, R. D., Brown, C. H., Hur, K., Marcus, S. M., Bhaumik, D. K., Erkens, J. A., … Mann, J. J. (2007). Early evidence on the effects of regulators’ suicidality warnings on SSRI prescription and suicide in children and adolescents. American Journal of Psychiatry, 164, 1356–1363. Giner, L., Jaussent, I., Olié, E., Béziat, S., Guillaume, S., Baca‐Garcia, E., … Courtet, P. (2014). Violent and serious suicide attempters: One step closer to suicide? Journal of Clinical Psychiatry, 75, e191–7. Goldberg, J., Perlis, R. H., Bowden, C. L., Thase, M. E., Miklowitz, D. J., Marangell, L. B., … Sachs, G. (2009). Manic symptoms during depressive episodes in 1380 patients with bipolar disorder: Findings from the STEP‐BD. American Journal of Psychiatry, 166, 173–181. Goodwin, F. K., & Jamison, K. R. (2007). Manic‐depressive illness: Bipolar disorders and recurrent depression. New York, NY: Oxford University Press. Gusmao, R., Quintao, S., McDaid, D., Arensman, E., Audenhove, C. V., Coffey, C., … Hegerl, U. (2013). Antidepressant utilization and suicide in Europe: An ecological multi‐national study. PLoS ONE, 8, e66455. Guzzetta, F., Tondo, L., Centorrino, F., & Baldessarini, R. J. (2007). Lithium treatment reduces suicide risk in recurrent major depressive disorder. Journal of Clinical Psychiatry, 68, 380–383. Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders: A meta‐ analysis. British Journal of Psychiatry, 170, 205–228. Hawton, K., Saunders, K., Topiwala, A., & Haw, C. (2014). Psychiatric disorders in patients presenting to hospital following self‐harm: A systematic review. Journal of Affective Disorders, 151, 821–830. Hawton, K., Sutton, L., Haw, C., Sinclair, J., & Harris, L. (2005). Suicide and attempted suicide in bipolar disorder: A systematic review of risk factors. Journal of Clinical Psychiatry, 66, 693–704. Hawton, K., & van Heeringen, K. (2009). Suicide. The Lancet, 373, 1372–1381. Hegerl, U., Althaus, D., Schmidtke, A., & Niklewski, G. (2006). The Alliance Against Depression: 2‐year evaluation of a community‐based intervention to reduce suicidality. Psychological Medicine, 36, 1225–1233. Henriksson, S., & Isacsson, G. (2006). Increased antidepressant use and fewer suicides in Jamtland county, Sweden, after a primary care educational programme on the treatment of depression. Acta Psychiatrica Scandinavica, 114, 159–167. Holma, I. A. K., Holma, K. M., Melartin, T. K., Ketokivi, M., & Isometsä, E. T. (2013). Depression and smoking: A 5‐year prospective study of patients with major depressive ­disorder. Depression and Anxiety, 30, 580–588. Høyer, E. H., Olesen, A. V., & Mortensen, P. B. (2004). Suicide risk in patients hospitalised because of an affective disorder: A follow‐up study, 1973–1993. Journal of Affective Disorders, 78, 209–217. Isaac, M., Elias, B., Katz, L. Y., Belik, S. L., Deane, F. P., Enns, M. W., … Swampy Cree Suicide Prevention Team. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. Canadian Journal of Psychiatry, 54, 260–268.



Major Mood Disorders and Suicidal Behavior

89

Isacsson, G., & Ahlner, J. (2014). Antidepressants and the risk of suicide in young persons— Prescription trends and toxicological analyses. Acta Psychiatrica Scandinavica, 129, 296–302. Isometsä, E. (2014). Suicidal behaviour in mood disorders—who, when, and why? Canadian Journal of Psychiatry, 59, 120–130. Isometsä, E., Heikkinen, M., Henriksson, M., Aro, H., & Lönnqvist, J. (1995). Recent life events and completed suicide in bipolar affective disorder: A comparison with major depressive disorder in Finland. Journal of Affective Disorders, 33, 99–106. Isometsä, E., Sund, R., & Pirkola, S. (2014). Post‐discharge suicides of inpatients with bipolar disorder in Finland. Bipolar Disorders, 16, 867–874. Kapusta, N. D., Niederkrotenthaler, T., Etzersdorfer, E., Voracek, M., Dervic, K., Jandl‐Jager, E., & Sonneck, G. (2009). Influence of psychotherapist density and antidepressant sales on suicide rates. Acta Psychiatrica Scandinavica, 119, 236–242. Katz, L. Y., Kozyrskyj, A. L., Prior, H. J., Enns, M. W., Cox, B. J., & Sareen, J. (2008). Effect of regulatory warnings on antidepressant prescription rates, use of health services and ­outcomes among children, adolescents and young adults. Canadian Medical Association Journal, 178, 1005–1011. Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626. Kim, C. D., Seguin, M., Therrien, N., Riopel, G., Chawkay, N., Lesege, A. D., & Turecki, G. (2005). Familial aggregation of suicidal behavior: A family study of male suicide completers from the general population. American Journal of Psychiatry, 162, 1017–1019. Kochman, F. J., Hantouche, E. G., Ferrari, P., Lancrenon, S., Bayart, D., & Akiskal, H. S. (2005). Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in children and adolescents with major depressive disorder. Journal of Affective Disorders, 85, 181–189. Koenders, M. A., Giltay, E. J., Spijker, A. T., Hoencamp, E., Spinhoven, P., & Elzinga, B. M. (2014). Stressful life events in bipolar I and II disorder: Cause or consequence of mood symptoms? Journal of Affective Disorders, 161, 55–64. Leon, A. C., Keller, M. B., Warshaw, M. G., Mueller, T. I., Solomon, D. A., Coryell, W., & Endicott, J. (1999). Prospective study of fluoxetine treatment and suicidal behavior in affectively ill subjects. American Journal of Psychiatry, 156, 195–201. Leverich, G. S., Altshuler Frye, M. A., Suppes, T., Keck, P. E., McElroy, S. L., Denicoff, K. D., … Post, R. M. (2003). Factors associated with suicide attempts in 684 patients with bipolar disorder in the Stanley Foundation Bipolar Network. Journal of Clinical Psychiatry, 64, 506–515. Lu, C. Y., Zhang, F., Lakoma, M. D., Madden, J. M., Rusinak, D., Penfold, R. B., … Soumerai, S. B. (2014). Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: Quasi‐experimental study. British Medical Journal, 348, g3596. Ludwig, J., Marcotte, D. E., & Norberg, K. (2009). Anti‐depressants and suicide. Journal of Health Economics, 28, 659–676. MacKinnon, D. F., Potash, J. B., McMahon, F. J., Simpson, S. G., dePaulo, J. R., Jr., The National Institutes of Mental Health Bipolar Disorder Genetics Initiative, & Zandi, P. P. (2005). Rapid mood switching and suicidality in familial bipolar disorder. Bipolar Disorders, 7, 441–448. Malone, K. M., Oquendo, M. A., Haas, G. L., Ellis, S. P., Li, S., & Mann, J. J. (2000). Protective factors against suicidal acts in major depression: Reasons for living. American Journal of Psychiatry, 157, 1084–1088. Mann, J. J., Waternaux, C., Haas, G. L., & Malone, K. M. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156, 181–189.

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Marzuk, P. M., Tardiff, K., Leon, A. C., Hirsch, C. S., Portera, L., Hartwell, N., & Iqbal, M. I. (1997). Lower risk of suicide during pregnancy. American Journal of Psychiatry, 154, 122–123. McGirr, A., Renaud, J., Seguin, M., Alda, M., Benkelfat, C., Lesage, A., & Turecki, G. (2007). An examination of DSM‐IV depressive symptoms and risk for suicide completion in major depressive disorder: A psychological autopsy study. Journal of Affective Disorders, 97, 203–209. Michalak, E. E., Yatham, L. N., & Lam, R. W. (2004). The role of psychoeducation in the treatment of bipolar disorder: A clinical perspective. Clinical Approaches to Bipolar Disorder, 3, 5–11. Miklowitz, D. J., & Johnson, S. L. (2006). The psychopathology and treatment of bipolar disorder. Annual Review of Clinical Psychology, 2, 199–235. Müller, D. J., Barkow, K., Kovalenko, S., Ohlraun, S., Fangerau, H., Kölsch, H., … Rietschel, M. (2005). Suicide attempts in schizophrenia and affective disorders with relation to some specific demographical and clinical characteristics. European Psychiatry, 20, 65–69. Nordentoft, M., Mortensen, P. B., & Pedersen, C. B. (2011). Absolute risk of suicide after first hospital contact in mental disorder. Archives of General Psychiatry, 68, 1058–1064. O’Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry, 1, 73–85. O’Leary, D., Paykel, E., Todd, C., & Vardulaki, K. (2001). Suicide in primary affective disorders revisited: A systematic review by treatment era. Journal of Clinical Psychiatry, 62, 804–811. Ohgami, H., Tearao, T., Shiotsuki, I., Ishii, N., & Iwata, N. (2009). Lithium in drinking water and risk of suicide. British Journal of Psychiatry, 194, 464–465. Oquendo, M. A., Galfalvy, H., Russo, S., Ellis, S. P., Grunebaum, M. F., Burke, A., & Mann, J. J. (2004). Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder and bipolar disorder. American Journal of Psychiatry, 161, 1433–1441. Oquendo, M. A., Perez‐Rodriguez, M. M., Poh, E., Sullivan, G., Burke, A. K., Sublette, M. E., & Galfalvy, H. (2014). Life events: A complex role in the timing of suicidal behavior among depressed patients. Molecular Psychiatry, 19, 902–909. Pirkola, S., Sund, R., Sailas, E., & Wahlbeck, K. (2009). Community mental‐health services and suicide rate in Finland: A nationalwide small‐area study. The Lancet, 373, 147–153. Pompili, M., Rihmer, Z., Akiskal, H. S., Innamorati, M., Iliceto, P., Akiskal, K. K., … Girardi, P. (2008). Temperament and personality dimensions in suicidal and nonsuicidal psychiatric inpatients. Psychopathology, 41, 313–321. Pompili, M., Gonda, X., Serafini, G., Innamorati, M., Sher, L., Amore, M., … Girardi, P. (2013). Epidemiology of suicide in bipolar disorders: A systematic review of the literature. Bipolar Disorders, 15, 457–490. Randall, J. R., Walld, R., Finlayson, G., Sareen, J., Martens, P. J., & Bolton, J. M. (2014). Acute risk of suicide and suicide attempts associated with recent diagnosis of mental disorders: A population‐based, propensity score‐matched analysis. Canadian Journal of Psychiatry, 59, 531–538. Rihmer, A., Rózsa, S., Rihmer, Z., Gonda, X., Akiskal, K. K., & Akiskal, H. S. (2009). Affective temperaments, as measured by TEMPS‐A, among nonviolent suicide attempters. Journal of Affective Disorders, 116, 18–22. Rihmer, Z. (2005). Prediction and prevention of suicide in bipolar disorder. Clinical Neuropsychiatry, 2, 48–54. Rihmer, Z. (2007). Suicide risk in mood disorders. Current Opinion in Psychiatry, 20, 17–22. Rihmer, Z., & Akiskal, H. S. (2006). Do antidepressants t(h)reat(en) depressives? Toward a clinically judicious formulation of the antidepressant‐suicidality FDA advisory in light of declining national suicide statistics from many countries. Journal of Affective Disorders, 94, 3–13.



Major Mood Disorders and Suicidal Behavior

91

Rihmer, Z., & Angst, J. (2009). Mood disorders—epidemiology. In B. J. Sadock, V. A. Sadock, & P. Ruiz (Eds.), Kaplan and Sadock’s comprehensive textbook of psychiatry (9th ed., pp. 1645–1653). Philadelphia, PA: Lippincott Williams and Wilkins. Rihmer, Z., Benazzi, F., & Gonda, X. (2007). Suicidal behaviour in unipolar depression: Focus on mixed states. In R. Tatarelli, M. Pompili, & P. Girardi (Eds.), Suicide in psychiatric ­disorders (pp. 223–235). New York, NY: Nova Science Publishers, Inc. Rihmer, Z., & Gonda, X. (2013). Pharmacological prevention of suicide in patients with major mood disorders. Neuroscience and Biobehavioral Reviews, 37, 2398–2403. Rihmer, Z., Rutz, W., & Barsi, J. (1993). Suicide rate, prevalence of diagnosed depression and prevalence of working doctors in Hungary. Acta Psychiatrica Scandinavica, 88, 391–394. Rucci, P., Frank, E., Kostelnik, B., Fagiolini, A., Malinger, A. G., Swartz, H. A., … Kupfer, D. J. (2002). Suicide attempts in patients with bipolar I disorder during acute and maintenance phases of intensive treatment with pharmacotherapy and adjunctive psychotherapy. American Journal of Psychiatry, 159, 1160–1164. Rutz, W., Walinder, J., von Knorring, L., Rihmer, Z., & Pihlgren, H. (1997). Prevention of depression and suicide by education and medication: Impact on male suicidality. An update from the Gotland study. International Journal of Psychiatry in Clinical Practice, 1, 39–46. Sánchez‐Gistau, V., Colom, F., Mané, A., Romero, S., Sugranyes, G., & Vieta, E. (2009). Atypical depression is associated with suicide attempt in bipolar disorder. Acta Psychiatrica Scandinavica, 120, 30–36. Sani, G., Tondo, L., Koukopoulos, A., Reginaldi, D., Kotzalidis, G. D., Koukopoulos, A. E., … Tatarelli, R. (2011). Suicide in a large population of former psychiatric patients. Psychiatry Clinical Neurosciences, 65, 286–295. Sarchiapone, M., Jaussent, I., Roy, A., Carli, V., Guillaume, S., Jollant, F., … Courtet, P. (2009). Childhood trauma as a correlative factor of suicidal behavior—via aggression traits. Similar results in an Italian and in a French sample. European Psychiatry, 24, 57–62. Sato, T., Bottlender, R., Kleindienst, N., & Möller, H.‐J. (2005). Irritable psychomotor elation in depressed inpatients: A factor validation of mixed depression. Journal of Affective Disorders, 84, 187–196. Schaffer, A., Isometsä, E. T., Tondo, L., H Moreno, D., Turecki, G., Reis, C., … Yatham, L. N. (2015). International Society for Bipolar Disorders Task Force on Suicide: Meta‐analyses and meta‐regression of correlates of suicide attempts and suicide deaths in bipolar disorder. Bipolar Disorders, 17, 1–16. Sher, L., Oquendo, M. A., Richardson‐Vejlgaard, R., Makhija, N. M., Posner, K., Mann, J. J., & Stanley, B. H. (2009). Effect of acute alcohol use on the lethality of suicide attempts in patients with mood disorders. Journal of Psychiatric Research, 43, 901–905. Simon, G. E., Hunkeler, E., Fireman, B., Lee, J. Y., & Savarino, J. (2007). Risk of suicide attempt and suicide death in patients treated for bipolar disorder. Bipolar Disorders, 9, 526–530. Sokero, P., Eerola, M., Rytsala, H., Melartin, T., Leskela, U., Lestela‐Mielonen, P., & Isometsä, E. (2006). Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness. Journal of Affective Disorders, 95, 95–102. Sondergard, L., Lopez, A. G., Andersen, P. K., & Kessing, L. V. (2007). Continued antidepressant treatment and suicide in patients with depressive disorder. Archives of Suicide Research, 11, 163–175. Sondergard, L., Lopez, A. G., Andersen, P. K., & Kessing, L. V. (2008). Mood stabilizing pharmacological treatment in bipolar disorders and the risk of suicide. Bipolar Disorders, 10, 87–94. Stone, M. B. (2014). The FDA warning on antidepressants and suicidality—why the controversy? The New England Journal of Medicine, 371, 1668–1671.

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Swann, A. C., Moeller, F. G., Steinberg, J. L., Schneider, L., Barratt, E. S., & Dougherty, D. M. (2007). Manic symptoms and impulsivity during bipolar depressive episode. Bipolar Disorders, 9, 206–212. Szádóczky, E., Vitrai, J., Rihmer, Z., & Füredi, J. (2000). Suicide attempts in the Hungarian adult population. Their relation with DIS/DSM‐III‐R affective and anxiety disorders. European Psychiatry, 15, 610–617. Szántó, K., Kalmár, S., Hendin, H., Rihmer, Z., & Mann, J. J. (2007). A suicide prevention program in a region with very high suicide rate. Archives of General Psychiatry, 64, 914–920. Takeshima, M., & Oka, T. (2013). Association between the so‐called “activation syndrome” and bipolar II disorder, a related disorder, and bipolar suggestive features in outpatients with depression. Journal of Affective Disorders, 151, 196–202. Tondo, L., Isacsson, G., & Baldessarini, R. J. (2003). Suicidal behaviour in bipolar disorder. CNS Drugs, 17, 491–511. Tondo, L., Lepri, B., & Baldessarini, R. (2007). Suicidal risk among 2826 Sardinian major affective disorder patients. Acta Psychiatrica Scandinavica, 116, 419–428. Tondo, L., Lepri, B., & Baldessarini, R. J. (2008). Suicidal status during antidepressant treatment in 789 Sardinian patients with major affective disorder. Acta Psychiatrica Scandinavica, 118, 106–115. Valenstein, M., Kim, H. M., Ganoczy, D., McCarthy, J. F., Zivin, K., Austin, K. L., … Olfson, M. (2009). Higher‐risk for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts. Journal of Affective Disorders, 112, 50–58. Valtonen, H. M., Suominen, K., Haukka, J., Mantere, O., Leppamaki, S., Arvilomni, P., & Isometsä, E. T. (2008). Differences in incidence of suicide attempts during phases of bipolar I and bipolar II disorders. Bipolar Disorders, 10, 588–596. Valtonen, H., Suominen, K., Mantere, O., Leppamaki, S., Arvilommi, P., & Isometsä, E. (2005). Suicidal ideation and attempts in bipolar I and bipolar II disorders. Journal of Clinical Psychiatry, 66, 1456–1462. Vita, A., De Peri, L., & Sacchetti, E. (2015). Lithium in drinking water and suicide prevention: A review of the evidence. International Clinical Psychopharmacology, 30, 1–5. Weinstock, L. M., Strong, D., Uebelacker, L. A., & Miller, I. W. (2009). Differential item functioning of DSM‐IV depressive symptoms in individuals with a history of mania versus without: An item response theory analysis. Bipolar Disorders, 11, 289–297. Wheeler, B. W., Gunnell, D., Metcalfe, C., Stephens, P., & Martin, R. M. (2008). The population impact on incidence of suicide and non‐fatal self harm of regulatory action against the use of selective serotonin reuptake inhibitors in under 18s in the United Kingdom: Ecological study. British Medical Journal, 336, 542–545. Whittington, C. J., Kendall, T., Fonagy, P., Cottrell, D., Cotgrove, A., & Boddington, E. (2004). Selective serotonin reuptake inhibitors in childhood depression: Systematic review of ­published and unpublished data. The Lancet, 363, 1341–1345. Yerevanian, B. I., Koek, R. J., Feusner, J. D., Hwang, S., & Mintz, J. (2004). Antidepressants and suicidal behaviour in unipolar depression. Acta Psychiatrica Scandinavica, 110, 452–458. Zalsman, G., Braun, M., Arendt, M., Grunebaum, M. F., Sher, L., Burke, A. K., … Oquendo, M. A. (2006). A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorder. Bipolar Disorders, 8, 558–565.

