The Role of Emotion Dysregulation in Suicidal Ideation Intensity and Suicide Attempts in Crisis Hotline Callers

Suicidality and Self-harm in Adolescents With Attention-Deficit/Hyperactivity Disorder and Subsyndromal ADHD

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.

The association between suicidality and treatment with Selective Serotonin Reuptake Inhibitors in older people with major depression: a systematic review

Previous literature has demonstrated a strong association between cigarette smoking, suicidal ideation and suicide attempts. This association has not previously been examined in a causal inference framework and could have important implications for suicide prevention strategies. We aimed to examine the evidence for an association between smoking behaviours (initiation, smoking status, heaviness, lifetime smoking) and suicidal thoughts or attempts by triangulating across observational and Mendelian randomisation analyses. First, in the UK Biobank, we calculated observed associations between smoking behaviours and suicidal thoughts or attempts. Second, we used Mendelian randomisation to explore the relationship between smoking and suicide attempts and ideation, using genetic variants as instruments to reduce bias from residual confounding and reverse causation. Our observational analysis showed a relationship between smoking behaviour, suicidal ideation and attempts, particularly between smoking initiation and suicide attempts (odds ratio, 2.07; 95% CI 1.91-2.26; P < 0.001). The Mendelian randomisation analysis and single-nucleotide polymorphism analysis, however, did not support this (odds ratio for lifetime smoking on suicidal ideation, 0.050; 95% CI -0.027 to 0.127; odds ratio on suicide attempts, 0.053; 95% CI, -0.003 to 0.110). Despite past literature showing a positive dose-response relationship, our results showed no clear evidence for a causal effect of smoking on suicidal ideation or attempts. This was the first Mendelian randomisation study to explore the effect of smoking on suicidal ideation and attempts. Our results suggest that, despite observed associations, there is no clear evidence for a causal effect.

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessLong-Term Study Backs Link Between Smoking, SuicidalityJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:15 Apr 2005https://doi.org/10.1176/pn.40.8.00400052While Americans worry about whether cigarette smoking will cause lung cancer, perhaps they should also pay attention to a lesser-known risk factor for the habit—suicide. Epidemiological studies going back at least a quarter century have linked cigarette smoking with suicide. And now another large epidemiological study does as well.This latest investigation was headed by Naomi Breslau, Ph.D., a professor of epidemiology at Michigan State University. Results appeared in the March Archives of General Psychiatry.In 1988, Breslau and her colleagues selected some 1,000 young adults to participate in their study. All were members of a health maintenance organization in the Detroit area. All were interviewed at baseline and at three, five, and 10 years after the study started. During each interview, their psychiatric health, smoking habits, and occurrence of suicidal thoughts and of suicidal attempts since the last interview were ascertained.As it turned out, subjects reported only 19 suicide attempts during the 10-year study period. Since 19 suicide attempts were not enough for a meaningful statistical analysis, Breslau and her team decided to lump suicidal attempts and suicidal thoughts together. Combining these gave 17 suicide attempts with the reporting of suicidal thoughts; two suicide attempts without the reporting of suicidal thoughts; and 130 suicidal thoughts without suicide attempts, for a total 132 suicidal thoughts and/or attempts.Breslau and her colleagues then attempted to see whether smoking at baseline, at the three-year assessment, and at the five-year assessment could be statistically linked with the combined number of suicidal thoughts or attempts during the subsequent study periods.The answer was yes. Compared with subjects who had never smoked, current smokers (those who had smoked during the past 12 months) were at a statistically significant increased risk of suicidal thoughts or attempts. In contrast, past daily smokers were not at increased risk for subsequent occurrence of suicidal thoughts or attempts.Moreover, this link between current cigarette smoking and suicidal thoughts or attempts held even when potentially confounding factors—prior suicidal thoughts or attempts, current or past major depression, and current or past substance abuse—were taken into consideration.And even though the study results did not find current cigarette smoking to be as grave a risk factor for suicidal thoughts or attempts as prior suicidal thoughts or attempts, or current or past major depression, they do suggest some practical implications.“Clinical psychiatrists should always be concerned and inquire about suicidality, self-destructive thoughts, et cetera,” Glenn Davis, M.D., a professor of psychiatry at Michigan State University and one of the study authors, said in an interview. “But with added knowledge that there is a connection between smoking and risk for suicidal behavior, they should be particularly sensitive to smoking history in their evaluation of patients.”“By highlighting current smoking, [this study further reinforces] the benefits of smoking cessation,” Donald Klein, M.D., a professor of psychiatry at Columbia University, pointed out to Psychiatric News.How current cigarette smoking might trigger suicidal thoughts or attempts is not known. Yet if it does play a causal role, Breslau and her team suspect that it may do so via an intermediary culprit—the enzyme monoamine oxidase (MAO), which is found in the liver and the central nervous system. It is crucial to the functions of the neurotransmitter serotonin. Low levels of MAO have been found in blood cells of current cigarette smokers, but not in those of ex-smokers, and low blood-cell levels of MAO in turn have been linked with violence and suicide.This investigation has several advantages over past ones on the subject. It took major depression, a well-established risk factor for suicide, into consideration, and it was quite sophisticated in design. Klein explained that it “incorporated major methodological advances by using prospective multiwave longitudinal psychiatric diagnoses in estimating whether smoking independently increases suicide-related behaviors.”The study had a weakness, however, which Breslau and her group acknowledged in their report: The researchers did not gather data about subjects' completed suicides, only about their suicidal thoughts and attempts.The study was funded by the National Institute of Mental Health.An abstract of “Smoking and the Risk of Suicidal Behavior” is posted online at<http://archpsyc.ama-assn.org/cgi/content/abstract/62/3/328>.▪ Arch Gen Psychiatry 2005 62 328 ISSUES NewArchived

