Suicidal–Related Thoughts of University Students

Suicide is a major public health concern accounting for 800 000 deaths globally each year. Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. The current article presents the integrated motivational–volitional (IMV) model of suicidal behaviour, one such theoretical model. We propose that defeat and entrapment drive the emergence of suicidal ideation and that a group of factors, entitled volitional moderators (VMs), govern the transition from suicidal ideation to suicidal behaviour. According to the IMV model, VMs include access to the means of suicide, exposure to suicidal behaviour, capability for suicide (fearlessness about death and increased physical pain tolerance), planning, impulsivity, mental imagery and past suicidal behaviour. In this article, we describe the theoretical origins of the IMV model, the key premises underpinning the model, empirical tests of the model and future research directions.

Predicting Hospitalization Versus Discharge of Suicidal Patients Presenting to a Psychiatric Emergency Service

A Suicide-Specific Diagnosis – The Case Against

Background: Suicide, defined as the intentional act of self-inflicted death, constitutes a significant global public health burden. Every year, over 700,000 individuals worldwide die by suicide. Studies in Iran have reported an alarming prevalence of suicidal behavior among students, with estimates of suicide attempts ranging from 1.8% to 3.5%, and suicidal ideation rates fluctuating between 6.2% and 42.7%. This complex phenomenon is influenced by a wide array of factors. A major challenge to effective suicide prevention strategies is the limited understanding of the mechanisms that lead from suicidal ideation to actual suicide attempts. Objectives: This study aimed to investigate the relationships between suicidal ideation, suicidal behaviors, and the constructs of the three-step theory within a student population. Methods: A cross-sectional design was employed, with convenience sampling enrolling 260 students from Zanjan University of Medical Sciences. Students consented to participate and completed various questionnaires, including the Beck Suicide Ideation Scale (BSSI), the Inventory of Motivations for Suicide Attempts (IMSA), the Suicidal Behaviors Questionnaire-Revised (SBQ-R), the Symptom Checklist-25 (SCL-25), the Acquired Capability for Suicide Scale (ACSS), and a single-item suicide attempt question. The participants ranged in age from 18 to 52 years (mean: 23.62, standard deviation: 5.48), with 75% of the sample being female, and 85% single. Data analysis was conducted using SPSS 24 and AMOS 24 software. Results: Correlation analysis revealed that psychic pain, hopelessness, and low belongingness were significantly and directly correlated with both suicidal ideations and behaviors (all P-values < 0.05). Structural equation modeling results demonstrated that the combination of pain and hopelessness directly predicted suicidal ideation (β = 0.318, P < 0.001) and low belongingness (β = 0.867, P < 0.001). These factors indirectly predicted suicidal behavior through suicidal ideation, capability for suicide, and low belongingness (β = 0.406, P < 0.001). Additionally, suicidal ideation was a strong direct predictor of suicidal behavior (β = 0.556, P < 0.001), and low belongingness directly predicted suicidal behaviors (β = 0.226, P < 0.001). However, the capability for suicide did not statistically predict suicidal behavior within this student sample. Conclusions: The findings support the validity of the three-step theory in a student population. Pain, hopelessness, and low belongingness were significant predictors of suicidal ideation and attempts among students, while the capability for suicide did not predict suicidal behavior in this context. These results provide a novel perspective by confirming the applicability of the three-step theory in a non-clinical student population, offering valuable insights into the interrelations of the model’s key components.

The study aimed to explore the suicidal process, suicidal communication and psychosocial situation of young suicide attempters in a rural community in Hanoi, Vietnam. Semi-structured interviews were conducted, in a community setting, with 19 suicide attempters aged 15-24 who had been consecutively hospitalized in an intensive care unit. In 12 of 19 cases, the first pressing, distinct and constant suicidal thoughts appeared less than one day before the suicide attempt in question. However, distress and mild, fleeting suicidal thoughts had been present up to six months before the suicide attempt in 16 cases. Five respondents had a suicide plan one to three days before attempting suicide. Altogether, 13 engaged in some form of suicidal communication before their attempt. This communication was, however, difficult for outsiders to interpret. Twelve of the respondents were victims of regular physical abuse and 16 had suffered psychological violence for at least one year before attempting suicide. Eighteen of the respondents used pesticides or raticides in their suicide attempts. None sought advice or consultation in the community despite long-standing psychosocial problems. The strategy of reducing the availability of suicide means (e.g., pesticides or raticides) in Asian countries should be complemented with a long-term suicide-preventive strategy that targets school dropouts and domestic violence, and promotes coping abilities and communication about psychological and social problems as well as recognition of signs of distress and suicidal communication.