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Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior Antoine Desîlets, Myriam Labossière, Alexander McGirr, and Gustavo Turecki Introduction Schizophrenia is a severe disorder characterized by disturbances in perception, thought, language, social function, and volition. With the absence of pathognomonic features (i.e., features distinctively and characteristically associated with the disorder), a diagnosis of schizophrenia is considered after ruling out relevant medical conditions, as well as substance abuse or medication‐induced symptoms (APA, 1994). The signs and symptoms of schizophrenia are categorized as “positive” and “negative.” The distinction between positive and negative relates to what is normally observed in the general population. In other words, positive symptoms reflect aberrant thought processes in which behavioral and thought disturbances represent the appearance of active symptoms, and are classically thought of as delusions, hallucinations, and disorganized or unusual thinking. Conversely, negative symptoms reflect a deterioration of normal behavior that include phenomena such as anhedonia (the loss of pleasure), flat affect, decreased emotional expression, concentration difficulties, and a progressive withdrawal from social activities. There is some evidence to suggest that positive symptoms decrease in intensity with age, perhaps in association with the normal decrease in brain dopamine levels over the life course (APA, 2013). Yet, negative symptoms are more stable and are associated with poor response to pharmacological therapy as well as poorer long‐term functional outcomes (Kirkpatrick & Tek, 2005). In this chapter, we discuss recent progress in clinical research examining suicidal behavior in populations affected by chronic psychotic disorders, such as schizophrenia, and highlight the evidence that has influenced or could eventually influence suicide prevention in individuals with psychotic disorders, as well as key questions/challenges for the future. Clear definitions and a specific classification system are critical to studying the etiology of suicide. Standardized criteria, however, have been an obstacle despite the clear consensus on their importance. In this chapter, we use the term suicidality to refer to a spectrum of self‐harming behaviors, cognitions, and aggregate variables of related concepts. We use the terms suicide or completed suicide in suicide studies, defining a phenotype characterized by (1) death as the result of some form of injury

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

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that is both (2) self‐inflicted and (3) likely intentional. Finally, we use the term “attempted suicide” as “a potentially self‐injurious behavior with a nonfatal outcome for which there is some evidence that the person intended to kill himself/herself.” Our discussion prioritizes those studies examining death by suicide and suicidal attempts above studies examining suicidal ideation or suicide risk.

Suicide in Psychotic Disorders Psychological autopsy studies examining consecutive deaths by suicide have revealed several major psychiatric diagnostic categories associated with elevated risk of suicide. Such studies have revealed the importance of psychotic disorders, with 2% to 12% of suicides meeting criteria for schizophrenia (Heila et al., 1997; Isometsa, 2001; Jones, Hacker, Cormac, Meaden, & Irving, 2012; Lesage et al., 1994) and an additional 5% meeting the criteria for schizoaffective disorder (Henriksson et  al., 1993; Lesage et al., 1994). In the inpatient setting, up to 76% of suicides meet criteria for schizophrenia (Balhara & Verma, 2012), whereas annual death rates from suicide once the diagnosis of schizophrenia is made are estimated to be around 0.4% to 0.8% (Balhara & Verma, 2012). Death by suicide in individuals with schizophrenia usually occurs early in the course of the disorder (Palmer, Pankratz, & Bostwick, 2005), and suicide is the leading cause of premature death in this population (Fenton, 2000). The loss of life in this young population and the potential years of life lost are a clear impetus for a better understanding. Although suicide rates are still very high and efforts should definitely continue to be made toward reducing suicidal behavior in the patient population with a diagnosis of schizophrenia, a nationwide Danish study shows a promising decreasing trend in suicide rates in psychotic disorders over the 1998–2005 period (Madsen & Nordentoft, 2013). The economic burden of chronic psychotic disorders on society is tremendous. A 1990 estimate placed the direct and indirect costs at $33 billion annually in the United States alone (Buchanan & Carpenter, 2005). The burden derives from the cost of treatments (including pharmacotherapy regimens) as well as the lost productivity of the affected individuals and, often, loved ones charged with their care. The greatest and most distressing social burden of chronic psychotic disorders, however, is the loss of life associated with suicide in this population.

The Risk of Suicide in Schizophrenia and Other Psychotic Disorders It is often cited in psychiatric textbooks and the broader scientific literature that 10% of patients with schizophrenia die by suicide (Miles, 1977; Tsuang, 1978). However, closer inspection of these seminal studies reveals that the authors were reporting the proportionate mortality attributable to suicide in this population. When examining proportionate mortality, only the deceased individuals in a population or sample are considered, and the causes of death for these individuals are defined. It is not surprising, therefore, that suicide is likely to proportionally represent a greater number of deaths



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early in life, and decrease as other causes of death including chronic medical conditions exert their influence later in life. More recently, the lifetime risk for suicide in schizophrenia has been re-evaluated, with the estimate sitting at 5% (Palmer et al., 2005). This, interestingly, is similar to other major psychiatric illnesses associated with death by suicide (Inskip, Harris, & Barraclough, 1998), such as major depressive disorder (4%; Coryell & Young, 2005) and borderline personality disorder (4%; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005). Patients with schizophrenia have an 8.5‐fold greater risk of death by suicide when compared to the general population (Kasckow, Felmet, & Zisook, 2011). Suicidal behavior, however, is estimated to occur in approximately 20–40% of patients with schizophrenia (Meltzer, 1998). The apparent “gender paradox” observed in suicide more generally, where approximately twice as many females attempt suicide than males while males represent approximately 80% of deaths by suicide, appears to apply to suicide in this diagnostic category as well (Alaraisanen et al., 2009; Hawton, Sutton, Haw, Sinclair, & Deeks, 2005; McGirr, Séguin, et al., 2006). As a whole, 50–80% of suicide attempts do not result in death (Balhara, et al., 2012). Previous attempts, however, represent a predisposing factor as they are associated with a tripled risk of completed suicide later in the course of the disease (Hor & Taylor, 2010). Several lines of evidence suggest that the period of greatest risk for suicide in schizophrenia is early on in the course of the disorder. It has often been reported that suicide usually occurs within the first 10 years of illness onset (Brown, 1997; Caldwell & Gottesman, 1990). Prior to their first treatment, up to 14–38% of patients with first‐ episode psychosis had already attempted suicide (Melle & Barrett, 2012; Bakst, Rabinowitz, & Bromet, 2010). In their re-evaluation of the lifetime risk of suicide in schizophrenia, Palmer et al. (2005) provide strong evidence that the rate of suicide observed in samples composed of patients with first‐episode psychosis was considerably higher than in samples composed of patients at various stages in the course of the disorder. This is consistent with the notion that those surviving the initial period of heightened risk go on to have a smaller, although still considerable, risk of death by suicide (Palmer et al., 2005). Similarly, a recent birth cohort study has reported that over 70% of suicides in this population occurred within the first 3 years of illness onset and all suicides occurred within the first 7 years after onset (Alaraisanen et al., 2009). This population also faces an increased risk of self‐harm as 38% of patients admitted engaging in acts of self‐mutilation within 2–12 years of follow‐up (Balhara & Verma, 2012). The decreasing temporal risk after onset begs the question: Is suicide even more strongly associated with psychotic symptoms of insufficient duration to meet criteria for a diagnosis of schizophrenia (6 months)? The evidence, as a whole, suggests that the relationship between suicide risk and onset of psychosis does not respect a simple function that decreases with time. Although perhaps limited in their ability to detect such disturbances, psychological autopsy studies suggest that brief psychotic disorders are not common among representative samples of people whose cause of death was suicide (Lesage et al., 1994). In fact, among representative suicides selected for the presence of a psychotic spectrum disorder, less than 3% did not meet the full criteria for schizophrenia or schizoaffective disorder (McGirr, Tousignant, et al., 2006). On the whole, the evidence suggests that we should focus our research efforts on chronic psychotic disorders, such as schizophrenia and schizoaffective disorder.

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Relationship with Other Suicide and Sociodemographic Characteristics Suicide in the context of schizophrenia is different from suicide more generally, in a number of respects. A systematic review recently pointed to an apparent contradiction in the association between age and suicide risk among people with schizophrenia (Hor & Taylor, 2010). It suggests that younger age is a risk factor for suicide in schizophrenia, but a later age of illness onset increases risk for suicide too (Hor & Taylor, 2010). A possible interpretation for this apparent contradiction is that suicide risk among patients with a diagnosis of schizophrenia may be moderated by insight and associated hopelessness, which are more pronounced earlier in the course of the illness. Also, these patients are less likely to be married when compared to patients with other diagnoses who die by suicide (McGirr & Turecki, 2008). Yet, consistent with the toll taken by the disorder on social functioning, being single is not a significant risk factor for suicide when psychotic suicides are compared to psychotic controls. This is contrary to what is observed in suicides more generally and suggests a uniformly high prevalence of this civil status in this population, irrespective of suicide status. As  such, unlike in suicides more generally, being single is of limited use as an indicator of risk for suicide in populations affected by chronic psychotic disorders (Hawton et al., 2005). Similarly, unemployment is a significant risk factor for suicide (Qin, Agerbo, & Mortensen, 2003), yet in chronic psychotic disorders it does not appear to be associated with an increased risk of suicide (Hawton et al., 2005). This is also likely related to the extremely high prevalence of unemployment in this population (Bell, Lysaker, & Milstein, 1996), and therefore its limited ability to aid in the detection of suicide risk. Another point of departure relates to education. Although there are conflicting reports (Agerbo, 2007), the most consistent finding in psychiatric populations has been an association between increased risk for suicide and lower levels of education (Qin et  al., 2003). In schizophrenia, however, there is a significant association with higher levels of education and suicide (Hawton et  al., 2005; McGirr, Tousignant, et al., 2006). In a study looking at different predictors of suicide attempts in patients with first‐ episode psychosis, it was observed that the most serious risk factor was previous suicide attempts, but that sexual abuse was also an important predictor of suicidal behavior (Carlborg, Winnerback, Jonsson, Jokinen, & Nordstrom, 2010; Melle & Barrett, 2012; Robinson et al., 2009). Compared to the general population, patients with schizophrenia tend to use more lethal means when attempting suicide, which leads to a higher case fatality ratio or lower attempts‐to‐suicide ratio (Besnier et al., 2009). As many of these differences can be attributed to the toll taken by the disorder, it is clear that trends from diagnostically unrestricted studies of suicide are of limited use in detecting, predicting, and preventing suicide in psychotic disorders. As such, researchers have highlighted the need to move beyond generalizing f­indings from suicides in general to this population and also progress beyond onducting studies in which psychotic suicides are compared to nonpsychotic c­ p­sychiatric outpatients.



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Characteristics of Psychotic Illness in Suicide With the increased risk associated with chronic psychotic disorders, many researchers have investigated the characteristics specific to these disorders. Recently, Hawton et  al. (2005) used a meta‐analytical approach to systematically examine the risk factors for suicide in schizophrenia. In the following section, we summarize these characteristics and risk factors drawing from a range of studies including Hawton et al.’s (2005) review. In the systematic review, negative symptoms (e.g., anhedonia, flat affect, decreased emotional expression, concentration difficulties, and a progressive withdrawal from social activities) were associated with a decreased risk of suicide in schizophrenia (Hawton et al., 2005), and we have also replicated this association in  a consecutive sample of suicides with chronic psychotic disorders (McGirr, Tousignant, et al., 2006). Intuitively, this is consistent with data suggesting poorer long‐term functional (i.e., not suicidal) outcomes in schizophrenia associated with negative symptoms: implicit in the concept of long‐term functional outcome is surviving the early years of chronic psychotic illness during which there is the greatest suicide risk. Yet, the process underlying the lower risk associated with negative symptoms has not been well elucidated, and it is unclear whether this represents a protective factor or more simply deficits in planning and inertia. However, it is imperative not to confuse negative symptoms with features of depression, the latter being associated with increased risk of suicide (Carlborg et  al., 2010). Recent studies in fact suggest that anhedonia could be more closely related to depression than to negative symptoms of schizophrenia (Loas, Azi, Noisette, Legrand, & Yon, 2009) and thus represent a risk factor for suicide completion. It is therefore important to place anhedonic symptoms in their clinical context in order to avoid early conclusions in terms of clinical outcome. Other typical symptoms of depression, such as agitation, hopelessness, worthlessness, and anxiety, have also been associated with an increased risk of death by suicide (Carlborg et al., 2010) Positive symptoms (e.g., delusions, hallucinations, and disorganized or unusual thinking), interestingly, have been associated with inconsistent results. When hallucinations and delusions are examined separately, hallucinations seem to be associated with an increased risk for suicide, whereas delusions are associated with a decreased risk (Melle & Barrett, 2012). However, these relationships only held true when studies employing a psychotic comparison group were examined. The literature highlights that suicide often occurs in the context of active psychotic illness. In their national cohort of suicides from Finland, Heila et al. (1997) reported an elevated frequency of active psychotic illness among individuals with schizophrenia who died by suicide. Similarly, compared to controls with psychotic disorders, people with schizophrenia who died by suicide were more likely to exhibit psychotic symptoms in the month preceding their deaths (Hu et al., 1991). Prospective studies report that suicidal behavior occurs predominantly among patients with schizophrenia who have experienced psychotic recurrences during the follow‐up period (Kaplan & Harrow, 1996). Further, in a sample of representative suicides, the severity, as opposed to mere presence, of psychotic symptoms is associated with an increased risk for suicide in this population (McGirr, Tousignant, et al., 2006).

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Although further research going beyond the broad clinical indicators is required, active illness appears to be the most useful indicator of risk for clinicians. Psychotic decompensation (exacerbation of the psychotic illness) comes with a plethora of priorities and treatment decisions, among which suicide risk should feature prominently. Other studies on patients with schizophrenia support an association between suicidal ideation and akathisia, a side effect of antipsychotic medication characterized by a state of motor and subjective restlessness. This afflicting condition has been found to cause profound distress and to precipitate violence and suicidality (Atbasoglu, Schultz, et al., 2001). Physical violence on its own has also been shown to correlate with a history of suicidal behavior (Suokas et al., 2010), as both are associated with marked impulsivity and emotional instability.

Insight into Psychotic Illness It has been well recognized for 20 years or more that there is a relationship between the degree of insight that individuals have into their illness and their risk of suicide. In short, greater insight into psychotic illness is associated with increased suicide risk (Bourgeois et al., 2004). However, even though an association between insight and suicidality has been observed, it seems that it is mostly the depressive feelings and hopelessness felt because of the insight into illness that mediates this association (Lopez‐Morinigo, Ramos‐Rios, David, & Dutta, 2012). In other words, it seems that a negative belief about the reality of schizophrenia spectrum disorders and the stigma around it may accentuate the suicidal behavior in these patients (Barrett et al., 2010; Melle & Barrett, 2012) and acceptance of the illness may decrease the risk of suicide (Sharaf, Ossman, & Lachine, 2012). A recent large multicenter study confirmed this relationship: greater insight into illness was associated with a shorter latency to future suicide attempts (Bourgeois et al., 2004) In terms of potential mechanisms of effect, this relationship may be a consequence of increased depressive symptoms that remain consistently elevated in the subgroup of patients with greater insight. Moreover, the Bourgeois et al. study suggested a difference in risk between those who had pre-existing insight and those patients in whom insight evolved as a result of treatment. The latter was associated with decreased risk of future suicide attempts. Clinically and conceptually, it is reasonable (and intuitive) to expect an association between a realistic and accurate evaluation of the difficulties associated with chronic psychotic disorder, the resulting “lost potential,” and an increase in the range of thoughts and feelings associated with suicide risk. Depressive symptoms and hopelessness would be associated with the degree of disparity between patients’ current employment prospects and their professional expectations prior to the onset of psychotic illness (Lewine, 2005). Most importantly, this association appeared to mediate (explain) the relationship between social class and increases in depressive symptoms and hopelessness. Consistent with this prediction, a demoralization syndrome has been described in schizophrenia where functional deterioration compared to premorbid abilities and nondelusional awareness of the toll of the illness leads to feelings of hopelessness, depression, and ultimately suicide (Drake, Gates, Whitaker, & Cotton, 1985). A recent test of this demoralization hypothesis suggested that depressive symptoms mediated



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the association between insight, greater premorbid adjustment, and history of s­uicidal behavior among patients with schizophrenia (Restifo, Harkavy‐Friedman, & Shrout, 2009). What has been confirmed by meta‐analysis is a direct association between fear of mental disintegration and increased risk of death by suicide (Hawton et al., 2005). Thus, not only are the immediate consequences of the disorder important risk factors for suicide, but individuals’ uncertainty regarding their future ability to function is also pertinent.

Psychopathology, Personality Traits, and Family History of Suicidal Behavior Comorbid Psychopathology Studies on suicide have consistently demonstrated the importance of psychopathology. Such studies suggest that upward of 90% of people who died by suicide meet diagnostic criteria for a psychiatric disorder at the time of death (Arsenault‐Lapierre, Kim, & Turecki, 2004). As previously discussed, chronic psychotic disorders are one of the diagnostic categories strongly associated with suicide. An important question in determining risk for suicide in chronic psychotic disorders has been the importance of concomitant psychopathology. This is a natural extension of the consistent finding from studies of suicide more generally that have highlighted the importance of comorbid disorders (Beautrais et  al., 1996; Hawton, Houston, Haw, Townsend, & Harriss, 2003; Henriksson et  al., 1993; Lesage et  al., 1994; Marttunen, Aro, Henriksson, & Lonnqvist, 1991; Muller et al., 2005; Rudd, Dahm, & Rajab, 1993), particularly mood disorders and psychopathology related to impulse dyscontrol such as substance abuse. However, when schizophrenia and other chronic psychotic disorders are compared to other suicides, the prevalence of comorbid p­sychopathology is considerably lower (McGirr & Turecki, 2008). The exception is drug abuse, where the prevalence is comparable in cases of chronic psychotic suicides and nonpsychotic suicides. Nevertheless, the individual with chronic psychotic disorders who also meets criteria for certain concomitant psychopathologies is at an increased risk for suicide. Indeed, meta‐analyses have confirmed the increased risk of suicidal behavior when schizophrenia is comorbid with depressive disorders (Hawton et  al., 2005), and they have also confirmed that a range of depressive symptomatology including hopelessness, worthlessness, low self‐esteem, and sleep disturbances are associated with suicidal behavior (Hawton et  al., 2005). Although some studies since the p­ublication of the meta‐analysis have failed to find an association between depressive disorders and suicide (Pompili et  al., 2009), almost all have replicated this association using a variety of designs, including psychological autopsies (McGirr, Tousignant, et  al., 2006) and chart reviews (Kuo, Tsai, Lo, Wang, & Chen, 2005; Sinclair, Mullee, King, & Baldwin, 2004). Moreover, comorbid depressive s­ymptoms are strongly related to the latency between date of discharge and date of  suicide in patients with schizophrenia, particularly among men (Karvonen et al., 2007). Yet, it is important to consider that although depression is associated with an increased risk for suicide in the population affected by chronic psychotic

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disorders, the prevalence of this comorbidity among psychotic suicides is significantly less elevated than suicides more generally. Psychopathology related to impulse dyscontrol, specifically cluster B personality disorders and substance abuse disorders, are also consistent risk factors in suicide more generally. Interestingly, the association between alcohol abuse and suicide has not typically emerged in studies comparing psychotic suicides to psychotic controls in meta‐analyses (Hawton et al., 2005) or in more recent studies (Kuo et al., 2005; McGirr, Tousignant, et  al., 2006; Pompili et  al., 2009). The association with alcohol abuse has, however, been reported in studies examining nonlethal suicidal behavior (Baca‐Garcia, Perez‐Rodriguez, Diaz Sastre, Saiz‐Ruiz, & de Leon, 2005; Gut‐Fayand et al., 2001). Overall, the evidence relating to comorbid psychopathology in the context of suicide occurring in chronic psychotic disorders suggests that depressive symptoms represent the greatest risk factor for suicide in this population. At the same time, drug abuse does appear to be associated with a marginal increase in risk for suicide in this population. Important psychopathological categories such as substance abuse and other psychopathology related to impulse dyscontrol appear to have limited predictive value as comorbid conditions in the context of chronic psychotic disorder.

