Greeting!
Could you please suggest any additional expected predictor of suicide among hospitalized psychiatric patients to be investigated for a future research?
This is the initial list:
1- being young,
2- male gender.
3- high level of education.
4- history of prior suicide attempts.
5- presence of depressive symptoms.
6- presence of active psychotic symptoms.
7- good insight to illness
Kind regards,,,
Ahmad.
From my experiences doing epidemiological research studies in different countries (Japan and US), the predictors are culture dependent. Because each culture/country has different tendencies in terms of frequencies across age groups, gender differences, reasons for attempt, method of attempt, religious affiliations etc. I'd be careful to generalize findings from other cultures. Good luck with your research!
Ahmad, Greeting
Family history of suicide and Chronic mental illness may play a role and could be included as predictors.
You might want to look at social factors as well like social ties, social status, religion. As for additional medical factors, sleep is correlated with suicidal thoughts.
50+ years of people researching this has still left us with no one being able to predict suicidal ideation or behavior (including suicide attempts and completed suicide) on an individual level. All of the things people list as predictors are predictors of groups of people and not individuals.
I believe the entire endeavor of attempting to predict suicidality (of any kind) in individuals has been a monumental waste of time. If researchers had spent a fraction of the time they devote to this prediction on looking at the phenomenology of suicidality, the field of suicidality research would be much further along.
Many people consider having a history of physical or sexual abuse as a risk factor that said patient is more likely to make a suicide attempt than another patient without said history. However, said patient may be purposely keeping themself alive in order to see that their abuser is properly dealt with by the criminal justice system. For this patient, the presence of their abuse history is actually a protective factor. Unfortunately, most clinicians do not allow themselves to think that such a factor could be protective and they automatically assume it is a 'risk' factor.
This is why the factors pages of the Sheehan-Suicidality Tracking Scale Clinically Meaningful Change Measure version (S-STS CMCM) (see link below) that I consulted on allows for all of the factors to impact the patient's suicidality as either a protective factor (lessens the suicidality) or as a 'risk' factor (increases the suicidality). The only way to know this is to ask each individual patient what impact said factor is having on their suicidality, as is done in the S-STS CMCM. It would be more helpful for clinicians to discuss these factors with each individual patient than to assume they understand the impact such a factor has on the patient's suicidality.
The following publication contains a copy of the standard S-STS and the S-STS CMCM. If anyone wishes to get a copy, please request it and I will send it along.
Article Status Update on the Sheehan-Suicidality Tracking Scale (S-STS) 2014
LECTURE ON EMILE DURKHEIM
SUICIDE (1897)
[Introduction: Durkheim argued that the consistency of suicide rates was a social fact, explained by the extent to which individuals were integrated and regulated by the constraining moral forces of collective life. Egoistic and altruistic suicide arose from the respective under-integration and over-integration of the individual by society. Anomic suicide and fatalistic suicide were respectively cause by under-regulation and over-regulation in the society. Durkheim observed that in Western society, anomie was leading to increased suicide rates.]
Durkheim’s definition of suicide: suicide is applied to every case of death which results directly or indirectly from a positive or negative act, carried out by the victim himself, knowing that it will produce this result.
Why is it a social fact: when we consider all suicides committed in a particular society during a specific time period as a whole, the total is not simply a sum of independent units, but constitutes in itself a new fact sui generis, which has its own unity and individuality, and therefore, its own pre-eminently social nature.
The rate of mortality due to suicide: in each time period, each society has a certain tendency towards suicide. The relative intensity of this tendency is measured by taking the relationship between the total of voluntary deaths and the population of all ages and sexes.
Durkheim wants to find the social causes of suicide (not personal or psychological) and therefore looks at the social environments (religious beliefs, family, political society, occupations, etc.)
He delineates four types of suicide: egoistic, altruistic, anomic and fatalistic
Egoistic Suicide:
He observes that the rate of suicide is less among Catholics and Jews than among Protestants. He prefers to make this comparison within a single society, rather than across societies where one of these religious groups is the majority, since each national society might have different reasons for having more or less suicides.
What are the reasons for this difference:
Partly because, whenever a religious community is a minority within a larger society, the community exercises strict control over its members. But, for Durkheim, this factor cannot adequately explain the difference.
The main reason is because Protestanism allows “free inquiry” to a much greater extent than either Judaism or Catholicism. Free inquiry is the effect of another cause, the overthrow of traditional beliefs. è in Protestanism there is more freedom of thought because it has fewer common beliefs and practices.
Suicide also increases with knowledge (education). But knowledge is not the cause of increased suicide. Rather, it is when religious society loses cohesion that a man seeks to have more knowledge and kill himself.
[The important point here is methodological. That two things are correlated doesn’t mean that one is the cause of the other.]
è Thus, religion preserves men from suicide because it constitutes society.
Then, there are other types of society which would have a similar effect: the family, and political society
Family: Married men and women (above 20 years of age) commit suicide less than unmarried people. Widowed people commit suicide more often than married people, but less often than single people.