Variability in terms and definitions to describe suicidal behaviours and ideation may have led researchers to duplicate their efforts in suicidology thereby possibly wasting valuable resources in a field where funding is scarce. Published nomenclatures appear not to reach a global use. This situation pushed some scholars to advocate for the use of a common nomenclature and a common classification to describe suicidal behaviour that would appeal to the majority of users, whatever their background and whichever their country. A first step towards a universal nomenclature could be to assess the variability of use of definitions and terms. The aims of this dissertation are to describe the published background in the field of nomenclatures, definitions and classifications, and provide a historical and cultural context to the use of terms and definitions to describe suicidal behaviours and ideation. The experimental part of this research consists in a worldwide study of definitions and terms for suicidal behaviours, the results of which were used to elaborate a universal English-language nomenclature of suicidal behaviours. A systematic literature review of contemporary English language nomenclatures found them to be logically organized according to outcome and intent. It appeared that the range of the nomenclatures was fundamental in how the nomenclature were logically organized. A systematic review of terms and definitions was performed based on the four most common characteristics of the definition of suicide found in the literature, i.e. outcome, intent, knowledge of the consequences of the act, and agency (self- or other-inflicted). These four characteristics appeared to cover the vast majority of the concepts underpinning existing definitions, enabled an explanation of the variability of published definitions and were considered for use as tool for research. Intent to die in the definition of suicide was quite agreed upon. However, some authors suggested that intent should refer to something other than death. A systematic review of contemporary classifications of suicidal behaviour revealed they were becoming increasingly precise and operational for clinical and research purposes. On the other hand, the development of new classification systems despite lack of international consensus on definitions and terms related to suicidal ideation and behaviour could potentially lead to an increased level of confusion. An examination of historical context revealed that the term ‘suicide’ appeared in Europe in a period of deep moral change during the seventeenth century, when attitudes toward suicide became more tolerant. A review in the Pacific Islands suggested that local traditional terms often referred to a method having close ties with the cultural context. The methodology of the Worldwide Study of Definitions and Terms for Suicidal Behaviors© (WSDTSB) was then described. The study rationale was to overcome the confusing landscape and poor agreement among authors of nomenclatures, definitions, terms, and classifications in the field of suicidology. The study questionnaire was developed on the basis of the four main criteria of the definition of suicidal behaviour: outcome, intent, knowledge (of the consequences of the act), and agency (self- or other-inflicted). Two types of participants were invited in the study. ‘Experts’, each representing a country, were recruited through international organizations. IASP members that were not national representatives comprised the comparison sample. Methodological limitations were that the study was conducted in the English-language only, and ‘experts’ were designated among IASP national representatives and in six cases among other international associations; in some cases, it is possible that these persons did not have more expertise than IASP members. The results of the WSDTSB were then analysed. Levels of agreement to statements enabled comparison between responses of samples (‘experts’ vs. IASP members), and countries’ language and income background groups, occupation and professional background groups. Regarding the definition of suicide, the highest levels of agreement and similarities between samples and groups were found for fatal outcome, non-clear-cut statements regarding intent and knowledge, and self-infliction. Regarding non-fatal suicidal behaviour and ideation, the highest levels of agreement and similarities between samples and groups were found for definitions of ‘suicide attempt’, ‘suicidal ideation’, ‘death wishes’, ‘suicide plan’, and ‘interrupted suicide attempt’. The results of the WSDTSB were discussed and a nomenclature of suicidal behaviours and ideation was proposed as a baseline for further steps towards a universal classification of suicidal behaviours and ideation. Other limitations of this study were a relatively low participation rate and the low representation of low- and middle-income countries, especially those of the African continent. The necessity to go further in the search of a universal nomenclature was discussed. It was suggested that further research should move on with the aim of elaborating a universal classification of suicidal behaviours possibly based on the results of the present study. Suggestions were made regarding further steps to take.

Help Seeking and Perceived Need for Mental Health Care Among Individuals in Canada With Suicidal Behaviors

Suicide risk in adults with Asperger's syndrome

Approximately half of those who attempt suicide report experiencing suicidal ideation and suicidal planning in advance; others deny these experiences. Some researchers have hypothesized that rapid intensification is due to past suicidal ideation and/or behaviors that are "mentally shelved" but remain available for rapid access later. To evaluate this hypothesis, we examined (a) temporal sequencing of suicidal ideation, suicidal planning, and suicidal behavior, and (b) speed of emergence of suicidal behavior in a prospective cohort study of 2744 primary care patients. Of 52 patients reporting suicidal behavior during follow-up, 20 (38.5%) reported suicidal ideation and planning prior to their suicidal behavior, 23 (44.2%) reported suicidal ideation but not planning, and nine (17.3%) denied both suicidal ideation and planning. Over half (n = 30, 57.7%) reported the onset of suicidal ideation and/or planning on the same day as or after their suicidal behavior (i.e., rapid intensification). Rapid intensification was not associated with increased likelihood of reporting recent or past suicidal ideation, planning, or behaviors, suggesting rapid intensification does not depend on prior experience with suicidal ideation and/or behaviors. Detecting primary care patients at risk for this form of suicidal behavior may be limited even with universal suicide risk screening.