Family History In the suicide literature more broadly, there is support for a genetic contribution to suicide using a variety of methodologies. Family studies are one such methodology where the occurrence of suicidal behavior among the relatives of individuals who have attempted or died by suicide is compared to the occurrence of suicidal behavior in the relatives of comparison subjects. Higher levels of suicidality among the relatives of individuals who have engaged in suicidal behavior is evidence of familial aggregation and suggestive of heritability. Such studies in suicide have c­onfirmed familial aggregation and suggested that it operates independently of p­sychopathology (Brent, Bridge, Johnson, & Connolly, 1996; McGirr et al., 2009). It is undoubtedly the case that suicide is the result of genetic and environmental interactions, yet both twin and adoption studies support a role for the g­enetic c­ontribution to suicide risk beyond shared and unshared environment (Roy, Segal, Centerwall, & Robinette, 1991; Statham et  al., 1998). This is also supported by adoption studies, which also confirm a genetic contribution to suicide (Wender et al., 1986). Although the increased risk for suicide and independence of familial liability from psychopathology has been reported in chronic psychotic disorders (McGirr, Tousignant, et al., 2006), the majority of studies do not support familial aggregation of suicide in the context of chronic psychotic disorders (Hawton et al., 2005; Kuo et al., 2005; Reutfors et al., 2009; Roy, 1982). Other recent studies have shown a positive association between a familial history of suicide and substance abuse and later suicide in patients with schizophrenia (Hor & Taylor, 2010). As a consequence of this conflicting evidence, it is thus important for the clinician to consider family history of suicide on a case‐by‐case basis, although the weight of evidence does not support incorporating this information into treatment decisions.



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Treatment of Chronic Psychotic Disorders: Implications for Suicide Risk An important concept in the treatment of chronic psychotic disorders is the inverse relationship between the duration of untreated psychosis and patient outcomes. Studies have demonstrated that poorer outcomes (on numerous indicators) are associated with the length of time an individual experiences a first psychotic episode without receiving medical attention (Kirkpatrick & Tek, 2005), so‐called “duration of untreated psychosis.” Recently, a large Scandinavian program for the early detection of schizophrenia demonstrated a reduction in suicidal behavior among psychotic individuals in the detection program’s catchment area compared to neighboring areas (Melle et  al., 2006). Consequently, this study illustrates the importance of early treatment and the considerable potential of reducing suicide risk in this population. Similarly, a systematic meta‐analysis demonstrated that earlier treatment of first‐episode psychosis could reduce suicide mortality (Challis, Nielssen, Harris, & Large, 2013). In addition, once detected, meta‐analyses have emphasized the importance of treatment adherence and the increased risk for suicide associated with nonadherence to treatment (Hawton et al., 2005). Some of the reasons to keep in mind regarding nonadherence to treatment in people with chronic psychotic disorders are lack of insight, particular beliefs about the medication, and substance abuse (Higashi et al., 2013; Carlborg et  al., 2010). Also, some adverse events related to the medication might lead to nonadherence, such as prolactin‐related adverse events (amenorrhea, galactorrhea, and gynecomastia; Brugnoli et al., 2012). A good medical therapeutic relationship and a good perception of the treatment plan are factors that can increase adherence in this population (Higashi et al., 2013).

Pharmacotherapy It has been more than a decade since initial reports suggested that pharmacological treatment with clozapine (an atypical antipsychotic) is associated with decreased suicidality in schizophrenia (Meltzer & Okayli, 1995). This initial study reported on a sample of neuroleptic‐resistant patients who then went on a course of clozapine, and found a reduction in suicide attempts compared to preclozapine treatment periods. This study’s suicide attempt results were reinforced by large decreases in a number of other indicators of suicide risk, including depressive symptoms, helplessness, and suicidal ideation. The role of clozapine as a suicide risk reducing agent in schizophrenia has been confirmed using a meta‐analytical approach (Hennen & Baldessarini, 2005). This meta‐analysis reported a greater than threefold reduction in the risk of suicidal behavior and, importantly, just under a threefold reduction in the rates of death by suicide when patients with schizophrenia are treated with clozapine. Another study also determined that clozapine treatment results in less hospitalization and less need for antidepressant, anxiolytics, or soporifics use (Meltzer et al., 2003). Unfortunately, the benefits of pharmacological management of suicidality in schizophrenia do not appear to extend beyond clozapine. In a study examining the effectiveness of many conventional and atypical antipsychotics in reducing rates of suicidal behavior compared to placebo, no other drug demonstrated benefits compared to

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placebo (Khan, Khan, Leventhal, & Brown, 2001). This is unfortunate, for clozapine is associated with numerous and significant side effects in addition to five black box warnings (agranulocytosis; seizures; myocarditis; increased mortality in geriatric patients, notably from cardiac‐related events; and other cardiovascular and respiratory effects, notably orthostatic hypotension resulting in collapse, respiratory and/or cardiac arrest) and is consequently only indicated for the treatment of resistant schizophrenia. However, a population‐based cohort study of over 26,000 patients with schizophrenia illustrated that the use of clozapine correlated with better adherence to treatment and lower rates of hospitalization. Moreover, 23 cases of agranulocytosis and one death occurred because of clozapine compared to 223 suicides and 831 suicide attempts, and an etiologic fraction calculation demonstrated that 95 suicides could have been prevented if clozapine was used instead of haloperidol (Ringback Weitoft et al., 2014). From a pharmacodynamic (the physiological effects of a drug) standpoint, however, the success of clozapine in reducing suicidal behavior suggests potential for isolating some of the therapeutic aspects of clozapine and perhaps developing new treatment options for the chronic psychotic patient at high risk of suicide. This avenue, however, has not yet yielded beneficial outcomes. In a randomized controlled trial comparing clozapine and olanzapine, a structural analogue of clozapine, olanzapine did not reduce suicidal behavior (Meltzer et al., 2003). The only other drug that has been shown to have antisuicidal effects is lithium, and its role in the prevention of suicide in the patient population with a diagnosis of schizophrenia is less clear than in the patient population with a diagnosis of bipolar disorder (Carlborg et al., 2010). Another important part of pharmacological management of people with schizophrenia relating to prevention of suicide is the consideration for treatment of depressive symptoms. Selective serotonin reuptake inhibitors (SSRIs) seem to diminish signs of  depression and also suicidal thoughts in patients with schizophrenia (Kasckow et al., 2011). However, at the moment, there is no concrete evidence to either support or refute antidepressant use to treat depression in this patient population (Whitehead et al., 2003; Schennach‐Wolff et al., 2010). The limited benefits of pharmacological management on suicidal behavior over placebo are difficult to reconcile with the clear benefits of psychiatric intervention on suicide outcomes, suggesting a strong role for the therapeutic relationship between health‐care provider and the patient with a chronic psychotic disorder over the specific actions of certain medications. More importantly, it suggests that support and vigilance on the part of clinicians and service providers can play an important role in curbing the significant loss of life in this population.

Nonpharmacological Therapy Nonpharmacological therapy is an integral component of the treatment for schizophrenia, and psychosocial interventions significantly reduce, as compared to treatment as usual, the risk of suicidal behavior in patients with schizophrenia (Donker et al., 2013). Supportive therapies, family‐based therapies, and conflict training (aimed at e­ducating the patient in the appropriate management of cognition and behavior in situations of conflict) are important in contributing to successful outcomes. Moreover, psychotherapy offers patients a forum facilitated by a trained therapist for discussing



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any difficulties, concerns regarding their illness or medication, stigma, or social isolation. Unfortunately, the opportunity to provide guidance and support is of limited value during the active phases of psychotic illness, yet guidance and support are of great value between such phases. However, it is important to give particular attention to first‐episode psychosis patients and carefully assess suicidality and insight in this population because they are at increased risk of suicide (Barrett et al., 2010; Gonda, Pompili, Serafini, & Rihmer, 2012). Again, directly targeting the negative view or opinions about the illness is a good way to decrease the risk of depression and hopelessness and ultimately suicide (Acosta, Aguilar, Cejas, & Gracia, 2013). Research on nonpharmacological therapy in reducing suicidal behavior among individuals with chronic psychotic disorders has not received the same attention in recent years as pharmacological treatments. However, several older studies suggest benefits in respect of the recurrence of psychotic decompensations and overall o­utcomes (Mueser & Berenbaum, 1990), particularly when individuals benefit from the additional support of living with family (Hogarty, Greenwald, et  al., 1997; Hogarty, Kornblith, et al., 1997). Yet, there is a dearth of information on the effects of psychotherapy specifically on suicidal behavior in this population. One promising form of nonpharmacological therapy, cognitive behavioral therapy (CBT), was shown in a recent meta‐analysis to reduce positive symptoms, though not suicide, in schizophrenia (Zimmermann, Favrod, Trieu, & Pomini, 2005). This meta‐ analysis indicated that CBT is most effective at reducing positive symptoms early in the course of the disorder. To directly investigate the effectiveness of CBT in relation to suicidal behavior in chronic psychotic disorders, a multicenter controlled trial was conducted. This trial had two arms: treatment as usual combined with either supportive therapy or CBT. In the first reports, the previously shown benefits on positive symptoms were replicated (Lewis et al., 2002; Tarrier et al., 2004). In the report focusing on suicidal behavior, however, the authors report that their CBT program did not have an effect on suicidal behavior (Tarrier, Haddock, Lewis, Drake, & Gregg, 2006). No advantage of CBT was found in a review of the recent literature (Jones et al., 2012) but the majority of studies lacked sufficient power to detect significant effects. It is important to specify, however, that the form of CBT applied in this study was designed to reduce positive symptoms and no modification was made to make it suitable to reducing suicidal behavior. From the standpoint of CBT therapy, the authors argue that reducing suicide risk in this population may be achieved by incorporating additional components targeting depression and hopelessness. An additional and exciting avenue in the treatment of schizophrenia that has shown considerable promise is cognitive enhancement therapy (Hogarty & Flesher, 1999), whereby training is used to improve attention, memory, problem solving, and social cognition. The underlying theory of this therapeutic approach is that deficits in social cognition and neurocognition are key components of chronic psychotic disorders. By providing multidimensional approaches that integrate computer‐assisted training with group‐based social cognition exercises, significant and sustained recovery of these deficits have been observed in chronic psychotic disorders (Hogarty et al., 2004). Similarly, studies that have incorporated neurocognitive training into vocational services for individuals with chronic psychotic disorders have demonstrated sustained improvements in cognitive ability (Greig, Zito, Wexler, Fiszdon, & Bell, 2007), but most importantly, they have demonstrated increases in participants’ ability to secure

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employment and increased productivity (Bell, Zito, Greig, & Wexler, 2008). Although systematic research is required to test whether these improvements extend to suicide and suicidal behavior, the improvements demonstrated with respect to social and occupational functioning should spur on those interested in improving suicide outcomes in this population to incorporate neurocognitive and social training. This may prove to be an invaluable approach to addressing the previously discussed expectation gap between premorbid abilities and functional deterioration as  a consequence of p­sychotic illness.

Conclusions Suicide in chronic psychotic disorders is unacceptably high and poses a major public health problem. Studies suggest that suicide is the leading cause of premature death in this population, occurring early in the course of the disorder, particularly among males. Acute psychotic illness and concomitant depressive disorders greatly increase the risk for suicide. Early recognition of these risk factors and swift intervention are clinically important for reducing suicide in this population. Similarly, programs targeted at the early detection of first‐episode psychosis and clinical treatment are associated with a decreased risk for suicide. Yet, with the exception of clozapine, pharmacological therapy does not reduce rates of suicidal behavior significantly more than placebo. In addition, treatment nonadherence is strongly asso­ciated with suicide and is likely to be as a result of increased acute psychotic decompensation. The degree of insight that an individual has into the disorder is associated with increased risk of suicide and suicidal behavior, particularly among individuals from a background characterized by higher socioeconomic status and who are confronted with a large disparity between their premorbid expectations and their current prospects. Newer treatment strategies, including social and neurocognitive training, offer promise in this respect, as they are associated with sustained improvements in social and n­eurocognitive deficits and additionally they improve patients’ ability to seek and maintain gainful employment. Finally, additional basic and applied research is required into the pharmacotherapeutic and nonpharmacotherapeutic treatments for suicide in schizophrenia and other chronic psychotic disorders.

Key Resources 1. Kasckow, J., Appelt, C., Haas, G., Huegel, S., Fox, L., Gurklis, J., & Daley, D. (2011). Development of a recovery manual for suicidal patients with schizophrenia. Schizophrenia Research, 130(1–3), 287–288. doi:10.1016/j.schres.2011.04.002 2. Donker, T., Calear, A., Grant, J., van Spijker, B., Fenton, K., & Hehir, K., … Christensen, H. (2013). Suicide prevention in schizophrenia spectrum disorders and psychosis: A systematic review. BMC Psychology, 1(1), 6. doi:10.1186/2050‐7283‐1‐6 3. Fenton, W. S. (2000). Depression, suicide, and suicide prevention in schizophrenia. Suicide and Life‐Threatening Behavior, 30(1), 34–49. 4. Carlborg, A., Winnerback, K., Jonsson, E. G., Jokinen, J., & Nordstrom, P. (2010). Suicide in schizophrenia. Expert Review of Neurotherapeutics, 10(7), 1153–1164.



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5. Torrey, E. (2013). Surviving schizophrenia: A family manual (6th ed.). Bethesda, MD: Harper Perennial. 6. Kasckow, J., Felmet, K., & Zisook, S. (2011). Managing suicide risk in patients with schizophrenia. CNS Drugs, 25(2), 129–143.

References Acosta, F. J., Aguilar, E. J., Cejas, M. R., & Gracia, R. (2013). Beliefs about illness and their relationship with hopelessness, depression, insight and suicide attempts in schizophrenia. Psychiatria Danubina, 25(1), 49–54. Agerbo, E. (2007). High income, employment, postgraduate education, and marriage: A suicidal cocktail among psychiatric patients. Archives of General Psychiatry, 64(12), 1377–1384. Alaraisanen, A., Miettunen, J., Rasanen, P., Fenton, W., Koivumaa‐Honkanen, H. T., & Isohanni, M. (2009). Suicide rate in schizophrenia in the Northern Finland 1966 birth cohort. Social Psychiatry and Psychiatric Epidemiology, 25, 25. APA. (1994). DSM‐IV: Diagnostic and statistical manual of mental disorders (4th. ed.). Washington, DC: American Psychiatric Press. APA. (2013). DSM‐IV: Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Press. Arsenault‐Lapierre, G., Kim, C., & Turecki, G. (2004). Psychiatric diagnoses in 3275 suicides: A meta‐analysis. BMC Psychiatry, 4, 37. Atbasoglu, E. C., Schultz, S. K., & Andreasen, N. C. (2001). The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia. J Neuropsychiatry Clin Neurosci, 13(3), 336–341. doi: 10.1176/jnp.13.3.336 Baca‐Garcia, E., Perez‐Rodriguez, M. M., Diaz Sastre, C., Saiz‐Ruiz, J., & de Leon, J. (2005). Suicidal behavior in schizophrenia and depression: A comparison. Schizophrenia Research, 75(1), 77–81. Bakst, S., Rabinowitz, J., & Bromet, E. J. (2010). Antecedents and patterns of suicide behavior in first‐admission psychosis. Schizophrenia Bulletin, 36(4), 880–889. doi: 10.1093/schbul/ sbp001 Balhara, Y. P., & Verma, R. (2012). Schizophrenia and suicide. East Asian Archives of Psychiatry, 22(3), 126–133. Barrett, E. A., Sundet, K., Faerden, A., Agartz, I., Bratlien, U., Romm, K. L., … Melle, I. (2010). Suicidality in first episode psychosis is associated with insight and negative beliefs about psychosis. Schizophrenia Research, 123(2–3), 257–262. doi: 10.1016/j.schres.2010.07.018 Beautrais, A. L., Joyce, P. R., Mulder, R. T., Fergusson, D. M., Deavoll, B. J., & Nightingale, S. K. (1996). Prevalence and comorbidity of mental disorders in persons making serious suicide  attempts: A case‐control study. The American Journal of Psychiatry, 153(8), 1009–1014. Bell, M. D., Lysaker, P., & Milstein, R. (1996). Clinical benefits of paid work activity in schizophrenia. Schizophrenia Bulletin, 22, 51–67. Bell, M. D., Zito, W., Greig, T., & Wexler, B. E. (2008). Neurocognitive enhancement therapy with vocational services: Work outcomes at two‐year follow‐up. Schizophrenia Research, 105(1–3), 18–29. Besnier, N., Gavaudan, G., Navez, A., Adida, M., Jollant, F., Courtet, P., & Lancon, C. (2009). Clinical features of suicide occurring in schizophrenia (I). Risk‐factors identification. Encephale, 35(2), 176–181. doi: 10.1016/j.encep.2008.02.009 Bourgeois, M., Swendsen, J., Young, F., Amador, X., Pini, S., Cassano, G. B., … Meltzer, H. Y. (2004). Awareness of disorder and suicide risk in the treatment of schizophrenia: Results of the international suicide prevention trial. The American Journal of Psychiatry, 161(8), 1494–1496.

106

Antoine Desîlets et al.

