Reasons for living and dying in suicide attempters: a two-year prospective study

Juliane Brüdern,Thomas Reisch,Konrad Michel,Annabarbara Stähli,Jeannette Brodbeck,David A Jobes,Anja Gysin-Maillart

doi:10.1186/s12888-018-1814-8

Abstract

BackgroundThe internal suicide debate hypothesis assumes that in a suicidal crisis, individuals are involved in an internal struggle over whether to live or die. Reasons for living (RFL) and Reasons for dying (RFD) are important individual reasons for staying alive (e.g. family) or wanting to die (e.g. hopelessness) and reflect this internal motivational conflict of the suicidal mind. The aim of this study was to explore the association between RFL and RFD of suicide attempters and current and future suicide ideation and behavior.MethodThe sample consisted of 60 patients who were admitted at a psychiatric emergency unit in Switzerland following an attempted suicide. They received treatment as usual, participated in an assessment interview and completed self-report questionnaires. Additionally, they were instructed to write down up to five individual RFL and RFD. The number of RFL and RFD responses, depressive symptoms, and suicide ideation were assessed at baseline and 6, 12, and 24 months follow-up. Outcome measures were suicide ideation and repeated suicide attempts. Multiple imputations were used in order to address missing data.ResultsThe number of RFD responses was the strongest predictor for increased suicide ideation at baseline. The number of RFL responses was not associated with suicide ideation and reattempts. RFD, depressive symptoms, and baseline suicide ideation predicted subsequent suicide reattempt up to 12 months later in simple regression analyses. Mediation analyses suggested that RFD mediated the effect of depressive symptoms at baseline on suicide ideation at 12-months follow-up.ConclusionRFL were unrelated to the mental health of study participants and did not function as protective factor against suicide risk. RFD may be an important motivational driver in the suicidal process. Clinical interventions should focus more on the reduction of RFD than on RFL in suicidal individuals.

Highlights

The internal suicide debate hypothesis assumes that in a suicidal crisis, individuals are involved in an internal struggle over whether to live or die
Numbers of reasons for living and reasons for dying and socio-demographic factors After the index suicide attempt at baseline participants reported significantly more Reasons for living (RFL) (M = 3.45, SE = 1.35) than Reasons for dying (RFD) (M = 1.90, SE = 0.55, t(59) = 5.71, p < .001), which corresponds to a strong effect (d = 1.00)
RFD at baseline correlated with Beck Depression Inventory (BDI) at baseline (r = .56, 95% CI [.37, .75], p < .001) and Beck Scale for Suicide Ideation (BSS) at baseline (r = .70, 95% CI [.54, .86], p < .001), BSS at T2 (r = .53, 95% CI [.31, .76], p < .001), and BSS at T4 (r = .29, 95% CI [.04, .53], p = .021)

Summary

Introduction

The internal suicide debate hypothesis assumes that in a suicidal crisis, individuals are involved in an internal struggle over whether to live or die. Prospective studies showed that individuals with few reasons for living were at increased risk for developing suicidal thoughts [8] and attempting suicide [9]. Participants who reported more RFL experienced less suicide ideation even at the highest severity of depression as compared to participants with only a small number of RFL. In line with these results, Gutierrez et al [11] showed that a low score on the “RFL-Survival and Coping Beliefs”-subscale was associated with an increased suicide risk. In this study internal risk factors (e.g. hopelessness and repulsion by life) were more useful in identifying individuals with an increased suicide risk compared to protective factors measured by the RFLI

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Discussion

Conclusion