What are the reasons? Durkheim looks at the constitution of the family group. The more children people have, the less likely they will commit suicide.
But in general, marriage protects men from suicide more so than women.
Political Society: In a society where collective sentiments are strong, there is patriotism, and political faith in the nation, then suicides are less. For that reasons, during periods of social upheavals and popular wars, the suicide rate goes down.
Durkheim’s general conclusions regarding egoistic suicide:
** Suicide varies inversely with the degree of integration of the social groups to which the individual belongs. Alternatively,
Suicide varies inversely with the degree of integration of religious society, degree of integration of domestic society (family), and that of political society.
Altruistic Suicide:
Just as “excessive individualism” leads to suicide, “insufficient individualism” also does.
Durkheim says that among “primitive” (tribal and non-western) people, suicide is common. In this case, a man or a woman might see it as his/her “duty” to commit suicide. (Such as a wife killing herself when her husband is dead; a man killing himself in old age, etc.) He calls this “altruistic suicide” for the following reason:
“Having designated as ‘egoism’ the condition in which the ego pursues its own life and is obedient only to itself, the designation ‘altruism’ adequately expresses the opposite condition, where the ego is not its own property.”
Durkheim observes that altruistic suicide is unlikely to occur much in modern western society where “individual personality is increasingly freed from the collective personality.”
Anomic Suicide:
Suicides increase during times of industrial and financial crises. However, the reason for increased suicide is not poverty.
For Durkheim, “crises of prosperity” (periods of economic growth and prosperity) also lead to increased rate of suicide.
This is “because they are [both] crises, in other words, disturbances of the collective order. Every disturbance of equilibrium, even though it may involve greater comfort and a raising of the general pace of life, provides an impulse to voluntary death.”
Why is this the case?
Society, which exerts a moral power over the individual, has the ability of regulating human needs and desires. But in times of crises (abrupt change of a positive or negative kind), the society becomes incapable of exercising regulation over individuals. It is then that suicides increase. Because when abrupt social change occurs, values and needs change. And it takes time for the reshaping, or regulation of different groups’ needs. Durkheim calls this state anomie.
He argues that in the world of industry and trade, there is a constant state of crisis and anomie. On the one hand religion has lost most of its power, on the other hand, nations have become preoccupied with industrial growth. Industry has become an end in itself, rather than a means to achieve an end. Therefore, he says, the rate of suicide in industrial and trade occupations is high.
**Anomie is a regular and specific factor in causing suicide in our modern societies. Anomic suicide is different from the previous two types in that “it does not depend on the way in which individuals are attached to society, but on the way in which they are regulated by society.”
Anomie can also be seen in marital relations. Divorce is an expression of this type of anomie, which consists of a weakening of “matrimonial regulation.”
Fatalistic Suicide:
This is the opposite of anomic suicide. It results from excessive regulation. Examples are suicides by very young husbands, childless married women, slaves, etc. These suicides are all attributable to excesses of physical or moral despotism. They are people whose futures are blocked and whose passions are suppressed by an oppressive discipline. But Durkheim thinks that this type of suicide is unimportant in modern society.
Conclusion: “the social suicide rate can only be explained sociologically. It is the moral constitution of the society which always determines the quota of voluntary deaths. For each population there is a collective force with a particular strength which impels men to kill themselves.”
THE ELEMENTARY FORMS OF THE RELIGIOUS LIFE (1915)
He deals with the origins of religions in this book.
His general argument: Religions is eminently social. Religious representations are collective representations which express collective realities; the rites are a manner of acting which take rise in the midst of the assembled groups and which are destined to excite, maintain or recreate certain mental states in these groups.
All religious beliefs, whether simple or complex, have a common characteristic: they presuppose a classification of all the things, real and ideal, of which men think, into two opposed groups: the profane and the sacred. This differentiation between the profane and the sacred is absolute.
*Sacred things are those which the interdictions protect and isolate. Profane are the things to which interdictions are applied.
*Religious beliefs are the representations which express the nature of sacred things and the relations which they have with each other or with profane things
*Rites are the rules of conduct which prescribe how a man should comport himself in the presences of sacred objects.
Durkheim’s definition of religion: a unified system of beliefs and practices relative to sacred things, i.e., things set apart and forbidden – beliefs and practices which unite into one single moral community called a Church, all those who adhere to them.
Origins of the Idea of the Totemic Principle
Totemism. A totem: a plant or an animal which is a symbol
A totem (a) is the outward and visible form of the totemic principle or god. (b) It is the symbol of the society called the clan. A totem is like a flag; it is the sign by which each clan distinguishes itself from the others.
**Then, a totem is both the symbol of god and the society. è apotheosis
“a god is not merely an authority upon whom we depend; it is a force upon which our strength relies. The man who obeys his god … and believes the god is with him, approaches the world with confidence…. Likewise, social action does not confine itself to demanding sacrifices, privations and efforts from us. For the collective forces is not entirely outside of us; it does not act upon us wholly from without; but rather, since society cannot exist except in and through individual consciousness, this force must also penetrate us and organize itself within us; it thus becomes an integral part of our being and by that very fact this is elevated and magnified.”