Brent, D. A., Bridge, J., Johnson, B. A., & Connolly, J. (1996). Suicidal behavior runs in f­ amilies: A controlled family study of adolescent suicide victims. Archives of General Psychiatry, 53(12), 1145–1152. Brown, S. (1997). Excess mortality of schizophrenia: A meta‐analysis. The British Journal of Psychiatry, 171, 502–508. Brugnoli, R., Novick, D., Haro, J. M., Rossi, A., Bortolomasi, M., Frediani, S., & Borgherini, G. (2012). Risk factors for suicide behaviors in the observational schizophrenia outpatient health outcomes (SOHO) study. BMC Psychiatry, 12, 83. doi: 10.1186/1471‐244x‐12‐83 Buchanan, R. W., & Carpenter, W. T. (2005). Concept of schizophrenia. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (8th ed., Vol. I). Philadelphia, PA: Lippincott Williams & Wilkins. Caldwell, C. B., & Gottesman, II. (1990). Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin, 16(4), 571–589. Challis, S., Nielssen, O., Harris, A., & Large, M. (2013). Systematic meta‐analysis of the risk factors for deliberate self‐harm before and after treatment for first‐episode psychosis. Acta Psychiatrica Scandinavica, 127(6), 442–454. doi: 10.1111/acps.12074 Coryell, W., & Young, E. A. (2005). Clinical predictors of suicide in primary major depressive disorder. Journal of Clinical Psychiatry, 66(4), 412–417. Drake, R. E., Gates, C., Whitaker, A., & Cotton, P. G. (1985). Suicide among schizophrenics: A review. Comprehensive Psychiatry, 26(1), 90–100. Fenton, W. S. (2000). Depression, suicide, and suicide prevention in schizophrenia. Suicide and Life‐Threatening Behavior, 30(1), 34–49. Gonda, X., Pompili, M., Serafini, G., & Rihmer, Z. (2012). Suicidal behavior in bipolar ­disorder: epidemiology, characteristics and major risk factors. Journal of Affective Disorders, 143, 16–26. Greig, T. C., Zito, W., Wexler, B. E., Fiszdon, J., & Bell, M. D. (2007). Improved cognitive function in schizophrenia after one year of cognitive training and vocational services. Schizophrenia Research, 96(1–3), 156–161. Gut‐Fayand, A., Dervaux, A., Olie, J. P., Loo, H., Poirier, M. F., & Krebs, M. O. (2001). Substance abuse and suicidality in schizophrenia: A common risk factor linked to impulsivity. Psychiatry Research, 102(1), 65–72. Hawton, K., Houston, K., Haw, C., Townsend, E., & Harriss, L. (2003). Comorbidity of axis I and axis II disorders in patients who attempted suicide. The American Journal of Psychiatry, 160(8), 1494–1500. Hawton, K., Sutton, L., Haw, C., Sinclair, J., & Deeks, J. J. (2005). Schizophrenia and suicide: Systematic review of risk factors. The British Journal of Psychiatry, 187, 9–20. Heila, H., Isometsa, E. T., Henriksson, M. M., Heikkinen, M. E., Marttunen, M. J., & Lonnqvist, J. K. (1997). Suicide and schizophrenia: A nationwide psychological autopsy study on age‐ and sex‐specific clinical characteristics of 92 suicide victims with schizophrenia. The American Journal of Psychiatry, 154(9), 1235–1242. Hennen, J., & Baldessarini, R. J. (2005). Suicidal risk during treatment with clozapine: A meta‐ analysis. Schizophrenia Research, 73(2–3), 139–145. Henriksson, M. M., Aro, H. M., Marttunen, M. J., Heikkinen, M. E., Isometsa, E. T., Kuoppasalmi, K. I., & Lonnqvist, J. K. (1993). Mental disorders and comorbidity in suicide. The American Journal of Psychiatry, 150(6), 935–940. Higashi, K., Medic, G., Littlewood, K. J., Diez, T., Granstrom, O., & De Hert, M. (2013). Medication adherence in schizophrenia: Factors influencing adherence and consequences of nonadherence, a systematic literature review. Therapeutic Advances in Psychopharmacology, 3(4), 200–218. doi: 10.1177/2045125312474019 Hogarty, G. E., & Flesher, S. (1999). Practice principles of cognitive enhancement therapy for schizophrenia. Schizophrenia Bulletin, 25(4), 693–708. Hogarty, G. E., Flesher, S., Ulrich, R., Carter, M., Greenwald, D., Pogue‐Geile, M., … Zoretich, R. (2004). Cognitive enhancement therapy for schizophrenia: Effects of a 2‐year randomized trial on cognition and behavior. Archives of General Psychiatry, 61(9), 866–876.



Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior

107

Hogarty, G. E., Greenwald, D., Ulrich, R. F., Kornblith, S. J., DiBarry, A. L., Cooley, S., … Flesher, S. (1997). Three‐year trials of personal therapy among schizophrenic patients living with or independent of family, II: Effects on adjustment of patients. The American Journal of Psychiatry, 154(11), 1514–1524. Hogarty, G. E., Kornblith, S. J., Greenwald, D., DiBarry, A. L., Cooley, S., Ulrich, R. F., … Flesher, S. (1997). Three‐year trials of personal therapy among schizophrenic patients living with or independent of family, I: Description of study and effects on relapse rates. The American Journal of Psychiatry, 154(11), 1504–1513. Hor, K., & Taylor, M. (2010). Suicide and schizophrenia: A systematic review of rates and risk  factors. Journal of Psychopharmacology, 24(4 Suppl.), 81–90. doi: 10.1177/ 1359786810385490 Hu, W. H., Sun, C. M., Lee, C. T., Peng, S. L., Lin, S. K., & Shen, W. W. (1991). A clinical study of schizophrenic suicides. 42 cases in Taiwan. Schizophrenia Research, 5(1), 43–50. Inskip, H. M., Harris, E. C., & Barraclough, B. (1998). Lifetime risk of suicide for affective disorder, alcoholism and schizophrenia. The British Journal of Psychiatry, 172, 35–37. Isometsa, E. T. (2001). Psychological autopsy studies—A review. European Psychiatry, 16(7), 379–385. Jones, C., Hacker, D., Cormac, I., Meaden, A., & Irving, C. B. (2012). Cognitive behavior therapy versus other psychosocial treatments for schizophrenia. Schizophrenia Bulletin, 38(5), 908–910. doi: 10.1093/schbul/sbs090 Kaplan, K. J., & Harrow, M. (1996). Positive and negative symptoms as risk factors for later suicidal activity in schizophrenics versus depressives. Suicide and Life‐Threatening Behavior, 26(2), 105–121. Karvonen, K., Sammela, H. L., Rahikkala, H., Hakko, H., Sarkioja, T., Meyer‐Rochow, V. B., … Timonen, M. (2007). Sex, timing, and depression among suicide victims with schizophrenia. Comprehensive Psychiatry, 48(4), 319–322. Khan, A., Khan, S. R., Leventhal, R. M., & Brown, W. A. (2001). Symptom reduction and suicide risk among patients treated with placebo in antipsychotic clinical trials: An analysis of the food and drug administration database. The American Journal of Psychiatry, 158(9), 1449–1454. Kirkpatrick, B., & Tek, C. (2005). Schizophrenia: Clinical features and psychopathology concepts. In B. J. Sadock & V. A. Sadock (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (8th ed., Vol. I). Philadelphia, PA: Lippincott Williams & Wilkins. Kuo, C. J., Tsai, S. Y., Lo, C. H., Wang, Y. P., & Chen, C. C. (2005). Risk factors for completed suicide in schizophrenia. Journal of Clinical Psychiatry, 66(5), 579–585. Lesage, A. D., Boyer, R., Grunberg, F., Vanier, C., Morissette, R., Menard‐Buteau, C., & Loyer, M. (1994). Suicide and mental disorders: A case‐control study of young men. The American Journal of Psychiatry, 151(7), 1063–1068. Lewine, R. R. (2005). Social class of origin, lost potential, and hopelessness in schizophrenia. Schizophrenia Research, 76(2–3), 329–335. Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P., Kingdon, D., … Dunn, G. (2002). Randomised controlled trial of cognitive‐behavioural therapy in early schizophrenia: Acute‐ phase outcomes. British Journal of Psychiatry Supplement, 43(7), s91–97. Loas, G., Azi, A., Noisette, C., Legrand, A., & Yon, V. (2009). Fourteen‐year prospective follow‐up study of positive and negative symptoms in chronic schizophrenic patients dying from suicide compared to other causes of death. Psychopathology, 42(3), 185–189. doi: 10.1159/000209331 Lopez‐Morinigo, J. D., Ramos‐Rios, R., David, A. S., & Dutta, R. (2012). Insight in schizophrenia and risk of suicide: A systematic update. Comprehensive Psychiatry, 53(4), 313–322. doi: 10.1016/j.comppsych.2011.05.015 Madsen, T., & Nordentoft, M. (2013). Changes in inpatient and postdischarge suicide rates in a nationwide cohort of Danish psychiatric inpatients, 1998–2005. Journal of Clinical Psychiatry, 74(12), e1190–1194. doi: 10.4088/JCP.13m08656

108

Antoine Desîlets et al.

Marttunen, M. J., Aro, H. M., Henriksson, M. M., & Lonnqvist, J. K. (1991). Mental disorders in adolescent suicide. DSM‐III‐R axes I and II diagnoses in suicides among 13‐ to 19‐year‐olds in Finland. Archives of General Psychiatry, 48(9), 834–839. McGirr, A., Alda, M., Séguin, M., Cabot, S., Lesage, A., & Turecki, G. (2009). Familial aggregation of suicide explained by cluster B traits: A three‐group family study of suicide controlling for major depressive disorder. The American Journal of Psychiatry, 166(10), 1124–1134. McGirr, A., Séguin, M., Renaud, J., Benkelfat, C., Alda, M., & Turecki, G. (2006). Gender and risk factors for suicide: Evidence for heterogeneity in predisposing mechanisms. Journal of Clinical Psychiatry, 67, 1612–1617. McGirr, A., Tousignant, M., Routhier, D., Pouliot, L., Chawky, N., Margolese, H. C., & Turecki, G. (2006). Risk factors for completed suicide in schizophrenia and other chronic psychotic disorders: A case‐control study. Schizophrenia Research, 84(1), 132–143. McGirr, A., & Turecki, G. (2008). What is specific to suicide in schizophrenia? Behavioural, clinical and sociodemographic dimensions. Schizophrenia Research, 98(1–3), 217–224. Melle, I., & Barrett, E. A. (2012). Insight and suicidal behavior in first‐episode schizophrenia. Expert Review of Neurotherapeutics, 12(3), 353–359. doi: 10.1586/ern.11.191 Melle, I., Johannesen, J. O., Friis, S., Haahr, U., Joa, I., Larsen, T. K., … McGlashan, T. (2006). Early detection of the first episode of schizophrenia and suicidal behavior. The American Journal of Psychiatry, 163(5), 800–804. Meltzer, H. Y. (1998). Suicide in schizophrenia: Risk factors and clozapine treatment. Journal of Clinical Psychiatry, 59(Suppl. 3), 15–20. Meltzer, H. Y., Alphs, L., Green, A. I., Altamura, A. C., Anand, R., Bertoldi, A., … Potkin, S. (2003). Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Archives of General Psychiatry, 60(1), 82–91. Meltzer, H. Y., & Okayli, G. (1995). Reduction of suicidality during clozapine treatment of neuroleptic‐resistant schizophrenia: Impact on risk‐benefit assessment. The American Journal of Psychiatry, 152(2), 183–190. Miles, C. P. (1977). Conditions predisposing to suicide: A review. Journal of Nervous and Mental Disease, 164(4), 231–246. Mueser, K. T., & Berenbaum, H. (1990). Psychodynamic treatment of schizophrenia: Is there a future? Psychological Medicine, 20(2), 253–262. Muller, D. J., Barkow, K., Kovalenko, S., Ohlraun, S., Fangerau, H., Kolsch, H., … Rietschel, M. (2005). Suicide attempts in schizophrenia and affective disorders with relation to some specific demographical and clinical characteristics. European Psychiatry, 20(1), 65–69. Palmer, B. A., Pankratz, V. S., & Bostwick, J. M. (2005). The lifetime risk of suicide in schizophrenia: A reexamination. Archives of General Psychiatry, 62(3), 247–253. Pompili, M., Lester, D., Grispini, A., Innamorati, M., Calandro, F., Iliceto, P., … Girardi, P. (2009). Completed suicide in schizophrenia: Evidence from a case‐control study. Psychiatry Research, 167(3), 251–257. Qin, P., Agerbo, E., & Mortensen, P. B. (2003). Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: A national register‐based study of all suicides in Denmark, 1981–1997. The American Journal of Psychiatry, 160(4), 765–772. Restifo, K., Harkavy‐Friedman, J. M., & Shrout, P. E. (2009). Suicidal behavior in schizophrenia: A test of the demoralization hypothesis. Journal of Nervous and Mental Disease, 197(3), 147–153. Reutfors, J., Brandt, L., Jonsson, E. G., Ekbom, A., Sparen, P., & Osby, U. (2009). Risk factors for suicide in schizophrenia: Findings from a Swedish population‐based case‐control study. Schizophrenia Research, 108(1–3), 231–237. Ringback Weitoft, G., Berglund, M., Lindstrom, E. A., Nilsson, M., Salmi, P., & Rosen, M. (2014). Mortality, attempted suicide, re‐hospitalisation and prescription refill for clozapine



Schizophrenia, Other Psychotic Disorders, and Suicidal Behavior

109

and other antipsychotics in Sweden – a register‐based study. Pharmacoepidemiology and Drug Safety, 23(3), 290–298. doi: 10.1002/pds.3567 Robinson, J., Cotton, S. Conus, P., Schimmelmann, B. G., McGorry, P., & Lambert, M. (2009). Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first‐episode psychosis. Australian and New Zealand Journal of Psychiatry, 43, 149–157. Roy, A. (1982). Suicide in chronic schizophrenia. The British Journal of Psychiatry, 141, 171–177. Roy, A., Segal, N. L., Centerwall, B. S., & Robinette, C. D. (1991). Suicide in twins. Archives of General Psychiatry, 48(1), 29–32. Rudd, M. D., Dahm, P. F., & Rajab, M. H. (1993). Diagnostic comorbidity in persons with suicidal ideation and behavior. The American Journal of Psychiatry, 150(6), 928–934. Schennach‐Wolff, R., Jager, M., Seemuller, F., Obermeier, M., Schmauss, M., Laux, G., … Riedel, M. (2010). Outcome of suicidal patients with schizophrenia: Results from a naturalistic study. Acta Psychiatrica Scandinavica, 121(5), 359–370. doi: 10.1111/j.1600-0447. 2009.01484.x Sharaf, A. Y., Ossman, L. H., & Lachine, O. A. (2012). A cross‐sectional study of the relationships between illness insight, internalized stigma, and suicide risk in individuals with schizophrenia. International Journal of Nursing Studies, 49(12), 1512–1520. doi: 10.1016/ j.ijnurstu.2012.08.006 Sinclair, J. M., Mullee, M. A., King, E. A., & Baldwin, D. S. (2004). Suicide in schizophrenia: A retrospective case‐control study of 51 suicides. Schizophrenia Bulletin, 30(4), 803–811. Statham, D. J., Heath, A. C., Madden, P. A., Bucholz, K. K., Bierut, L., Dinwiddie, S. H., … Martin, N. G. (1998). Suicidal behaviour: An epidemiological and genetic study. Psychological Medicine, 28(4), 839–855. Suokas, J. T., Perala, J., Suominen, K., Saarni, S., Lonnqvist, J., & Suvisaari, J. M. (2010). Epidemiology of suicide attempts among persons with psychotic disorder in the general population. Schizophrenia Research, 124(1–3), 22–28. doi: 10.1016/j.schres.2010.09.009 Tarrier, N., Haddock, G., Lewis, S., Drake, R., & Gregg, L. (2006). Suicide behaviour over 18 months in recent onset schizophrenic patients: The effects of CBT. Schizophrenia Research, 83(1), 15–27. Tarrier, N., Lewis, S., Haddock, G., Bentall, R., Drake, R., Kinderman, P., … Dunn, G. (2004). Cognitive‐behavioural therapy in first‐episode and early schizophrenia. 18‐month follow‐ up of a randomised controlled trial. The British Journal of Psychiatry, 184, 231–239. Tsuang, M. T. (1978). Suicide in schizophrenics, manics, depressives, and surgical controls. A  comparison with general population suicide mortality. Archives of General Psychiatry, 35(2), 153–155. Wender, P. H., Seymour, S. K., Rosenthal, D., Schulsinger, F., Ortmann, J., & Lunde, I. (1986). Psychiatric disorders in the biological and adoptive families of adopted individuals with affective disorders. Archives of General Psychiatry, 43, 923–929. Whitehead, C., Moss, S., Cardno, A., & Lewis, G. (2003). Antidepressants for people with both schizophrenia and depression. Cochrane Database of Systematic Reviews, 2, Cd002305. doi: 10.1002/14651858.cd002305 Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2005). The McLean Study of Adult Development (MSAD): Overview and implications of the first six years of prospective follow‐up. Journal of Personality Disorders, 19(5), 505–523. Zimmermann, G., Favrod, J., Trieu, V. H., & Pomini, V. (2005). The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: A meta‐analysis. Schizophrenia Research, 77(1), 1–9.

6

Substance Use Disorders and Suicidal Behavior A Conceptual Model Kenneth R. Conner and Mark A. Ilgen

Introduction This chapter reviews evidence linking the presence of alcohol use disorders (AUDs) and some drug use disorders (DUDs) to suicide attempts and suicide. The chapter focuses on key distal risk factors (severity of substance use disorder (SUD), ­aggression/impulsivity, negative affectivity) and proximal risk factors (active sub­ stance use and symptoms, interpersonal stress, depressive symptoms) for suicidal behavior within SUD populations. A theoretical model is presented that posits that the distal risk factors (e.g., negative affectivity) increase the probability for the proximal risk factors (e.g., depressive symptoms), which in turn increase the likelihood of suicidal behavior. The proximal risk factors are conceptualized as partial mediators of the relationship between the distal variables and suicidal behavior. Key decisions that informed the development of the model along with limitations and caveats are explained. The chapter concludes with a discussion of ways to test the conceptual framework, ­directions for future studies, and resources pertaining to SUDs and suicidal behavior.

Terms Used Throughout AUD = alcohol use disorder including alcohol abuse and alcohol dependence. DUD = drug use disorder (nonalcohol) including abuse or dependence on cocaine, opiates, and so forth, excluding tobacco dependence. SUD = substance use disorder inclusive of one or more AUD or DUD. Suicide attempt = self‐injurious behavior with at least some intent to die with a non­ fatal outcome (note that for the chapter, the term refers to nonfatal attempts only to distinguish them from suicide). Suicide = self‐injurious behavior with at least some intent to die that results in death.

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.



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Suicidal behavior = suicide attempt or suicide. Risk factor = attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury. Distal risk factor = variable that creates a long‐term diathesis for suicidal behavior. Proximal risk factor = variables that influence risk and are in evidence near the time of suicidal behavior. Mediator = variable that explains fully (full mediation) or in part (partial mediation) the association between two variables. Moderator = a variable that increases or decreases the strength of association between two variables.