A Suicide-Specific Diagnosis – The Case For

Previous studies have suggested that stereotypes towards suicide, including endorsement of suicide and stigma toward suicide, may contribute to suicidal ideation and behaviors. However, this has not been examined directly. In this study, we examined whether endorsement of suicide and stigma toward suicide are involved in the pathway from suicidal ideation to suicide attempts among college students. To this end, we used the Suicidal Ideation Attributes Scale (SIDAS), the Suicidal Behaviors Questionnaire-Revised (SBQ-R), and the Stigma of Suicide Scale (SOSS) to assess suicidal ideation, suicide attempts, endorsement of suicide, and stigma toward suicide, respectively, in a sample of 944 Chinese college students (mean age, 20.97 years). Using mediation analysis, we found that suicidal ideation partially mediated the relationship between endorsement of suicide and suicide attempts and between stigma toward suicide and suicide attempts. These findings provide novel evidence that endorsement of suicide and stigma toward suicide are closely associated with suicide attempts, but partially through the influences of suicidal ideation. Future studies should elaborate on their longitudinal relationships. Implications of these findings for clinical practices are discussed with reference to the ideation-to-action framework of suicide, aiming to reduce suicidal behaviors.

Ed Shneidman reports on his 1971 analysis of the suicides that had occurred in the Terman Gifted Children Study. Begun in the 1920s at Stanford University, Professor Lewis Terman identified 1,528 high-IQ California students and, over the years, they have been continuously followed. Today, the remaining subjects (about 100) have a mean age of 93. In his uniquely Shneiderian manner, Ed relates how, in 1971, he utilized a psychological autopsy approach to accurately predict the suicides of a small subsample of the 20 suicides that had occurred to date among the 857 male participants. Almost 35 years later, he shares with us his slightly revised view of those factors that he believes play significant predictable roles in the eventuality of suicide. Jeremy Kisch et al. report on analyses from the Spring 2000 National College Health Assessment Survey (NCHA), sponsored by the American College Health Association. This is the largest and most comprehensive survey to date (15,977 college students) that provides a replication of the CDC's 1995 National College Health Risk Behavior Survey (NCHRBS). This study investigates the relationship between suicidal behavior and depressed mood, as well as other risk factors which increase vulnerability to suicidal behavior. Of particular note is that less than 20% of college students reporting suicidal ideation or attempts were receiving treatment (psychotherapy and/or medications). Adolescent suicide continues to be a major focus of much research as evidenced by the number and range of studies published in SLTB over the years. Researchers have appropriately focused on identifying critical risk factors associated with suicidal behaviors. Thompson et al. explored the roles of anxiety, depression, and hopelessness as mediators between known risk factors and suicidal behaviors among 1,287 potential high school dropouts. As a step toward theory development, a model was tested that posited the relationships among these variables and their effects on suicidal behaviors. The results showed direct effects of depression and hopelessness on suicidal behaviors for males, and direct effects of hopelessness, but not depression, for females. For both males and females, anxiety was directly linked to depression and hopelessness; drug involvement had both direct and indirect effects on suicidal behavior. Lack of family support showed indirect influences on suicidal behaviors through anxiety for both males and females as hypothesized. As the authors point out, for mental health professionals, school personnel, and prevention scientists working with at-risk or suicidal youth, the findings make evident the need to address multiple co-occurring problem behaviors such as drug involvement, emotional distress, and suicidal behaviors. Over the years, SLTB has published data emanating from the CDC's Youth Risk Behavior Survey (YRBS), which is conducted biannually. (see SLTB 30: 304–312; 32: 321–323). The four questions that measure suicidal ideation and attempts are ordered along an implicit continuum of development and severity from seriously considering suicide, to planning, to actually attempting suicide, and, finally, to requiring medical attention for a suicide attempt. As presented by Victor Perez, this process assumes a straightforward sequence of suicidal thought and action and is the underpinning of the content and order of the YRBS questions. However, the assumed ordinal properties of the four questions had never been empirically tested. Brener, Krug, and Simon (SLTB 30: 304–312) found discrepancies in the trends of responses to the questions measuring suicidal activity in their analysis of the YRBS from 1991–1997. Specifically, they showed that although the percentage of students who reported having seriously considered or attempted suicide in the past 12 months had declined steadily since 1991, the percentage of students requiring medical attention for an injurious suicide attempt had increased. They concluded that injurious suicide attempts might not be linked to seriously considering or planning a suicide attempt. Perez examines the assumed ordinal relationship in the 1999 Youth Risk Behavior Survey by constructing a trajectory that identifies all possible response patterns among the four questions measuring suicidal activity. Significant differences between means of dependent variables at each level of the normative trajectory supported the hypothesis that frequency of risk behaviors increases monotonically with successive suicidal thought and behavior. Research on the relationship between schizophrenia and suicidal behaviors has languished until recently (see SLTB 30: 34–49; 34: 66–76; 34: 76–86; 34: 311–319). Camilla Haw et al. identify the risk factors for deliberate self-harm (DSH) in schizophrenia. They provide an explanation and reference to their use of the broader (European) term DSH, rather than attempted suicide. Although there are several published review articles on risk factors for suicide and suicidal behavior in schizophrenia, there are few reviews which make any mention of risk factors for DSH, and there is an assumption that the risk factors for DSH and suicide are the same. Haw et al. examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Five variables (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, while one (unemployment) was associated with a reduced risk. In a continuing series of studies (see SLTB 27: 153–163), Eric Blaauw et al. focus on the prevention of suicide in jails and prisons. This current study aims to identify combinations of characteristics (demographic, psychiatric, and criminal) that are capable of identifying potential suicide victims. Characteristics of 95 suicide victims in the Dutch prison system were compared with those of a random sample of 247 inmates in ten jails. Combinations of indicators for suicide risk were also tested for their capability of identifying 209 suicides in U.S. jails and 279 prison