“the totemic principle, and in general, every religious force, [is] outside of the object in which it resides. It is because the idea of it is in no way made up of the impressions directly produced by this thing upon our senses or minds. Religious force is only the sentiment inspired by the group in its members, but projected outside of the consciousness that experience them, and objectified. To be objectified, they are fixed upon some object which thus becomes sacred; but any object might fulfill this function.”
“the sacred character assumed by an object is not implied in the intrinsic properties of the latter: it is added to them. The world of religious things is not one particular aspect of empirical nature; it is superimposed upon it.
**”Thus social life, in all its aspects and in every period of its history, is made possible only by a vast symbolism.” Collective sentiments can be symbolized through material emblems, but also through real or mythical people.
***”this reality, which mythologies have represented under so many different forms, but which is the universal and eternal objective cause of these sensations sui generis out of which religious experience is made, is society. We have shown what moral forces it develops and how it awakens this sentiment of a refuge, of a shield and of a guardian support which attaches the believer to his cult. It is that which raises him outside himself; it is even that which made him. For that which makes a man is the totality of the intellectual property which constitutes civilization, and civilization is the work of society. This is explained by the preponderating role of the cult in all religions, whichever they may be. This is because society cannot make its influence felt unless it is in action, and it is not in action unless the individuals who compose it are assembled together and act in common. It is by common action that it takes consciousness of itself and realizes its position…”
“it may be said that nearly all the great social institutions have been born in religion….. If religion has given birth to all that is essential in society, it is because the idea of society is the soul of religion…”
Systematic idealization is a characteristic of all religions. Men have idealized a world (a sacred one) which exists above their profane life. Although this ideal world exists only in thought, men attribute a higher dignity to it.
“The formation of the ideal world is … a natural product of social life.” “A society can neither create itself nor recreate itself without at the same time creating an idea.” “The ideal society is not outside of the real society; it is a part of it.”
“For a society is not made up merely of the mass of individuals who compose it, the ground which they occupy the things which they use…., but above all is the idea which it forms of itself.”
“Thus the collective ideal which religion expresses is far from being due to a vague innate power of the individual, but it is rather at the school of collective life that the individual has learned to idealize.”
Durkheim emphasizes that his theory of religion is different from historical materialism (Karl Marx) in that he does not see religion as simply a translation of the material forms of society into a different language. Collective consciousness is more than an epiphenomenon of the material basis of society.
Every society needs to regularly reaffirm and uphold its collective sentiments and collective ideals. This requires reunions, assemblies, and meetings where people get together and reaffirm their common sentiments.
Science versus religion:
Scientific thought is a more perfect form of religious thought. There is a historical tendency for science to replace religion in society.
But science cannot deny religion. Yet, in one sphere, namely the speculative function of religions, science contends with religion. It doesn’t allow religion the right to dogmatize upon the nature of things, because science claims the competence to know the world and men.
https://scholar.google.co.th/scholar?hl=en&as_sdt=0,5&q=suicide+durkheim
you also need to consider the context of your question. Completed suicide risk varies across cultures. Many of the answers so far are sayng useful things. Michael Spilka is specific to psychiatric patients and identifies current evidence on this topic. however, there are no 'predictors' of suicide per se, only risk and protective factors. See Keith Hawton for more details but also check out Rose's fabulous essay on the problems of predicting suicide. sorry I don't have a reference for this. perhaps others will remember the paper!
Thanks for your comments dear Lucy. As you know, suicide has different levels, suicidal ideation, sucidal intent, suicidal attempt, and complete suicide. I will not investigate the last one because the patient has already dead in this situation. I am going to investigate predictors of suicidal ideation, suicidal intent, and suicidal attempt within the last month. My focus is the Arab hospitalized psychiatric patients. Sincerely, Ahmad.
My experience has also shown that family history of suicide is associated with suicide
I would suggest reading what has been written by the late Edwin Shneidman on "Psychache" and asking your suicidal patients if they hurt and where - they can point. Ed said it was psychological, but I would argue it has to be located in the body to be felt as such patients assuredly do feel it and kill the body to rid themselves of the suffering of this deeply felt conscious and unconscious state.
I have recently created a guide for career service workers which included a section on suicidal idea based on research because job loss can be a major stressor. Here is an excerpt.
"Potentially anyone can be suicidal. It is a part of the human condition when experiencing great suffering. Most people do not act on these thoughts and only a small number of suicides happen without warning. All threats should be taken seriously.
Suicide is complex with no single cause. It is the interaction of many factors that contribute to a person’s decision to end their life including: depression, recent loss, addictions, childhood trauma, serious physical illness, sexuality and gender identity issues, medication side effects, social isolation, financial stress, or major life changes which can make some people feel overwhelmed and unable to cope. It is not the nature of the stressor but feeling that they are unbearable. People who experience suicidal thoughts are often suffering tremendous psychological pain and feelings of hopelessness, despair and helplessness. People feel as if their pain will never end and suicide is a way to stop their suffering.