Conceptual Model of Risk for Suicidal Behavior Among Individuals With SUDs Conceptual Model: Our conceptual model of distal and proximal risk factors for ­suicidal behavior among individuals with SUDs is shown in Figure 6.1. Among indivi­ duals with an SUD, we posit that greater substance‐related severity and personality features of aggression/impulsivity and negative affectivity are distal risk factors, and that proximal risk factors include active substance use and impairment, interpersonal stress, and depressive episodes and symptoms. Integrating distal and proximal risk factors, we further hypothesize that distal risk factors promote proximal variables that in turn lead to acts of suicide, consistent with the idea that proximal risk factors serve as partial mediators of the association between distal risk factors and suicidal behavior. That is, individuals with a severe SUD, a propensity for aggressive/impulsive behavior, and/or who are prone to experience negative affect are judged to be more likely at any given time to show active substance use and symptoms, to experience current depressive symptoms, and/or to experience interpersonal stress. Supporting these ideas, a pattern of aggression and severe SUD may be expected to increase the likelihood of chronic substance use and symptoms, relapse to substance use, and interpersonal conflicts and disruptions. The role of negative affectivity in the development of depressive episodes is also clear, as we will discuss. Although we emphasize the distinction between distal and proximal risk factors and discuss their interrelationship, variables within a category may also influence one another. For example, we point out that within the proximal risk domain, active substance use and

SUD

Distal factors/ moderators

Proximal factors/ mediators

Severe SUD aggression/impulsivity negative affectivity

Active SUD depression interpersonal stress

Suicidal behavior

Figure  6.1  Model of suicidal behavior among individuals with SUDs. Note. Moderating effects are depicted by a broken arrow and mediating effects by unbroken arrows.

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interpersonal life events are potent precursors of major depressive episodes. The distal risk factors (e.g., negative affectivity) may also serve to interact with SUDs such that combinations of variables (e.g., negative affectivity and SUDs) confer more (or less) risk than would be expected based on their association with suicidal behavior consid­ ered separately, consistent with a moderating effect (Conner et al., 2013). Figure 6.1 depicts potential moderating effects of distal factors on the association between SUDs and suicidal behavior through the broken arrow that intersects the pathway from SUDs to suicidal behavior. Key decisions in developing the model along with limitations and caveats. All proposed relationships are intended to be testable, and the model is intended to be applicable to both suicide attempts and suicide, outcomes that are largely d ­ istinguished by age, sex, and lethality of method (Beautrais, 2001; Friedmann & Kohn, 2008). A focus on active substance use and impairment is straightforward, given a focus on individuals with SUDs. A focus on depression and interpersonal stress in proximal risk is also indicated because these are prevalent difficulties among individuals with SUDs as well as potent risk factors for suicidal behavior. Because the study of proximal risk among individuals with an SUD is a nascent research area, particularly among ­individuals with specific DUDs, further study of other stressors and other disorders may show the need to expand the model. Also, the model presumes that factors ­influencing risk are broadly similar across different types of substances. Indeed, recent cross‐sectional analysis of national survey data from adolescents examined the association between type of substance used and risk of suicide attempt (Wong, Zhou, Goebert, & Hishinuma, 2013). Each of the 10 specific substances assessed, including alcohol, was associated with risk of suicide attempt, although the risks associated with heroin and methamphetamines stood out as particularly strong. Similar data are needed to examine the extent to which specific SUDs (including AUD) relate to ­suicidal behaviors in adults. Subsequent work could then examine if the specific risk factors differ between substances. Much of the basis for the model comes from studies of individuals with AUD, and so its relevance to other SUD populations requires further study. The model begins with distal risk factors but does not seek to explain the causes (genetic, developmental, etc.) of these factors. The model is a general framework for risk among individuals with SUDs and does not address specific SUDs (e.g., cocaine use disorder). The terms distal and proximal are useful heuristics though the boundaries between categories are per­ meable, for example, between negative affectivity and major depression. The model considers proximal use of substances, particularly alcohol, but does not focus on other acute variables such as warning signs that concern the probability of suicidal behavior within a very short window of time (Rudd et al., 2006).

Evidence for the Conceptual Model: Research Showing that Individuals with SUDs are at Elevated Risk As noted previously, much of the research on SUDs and suicidal behavior is based on studies of AUDs. Although it is clear that AUD confers risk for suicide, risk estimates vary considerably as a function of study design and population; for example, a meta‐ analysis of retrospective case‐control studies estimated that individuals with AUD are



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at approximately 2.6 (95% CI = 1.4, 2.35) times greater risk for suicide compared to individuals without AUD (Darvishi, Farhadi, Haghtalab, & Poorolajal, 2015), whereas a meta‐analysis of longitudinal studies estimated that individuals with AUD identified through treatment venues are at approximately 9.8 (95% CI = 9.0, 10.7) times greater risk for suicide compared to the general population (Wilcox, Conner, & Caine, 2004). The meta‐analysis by Darvishi et al. (2015) also concluded that risk for suicide associated with AUD does not differ as a function of age or sex, yet potential age or sex differences remain poorly researched and may depend on the population studied and the methodology used. For example, a large‐scale, prospective analysis of individuals treated by the Veterans Health Administration found that both AUDs and SUDs were associated with greater risk in women than in men, suggesting that AUD may be an especially potent risk factor in female veterans (Ilgen et al., 2010). Along with conferring increased risk for suicide, it is also important to point out that AUDs and other SUDs are prevalent disorders, with available data indicating that they are the second most prevalent mental disorder among suicide decedents, behind only mood disorders (Cavanagh, Carson, Sharpe, & Lawrie, 2003). Moreover, psychological autopsy studies of adults using a controlled research design show that an AUD confers risk after adjusting for other risk factors (Cheng, 1995; Kolves, Varnik, Tooding, & Wasserman, 2006). An exception comes from a report from China that did not show that an AUD confers risk for suicide (Phillips et al., 2002). However, the increasing rates of drinking and AUDs among men in China (Zhou et al., 2009) suggest that AUDs may play an increasing role in suicide there. Data also support the assertion that AUDs confer risk for suicide attempts (Kessler, Borges, & Walters, 1999), and indeed they may be especially potent risk factors for an attempt (Rossow, Romelsjo, & Leifman, 1999). Individuals enrolled in alcoholism treatment are especially likely to have a suicide attempt history with an estimate of almost 45% of those in AUD treatment reporting a lifetime attempt (Roy, Lamparski, DeJong, Moore, & Linnoila, 1990; Wojnar et al., 2009). Although we emphasize AUD in this review, several studies have also shown that less severe patterns of use, such as “alcohol‐ related problems,” confer risk for suicide after adjustment for other risk factors (e.g., LeardMann et al., 2013). Drawing firm conclusions about the relationship between many specific DUDs and suicide is difficult owing to limited data. A meta‐analysis was not able to estimate risk for most specific categories of DUDs (Wilcox et al., 2004). There were sufficient data, however, to estimate that individuals obtaining treatment for an opioid use disorder were at 13.5 (95% CI = 10.5–17.2) times greater risk for eventual suicide compared to individuals of comparable age and sex residing in the community not receiving such treatment. Similar results were obtained when intravenous DUDs were examined. Although lacking a control group and limited to those tested for specific substances (less than 50% of those who died by suicide), results of coroners’ reports from 13 states in the United States indicate that cocaine was present in 9% to 17% of suicide decedents and opiates were present in 8% to 18% depending on the racial/ethnic group, percentages that are higher than would be expected in the general population (Karch, Barker, & Strine, 2006). An Australian study found that approximately 16% of amphetamine‐related deaths and 11% of opiate‐related deaths were due to suicide (Degenhardt, Roxburgh, & Barker, 2005). Overall, the available evidence consis­ tently links stimulants (cocaine and amphetamines) and opiates (both licit and illicit) to suicide mortality. In terms of research on suicide attempts, national survey data in

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the United States indicate that risk of lifetime attempt is 5.9 (95% CI = 3.4–10.2) times greater in those with a diagnosis of drug abuse and 5.8 (95% CI = 3.3–10.1) times greater for those with a diagnosis of drug dependence (Kessler et  al., 1999). In addition, a study of regular users of heroin and/or psychostimulants indicates that suicidal behaviors are reported in almost one in three of these individuals (Darke, Torok, Kaye, & Ross, 2010). Data from SUD treatment settings also indicate that individuals treated for cocaine dependence (Roy, 2001), opiate dependence (Darke, Ross, Lynskey, & Teesson, 2004), and a mixture of SUDs (Ilgen, Jain, Lucas, & Moos, 2007; Wines, Saitz, Horton, Lloyd‐Travaglini, & Samet 2004) have high ­lifetime prevalence rates of suicide attempts.

Evidence for the Conceptual Model: Distal Risk Factors for Suicidal Behavior Among Individuals With SUDs Severe SUD as a distal risk factor. AUD severity has been measured in a variety of ways including earlier onset of problem drinking or alcoholism, greater number of lifetime AUD symptoms, alcohol dependence versus abuse only, binge drinking pattern, comorbid drug use disorder, and comorbid medical disorders (Penick et al., 1999). Studies of individuals with AUDs consistently show that such indicators of  AUD severity serve as distal risk factors for suicide attempts (Hasin, Grant, & Endicott, 1988; Preuss et al., 2002; Roy et al., 1990). Limited prospective data also suggest that AUD severity predicts subsequent suicide attempts (Preuss et al., 2003). Co‐occurring drug use and drug use disorder stands out as the indicators of AUD severity that have been most consistently demonstrated to represent a distal risk factor for suicidal behavior among individuals with AUDs (Preuss et al., 2002; Roy et al., 1990). Data also show that SUD severity is associated with greater likelihood of suicide attempts, with cross‐sectional analyses indicating that individuals treated for SUDs who make suicide attempts report more sedative use, polysubstance use, and more severe drinking and alcohol use disorder compared to nonattempters (Ilgen, Harris, Moos, & Tiet, 2007; Wines et al., 2004). These findings are consistent with data from samples of individuals in treatment for specific DUDs. Among those treated for cocaine use disorders, greater severity of alcohol or opiate use prior to treatment is associated with greater likelihood of a history of suicide attempt (Roy, 2001). Among individuals with opiate use disorders, lifetime suicide attempts are more common in those with co‐occurring alcohol, marijuana, cocaine, and sedative use disorders (Maloney, Degenhardt, Darke, Mattick, & Nelson, 2007), benzodiazepine use (Darke et al., 2004) and more extensive polysubstance use (Darke et al., 2004; Maloney et al., 2007). A few studies have examined the longitudinal predictors of suicide attempt following SUD treatment and have found that sedative use (Wines et al., 2004) and longer duration of lifetime cocaine use and greater severity of baseline alcohol p ­ roblems (Ilgen, Harris, et al., 2007) predict posttreatment suicide attempts. In addition, in a study of opiate users, greater polysubstance misuse was associated with greater likelihood of subsequent suicide attempt even after accounting for ­baseline suicidal thoughts and prior attempts (Darke et al., 2007). Collectively, these data indicate that individuals with more severe SUDs are at elevated long‐term risk for suicidal behavior compared to individuals with less severe SUDs.



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Negative affectivity as a distal risk factor. Vulnerability to experiencing negative affect such as anger, sadness, and anxiety, commonly referred to as neuroticism or negative affectivity, is associated with most psychiatric conditions including major depressive disorder (Ormel, Oldehinkel, & Vollebergh, 2004). There is a wealth of evidence that negative affectivity is strongly associated with depression, including as a predictor of major depression (Kendler, Neale, Kessler, Heath, & Eaves, 1993) and the recurrence and persistence of depressive symptoms (Surtees & Wainwright, 1996). Similarly, studies of people with SUDs also show that negative affectivity distinguishes those with higher levels of depressive symptoms (McCormick, Dowd, Quirk, & Zegarra, 1998; Piedmont & Ciarrochi, 1999). Negative affectivity may play a role in suicidal behavior among individuals with SUDs by promoting depressive disorders and symptoms. Substance use may also develop or continue as an effort to cope with high levels of negative affect (Cooper, Frone, Russell, & Mudar, 1995), suggesting another mechanism in which negative affectivity may increase long‐term risk. Individuals with AUD as opposed to other SUDs may be especially vulnerable to this cycle (McGue, Slutske, & Iacono, 1999). Studies consistently show that negative affectivity differentiates individuals with AUD (Roy, 2003) and SUD (Darke et al., 2004; Roy, 2003; Wines et al., 2004) with a history of suicide attempts, consistent with the idea that it serves as a distal risk factor. Aggression/impulsivity as a distal risk factor. A comprehensive review ­identified numerous reports showing that measures of aggression distinguish individuals who make suicide attempts from those who die by suicide (Brezo, Paris, & Turecki, 2006). Studies using AUD samples of veterans (Windle, 1994) and with comorbid ­depression (Sher et al., 2005) as well as those in treatment (Koller, Preuss, Bottlender, Wenzel, & Soyka, 2002) showed that measures of aggression or diagnoses associated with aggression/impulsivity differentiated those with and without a history of suicide attempts. A large psychological autopsy study showed that higher aggression uniquely distinguished suicide decedents with AUD from those without AUD after ­multivariate adjustment (Chachamovich, Ding, & Turecki, 2012). The findings among ­individuals with SUDs are similar to studies of AUDs; for example, those seeking SUD treatment who have a lifetime suicide attempt report more difficulty controlling violent behavior than those without a lifetime attempt (Tiet, Ilgen, Byrnes, & Moos, 2006). Further, a study examining the association between self‐reports of prior aggression and suicidal ideation in patients seeking SUD treatment indicates that aggression toward a partner is more strongly associated with risk of suicidal ideation than aggression toward a nonpartner (Ilgen et al., 2009). There is not a clear consensus on the definition or measurement of impulsivity, and some have questioned the role of impulsivity in suicidal behavior (Anestis, Sobery, Gutierrez, Hernandez, & Joiner, 2014). Indeed, there are fewer reports showing that measures that are specifically designed to assess impulsivity confer risk for suicide attempts or suicide compared to abundant evidence using measures of aggression or those that tap both aggression and impulsivity (Brezo et  al., 2006). On the other hand, there is compelling evidence that altered brain serotonin‐mediated neurotrans­ mission implicated in impulsive aggression confers risk for suicide attempts and suicide, and there are also some reports showing that impulsivity confers added risk (Turecki, 2005). Also, a recent large and comprehensive survey of military service members found that “Intermittent Explosive Disorder,” a condition characterized by  poor impulse control coupled with aggressive/angry outbursts, was one of the

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s­ trongest predictors of suicidal behaviors prior to and after military deployment (Nock et al., 2014). Moreover, studies of impulsivity and suicidal behavior have generally used limited self‐report measures of impulsivity, and the use of superior laboratory measures of impulsivity that assess rash and inaccurate decision‐making under experimental con­ ditions may show stronger associations (Dougherty et al., 2004). Along these lines, a study found that individuals with AUDs who make impulsive suicide attempts (those with 30 min or less of preplanning) also have deficits in behavioral measures of impul­ sivity (Wojnar et al., 2009). Overall, although evidence pertaining to impulsivity and suicidal behavior is leaner than data on aggression, the balance of the evidence indicates that impulsivity increases risk for suicidal behaviors, perhaps by acting in combination with aggression consistent with the notion of impulsive (­reactive) aggression.

Evidence for the Conceptual Model: Proximal Risk Factors Among Individuals With SUDs Active substance use and impairment as a proximal risk factor. Available data suggest that recent drinking patterns are more severe among those with AUDs ­ attempting suicide (Cornelius, Salloum, Day, Thase, & Mann, 1996) or dying by suicide (Murphy, Wetzel, Robins, & McEvory, 1992) compared to nonsuicidal indi­ viduals with AUDs. There are also consistent data showing that a substantial minority of suicide decedents and suicide attempters had positive blood alcohol levels (Cherpitel, Borges, & Wilcox, 2004) and that high blood alcohol levels are the norm in these cases (Kaplan et al., 2013). Moreover, reports using nonsuicide control con­ ditions show that acute use of alcohol confers proximal risk for suicidal behavior and that risk is increased with greater volume of drinking, consistent with a dose–response relationship (Bagge et  al., 2013; Branas, Richmond, Ten Have, & Wiebe, 2011). These data underscore the importance of acute use of alcohol as a proximal risk factor for suicidal behavior. A large national sample of veterans seeking SUD treatment showed a correlation between use of cocaine and suicide attempt within the prior 30 days, suggesting that use of cocaine also serves as a proximal risk factor (Ilgen, Harris, et al., 2007). Collectively, these reports support the commonsense conclusion that active and severe alcohol use including drinking in the event is a potent proximal risk factor for suicidal behavior, and that there is a need for more research on risk associ­ ated with proximal use of other substances (e.g., cocaine). Depressive disorders and symptoms as a proximal risk factor. Psychological autopsy studies that have used control groups of living individuals with AUDs (or SUDs) have shown increased rates of depression immediately preceding suicide among those with AUDs (Conner, Beautrais, & Conwell, 2003a; Murphy, Wetzel, Robins, & McEvory, 1992) and SUDs (Cheng, 1995; Schneider et al., 2006), sub­ stantiating the role of depression in proximal risk. Indeed, an empirical review of psychological autopsy studies concluded that SUD (most often AUD) and major depression is the most frequent pattern of comorbidity reported in studies worldwide (Cavanagh, Carson, Sharpe, & Lawrie, 2003). Presumably, a similar relationship exists between depression and proximal risk for suicide in those with other DUDs (in addition to alcohol); however, little data are available on this topic. Several studies show that co‐occurring depressive disorders confer lifetime risk for suicide attempt among individuals with SUDs (Darke et al., 2007; Preuss et al., 2002;



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Wines et al., 2004) and that both substance‐induced depression and that occurring independent of substance use are associated with lifetime risk for attempted suicide (Aharonovich et al., 2002; Preuss et al., 2002). Data from AUD samples also show that depression is a potent proximal risk factor for suicide attempt (Conner et  al., 2003a, 2012) and that both substance‐induced depression and independent depres­ sion confer proximal risk (Conner et al., 2014). Interpersonal stress as a proximal risk factor. Interpersonal life events, most ­commonly a threat to or disruption in a relationship with an intimate partner (e.g., breakup), were the most common stressful events preceding suicide in several psychological autopsy case series of adults with AUDs (Duberstein, Conwell, & Caine, 1993; Heikkinen et  al., 1994; Murphy, 1992). A study of this type that included a ­control group of nonsuicidal individuals with AUDs showed that, after controlling for depressive episodes and other risk factors, those who experienced a partner‐relationship event were at elevated risk for suicide (OR = 4.60; 95% CI = 1.46–14.57), as were those who experienced an interpersonal event involving another important person in the individual’s life (OR = 4.85; 95% CI = 1.50–15.66). Moreover, a study of proximal risk for suicide attempts in an AUD sample (Conner et al., 2012) showed that major (i.e., severe) interpersonal events was the only category of stressful life event to confer proximal risk for suicide attempt (OR = 5.50; 95% CI = 1.73–17.53). Data also show that indicators of chronic interpersonal stress confer risk, including reports that, among various SUD populations, risk for suicide attempt is associated with loneliness (Johnsson & Fridell, 1997) and interpersonal loss (Johnsson & Fridell, 1997), and risk for suicide is associated with living alone (Murphy et al., 1992). Overall, the data suggest that interpersonal stress may be manifested through conflicted relations that lead to an acute disruption, most commonly a partner‐­relationship breakup, as well as among individuals with impoverished interpersonal relationships who presumably experience chronic aloneness.