suicides in England and Wales. A combination of two demographic characteristics (age over 40, homelessness), two criminal characteristics (one prior incarceration, violent offense), and two indicators of psychiatric problems (history of psychiatric care, history of hard drug abuse) proved capable of identifying 82 percent of the suicide victims in the Netherlands at a specificity of .82 in the general inmate population. Less powerful combinations correctly classified 53% of the U.S. suicides and 47% of the U.K. suicides. Blaauw and colleagues conclude that a small set of demographic and criminal characteristics and indicators of psychiatric problems is useful for the identification of suicide risk in jails and prisons. They point out that the characteristics can easily be incorporated in a screening device that can be administered during the intake process for new inmates. Some risk factors for suicidal behavior are similar to those often studied in the field of criminology. The link between suicide and crime is most apparent when there is a homicide followed by suicide. People who kill others rarely kill themselves afterward. When they do, they are more likely to have killed someone with whom they are intimately involved—an intimate partner or a child. A review of the literature on this phenomenon in Australia, Canada, and the United States showed that, in all three countries, the majority of those who commit suicide after a homicide are male partners or ex-partners of female victims. Using data on over 700 intimate femicides, Myrna Dawson examined the role of premeditation in cases of intimate femicide-suicide compared to killings that do not culminate in a suicide. Her results show that premeditation is more likely to occur in cases involving the offenders' suicide, but that evidence of premeditation varies depending on the type of suicidal killer. Michel Préville et al. present the results of a psychological autopsy investigation of 101 adults aged 60 years and older who died by suicide in Quebec in 1998–1999. The study looks at a number of variables from proxy survivor interview data, including health- and mental health-related behaviors, mental health diagnoses, and social and demographic variables. In this study, 42.6% of the suicide cases presented with mental disorders at the time of their death (mainly depression), and nearly 44% of the suicide cases had no current or pre-existing psychiatric condition. Only 27.7% of the cases did not express any idea of death during the 6-month period preceding their suicidal death. Interestingly, 53.5% of the suicide cases consulted a general practitioner or specialist during the 2-week period preceding their death. The authors suggest that family members and friends could play an important role in preventing elderly suicide attempts by encouraging their parents to discuss their suicidal thoughts with their general practitioner. The results show some similar and some disparate results compared to other studies of elderly suicides, indicating the need for research that examines the complex causal nature of the relationship between mental disorders and suicide among the elderly. Adding to his studies of homeless veterans who abuse substances (SLTB 33:430–432), Brent Benda studied 315 male and 310 female homeless military veterans in a V.A. inpatient program designed to treat substance abusers, many of whom also suffer psychiatric disorders. The study examined gender differences in factors associated with the odds of having suicidal thoughts, and of attempting suicide, in comparison to being nonsuicidal. Childhood and current sexual and physical abuses, depression, fearfulness, relationship problems, limited social support, and low self-esteem were more strongly associated with suicidal thoughts and attempts for women than for men veterans. Extent of alcohol and other drug abuse, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women. While anticipating the release of the CDC's final 2002 national suicide death numbers and rates, there have been different explanations offered for the apparent slow, but steady decline in national suicide rates over the last years. In 1996 the rate was 11.52/100,000; 11.23 in 1997; 11.13 in 1998; 10.47 in 1999; 10.43 in 2000, and 10.69 in 2001. By the time you receive this issue, we will know whether the trend is heading downward or beginning to climb back up. Recently, my attention was drawn to an Editorial originally published on July 30, 1904, in the Journal of the American Medical Association, entitled, “The Increase in Suicide.” I have excerpted portions as follows: The increase of suicide has come to be such a marked feature of social statistics in this country that physicians must be made to realize the possibilities there may be of bringing about a decrease in this unfortunate matter by more care and prevision. Suicides are somewhat more than twice as frequent now as they were ten years ago. … Carefully collected statistics show that there was a constant increase from 3,531 suicides in 1891 to 6,600 in 1897, then a drop in 1898 to 5,920, and in 1899 to 5,340. In 1900 there were 6,755 suicides, an increase of over 150 above the figures for 1897, the highest previous number, and there has been a constant increase since, in 1903 the number of suicides being very close to 8,600. During the last thirteen years—that is, since 1891, there have been altogether 77,617 cases of suicide reported in the newspapers of this country. The decrease in the number of suicides during 1898 and 1899 is not surprising, if we remember the conditions that prevailed in the commercial world at that time. After a period of hard times there was the wave of prosperity and a decided reaction in men's feelings that made the future look bright enough for everyone. Curiously enough, the statistics, however, do not show that city life is so much harder on the people than country life. During the last ten years, the suicide rate in fifty cities of this country has about doubled. That is, however, only in proportion to the suicide rate throughout all the rest of the country and does not especially condemn the high pressure of large city life as a disturbing factor of mentality. The most serious thing about the statistics is the fact that, though suicides are more common among men than women in all countries, the difference is gradually growing less, and in recent years, this has been quite marked. (43: 333–334) The 1890 census data from some states was partially destroyed by a fire in 1921; however, the federal records indicate an 1890 U.S. census of 62,116,811. Using this number, the rates are as follows: 5.68/100,000 in 1891, 10.63 in 1897, 9.53 in 1898, and 8.60 in 1899. The official U.S. census in 1900 was 74,607,225. In 1900, there were 6,755 suicides, yielding a rate of 9.05/100,000. In 1903, there was a significant increase in the number of suicides to approximately 8,600. Using the 1900 census, the suicide rate rose to 11.53/100,000. During the 13-year period between 1891–1903 there were 77,617 suicides, or approximately 5,971/year. This yields a roughly estimated rate of 9.61/100,000 for this 13-year period. Taken as a whole for the years surrounding the turn of the 20th century, the rate hovered around 9–10/100,000. One hundred years later, we continue to grapple with similar rates and similar risk factors.