Suicide affects people across the ages, incomes and social circumstances - although youth (between 15 and 30 years), men, Inuit, Métis and First Nations young people and older adults are at greater risk. Not all people who die from suicide have a mental illness and not all people with mental illness feel suicidal. However, 90% of people who do end their lives on reflection were experiencing a mental health problem / illness – most frequently an undiagnosed, under treated, or untreated depression."
The American Association of Suicidology has a tool to help you remember the warning signs of suicide.
IS PATH WARM
I Ideation – is the person thinking or talking about suicide?
S Substance abuse – has the person increased their use of drugs and alcohol?
P Purposelessness – does the person express thought that their life has no meaning or purpose?
A Anxiety – does the person seem uncomfortable or agitated?
T Trapped – is their personal perception that they cannot see a way forward or find solutions to their problems?
H Hopelessness – are they expressing feelings of being hopeless, helpless, or unworthy?
W Withdrawn – are they stepping away from people and activities they use to enjoy?
A Anger – do they seem agitated, irritable and out of sorts? Are they impulsive or violent?
R Recklessness – they may be behaving in ways that they do not care if they are safe or at risk of getting hurt
M Mood changes – signs of depression like sadness, changes in sleep and eating, a flatness in mood, neglecting self-care, or not enjoying things they use to enjoy.
Other signs or behaviour of risk include people reconnecting with old friends and extended family to say good bye, giving away prized possessions and or making a Will. People who have made past suicide attempt may be at greater risk.
I hope this is helpful. Here is the source of this information with references.
http://ceric.ca/resource/career-services-guide-supporting-people-affected-by-mental-health-issues/
Just a tangential point that is probably worth adding to this discussion is that, in general, although there are statistical associations with various predictors it is, in general, not possible to predict suicide accurately at the individual level through the use of such indicators. I personally believe that this is due to the fact that suicide is sometimes impulsive in reaction to strong emotions arising from sometimes unpredictable events (substance use can be involved in increasing impulsivity) whereas in other circumstances it is a decision people make based on a perception (often distorted by depression and often manifesting as hopelessness) that the benefits of continuing life are not sufficient to justify endurance of current distress. Indicators can increase one's level of suspicion but t is not easy to capture the subtleties using indicators, so we must be respectful of the need for a person-centred approach, at least in clinical settings. Also, from a public health point of view, access to means of suicide is important - many of the public health measures are designed to make it more difficult to die as a result of an impulsive decision, e.g. the design of bridges, availability of poisons etc.
The patient has suffered a loss of someone very close, such as; a spouse or child.
Thank you so much for all scholars who helped me in this investigation. All your comments are valuable for me and must be considered. One issue is, suicide can not be predicted one hundred percent. However, health care professionals had to be aware about factors that may increase the risk of suicide in this population to take a protective action. Unfortunately, five successful committed suicides were completed within 4 years in one hospital that I know, despite patients were within the hospital setting.
Great Question & interesting answers, since I am from the US curious if it truly suicidal ideation is that different across countries..... Having worked with adolescents in particular around this issue - it is usually incredible pain, over-whelmment & hopelessness... but here is a reference that might be helpful:
Suicidal Phenomena using the FDA 2012 Draft Guidance Document on Suicide Assessment. (2014). A Critical Review by DAVID V. SHEEHAN, MD, MBA; JENNIFER M. GIDDENS; and KATHY HARNETT SHEEHAN, PhD. in Innovationa in CLINICALNEUROSCIENCE [VOLUME 11, NUMBER 9–10, SEPTEMBER–OCTOBER 2014]
It is probable that different factors precipitate suicidal behavior in individuals with different psychiatric diagnoses, but the strongest predictor across all diagnoses is a prior suicide attempt (not just suicidal ideation). It is debatable whether the predictors for non-fatal and fatal suicidal behavior differ; in my setting (China) they are quite similar.
In my studies (in China, where male and female rates are similar and many suicides and attempted suicides occur in persons without a diagnosable mental illness) the greatest predictors after a prior attempt are a) severity of depressive affect (independent of diagnosis); b) accumulative psychological impact of chronic negative life events, c) accumulative psychological impact of acute negative life events, and d) level of impulsivity.
Michael Phillips
We have found that there is some variation between countries so the following is based on UK experience but there are regional differences. Our key risk groups are:
· young and middle aged men
· people in the care of mental health services
· people with a history of self-harm
· people in contact with the criminal justice system
· specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers.
Our review of the evidence suggests the following:
Mental illness
Across all age groups, genders and in a wide range of geographical locations, several diagnoses of mental illness, including affective disorders, schizophrenia, personality disorders and childhood disorders, and a history of psychiatric treatment in general have been established as risk factors for completed suicide. In schizophrenia and borderline personality disorder suicide risk appears to be elevated around the time of first diagnosis. For bipolar disorder and schizophrenia the elevated risk of suicide is further exacerbated by other risk factors, such as a history of suicide attempts, other psychiatric diagnoses, drug or alcohol misuse, anxiety, recent bereavement, severity of symptoms and hopelessness.