Future Directions Tests of the conceptual model. Rarely do we anticipate that, among individuals with SUDs, suicide attempts or suicides will be carried out by individuals who do not have distal risk factors (i.e., severe SUD, aggression/impulsivity, negative affectivity). Similarly, rarely do we anticipate that suicide attempts or suicides will occur during periods of remission from SUD, while nondepressed, and in the absence of marked interpersonal stress. We also presume that suicidal behavior will be most likely to occur when more than one distal (and proximal) risk factor is in evidence. At any given time, individuals with severe SUD, those prone to aggression/impulsivity, and/ or those vulnerable to negative affect are especially likely to experience the aforemen­ tioned proximal risk factors (interpersonal stress, etc.). In other words, distal risk var­ iables are purported to promote the occurrence of proximal risk factors that, in turn, mark periods of increased risk among vulnerable SUDs. In this scenario, proximal risk factors are hypothesized to mediate the association between distal risk factors and sui­ cidal behavior. We hypothesize partial mediation rather than full mediation given available data suggesting that distal risk factors contribute variance to suicidal behavior after adjusting for proximal risk factors. Formal procedures can be used to test partial versus full mediation (Cole & Maxwell, 2003).

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We expect that the distal factors we outline (negative affectivity, etc.) are associated with risk over and above that attributable to SUD. Formal analytic procedures can be used to understand potentially more complex moderating relationships; for example, whether SUD and a distal factor in combination confer less risk than expectation in light of their risk assessed independently, termed a subadditive effect, or if SUD and a distal factor in combination confer greater risk than expectation in light of their risk assessed separately, known as a synergistic effect (Conner et al., 2013). There are few studies on moderators of the association between SUDs and suicidal behavior (Conner et al., 2003b, 2013), making it speculative whether the proposed distal risk factors serve as moderators and if synergistic or subadditive effects are more likely. Interestingly, although synergism has been more commonly proposed, strong conceptual a­ rguments can also be made for subadditivity, for example, shared etiology of distal risk factors (e.g., aggression/impulsivity), and SUD may produce subadditive risk for suicidal behavior when these variables are considered in combination (Conner et al., 2013). Another strategy to examine the model is to design and test interventions that target the risk factors in the model. Consistent with the call for the study of m ­ echanisms of change in intervention research (Nock, 2007), we predict that the incidence or recur­ rence of suicidal behavior will be reduced to the extent to which the distal and proximal risk factors are successfully addressed in treatment, with proximal factors being most amenable to short‐term change. Given the low base rate of suicidal behavior, proxy outcomes (e.g., suicidal ideation) and/or the use of high‐risk clinical subpopulations (e.g., recent suicide attempters) will be needed to provide practical tests of these ideas. Data suggesting that interventions targeting suicidal behavior are ­ efficacious in reducing SUD symptoms (Harned et al., 2008) and that SUD treatment may reduce the risk for suicidal behavior (Ilgen, Harris, et al., 2007; Ilgen, Jain, et al., 2007) pro­ vide reasons for optimism. Although we are not aware of any research in this area, it is ­possible that future research examining the efficacy of interventions that target inter­ personal problem solving could also examine suicidal behaviors as ­outcomes. Given that all of these factors are conceptualized as partial mediators of suicidal behaviors, interventions designed to reduce suicide risk among those with SUDs will likely be more effective if they addressed more than one of these domains simultaneously.

Additional Directions Role of evidence in influencing suicide prevention activities:  Historically, although substantial resources have been invested in prevention and treatment of SUDs and suicidal behavior, respectively, these initiatives have been relatively distinct from one another. Given the evidence for a major role of SUDs in suicidal behavior, the time has come to link these efforts including by integrating suicide prevention activities into settings that treat individuals with SUDs (Center for Substance Abuse Treatment, 2009), weaving evidence‐based SUD interventions into suicide prevention settings such as psychiatric emergency rooms and/or suicide prevention call centers (Conner, Bagge, Goldston, & Ilgen, 2014), and by examining the impact of policies directed at prevention (or mitigation) of substance use and SUD on rates of suicide (or suicide attempts) in populations (Pridemore & Snowden, 2009). Overall, the field would benefit from more comprehensive approaches that seek to pair efforts to prevent and treat SUDs and suicidal behavior.



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Key opportunities for the future:  We call for better integration of prevention, treatment, and research efforts related to substance use and suicidal behavior. For example, within the United States, the Affordable Care Act will likely expand the access to SUD treatment and encourage broader availability of these services outside of purely specialty care settings. These SUD interventions have the potential to reduce the likelihood of subsequent substance use among individuals with SUDs who receive these services. However, as outlined within our conceptual model, while levels of current substance use and impairment contribute substantially to risk among those with an SUD, other potent proximal factors that are amenable to intervention (i.e., co‐occurring depression, interpersonal difficulties) are also often at play. Accordingly, we suggest that efforts to prevent suicidal behavior in those with SUDs would be more likely to reduce suicidal behaviors if these efforts also addressed co‐occurring depressive symptoms and improved interpersonal relation­ ships using evidence‐based strategies. Future research would be needed to see if these approaches decrease risk for suicidal behavior (compared to usual care for SUD or other appropriate comparisons), are practical to implement, and can be done in a cost‐effective manner.

Key Resources Practical Treatment Materials 1. Treatment manual: Center for Substance Abuse Treatment. (2009). Addressing s­uicidal

thoughts and behaviors in substance abuse treatment, Treatment Improvement Protocol Number 50 (TIP 50). No. HHS No. (SMA) 09‐4381). Rockville, MD: Substance Abuse and Mental Health Services Administration. 2. Video training to introduce the manual: VA Employee Education System (Producer). (2010). Addressing suicidal thoughts & behaviors in substance abuse treatment [Video/DVD]. Washington, DC. Web link: https://www.youtube. com/watch?v=1n2QZlheuzc 3. Evaluation of the video training and manual: Conner, K. R., Wood, J., Pisani, A.  R., & Kemp, J. (2013). Evaluation of a suicide prevention training curriculum for substance abuse treatment providers based on Treatment Improvement Protocol Number 50 (TIP 50). Journal of Substance Abuse Treatment, 44, 13–16.

Reviews of the Literature 1. Borges, G., & Loera, C. R. (2010). Alcohol and drug use in suicidal behaviour. Current Opinions in Psychiatry, 23, 195–204. 2. Center for Substance Abuse Treatment. (2008). Substance abuse and suicide ­ prevention: Evidence and implications—A white paper. DHHS Pub. No. SMA‐08‐4352. Rockville, MD: Substance Abuse and Mental Health Services Administration, http://www.samhsa.gov/ matrix2/508SuicidePreventionPaperFinal.pdf 3. Conner, K. R., Bagge, C. L., Goldston, D. M., & Ilgen, M. A. (2014). Alcohol and suicidal behavior: What is known and what can be done. American Journal of Preventive Medicine, 47(Suppl), S204–S208. 4. Darvishi, N., Farhadi, M., Haghtalab, T., & Poorolajal, J. (2015). Alcohol‐related risk of ­suicidal ideation, suicide attempt, and completed suicide: A meta‐analysis. PLoS ONE. doi: 10.1371/journal.pone.00126870. Published online May 20, 2015.

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References Aharonovich, E., Liu, X., Nunes, E., & Hasin, D. S. (2002). Suicide attempts in substance abusers: Effects of major depression in relation to substance use disorders. American Journal of Psychiatry, 159, 1600–1602. Anestis, M. D., Sobery, K. A., Gutierrez, P. M., Hernandez, T. D., & Joiner, T. E. (2014). Reconsidering the link between impulsivity and suicidal behavior. Personality and Social Psychology Review, 18(4), 366–386. Bagge, C. L., Lee, H. J., Schumacher, J. A., Gratz, K. L., Krull, J. L., & Holloman, G., Jr. (2013). Alcohol as an acute risk factor for recent suicide attempts: A case‐crossover a­ nalysis. Journal of Studies on Alcohol and Drugs, 74, 552–558. Beautrais, A. L. (2001). Suicides and serious suicide attempts: Two populations or one? Psychological Medicine, 31, 837–845. Branas, C. C., Richmond, T. S., Ten Have, T. R., & Wiebe, D. J. (2011). Acute alcohol ­consumption, alcohol outlets and gun suicide. Substance Use and Misuse, 46, 1592–1603. Brezo, J., Paris, J., & Turecki, G. (2006). Personality traits as correlates of suicidal ideation, suicide attempts, and suicide completion: A systematic review. Acta Pscyhiatrica Scandinavica, 113, 180–206. Cavanagh, J. T. O., Carson, A. J., Sharpe, M., & Lawrie, S. M. (2003). Psychological autopsy studies of suicide: A systematic review. Psychological Medicine, 33, 395–405. Center for Substance Abuse Treatment. (2009). Addressing suicidal thoughts and behaviors in substance abuse treatment, Treatment Improvement Protocol Number 50 (TIP 50). No. HHS No. (SMA) 09‐4381.). Rockville, MD: Substance Abuse and Mental Health Services Administration. Chachamovich, E., Ding, Y., & Turecki, G. (2012). Levels of aggressiveness are higher among alcohol‐related suicides: Results from a psychological autopsy study. Alcohol, 46, 529–536. Cheng, A. T. A. (1995). Mental illness and suicide. British Journal of Psychiatry, 170, 441–446. Cherpitel, C. J., Borges, G. L. G., & Wilcox, H. C. (2004). Acute alcohol use and suicidal behavior: A review of the literature. Alcoholism: Clinical and Experimental Research, 28(5S), S18S–S28. Cole, D. A., & Maxwell, S. E. (2003). Testing mediational models with longitudinal data: Questions and tips in the use of structural equation modeling. Journal of Abnormal Psychology, 4, 558–577. Conner, K. R., Bagge, C. L., Goldston, D. M., & Ilgen, M. A. (2014). Alcohol and suicidal behavior: What is known and what can be done. American Journal of Preventive Medicine, 47(Suppl.), S204–S208. Conner, K. R., Beautrais, A. L., & Conwell, Y. (2003a). Risk factors for suicide and medically serious suicide attempts among alcoholics: Analyses of Canterbury Suicide Project Data. Journal of Studies on Alcohol, 64, 551–554. ­ etween Conner, K. R., Beautrais, A. L., & Conwell, Y. (2003b). Moderators of the relationship b alcohol dependence and serious suicidal behavior: Analyses of Canterbury Suicide Project Data. Alcoholism: Clinical and Experimental Research, 27, 1156–1161. Conner, K. R., Bohnert, A. S., McCarthy, J. F., Valenstein, M., Bossarte, R., Ignacio, R., … Ilgen, M. A. (2013). Mental disorder comorbidity and suicide among 2.96 million men receiving care in the Veterans Health Administration health system. Journal of Abnormal Psychology, 122, 256–263. Conner, K. R., Gamble, S. A., Bagge, C. L., He, H., Swogger, M. T., Watts, A., & Houston, R. J. (2014). Substance‐induced depression and independent depression in proximal risk for suicidal behavior. Journal of Studies on Alcohol and Drugs, 75, 567–572. Conner, K. R., Houston, R. J., Swogger, M. T., Conwell, Y., You, S., He, H., … Duberstein, P. R. (2012). Stressful life events and suicidal behavior in adults with alcohol use disorders: Role of event severity, timing and type. Drug and Alcohol Dependence, 120, 155–161.



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Cooper, L. M., Frone, M. R., Russell, M., & Mudar, P. (1995). Drinking to regulate positive and negative emotions: A motivational model of alcohol use. Journal of Personality and Social Psychology, 69, 990–1005. Cornelius, J. R., Salloum, I. M., Day, N. L., Thase, M. E., & Mann, J. J. (1996). Patterns of suicidality and alcohol use in alcoholics with major depression. Alcoholism: Clinical and Experimental Research, 20, 1451–1455. Darke, S., Ross, J., Lynskey, M., & Teesson, M. (2004). Attempted suicide among entrants to three treatment modalities for heroin dependence in the Australian Treatment Outcome Study (ATOS): Prevalence and risk factors. Drug and Alcohol Dependence, 73, 1–10. Darke, S., Ross, J., Williamson, A., Mills, K. L., Havard, A., & Teesson, M. (2007). Patterns and correlates of attempted suicide by heroin users over a 3‐year period: Findings from the Australian Treatment Outcome Study. Drug and Alcohol Dependence, 87, 146–152. Darke, S., Torok, M., Kaye, S., & Ross, J. (2010). Attempted suicide, self‐harm and violent victimi­ sation amongst regular illicit drug users. Suicide and Life‐Threatening Behavior, 40, 587–596. Degenhardt, L., Roxburgh, A., & Barker, B. (2005). Underlying causes of cocaine, amphetamine and opioid related deaths in Australia. Journal of Clinical Forensic Medicine, 12, 187–195. Dougherty, D. M., Mathias, C. W., Marsh, D. M., Papageorgiou, T. D., Swann, A. C., & Moeller, F. G. (2004). Laboratory measured behavioral impulsivity relates to suicide attempt history. Suicide and Life‐Threatening Behavior, 34, 374–385. Duberstein, P. R., Conwell, Y., & Caine, E. D. (1993). Interpersonal stressors, substance abuse, and suicide. The Journal of Nervous and Mental Disease, 181, 80–85. Friedmann, H., & Kohn, R. (2008). Mortality, or probability of death, from a suicidal act in the United States. Suicide and Life‐Threatening Behavior, 38, 287–301. Harned, M. S., Chapman, A. L., Dexter‐Mazza, E. T., Murray, A., Comtois, K. A., & Linehan, M. M. (2008). Treating co‐occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2‐year randomized trial of Dialectical Behavior Therapy versus community treatment by experts. Journal of Consulting and Clinical Psychology, 76, 1068–1075. Hasin, D., Grant, B. F., & Endicott, J. (1988). Treated and untreated suicide attempts in sub­ stance abuse patients. The Journal of Nervous and Mental Disease, 176, 289–294. Heikkinen, M. E., Aro, H. M., Henriksson, M. M., Isometsä, E. T., Sarna, S. J., Kuoppasalmi, K. I., & Lönnqvist, J. K. (1994). Differences in recent life events between alcoholic and depressive nonalcoholic suicides. Alcoholism: Clinical and Experimental Research, 18, 1143–1149. Ilgen, M. A., Bohnert, A. S. B., Ignacio, R., McCarthy, J. F., Valenstein, M. A., Kim, H. M., & Blow, F. C. (2010). Psychiatric diagnoses and risk of suicide in patients treated by the Department of Veterans Affairs. Archives of General Psychiatry, 67, 1152–1185. Ilgen, M. A., Chermack, S. T., Murray, R., Walton, M. A., Barry, K. L., Wojnar, M., & Blow, F. C. (2009). The association between partner and non‐partner aggression and suicidal ideation in patients seeking substance use disorder treatment. Addictive Behaviors, 34, 180–186. Ilgen, M. A., Harris, A. H. S., Moos, R. H., & Tiet, Q. Q. (2007). Predictors of suicide attempt one year after entry into substance use disorder treatment. Alcoholism: Clinical and Experimental Research, 31, 635–642. Ilgen, M. A., Jain, A., Lucas, E., & Moos, R. H. (2007). Substance use‐disorder treatment and a decline in attempted suicide during and after treatment. Journal of Studies on Alcohol, 68, 503–509. Johnsson, E., & Fridell, M. (1997). Suicide attempts in a cohort of drug abusers: A 5‐year follow‐up study. Acta Pscyhiatrica Scandinavica, 96, 362–366. Kaplan, M., McFarland, B., Huguet, N., Conner, K. R., Caetano, R., Giesbrecht, N., & Nolte, K. (2013). Acute alcohol intoxication and suicide: Gender stratified findings from the National Violent Death Reporting System. Injury Prevention, 19, 38–43. doi. 10.1136/ injuryprev‐2012‐040317

122

Kenneth R. Conner and Mark A. Ilgen

Karch, D. L., Barker, L., & Strine, T. W. (2006). Race/ethnicity, substance abuse, and mental illness among suicide victims in 13 US states: 2004 Data from the National Violent Death Reporting System. Injury Prevention, 12(Suppl.), ii22–ii27. Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1993). A longitudinal twin study of personality and major depression in women. Archives of General Psychiatry, 50, 853–862. Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–625. Koller, G., Preuss, U. W., Bottlender, M., Wenzel, K., & Soyka, M. (2002). Impulsivity and aggression as predictors of suicide attempts in alcoholics. European Archives of Psychiatry & Clinical Neuroscience, 252, 155–160. Kolves, K., Varnik, A., Tooding, L. M., & Wasserman, D. (2006). The role of alcohol in suicide: A case‐control psychological autopsy study. Psychological Medicine, 36, 923–930. LeardMann, C. A., Powell, T. M., Smith, T. C., Bell, M. R., Smith, B., Boyko, E. J., … Hoge, C. W. (2013). Risk factors associated with suicide in current and former US military ­personnel. JAMA, 310, 496–506. Maloney, E., Degenhardt, L., Darke, S., Mattick, R. P., & Nelson, E. (2007). Suicidal behav­ iour and associated risk factors among opioid‐dependent individuals: A case‐control study. Addiction, 102, 1933–1941. McCormick, R. A., Dowd, E. T., Quirk, S., & Zegarra, J. H. (1998). The relationship of NEO‐ PI performance to coping styles, patterns of use, and triggers for use among substance abusers. Addictive Behaviors, 23, 497–507. McGue, M., Slutske, W., & Iacono, W. G. (1999). Personality and substance use disorders: II. Alcoholism versus drug use disorders. Journal of Consulting and Clinical Psychology, 67, 394–404. Murphy, G. E. (1992). Suicide in alcoholism. New York, NY: Oxford University Press. Murphy, G. E., Wetzel, R. D., Robins, E., & McEvory, L. (1992). Multiple risk factors predict suicide in alcoholism. Archives of General Psychiatry, 49, 459–463. Nock, M. K. (2007). Conceptual and design essentials for evaluating mechanisms of change. Alcoholism: Clinical & Experimental Research, 31(Suppl), S3–S12. Nock, M. K., Stein, M. B., Heeringa, S. G., Ursano, R. J., Fullerton, C. S., Hwang, I., … Army STARRS Collaborators. (2014). Prevalence and correlates of suicidal behavior among sol­ diers: Results from the Army Study to Assess Risk and Resilience in Service members (Army STARRS). JAMA Psychiatry, 71, 514–522. doi:10.1001/jamapsychiatry.2014.30 Ormel, J., Oldehinkel, A. J., & Vollebergh, W. (2004). Vulnerability before, during, and after a major depressive episode: A 3‐wave population based study. Archives of General Psychiatry, 61, 990–996. Penick, E. C., Nickel, E. J., Powell, B. J., Liskow, B. I., Campbell, J., Dale, T. M., … Noble, E. (1999). The comparative validity of eleven alcoholism typologies. Journal of Studies on Alcohol, 60, 188–202. Phillips, M. R., Yang, G., Zhang, Y., Wang, L., Ji, H., & Zhou, M. (2002). Risk factors for suicide in China: A national case‐control psychological autopsy study. The Lancet, 360, 1728–1736. Piedmont, R. L., & Ciarrochi, J. W. (1999). The utility of the Revised NEO Personality Inventory in an outpatient, drug rehabilitation context. Psychology of Addictive Behaviors, 13, 213–226. Pridemore, W. A., & Snowden, A. J. (2009). Reduction in suicide mortality following a national alcohol policy in Slovenia: An interrupted time‐series analysis. American Journal of Public Health, 99, 915–920. doi: 10.2105/AJPH.2008.146183 Preuss, U. W., Schuckit, M. A., Smith, T. L., Danko, G. P., Bucholz, K. K., Hesselbrock, M. N., … Kramer, J. (2003). Predictors and correlates of suicide attempts over 5 years in 1,237 alcohol‐dependent men and women. American Journal of Psychiatry, 160, 56–63.