We aimed first to identificate psychopathological variables differentiating between suicide ideators, suicide attempters and patients without suicide ideation or attempts, and second to identificate better predictors of suicide attempts longitudinally. We compared suicide ideation, hopelessness, borderline symptoms, frequency, types, number of different non-suicidal self-injury (NSSI) methods, intrapersonal and interpersonal functionality of NSSI in a sample of 238 patients with Eating Disorders (1) with no history of suicide ideation or suicide attempts (n=150); (2) with recent suicide ideation (n=65); and (3) with suicide attempts in the previous year (n=23). In addition, we analyzed the predictive power of the mentioned variables over the number of suicide attempts 7 months after the first assessment. The group of suicide attempters showed a major number of different methods of NSSI, higher frequency of NSSI, cutting, and more NSSI intra and interpersonal functions than the group of ideators. Unlike in previous studies, hopelessness did not differentiate between patients with ideation and suicide attempts. In addition, the best predictor of suicide attempts 7 months later was frequency of NSSI at T1 (N=123). Cutting, frequency and different methods of NSSI, intra and interpersonal functions were risk factors that differentiated ideators from attempters, being frequency of NSSI the best predictor of suicide attempts longitudinally. Thus, patients with ED with NSSI should be the focus of preventive interventions for suicidal behavior.

Individuals with Attention-Deficit Hyperactivity Disorder (ADHD) are at an increased risk of suicidal ideation and attempts compared to the general population. However, the mechanisms underlying suicidal behaviors in this group remain poorly understood. The role of childhood trauma, which frequently co-occurs with ADHD, and emotional dysregulation in suicidal behaviors remains unclear. This study employs a case-control design to investigate the impact of childhood trauma and emotional dysregulation on suicidal tendencies in adults with ADHD. A total of 160 adults diagnosed with ADHD who presented to the Adult Neurodevelopmental Disorders Clinic at Selçuk University, along with 107 typical controls, were included in the study. Participants were assessed using the Structured Clinical Interview for DSM-5, Adult ADHD Self-Report Scale, Suicidal Ideation Scale, Childhood Trauma Questionnaire, and the Difficulties in Emotion Regulation Scale-Short Form. Regression and mediation models were conducted to examine factors influencing suicidal tendencies, controlling for sociodemographic and clinical variables. Compared to controls, individuals with ADHD exhibited significantly higher levels of suicidal ideation, childhood trauma, and emotional dysregulation. Regression analysis revealed a positive association between childhood trauma, emotional dysregulation, and suicidal ideation. However, ADHD symptoms did not directly contribute to increased suicidal ideation; rather, their effect was mediated through childhood trauma and emotional dysregulation. Additionally, the presence of depression was significantly associated with both suicide attempts and suicidal ideation. These findings suggest that childhood trauma and difficulties in emotion regulation play critical roles in suicidal ideation among individuals with ADHD. In addition to depression treatment, comprehensive interventions targeting childhood trauma and emotional dysregulation may serve as promising strategies for reducing suicidal behaviors.

The associations between health risk behaviors and suicidal ideation and attempts in an urban Chinese sample of adolescents