Attempted suicide
Those who self-harm have a much greater risk of dying by suicide compared with those who do not engage in this behaviour. However it is important to note that self-harm itself is not attempted suicide, and that many people who do self harm use this as a coping strategy.
Substance misuse
Substance misuse increases the risk of suicide attempt and death by suicide. The risk associated with opioid use disorders and mixed intravenous drug use is greater than that for alcohol misuse. The risk of suicide from alcohol misuse is greater among women than among men.
Epilepsy
There is increased suicide risk associated with epilepsy. This risk varies across different types of epilepsy and in relation to the degree of severity of the effects of the illness.
Personality traits
There may be increased suicide risk associated with particular individual/personality factors. The evidence is not consistent. Nevertheless, it can be stated with reasonable confidence that suicide risk is higher in a wide range of personality traits including hopelessness, neuroticism, extroversion, impulsivity, aggression, anger, irritability, hostility, anxiety, attention deficit hyperactivity disorder (ADHD) and eating disorders such as anorexia nervosa and bulimia; and low problem- solving skills.
Menstrual cycle, pregnancy and abortion
The risk of suicide attempt may increase in phases of the menstrual cycle which have lower oestrogen levels and in women who suffer from pre-menstrual syndrome. Pregnancy was also identified as a period during which women may experience elevated risk of suicidal behaviour. There is limited evidence that suicide rates are higher in women who have abortions compared to those who carry the baby to full term. However, careful analysis and replication of these findings is required.
Unemployment
Unemployment is linked to elevated risk of suicide. Occupational social class and suicide and deliberate self-harm are inversely linked: the lower the social class, the higher the risk of suicidal behaviour.
Poverty
Poverty and deprivation are linked to suicide risk at an area level. Areas with greater levels of socio-economic disadvantage have higher suicide rates.
It is also worth looking at protective factors, ie things that reduce the risk of suicide.
Coping skills
Problem-solving skills may be protective against suicidal behaviour among those who have attempted suicide. A number of coping skills requiring an element of self agency appear to be protective against suicidal behaviour particularly among adolescents, including self-control and self-efficacy, instrumentality, social adjustment skills, positive future thinking and sublimation. Being in control of emotions, thoughts and behaviour can mediate against suicide risk associated with sexual abuse among adolescents.
Reasons for living
High levels of reasons for living, future orientation and optimism protect against suicide attempt among those with depression. There is some evidence that those who have previously attempted suicide can develop positive coping strategies to protect themselves against future suicidal behaviour. Resilience factors are better predictors of suicidal behaviour than the amount of exposure to stressful life events.
Physical activity and health
There is some evidence that an attitude towards sport as a healthy activity and participation in sporting activity is protective against suicidal behaviour among adolescents. A perception of positive health may be protective against suicide among females who have experienced sexual abuse.
Family connectedness
Good relationships with parents mitigate against suicide risk, especially in adolescents and including those who have been sexually abused. Positive family relationships also provide a protective effect for adolescents including those with learning disabilities. Further evidence suggests that positive maternal coping strategies can have a protective effect on female adolescents. Having children living at home is protective against suicide for women; however, another study indicates that this protective effect may not exist among women who are HIV-positive.
Marriage is a protective factor against. There is also evidence that marriage has a protective buffering effect against socio-economic inequalities related to suicide, particularly for men. It is important to consider other variables including the finding that married men were less likely than non-married men to have problems with drugs, sex, gambling and having used or currently using psychiatric medicine.
Supportive schools
Supportive school environments, including access to healthcare professionals, are important protective factors among adolescents including those who have experienced sexual abuse, those with learning disabilities and those who identify as lesbian, gay, bisexual or transgendered.
Social support
Social support in general is protective against suicide among a range of population groups, including black Americans and women who have experienced domestic abuse.
Religious participation
There is a wide range of evidence to suggest that religious participation may be a protective factor against suicidal behaviour. However, the protective effect of religious participation can vary according to the level of secularisation within a country or community and social and cultural integration. Moral sanctions against suicide promoted by members of a religious community may have wider protective effect on the non-religious members of a community where the religious members are in the majority. Religious observance does not confer equal protection on individuals. Other factors, such as the observance of traditional cultural rituals, may have a stronger protective effect.
Employment
There is some evidence that employment, especially full-time, has a protective effect against suicide. However, employment was not found to be protective among women who were HIV-positive.
Exposure to suicidal behaviour
One study found that exposure to accounts of suicidal behaviour in the media and, to a lesser extent, exposure to the suicidal behaviour of friends or acquaintances may be protective against nearly lethal suicide attempts. However, it is important to note that there is also a body of evidence of the suicide risks associated with media reporting.
Social values
Traditional social values may have a protective effect against suicidal behaviour among adolescent girls, while individualistic values may have a protective effect among adolescent boys.
Health treatment
Access to treatment by a health professional may be protective against repeat suicide attempts.