Substance Use Disorders and Suicidal Behavior

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Preuss, U. W., Schuckit, M. A., Smith, T. L., Danko, G. P., Buckman, K., Bierut, L., … Reich, T. (2002). Comparison of 3190 alcohol‐dependent individuals with and without suicide attempts. Alcoholism: Clinical and Experimental Research, 26, 471–477. Rossow, I., Romelsjo, A., & Leifman, H. (1999). Alcohol abuse and suicidal behavior in young and middle aged men: Differentiating between attempted and completed suicide. Addiction, 94, 1199–1207. Roy, A. (2001). Characteristics of cocaine‐dependent patients who attempt suicide. American Journal of Psychiatry, 158, 1215–1219. Roy, A. (2003). Distal risk factors for suicidal behavior in alcoholics. Journal of Affective Disorders, 77, 267–271. Roy, A., Lamparski, D., DeJong, J., Moore, V., & Linnoila, M. (1990). Characteristics of alco­ holics who attempt suicide. American Journal of Psychiatry, 147, 761–765. Rudd, M. D., Berman, A. L., Joiner, T. E., Nock, M. K., Mandrusiak, M., Van Orden, K. A., & Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life‐Threatening Behavior, 36, 255–262. Schneider, B., Georgi, K., Weber, B., Schnabel, A., Ackermann, H., & Wetterling, T. (2006). Risk factors for suicide in substance‐related disorders. Psychiatrische Praxis, 33, 81–87. Sher, L., Oquendo, M. A., Galfalvy, H. C., Grunebaum, M. F., Burke, A. K., Zalsman, G., & Mann, J. J. (2005). The relationship of aggression to suicidal behavior in depressed patients with a history of alcoholism. Addictive Behaviors, 30, 1144–1153. Surtees, P. G., & Wainwright, N. W. (1996). Fragile states of mind: Neuroticism, vulnerability and the long‐term outcome of depression. British Journal of Psychiatry, 169, 338–347. Tiet, Q. Q., Ilgen, M. A., Byrnes, H. F., & Moos, R. H. (2006). Suicide attempts among sub­ stance use disorder patients: An initial step toward a decision tree for suicide management. Alcoholism: Clinical and Experimental Research, 30(6), 998–1005. Turecki, G. (2005). Dissecting the suicide phenotype: The role of impulsive‐aggressive behav­ iours. Journal of Psychiatry and Neuroscience, 30, 398–408. Wilcox, H. C., Conner, K. R., & Caine, E. D. (2004). Association of alcohol and drug use dis­ orders and completed suicide: An empirical review of cohort studies. Drug and Alcohol Dependence, 76(Suppl.), S11–S19. Windle, M. (1994). Characteristics of alcoholics who attempted suicide: Co‐occurring disor­ ders and personality differences with a sample of male Vietnam era veterans. Journal of Studies on Alcohol, 55, 571–577. Wines, J. D., Saitz, R., Horton, N. J., Lloyd‐Travaglini, C., & Samet, J. H. (2004). Suicidal behavior, drug use and depressive symptoms after detoxification: A 2‐year prospective study. Drug and Alcohol Dependence, 76(Suppl. 7), S21–S29. Wojnar, M., Ilgen, M. A., Czyz, E., Strobbe, S., Klimkiewicz, A., Jakubczyk, A., … Brower, K. (2009). Impulsive and non‐impulsive suicide attempts in patients treated for alcohol dependence. Journal of Affective Disorders, 115, 131–139. Wong, S. S., Zhou, B., Goebert, D., & Hishinuma, E. S. (2013). The risk of adolescent suicide across patterns of drug use: A nationally representative study of high school students in the United States from 1999 to 2009. Social Psychiatry and Psychiatric Epidemiology, 48, 1611–1620. Zhou, L., Conner, K. R., Phillips, M. R., Caine, E. D., Xiao, S., Zhang, R., & Gong, Y. (2009). Epidemiology of alcohol abuse and dependence in rural Chinese men. Alcoholism: Clinical and Experimental Research, 33, 1770–1776.

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Personality Disorders and Suicidality Joel Paris Introduction As defined by DSM‐5 (American Psychiatric Association, 2013), personality disorders are characterized by abnormal patterns of inner experience and behavior that affect cognition, emotion, interpersonal functioning, and impulse control, are inflexible and pervasive, lead to clinically significant distress or impairment, are stable and of long duration, and have an onset in adolescence or early adulthood. Personality disorders are common in practice, and were identified in about 45% of all patients in a large clinical sample (Zimmerman, Rothschild, & Chelminski, 2005). However, most of the research literature focuses on borderline personality disorder, in which suicidality is a key feature. Although there is evidence that about 5% of patients with antisocial personality will also die by suicide (Links, Gould, & Ratnayake, 2003; Martin, Cloninger, Guze, & Clayton, 1985; Robins, 1966), these patients are more likely to be seen in forensic settings than in psychiatric clinics. Although little is known about suicidality in other personality disorder categories, borderline personality disorder, associated with a wide range of psychopathology, has been the main object of clinical concern and research interest. Borderline personality disorder is characterized by unstable mood, impulsive behaviors, and unstable interpersonal relationships (Paris, 2008a). Suicidality (i.e., suicidal thoughts and threats), self‐harm behaviors (such as cutting), and suicidal behaviors (particularly overdoses) are among its defining features. As reported by Soloff, Lynch, Kelly, Malone, and Mann (2000), patients with borderline personality disorder make a mean of three lifetime suicide attempts. Self‐harm behaviors in borderline personality disorder usually involving superficial cuts to the wrists and arms, are very common, but it is important to understand that this behavior is not suicidal in intent. For the most part, patients cut to relieve emotional tension, not to die (Brown, Comtois, & Linehan, 2002). Patients with borderline personality disorder, who have problems with emotion regulation, may cut themselves addictively to reduce painful inner states (Linehan, 1993). In contrast, overdoses of pills can be suicidal in intent, and are sometimes life‐ threatening, but these behaviors vary greatly, both in nature and intent (Soloff et al., 2000). Overdoses usually occur following stressful life events, and patients describe their motivation as a wish to escape (Brown et al., 2002). Most of these incidents are The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.



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marked by ambivalence, using small quantities of medication and/or calling significant others for help. Even when potentially fatal overdoses are taken, patients will often contact people who are in a position to intervene. It is well established that people who make suicide attempts and those who die by suicide are separate but overlapping populations (Beautrais, 2001). Hawton, Zahl, and Weatherall (2003), in a large‐scale follow‐up of patients who were seen in an emergency room following a suicide attempt, found that only about 3% eventually died by suicide. Most repetitive suicide attempts in young women occur in their 20s, and then decrease with time (Maris, 1981), whereas overdoses in borderline personality disorder are most common in younger patients (Soloff et al., 2000). The strongest predictors of these attempts are not borderline personality disorder itself, but comorbid depression and substance use (Wedig et al., 2012). There may also be biological differences, as reflected in structural brain abnormalities, that discriminate patients with frequent suicide attempts from those who do not make such attempts (Soloff et al., 2012). Although it is difficult to predict which patients will eventually die by suicide, attempts of high lethality are associated with greater illness severity, older age, and poor psychosocial function (Soloff & Chiapetta, 2012). In spite of repetitive suicidal behavior, as with other clinical groups, most patients with borderline personality disorder will not kill themselves (Paris, 2003). Nonetheless, as shown by psychological autopsy methods, a borderline personality disorder diagnosis is frequent among those young people who die by suicide (Lesage et al., 1994; Lesage et  al., 2008; Hunt et  al., 2006; Tidemaln, Elofsson, Stefansson, Waern, & Runeson, 2005). In these reports, personality disorders can be identified in about half of cases under the age of 35, with borderline personality disorder being the most common diagnostic category. Follow‐back research, in which cohorts are studied retrospectively to determine long‐term outcome, has estimated how often patients with borderline personality d­isorder kill themselves. Two of these studies found that suicide occurs in about 10%  of cases (Paris & Zweig‐Frank, 2001; Stone, 1990), although lower rates (3%–4%) were reported in a third study (McGlashan, 1986). The suicide rate has also been lower, under 5%, in prospectively followed cohorts (Zanarini, Frankenburg, Hennen, & Silk, 2012). However, patients who agree to be followed prospectively may be less likely to die by suicide. Also, each sample has unique characteristics, and there could be a relationship between mortality and lower socioeconomic status (Paris & Zweig‐Frank, 2001). By and large, suicides in borderline personality disorder occur late in the course of illness and follow long courses of unsuccessful treatment (Paris, 2003). One 15‐year follow‐up found the mean age at suicide to be 30 (Stone, 1990), whereas a 27‐year follow‐ up reported a mean age of 37, with a standard deviation of 10 (Paris & Zweig‐Frank, 2001). It follows that patients are not at highest risk when they are young, even if they are frequent visitors to the emergency room. Although the great majority of patients with borderline personality disorder can be expected to improve over time, most mortality occurs in those who fail to recover. Gender is another factor that affects suicide, with men having higher mortality rates and women making more nonfatal attempts (Beautrais, 2001). Most clinical cases of borderline personality disorder are female and treatment seeking (Zimmerman, Rothschild, & Chelminski, 2000), but epidemiological studies suggest that males in the community have this disorder in equal numbers, even if they do not present clinically

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(Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Lenzenweger, Lane, Loranger, & Kessler, 2007). Males with borderline personality disorder may also have a different pattern of suicidality, in that their suicide attempts tend to be fatal. Thus, nearly a third of youth suicides can be diagnosed by psychological autopsy, and most are male (Lesage et al., 1994). Autopsy studies of borderline personality disorder patients who died by suicide also show a preponderance of males (McGirr, Paris, Lesage, Renaud, & Turecki, 2007). Finally, men are less likely to seek help; few of the cases in  these studies (Lesage et al., 1994; McGirr et al., 2007) were in treatment at the time of their death.

The Management of Suicidality in Borderline Personality Disorder Although much research has examined the outcome of suicidality in mental disorders (e.g., Black, Warrack, & Winokur, 1985), research literature on the management of suicidality in borderline personality disorder is surprisingly thin. A search of Medline from 1946 to 2014 with the key words “personality disorder and suicide or suicidality” yielded nearly 4,000 references, but the vast majority were clinical reports or studies in which personality disorder was assessed incidentally. A Medline search over the same period using the keywords “personality disorder and suicide prevention” yielded only 25 references, none of which directly assessed prevention. To come to firmer conclusions, clinical trials are essential. Even so, the results of randomized trials are not always generalizable to populations seen in clinical practice (Westen & Morrison, 2001). This problem could be even greater in chronically suicidal patients who are rarely found in clinical trials. Patients with borderline personality disorder have complex courses of treatment, with significant suicide attempt histories, as well as repeated emergency room visits and hospitalizations. They may undergo multiple periods of psychotherapy, as well as receive multiple prescriptions in a polypharmacy “cocktail” (Zanarini, Frankenburg, Khera, & Bleichmar, 2001). There is little evidence that these interventions consistently prevent patients from dying by suicide. Much of the effort into trying to prevent patients with borderline personality disorder from taking their own lives occurs in hospital (Hull, Yeomans, Clarkin, Li, & Goodman, 1996). Although admission for suicidal threats was recommended by the American Psychiatric Association guidelines for the treatment of borderline personality disorder (Oldham et al., 2001), this is not an evidence‐based intervention: there are no data showing that hospital admission has any preventive effect against suicide in this population (Paris, 2008a). Moreover, repeated hospitalizations can be counterproductive, because they interfere with outpatient treatment and make it difficult for patients to stay in the workplace. They sometimes lead to “regression,” with an increase of symptoms based on behavioral reinforcement of suicidal behavior (Linehan, 1993). If, for example, patients do not want to be discharged, they may self‐harm or overdose, even on inpatient units designed to prevent such behaviors. In contrast, there is stronger evidence for well‐structured ambulatory treatment. Although these treatments have not been shown to prevent suicide, the past decade has yielded new data on the efficacy of psychotherapies specifically designed for patients with borderline personality disorder (Paris, 2010). It is now clear that although psychological treatments of a generic nature are often ineffective, well‐structured



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methods that have been tested in clinical trials are often effective in addressing the symptoms of borderline personality disorder. These more specific methods can now be considered as a gold standard for management.

Dialectical Behavior Therapy The most extensively investigated method is dialectical behavior therapy (Linehan, 1993), which offers individual and group therapy over a year, designed to teach e­motion regulation and interpersonal skills. Its efficacy has been confirmed in two randomized controlled trials (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et  al., 2006), bolstered by several replications (Paris, 2010). The main positive outcomes of dialectical behavior therapy are reductions in overdoses, in emergency room visits for suicidality, in frequency of self‐harm, and in reduced hospital admissions (Linehan et al., 1991, 2006). There was only one death by suicide in the first trial, and none in the second, although patients who are most likely to die by suicide may not sign up for clinical trials.

Other Psychotherapy Methods Several other psychotherapy methods have been tested. Mentalization‐based therapy (Bateman & Fonagy, 1999, 2006) is based on teaching patients to recognize emotional states in themselves and in others. Transference‐focused psychotherapy (Clarkin, Levy, Lenzenweger, & Kernberg, 2006) uses problems in relating to the therapist as a way of changing difficulties in interpersonal relationships. Schema therapy (Giesen‐Bloo et al., 2006) aims to change cognitive schema derived from early adverse experiences. Systems Training for Emotional Predictability and Problem Solving (Blum, St. John, Pfohl, & Black, 2008) teaches emotion regulation and interpersonal skills in a group setting. Standard cognitive therapy (Davidson et al., 2006) has also been tested. All are efficacious to some degree. It seems likely that any psychological treatment that is well structured and specifically designed for emotion dysregulation will be superior to standard clinical management. A Cochrane report (Stoffers et al., 2012b) reached the conclusion that therapy for borderline personality disorder has promising evidential support. The personality traits that underlie borderline personality disorder (Siever & Davis, 1991) can help us understand the roots of chronic suicidality. Suicidal thoughts and actions are responses to painful emotions. Patients with borderline personality disorder suffer from severe affective instability, also called emotion dysregulation: rapid changes in mood related to environmental stressors (Russell et al., 2007). This is the least likely aspect of the disorder to remit on long‐term follow‐up (Paris, 2003). Most effective therapies specifically target affective instability (Koenigsberg, 2010), and dialectical behavior therapy works on the regulation of emotion (Linehan, 1993). All methods involve teaching patients how to regulate negative emotions in new ways, replacing dysfunctional behaviors such as cutting or overdosing with less-destructive responses. The second trait that characterizes borderline personality disorder is impulsivity (Crowell, Beauchaine, & Linehan, 2009). A lack of control over impulses makes patients more likely to turn to suicidal actions when emotionally dysregulated, and the frequency of suicide attempts is strongly related to this trait (Soloff et al., 2000). Again, all methods of psychotherapy attempt to reduce impulsivity by teaching patients to stand outside their emotions and hold off action pending reflection.

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Pharmacological Approaches The efficacy of pharmacological agents in borderline personality disorder is not well established (Paris, 2015). Although some agents have nonspecific calming effects, no clinical trials have ever documented remission of borderline personality disorder with drug treatment. Yet many patients are on multiple medications—antidepressants, mood stabilizers, and/or neuroleptics, even if these practices are not evidence based. A Cochrane report (Stoffers et al., 2012a) found insufficient evidence to recommend any drug with confidence. A similar conclusion was reached by the British National Institute for Health and Care Excellence (Kendall, Burbeck, & Bateman, 2010). Moreover, the use of drugs to treat borderline personality disorder leads to a burden of significant side effects. Unfortunately, polypharmacy was encouraged by the American Psychiatric Association guidelines (Oldham et al., 2001), a document that has never been revised, and is now out of date. Clinicians would be better advised to follow the recommendations of Cochrane (Stoffers et  al., 2012b) or the National Institute of Care and Health Excellence (2015), both of which recommend specific forms of psychotherapy, whereas the use of medications (such as low doses of antipsychotic agents) is advised to be sparing, short‐term, and designed for symptomatic relief. Another problem with borderline personality disorder is that it may not be d­iagnosed at all. The clinical picture may be seen as a bipolar variant (Akiskal, Chen, Davis, & Puzantian, 2001), leading to the prescription of mood‐stabilizing drugs that  have unclear effects on suicidal behavior (Paris, Gunderson, & Weinberg, 2007), in contrast to the psychotherapies that consistently reduce self‐harm and suicide attempts.