Background: Although emotion dysregulation and adverse childhood experiences (ACEs) are key psychosocial risk factors for suicidal ideation and suicide attempts, it remains unclear which specific dimensions of these factors can distinguish the transition from ideation to attempts. Aims: To determine whether specific dimensions of emotion dysregulation and adverse childhood experiences differentiate young adults with histories of suicidal ideation from those with histories of suicide attempts. Method: A sample of 418 young adults (63% non-Latinx White; 71% female; M = 23.56, SD = 2.85) completed measures of ACEs, emotion dysregulation, and suicidal ideation and attempts. Multinomial logistic regression assessed how specific dimensions of emotion dysregulation and ACEs predicted membership in three groups: no history of ideation or attempts, ideation only, and attempt history, controlling for depressive symptoms, age, and gender. Results: The suicidal ideation group reported greater cumulative ACEs and depressive symptoms than those without ideation/attempt history. The suicide attempts group reported greater ACEs and difficulties with goal-directed behavior than the other two groups. Difficulties engaging in goal-directed behavior and emotional awareness were more predictive of membership in the suicide attempts than the suicidal ideation group. Limitations: The cross-sectional, retrospective design, and predominantly White female sample limit causal inferences and generalizability. Conclusion: Focusing on specific emotion regulation strategies may improve outcomes for young adults at risk for suicidal ideation and attempts and with a history of ACEs. Goal-directed behavior and emotional awareness offer promising targets for intervention to reduce suicide risk in this population.

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.

BackgroundVery little is known about suicide attempts in middle-aged women in Mexico. The aims of this study were to determine: 1) the prevalence of suicidal ideation and suicide attempts in middle-aged women in Durango City, Mexico; and 2) the suicide attempt prevalence association with the sociodemographic, clinical, and behavioral characteristics of the women studied.MethodsThrough a cross-sectional study, 395 middle-aged women were surveyed. Suicidal ideation, suicide attempt data, and the characteristics of the women were obtained with the aid of a questionnaire. Bivariate and multivariate analyses were used to determine the association between suicide attempts and the characteristics of women.ResultsOf the 395 women (mean age: 46.97 ± 5.34 years) studied, 50 (12.7%) had suicide ideation, and 20 (5.1%) had suicide attempts. The number of suicide attempts among these 20 women varied from 1 to 10 times. The most frequent method used for suicide attempt was intake of medicaments (in 11 women). None of the sociodemographic characteristics was associated with suicide attempts. Women with suicide ideation, abdominal pain frequently, and reflexes impairment had a significantly higher frequency of suicide attempts than those without these characteristics. Logistic regression of behavioral variables showed that only the variable alcohol consumption was independently associated with suicide attempts (odds ratio = 2.82; 95% confidence interval: 1.01 - 7.84; P = 0.04).ConclusionsResults suggest that suicidal ideation and suicide attempts are prevalent among women of middle-age attending a public primary care center in Durango City. This is the first report of an association between suicide attempts and reflexes impairment. Factors associated with suicide attempts found in this study may help in the design of preventive measures against suicide.

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

Suicide and suicidal behavior are major public health problems, especially among adolescents and young adults. Previous research has established links between parental bonding and suicidality; however, it remains unclear whether parental bonding is associated with suicide ideation, the progression from suicide ideation to suicide attempts, or both. This study examined the relation of parental bonding to suicide ideation and suicide attempts in adolescents from two settings: (1) acute psychiatric care (n=172) and (2) high school (n=426). All participants were administered validated measures of parental bonding, suicide ideation, and suicide attempts, as well as emotion dysregulation, loneliness, and self-worth. In the psychiatric sample, lower parental care significantly differentiated adolescents with a history of suicide attempts from those with suicide ideation only or without histories of suicidality. This pattern remained even after controlling for other known correlates of suicidality (i.e., emotional dysregulation, loneliness, and low self-worth). Similar effects were found in the community sample, although these findings failed to reach statistical significance. In both samples, parental overprotection was not associated with suicide ideation or suicide attempts. Results suggest that parental care may be an important risk factor for youth suicidal behavior and may help differentiate suicide attempters from suicide ideators.

Suicidal ideation and attempts are growing public health concerns globally. Evidence from high-income countries suggests that individuals with psychosis and bipolar disorder are at increased risk of suicidal ideation and attempts, but there is a scarcity of evidence from South Asia. To estimate the prevalence of suicidal ideation and attempts in individuals with psychosis and bipolar disorder in South Asia. In this systematic review and meta-analysis, four databases (PsycINFO, Web of Science, EMBASE and Medline) were searched until December 2022. Pooled prevalence was estimated with random-effects models. Heterogeneity was quantified with the I2-statistic. The pooled sample size across the 21 studies was 3745 participants, 1941 (51.8%) of which were male. The pooled prevalence of suicide attempts in South Asian people with either psychosis or bipolar disorder was 22% (95% CI 17-27; n = 15). The pooled prevalence of suicidal ideation with psychosis or bipolar disorder combined was 38% (95% CI 27-51; n = 10). Meta-regression, subgroup and sensitivity analysis showed that the pooled prevalence estimates for both suicide attempt and ideation remained unaffected by variations in critical appraisal ratings and study designs. Only one study reported data on suicide-related deaths. One in four individuals diagnosed with psychosis or bipolar disorder have reported suicide attempts, whereas up to one in three have experienced suicidal ideation. These findings underscore the urgent need for clinicians to regularly assess and monitor suicidal ideation and attempts among individuals with these disorders in South Asia.

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