Thank you so much for your valuable information dear Patricia, Michael, and David. Hope you the best. Best regards...
Hey Ahmad... just a note of caution regarding your mention of "being young" as a risk factor for suicide in hospitalized patients. You may be right if talking of risk of self-harm, but if you are referring to risk for completed suicide, "being old" is actually a huge risk, particularly "being old + male".
Suicide is a leader in causes of death in populations of young, but that is augmented by the fact that death in general is a very rare event for young populations. And it is certainly wise to treat against any acts of self-harm, regardless if the intent is death or not Often young people self-harm without a clear intent to death... the tragedy is that such events often end in death (e.g., destroy liver via over-dose of Tylenol). Youth = increased reckless behavior = high risk, by definition.
Some other variables you may want to consider are time of year and day of the week. In North America, July is the month when in-patient suicides have traditionally peaked. Some days of the week may be of particular concern where you are, different from other places. Counter-intuitively, schizophrenia and substance-use hx appear protective in some patient populations (e,g., where I am).
Moving back to "age" risk in general, within the total population of persons admitted for mental health problems within Canada, risk of completed suicide actually increases with the patient age at admission. Watch out for elderly depressed males!
Ohhhh, Yes! elderly people... thank you so much for your caution and reminder! best regards dear Bob...
From my experiences doing epidemiological research studies in different countries (Japan and US), the predictors are culture dependent. Because each culture/country has different tendencies in terms of frequencies across age groups, gender differences, reasons for attempt, method of attempt, religious affiliations etc. I'd be careful to generalize findings from other cultures. Good luck with your research!
There is a proffessor in Scotland who is one of the worlds most prolific suicide researchers so look up his work he is Professor Rory O'Connor
Although there are several factors associated with suicide attempts but low serum cholesterol and LDL are highly predictive for suicide.
Engelberg, Hyman. "Low serum cholesterol and suicide." The Lancet 339.8795 (1992): 727-729.
Thank you so much dear Shayan, very interesting to know that low serum cholesterol and LDL are highly predictive for suicide. Kind regards.
"low serum cholesterol and LDL are highly predictive for suicide"
This is an old paper, and I think this correlation has now been shown to be a statistical artefact.
Well, I prepared recent data about the impact of serum lipids (including cholesterol) on suicidal behavior ...
- da Graça Cantarelli, Maria, et al. "Potential neurochemical links between cholesterol and suicidal behavior." Psychiatry research 220.3 (2014): 745-751.
- Baek, Ji Hyun, et al. "Serum lipids, recent suicide attempt and recent suicide status in patients with major depressive disorder." Progress in Neuro-Psychopharmacology and Biological Psychiatry 51 (2014): 113-118.
- Ainiyet, Babajohn, and Janusz K. Rybakowski. "Suicidal behaviour and lipid levels in unipolar and bipolar depression." Acta neuropsychiatrica 26.05 (2014): 315-320.
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Biological
Genetics
Psychiatric illness
Recovery period from acute episode of mental illness
Physical illness
Sociological
Changing family structure
From a marginalised social group
Marital breakdown
Anniversary of a significant negative event
Changing cultural values and religious practices
Unemployment/employment
Alcohol and substance misuse
Increased availability of methods of suicide
Lack of social supports
Psychological
Mental well-being
Personality
Psychosocial
Chronic mood disorder
Great question, Ahmad!
I have given the question 'How to discriminate patients with depression who will not try to commit suicide from depressed patients who will try to commit suicide?' lots of thoughts and my research is more oriented versus biological psychiatry, especially investigating the relation of inflammations to suicidility.
Besides the genetic/biological differences that may underlie suicidal behavior and other relevant factors which need to be considered, that have been named already in the discussion, I want to bring in SOC (Sense of Coherence) into the equation.
The SOC scale stems from the work Antonovsky (1987) and is a measure of how the patient perceives daily life. It has three compontents: Is life comprehensible, manageable and meaningful?
There are only a few studies which have investigated the relation of SOC to suicidality, and to me it seems very relevant to look closer at the questions being asked in the SOC Scale.
Below you can find some examples of studies investigating the relation of SOC to suicidal behavior.
Good luck with your research!
Best regards
Cécile Grudet, PhD Student
One study is from 1992:
Br J Clin Psychol. 1992 Sep;31 ( Pt 3):293-300.
Sense of coherence, self-esteem, depression and hopelessness as correlates of reattempting suicide.
Petrie K1, Brook R.
Author information
Abstract
Sense of coherence (SOC) has been proposed as a psychological factor that predicts good health and positive adjustment. The three components ofSOC: manageability, comprehensibility and meaning were assessed together with depression, hopelessness and self-esteem as factors predicting future suicidal ideation and behaviour in parasuicides. One hundred and fifty hospitalized parasuicides were evaluated on these measures and followed up after six months to determine their current level of suicidal ideation and whether they had been readmitted for a further attempt or killed themselves in the intervening period. Suicidal ideation on admission was best predicted by a low score on the SOC meaning subscale and also significantly related to the other predictor variables. Suicidal ideation at the six-month follow-up was best predicted by the SOC subscales manageability and comprehensibility. These two SOC subscales also emerged as discriminators of suicidal behaviour over the six months following admission. Overall prediction of suicidal behaviour was enhanced by also including the background variables of age, a history of previous attempts, unemployment and whether the attempter was living alone. The study ends with a discussion of the importance of widening the focus when assessing and predicting suicidal risk to include not only predictions based on pathology but also psychological factors that promote adjustment.