The Acceptability of Suicide Among Rural Residents, Urban Residents, and College Students from Three Locations in China

BackgroundIn early adolescence, youth are highly prone to suicidal behaviours. Identifying modifiable risk factors during this critical phase is a priority to inform effective suicide prevention strategies.AimsTo explore the risk...

The aims of the study were to identify the prevalence and sociodemographic and clinical correlates of suicidal behaviours using data from a cross-sectional survey among those with major depressive disorder (MDD) in Singapore. The Singapore Mental Health Study (SMHS) was a cross-sectional epidemiological study that surveyed Singapore residents (Singapore citizens and permanent residents) aged 18 years and above. The assessment of mental disorders was established using version 3.0 of the Composite International Diagnostic Interview (CIDI 3.0). For the purposes of this study, suicidal behaviour was assessed by questions which were asked to respondents who answered positively to the screening questions in the CIDI 3.0 "Depression" module. The prevalence of suicidal ideation, plan and attempt among those with lifetime MDD was 43.6%, 13.7% and 12.3%, respectively. We found that suicidal ideation, plan and attempt were significantly associated with ethnicity, education and income. The rate of those who had sought some professional help was higher among those with suicidal plan (71.7%) and attempt (72.3%) as compared to those with suicidal ideation (48.7%) and those with MDD but no suicidal behaviour (29%). Individuals with MDD and suicidal behaviour do differ from their non-suicidal counterparts as they have a different sociodemographic and clinical profile. There is a need for more research and a better understanding of this population which in turn could lead to the development and implementation of relevant interventions.