Conclusions and Implications for Practice One of the unique aspects of borderline personality disorder is chronicity of suicidal ideation. Patients with mood disorders are suicidal when depressed, but put these ideas aside when they go into remission. In contrast, patients with borderline personality disorder may consider suicide on a daily basis for months to years, and only go into remission much later. Suicidal ideas will vary in intensity over time, waxing when life events are stressful, and waning when they are not (Paris, 2006). By themselves, suicidal thoughts are too common to be useful in predicting suicidal actions. Patients with suicidal behaviors are at a statistically higher risk, but one cannot accurately assess long‐term outcome. Death by suicide is a rare event relative to suicide attempts, and large‐scale follow‐up studies have found it impossible to make these predictions (Goldstein, Black, Nasrallah, & Winokur, 1991; Pokorny, 1982). The main problem is false positives (patients who fit the profile but never kill themselves). In addition, there are false negatives, in that some individuals who do not appear to be at heightened risk will actually engage in suicidal behavior. Most patients with borderline personality disorder, in spite of having suicidal thoughts for long periods of time, and multiple suicide attempts, never kill themselves. Thus, the level of alarm created by young women with borderline personality disorder who present in clinics and emergency rooms with suicidal ideas is not justified, even if some threats can be dramatic or even blood‐curdling. Clinicians should not be distracted from their tasks by fear of suicidality. Chronic suicidality can be draining, but in borderline personality disorder, suicidality “goes with the territory” (Maltsberger & Buie, 1978; Schwartz, Flinn, & Slawson, 1974),



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and most patients cannot be treated without the clinician accepting a calculated risk (Maltsberger, 1994). Moreover, recommending emergency room visits and hospitalization is not advisable, as these options tend to reinforce the very behaviors they are designed to treat (Linehan, 1993; Paris, 2007). Moreover, when suicidality is chronic, admission to hospital provides only temporary relief; most patients will continue to have suicidal ideas after discharge. To avoid the harm of repetitive admissions, one might prefer day treatment, which is supported by some evidence in the management of borderline personality disorder (Bateman & Fonagy, 1999), and offers the advantages of admission (intensive treatment by an experienced team) without its disadvantages. Unfortunately, these programs usually have waiting lists, and are not accessible in a crisis. In practice, patients with borderline personality disorder continue to be held over in emergency rooms or admitted to wards. These options are often determined by a fear of litigation. However to minimize the risk of lawsuits, one can ensure that careful records are kept, that consultation with colleagues is carried out, and that families become involved early on (Gutheil, 1992; Gutheil & Brodsky, 2008). In spite of the clinical importance of the problem, research on suicidality in borderline personality disorder has progressed slowly. It would be helpful to have longitudinal data on patients who are at high risk for suicide. Hospital admission can only be j­ustified by either a near‐fatal attempt or a micropsychotic episode (Paris, 2008a). We should also try to distinguish patients who want to kill themselves from those who mainly want to communicate distress. Although some patients with borderline personality disorder may die by suicide, if we have no evidence that this outcome can be prevented, it is better to conduct treatments that are evidence based and not be p­aralyzed by fear.

Key Resources 1. National Institute for Health and Care Excellence (2015). Personality disorders: Borderline and antisocial. London, England: National Institute of Health and Care Excellence. http://www. nice.rg.uk/guidance/qs88/resources/guidance‐personality‐disorders‐borderline‐and‐ antisocial‐pdf 2. Paris, J. (2015). A concise guide to personality disorders. Washington, DC: American Psychological Association Publishing. 3. Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012b). Psychological therapies for people with borderline personality. Cochrane Database of Systematic Reviews, 8, CD005652.

References Akiskal, H., Chen, S., Davis, G., & Puzantian, V. (2001). Do patients with borderline p­ersonality disorder belong to the bipolar spectrum? Journal of Affective Disorders, 67, 221–228. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing. Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry, 156, 1563–1569.

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Bateman, A., & Fonagy, P. (2006). Mentalization‐based treatment for borderline personality disorder: A practical guide. Oxford, England: Oxford University Press. Beautrais, A. L. (2001). Suicides and serious suicide attempts: Two populations or one? Psychological Medicine, 31, 837–845. Black, D. W., Warrack, G., & Winokur, G. (1985). The Iowa record‐linkage study: I. Suicides and accidental deaths among psychiatric patients. Archives of General Psychiatry, 42, 71–75. Blum, N., St John, D., Pfohl, B., & Black, D. W. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1‐year follow‐up. American Journal of Psychiatry, 165, 468–478. Brown, M. Z., Comtois, K. A., & Linehan, M. M. (2002). Reasons for suicide attempts and nonsuicidal self‐injury in women with borderline personality disorder. Journal of Abnormal Psychology, 111, 198–202. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164, 1–8. Coid, J., Yang, M., Tyrer, P., Roberts, A., & Ullrich, S. (2006). Prevalence and correlates of personality disorder in Great Britain. British Journal of Psychiatry, 188, 423–431. Crowell, S. E., Beauchaine, T. P., & Linehan, M. M. (2009). A biosocial developmental model of borderline personality: Elaborating and extending Linehan’s theory. Psychological Bulletin, 135, 495–510. Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Tata, P., & Murray, H. (2006). The effectiveness of cognitive behavior therapy for borderline personality disorder: Results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of Personality Disorders, 20, 450–465. Giesen‐Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T.,… Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: randomized trial of schema‐focused therapy vs. transference‐focused psychotherapy. Archives of General Psychiatry, 63, 649–658. Goldstein, R. B., Black, D. W., Nasrallah, A., & Winokur, G. (1991). The prediction of suicide. Archives of General Psychiatry, 48, 418–422. Gutheil, T. G. (1992). Suicide and suit: Liability after self‐destruction. In D. Jacobs (Ed.), Suicide and clinical practice (pp. 147–167). Washington, DC: American Psychiatric Publishing. Gutheil, T. A., & Brodsky, A. (2008). Preventing boundary violations in clinical practice. New York, NY: Guilford Press. Hawton, K., Zahl, D., & Weatherall, R. (2003). Suicide following deliberate self‐harm: Long‐term follow‐up of patients who presented to a general hospital. British Journal of Psychiatry, 182, 537–542. Hull, J. W., Yeomans, F., Clarkin, J., Li, C., & Goodman, G. (1996). Factors associated with multiple hospitalizations of patients with borderline personality disorder. Psychiatric Services, 47, 638–641. Hunt, I. M., Kapur, N., Robinson, J., Shaw, J., Flynn, S., Bailey, H., … Parsons, R. (2006). Suicide within 12 months of mental health service contact in different age and diagnostic groups: National clinical survey. British Journal of Psychiatry, 188, 135–142. Kendall, T., Burbeck, R., & Bateman, A. (2010). Pharmacotherapy for borderline personality disorder: NICE guideline. British Journal of Psychiatry, 196, 158–159. Koenigsberg, H. (2010). Affective instability: Toward an integration of neuroscience and psychological perspectives. Journal of Personality Disorders, 24, 60–82. Lesage, A. D., Boyer, R., Grunberg, F., Morisette, R., Vanier, C., Morrisette, R., … Loyer, M. (1994). Suicide and mental disorders: A case control study of young men. American Journal of Psychiatry, 151, 1063–1068.



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Lesage, A. D., Seguin, M., Guy, A., Daigle, F., Bayle, M.‐N., Chawky, N., … Turecki, G. (2008). Systematic services audit of consecutive suicides in New Brunswick: The case for coordinating specialist mental health and addiction services. Canadian Journal of Psychiatry, 53, 671–678. Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM‐IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 62, 553–556. Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder. New York, NY: Guilford. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. (1991). Cognitive behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060–1064. Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L.. … Lindenboim, N.. (2006). Two‐year randomized controlled trial and follow‐up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757–766. Links, P. S., Gould, B., & Ratnayake, R. (2003). Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Canadian Journal of Psychiatry, 48, 301–310. Maltsberger, J. T. (1994). Calculated risk taking in the treatment of suicidal patients: Ethical and legal problems. Death Studies, 18, 439–452. Maltsberger, J. T., & Buie, D. H. (1974). Countertransference hate in the treatment of suicidal patients. Archives of General Psychiatry, 30, 625–633. Maris, R. (1981). Pathways to suicide. Baltimore, MD: Johns Hopkins Press. Martin, R. L., Cloninger, C. R., Guze, S. B., & Clayton, P. J. (1985). Mortality in a follow‐up of 500 psychiatric outpatients. II. Cause‐specific mortality. Archives of General Psychiatry, 42, 58–66. McGirr, A., Paris, J., Lesage, A., Renaud, J., & Turecki, G., (2007). Risk factors for suicide completion in borderline personality disorder: A case‐control study of cluster B comorbidity and impulsive aggression. Journal of Clinical Psychiatry, 68, 721–729. McGlashan, T. H. (1986). The Chestnut Lodge follow‐up study III: Long‐term outcome of borderline personalities. Archives of General Psychiatry, 43, 2–30. National Institutes for Health and Care Excellence. (2015). Personality disorders: Borderline and antisocial. London, England: National Institute of Health and Care Excellence. http:// www.nice.org.uk/guidance/qs88/resources/guidance‐personality‐disorders‐borderline‐and‐ antisocial‐pdf Oldham, J. M., Gabbard, G. O., Goin, M. K., Gunderson, J., Soloff, P., Spiegel, D., … Phillips, K. A. (2001). Practice guideline for the treatment of borderline personality disorder. American Journal of Psychiatry, 158(Suppl.), 1–52. Paris, J. (2002). Chronic suicidality in borderline personality disorder. Psychiatric Services, 53, 738–742. Paris, J. (2003). Personality disorders over time. Washington, DC: American Psychiatric Press. Paris, J. (2006). Half in love with easeful death: The meaning of chronic suicidality. Mahwah, NJ: Lawrence Erlbaum. Paris, J. (2008a). Treatment of borderline personality disorder: A guide to evidence‐based practice. New York, NY: Guilford Press. Paris, J. (2008b). Clinical trials in personality disorders. Psychiatric Clinics of North America, 31, 517–526. Paris, J. (2010b). Effectiveness of differing psychotherapy approaches in the treatment of borderline personality disorder. Current Psychiatry Reports, 12, 56–60. Paris, J. (2015). A concise guide to personality disorders. Washington, DC: American Psychological Association Publishing. Paris, J., Gunderson, J. G., & Weinberg, I. (2007). The interface between borderline personality disorder and bipolar spectrum disorder. Comprehensive Psychiatry, 48, 145–154.

132

Joel Paris

Paris, J., & Zweig‐Frank, H. (2001). A twenty‐seven year follow‐up of borderline patients. Comprehensive Psychiatry, 42, 482–487. Pokorny, A. D. (1982). Prediction of suicide in psychiatric patients: Report of a prospective study. Archives of General Psychiatry, 40, 249–257. Robins, L. (1966). Deviant children grown up. Baltimore, MD: Williams and Wilkins. Schwartz, D. A., Flinn, D. E., & Slawson, P. F. (1974). Treatment of the suicidal character. American Journal of Psychotherapy, 28, 194–207. Siever, L. J., & Davis, K. L. (1991). A psychobiological perspective on the personality disorders. American Journal of Psychiatry, 148, 1647–1658. Soloff, P. H., & Chiapetta, L. (2012). Subtyping borderline personality disorder by suicidal behavior. Journal of Personality Disorders, 26, 468–480. Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M., & Mann, J. J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: A comparative study. American Journal of Psychiatry, 157, 601–608. Soloff, P. H., Pruitt, P., Shamra, M., Radwan, J., White, R., & Diwadkar, V. A. (2012). Structural brain abnormalities and suicidal behavior in borderline personality disorder. Psychiatry Research, 46, 516–525. Stoffers, J., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012a). Pharmacological interventions for borderline personality disorder. Cochrane Database of Systematic Reviews, 6, CD005653. Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012b). Psychological therapies for people with borderline personality. Cochrane Database of Systematic Reviews, 8, CD005652. Stone, M. H. (1990).The fate of borderline patients. New York, NY: Guilford. Tidemalm, D., Elofsson, S., Stefansson, C.‐G., Waern, M., & Runeson, B. (2005). Predictors of suicide in a community‐based cohort of individuals with severe mental disorder. Social Psychiatry and Psychiatric Epidemiology, 40, 595–600. Wedig, M. M., Silverman, M. H., Frankenburg, F. R., Reich, D. B., Fitzmaurice, G., & Zanarini, M. C. (2012). Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow‐up. Psychological Medicine, 42, 2395–2404. Westen, D., & Morrison, K. (2001). A multidimensional meta‐analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69, 875–899. Zanarini, M. C., Frankenburg, F. R., Khera, G. S., & Bleichmar, J. (2001). Treatment histories of borderline inpatients. Comprehensive Psychiatry, 42, 144–150. Zanarini, M. C., Frankenburg, F., Reich, B., & Fitzmaurice, G. (2012). Attainment and stability of sustained symptomatic remission and recovery among borderline patients and Axis II comparison subjects: A 16‐year prospective follow‐up study. American Journal of Psychiatry, 169, 476–483. Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of DSM‐IV personality disorders in psychiatric outpatients. American Journal of Psychiatry, 162, 1911–1918.

8

The Association Between Physical Illness/Medical Conditions and Suicide Risk Maurizio Pompili, Alberto Forte, Alan L. Berman, and Dorian A. Lamis Introduction Physical diseases and mental disorders often present together increasing the risk of suicidal thoughts and behaviors. Several studies have documented high rates of suicidal behavior among patients suffering from a variety of medical conditions ­ (Berman & Pompili, 2011; Mackenzie, Popkin, & Blumenthal, 1990), and several authors have identified medical conditions as a risk factor for suicide (Berman, Silverman, & Bongar, 2000). Medical conditions are also frequently associated with anxiety, depression, and substance use disorders, which are all related to suicidal thoughts (Scott et al., 2007). The associations between medical conditions, depression, and suicide are complex and still not well understood (Berman et al., 2000; Mackenzie et al., 1990). Several studies have attempted to investigate these associations, suggesting that they should be examined in light of the relevant pathophysiological and biochemical characteristics underlying different medical conditions (Berman et al., 2000; Mackenzie et al., 1990). In addition to the various medical diagnoses, each individual has specific p ­ ersonality and temperamental traits that may contribute to the onset of a specific disease, while at the same time leading to the development of a mental disorder. Furthermore, a medical condition may result in significant changes in the quality of life and also affect social and interpersonal relationships. The objective of this chapter is to provide an overview of the international literature regarding the association between medical illnesses and suicide, suicide attempts, and ideation. Specifically, we will describe the conditions in which this phenomenon is most relevant: multiple sclerosis (MS), epilepsy, Huntington’s disease, cancer, HIV, end‐stage kidney disease, diabetes mellitus, and stroke.

The International Handbook of Suicide Prevention, Second Edition. Edited by Rory C. O’Connor and Jane Pirkis. © 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.

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Multiple Sclerosis Several studies have reported an increased risk of suicide in patients with MS, although the literature is not consistent regarding the degree of risk (Pompili, Forte, et  al., 2012). In a longitudinal study of patients with MS, researchers found that the suicide rate was 14 times higher than that of the general population (Brønnum‐Hansen, Stenager, Nylev Stenager, & Koch‐Henriksen, 2005). A longitudinal study with a sample of more than 5,000 patients with MS revealed that there was an higher risk of suicides when compared to what would be expected, and this risk was markedly higher among patients who were less than 30 years old, male, and within the first 5 years of their diagnosis of MS (Stenager et al., 1992). In a 16‐year longitudinal study of 3,126 patients in Canada, it was reported that the percentage of deaths by suicide was 7.5 times higher than that of the general population, and 15.1% of all patient deaths were attributed to suicide (Sadovnick, Eisen, Ebers, & Paty, 1991). Brønnum and colleagues (2005) demonstrated that among 10,174 Danish individuals with MS, the risk of suicide was more than double that of the general population; the risk was particularly increased in the first year after diagnosis, although it remained elevated for many years after diagnosis. The suicide risk was higher for men, who also showed a higher frequency of lifetime suicidal behavior. Finally, the authors identified several predictors of suicidal ideation, including social isolation, a diagnosis of major depression, and/or alcohol abuse. In a large‐scale Danish study selected from the national MS registry, Koch‐ Henriksen and colleagues compared the causes of death of patients with MS with those in the general population, finding that deaths by suicide were more frequent among MS patients (Koch‐Henriksen, Brønnum‐Hansen, & Stenager, 1998). In a large Swedish study of more than 12,000 MS inpatients (Fredrikson, Cheng, Jiang, & Wasserman, 2003), researchers found that the suicide risk was 2.3 times the expected rate. In 5,052 deaths, there were 90 cases of suicide (1.8%), and the suicide rate was higher (p 45 years) Divorced, widowed, or single Unemployed Historical risk factors Previous suicide attempts, especially with high intentionality and lethality Positive familial history for suicide History of physical or sexual abuse

Risk Factors for Suicide in HIV A recent study of 211 HIV‐positive patients reported the following risk factors for suicide: female gender; age up to 47 years; unemployment; anxiety; depression; and abuse or addiction to psychoactive substances (Passos et al., 2014). Numerous factors are connected with suicidal behavior in those with HIV infection (Catalan et  al., 2011). Table 8.2 provides a summary. There are several medical risk factors that are relevant to suicide risk in HIV patients, including physical symptoms or failed medical treatment (Sherr et al., 2008). Other medical risk factors include first hospitalization, the lack of autonomy or the appearance of intractable or/and chronic pain, and the presence of delirium or confusion caused by dysfunction of the central nervous system (HIV encephalopathy). In conclusion, HIV is characterized by a high prevalence of suicidal ideation or suicide attempts. The initial phase is characterized by increased risk, with highest risk being associated with older women, homosexuals, and those suffering from psychiatric illness.

End‐Stage Kidney Disease End‐stage kidney disease (ESKD), by definition, requires a life‐saving treatment such as dialysis or a kidney transplant. It has been estimated that more than 1.4 million people worldwide receive renal replacement therapy, and recent data indicate a growth of incidence of about 8% annually. In recent years, researchers have studied the association between chronic renal disease and suicidal behavior, in particular among patients undergoing hemodialysis therapy (HD; Pompili et  al., 2013). The evidence suggests that suicidal behavior is not only related to environmental factors, psychosocial factors, and to health status, but that it is also associated with a lack of effective coping strategies to reduce stress during treatment (Kurella, Kimmel, Young, & Chertow, 2005).

The Association Between Physical Illness/Medical Conditions and Suicide Risk 141 In addition, patients receiving dialysis treatment often live with certain restrictions associated with their impaired renal function. In one study, 5% of patients on dialysis had engaged in self‐injurious behaviors, which ranged from excessive consumption of food or drink to injury by firearm (Pompili et al., 2013). Moreover, patients undergoing dialysis treatment often experience radical changes that require a series of social and psychological adaptations for the patient and their families (Bohlke et al., 2008). Therefore, owing to many restrictions and the stress caused by ESKD, many patients discontinue their treatment; it has been estimated that each year approximately 21% of ESKD patients who die of kidney failure in the United States made the decision to suspend the dialysis before their death.

Risk Factors for Suicide in ESKD Haenel, Brunner, and Battegay (1980) first examined suicide rates among hemodialysis patients. The authors found that suicides occurred more frequently in hemodialysis patients, around 10 times more in comparison to the general population. The factors involved in the increased risk of suicide were poor quality of life, easy access to the means of suicide (by increasing levels of salt or potassium or through the intake of excess fluids), older age, and elevated risk of developing other systemic diseases such as diabetes and cancer. Subsequent studies have shown that the risk of suicidal ideation and suicide attempts is higher in hemodialysis patients, 10 to 15 times higher than in the general population, particularly in patients who have been diagnosed with depression and/or anxiety (Pompili et al., 2013). Suicide in these patients is associated with certain demographic characteristics (such as age >75 years, male gender, white or Asian race) and health and medical factors (ischemic heart disease, peripheral vascular disease, cancer, chronic obstructive pulmonary disease, alcohol or drug addiction, serum albumin