Another study is more recent (2012):
J Psychiatr Ment Health Nurs. 2012 Feb;19(1):62-9. doi: 10.1111/j.1365-2850.2011.01755.x. Epub 2011 May 30.
Sense of coherence and suicidality in suicide attempters: a prospective study.
Sjöström N1, Hetta J, Waern M.
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Abstract
The usefulness of the Sense of Coherence (SOC) scale in the nursing setting is well-established, and an association between SOC and suicidality has been suggested. The aim was to test whether low SOC at index attempt is an independent predictor of suicidality at 2-month follow-up and of risk for repeat attempt. The study, which had a prospective cross-sectional design, included patients admitted to hospital after a suicide attempt. They were interviewed by means of Structured Clinical Interview for DSM-IV. Participants (n=155) completed the SOC scale and the Comprehensive Psychopathological Self-rating Scale for Affective Syndromes. Suicidality was rated with the Suicide Assessment Scale. Instruments were employed again at follow-up. Non-fatal/fatal repetition within 3 years was determined by review of hospital records. Low SOC at baseline predicted high suicidality at follow-up. The association remained after adjustment for major depression and affective symptom burden. Repeat attempts were made by 54 persons. Low baseline SOC was associated with repeat attempt, but the association did not remain after adjustment for major depression and symptom burden. Low SOC ratings could be a marker of risk for high suicidality in the aftermath of a suicide attempt. The SOC scale could be incorporated in nursing assessments of suicide attempters.
© 2011 Blackwell Publishing.
PMID:
22074158
[PubMed - indexed for MEDLINE]
And another one from 2010:
Ment Illn. 2010 Feb 11;2(1):e3. doi: 10.4081/mi.2010.e3. eCollection 2010.
Death by suicide long after electroconvulsive therapy. Is the sense of coherence test of Antonovsky a predictor of mortality from depression?
Berg JE1.
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Abstract
Prediction of increased risk of suicide is difficult. We had the opportunity to follow up 20 patients receiving electroconvulsive therapy (ECT) because of severe depression. They filled in the Antonovsky sense of coherence test (SOC) and Beck depression inventory (BDI) before and after a series of ECT treatments. Seventeen surviving patients had a mean observation time of 20.6 months, whereas the three deceased patients had 11.3 months. There was a lower mean age at onset of illness and a longer mean duration of disease in the deceased. Other clinical parameters did not differ. The surviving patients had a significant decrease on the BDI from 35 to 18 (P
one of my poem titled '' history , a frightening nightmare, or a beautiful dream? '' may delineate this issue ., available at Researchgate .
50-minute therapy sessions that do not allow time to get to the root of the issues.
Hi Ahmad - with risk of being redundant, have you looked into SAD PERSONAS scale?
(see: http://www.capefearpsych.org/documents/SADPERSONS-suiciderisk.pdf)
Although cursory, this scale is often used as a routine suicide assessment instrument. The actual risk (or acuteness) will depend on a number of personal factors that primary caregivers or clinicians involved with a particular patient's treatment will have a better idea of.
withdrawal, negativity, getting rid of belongings, faking your way to please others, hiding feelings. I can really be a good person to ask about this if you need further information because I have been through the system myself and with my daughter.
family history of suicide, gender (male), age (+65), sexual identity, ethnicity, presence of of axis 1, 2, and 3, help seeking behaviour, hopelessness, ideation, intent, previous attempts and lethality, history of childhood abuse (physical, emotional and/or sexual), bereavement, break up of long standing relationships, unemployment (financial support), social support, problems with the leal system, access to means (poison, gun, alcohol, drugs, rob), leaving a note behind, planning (has the patient actually planned how h/she is going about it).
21 suicide risk factors, all evidence-based.
Regards
Yami
With so many predictors (I stopped counting at 30) some 'evidence-based' (whatever that means), others experiential, a warning not to generalise across cultures and no mention of interactions is there any meaning to this? Most of these predictors apply to me, so here's the predictor I want - the chance of me attempting suicide in the next year. A percentage figure might assure me that somebody knows what they're talking about.
"here's the predictor I want - the chance of me attempting suicide in the next year"
Other than establishing if the suicide risk is higher or lower than average, even much higher, I don't think any useful prediction can be made in a specific case. The statistical basis for this is too imprecise.
The physical environment. Why is this always forgotten? It's a big factor, and perhaps the only thing we can effectively change! See just about any of my articles - especially: Golembiewski, Jan. (2015). Making things happen: how the environment triggers actionXD Experience Design Journal (Vol. 1, pp. 10-13). Sydney: Faye Q. Miller.
Some colleagues at Griffith University , QUT and I are working on a Design Out Suicide initiative - at the moment it's in its early stages - but stay posted.
I've read that genetics can predispose someone to be at a higher risk for suicide.
Greetings!
One overlooked risk factor, I believe, is the functioning of ones family (if present). I have recently witnessed three suicides (two at my clinic and one close friend) and I strongly believe that these could have been prevented, given that the families of those three persons would have been given adequate support: (I) help with housekeeping and (II)professional counselling focusing on everyday guilt feelings towards ones family.
Guidelines in Sweden concerning the handling of suicide totally lack (I) and (II) are only mentioned in the aftermath of the already committed suicide. I hope that this is the case solely in Sweden, but the difficulty of finding scientific papers that cover these factors (especially I) points in the opposite direction.
Pontus I cover such risk factors as trying to please family and significant others in my paper on positive psychology interventions for suicide in young people do feel free to take a look at it here.
https://www.researchgate.net/publication/281347100_Personal_and_Collective_Resilience_Building__A_Suicide_Prevention_Program_for_Schools_Using_Positive_Psychology_Consultancy_Project_for_an_Irish_Secondary_School
Thesis Personal and Collective Resilience Building – A Suicide Prev...
Caroline , thanks for sharing your paper on ''significant others '' , spot on !
Please see my research on Serious Suicide Attempters.
I'm currently working on a play about survivors of jumps off the Golden Gate Bridge.
David H.Rosen,M.D.
The physical environment is constantly overlooked - but I think it to be essential. A hypothesis I'm working with appears to cover about 75% of suicide cases, particularly those in psychotic and manic patients (ie. outside the gamut that was brought to our attention by Lucy Webb (above). The idea is simple - objects and contexts tell stories: we read narratives everywhere, and we naturally react to them, and that's normal. But what's not normal is when we react to negative narrative suggestions. These become triggers when 'the brakes aren't on' that is, when there's too little frontal inhibition (See my articles 2012,2014). Anyway some opportunities suggest suicide: a bus hurtling down a street, a cliff, rope, pills... they do so in cinema, in theatre.. and also in real life. So to people with diminished frontal inhibition, these action cues are irresistible triggers for action. This will be a major cause of suicide, but only in a minority of cases - especially when there is no reason to suicide or period of suicidal ideation.
Golembiewski, Jan. (2012). All common psychotic symptoms can be explained by the theory of ecological perception. Medical Hypotheses, 78, 7-10. doi: 10.1016/j.mehy.2011.09.029
Golembiewski, Jan. (2014). Introducing the concept of reflexive and automatic violence: a function of aberrant perceptual inhibition. Archives of Psychiatry and Psychotherapy, 16(4), 5-13. doi: 10.12740/app/33358
B.Skodlar and J.Parnas have made some very interesting and original papers about suicidality in schizophrenia in a phenomenological point of view. They focused on self disturbance as a major and independant risk factor. They claim that suicidality in schizophrenia cannot be understoud with a comorbid-depression model, but must be reconceptualize.
You can see :
Skodlar, Parnas (2010) Self-disorder and subjective dimensions of suicidality in schizophrenia. - Comprehensive Psychiatry
Regards
The problem with all of the studies that have been conducted on "risk factors" and "protective factors" is that they are using a linear, progressive model of suicidality. My recent analysis of a dataset of 43,690 events of suicidality in one subject over 3 years shows that this subject's suicidality is non-linear, dynamic, and chaotic (see chapter 2 in my recent book; Suicidality: A Roadmap for Assessment and Treatment). We need to be using non-linear, dynamic models for these types of analysis. Until the proper modeling is used for such analysis, we cannot have any confidence in the results.
This is not to mention the issues inherent in using a transnosological approach which puts all suicidal people into the same studies. It is quite likely that people experiencing a command hallucination to kill themself will have different risk and protective factors than someone that is suicidal because they were diagnosed with ALS and both of these groups will have different risk and protective factors from someone that is suicidal because their entire family just died in an accident. Each of these groups are likely to have different risk and protective factors and are likely to respond differently to treatment. This is why we included a classification system, diagnostic criteria, and a structured diagnostic interview for 9 distinct suicidality disorders in our book (see chapters 6.1 and 14.11, respectively). We believe each of these groups must be looked at individually if the field of suicidality research is to move forward.
Book Suicidality: A Roadmap for Assessment and Treatment
There are several suicide predictors, among which, the deep depressions, mutisms, isolations, incapacity to love, absence of positive self-image, emotional frustrations, lack of individual values, personal, relatives, etc.
I thank all of you for your interest in this vital topic. Several publications of mine concern this issue. For example "The Serious Suicide Attempt :Epidemiological and Follow-up Study of 886 Patients"(1970) [Amer.J.Psychiatry] and a subsequent "... Five year follow-up study of the same patients (1976) [JAMA]. It is profound that many of the predictors remain constant. David H.Rosen, now on the faculty at OHSU in Psychiatry.
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