Attempt Status Research Articles

Suicide Attempters and Repeaters

Relationships between depression and coping among nonattempters, attempters, and repeaters of suicidal acts were examined across adolescence. A representative sample of students (T1: n = 2464; mean age, 13.7 years; 50.8% female; 88.3% participation) was reassessed with the same questionnaire after 1 year (T2). High scorers on the Mood and Feelings Questionnaire were gender- and age-matched randomly with low and middle scorers. This subset was assessed using diagnostic interviews at T2 (n = 345, 94% participation) and 5 years later using the same interview and questionnaire (T3, n = 252; mean age, 20.0 years; 73% participation). The Coping Inventory for Stressful Situations measured coping as three stable traits. Coping changed partly with age, depression, and attempt status. Differences in depression emerged before coping differences and remained stable. Consistently, repeaters reported higher depression and lesser task-oriented coping. Antecedent depression predicted decreased task-oriented coping and increased emotional coping at age 20 years.

Structural brain abnormalities and suicidal behavior in borderline personality disorder

BackgroundStructural brain abnormalities have been demonstrated in subjects with BPD in prefrontal and fronto-limbic regions involved in the regulation of emotion and impulsive behavior, executive cognitive function and episodic memory. Impairment in these cognitive functions is associated with increased vulnerability to suicidal behavior. We compared BPD suicide attempters and non-attempters, high and low lethality attempters to healthy controls to identify neural circuits associated with suicidal behavior in BPD. MethodsStructural MRI scans were obtained on 68 BPD subjects (16 male, 52 female), defined by IPDE and DIB/R criteria, and 52 healthy controls (HC: 28 male, 24 female). Groups were compared by diagnosis, attempt status, and attempt lethality. ROIs were defined for areas reported to have structural or metabolic abnormalities in BPD, and included: mid-inf. orbitofrontal cortex, mid-sup temporal cortex, anterior cingulate, insula, hippocampus, amygdala, fusiform, lingual and parahippocampal gyri. Data were analyzed using optimized voxel-based morphometry implemented with DARTEL in SPM5, co-varied for age and gender, corrected for cluster extent (p < .001). ResultsCompared to HC, BPD attempters had significantly diminished gray matter concentrations in 8 of 9 ROIs, non-attempters in 5 of 9 ROIs. Within the BPD sample, attempters had diminished gray matter in Lt. insula compared to non-attempters. High lethality attempters had significant decreases in Rt. mid-sup. temporal gyrus, Rt. mid-inf. orbitofrontal gyrus, Rt. insular cortex, Lt. fusiform gyrus, Lt. lingual gyrus and Rt. parahippocampal gyrus compared to low lethality attempters. ConclusionsSpecific structural abnormalities discriminate BPD attempters from non-attempters and high from low lethality attempters.

Precipitating Events in Adolescent Suicidal Crises: Exploring Stress‐Reactive and Nonreactive Risk Profiles

Factors distinguishing adolescents who experienced a precipitating event in the week preceding a suicidal crisis from those who did not were examined. Among 130 suicidal inpatients (mean age = 15.01 years), those who experienced a precipitating event reported significantly lower depressive symptom scores, better perceived problem solving, less suicidal intent, and a lower rate of prior suicide attempts than those without a precipitating event. Levels of trait impulsivity, suicidal ideation, and current attempt status did not differentiate groups. Findings provide preliminary evidence consistent with at least two possible pathways to a suicidal crisis. Clinical implications and future directions are discussed.

Improving the accuracy of suicide attempter classification

Psychometrical questionnaires such as the Barrat's impulsiveness scale version 11 (BIS-11) have been used in the assessment of suicidal behavior. Traditionally, BIS-11 items have been considered as equally valuable but this might not be true. The main objective of this article is to test the discriminative ability of the BIS-11 and the international personality disorder evaluation screening questionnaire (IPDE-SQ) to predict suicide attempter (SA) status using different classification techniques. In addition, we examine the discriminative capacity of individual items from both scales. Two experiments aimed at evaluating the accuracy of different classification techniques were conducted. The answers of 879 individuals (345 SA, 384 healthy blood donors, and 150 psychiatric inpatients) to the BIS-11 and IPDE-SQ were used to compare the classification performance of two techniques that have successfully been applied in pattern recognition issues, Boosting and support vector machines (SVM) with respect to linear discriminant analysis, Fisher linear discriminant analysis, and the traditional psychometrical approach. The most discriminative BIS-11 and IPDE-SQ items are "I am self controlled" (Item 6) and "I often feel empty inside" (item 40), respectively. The SVM classification accuracy was 76.71% for the BIS-11 and 80.26% for the IPDE-SQ. The IPDE-SQ items have better discriminative abilities than the BIS-11 items for classifying SA. Moreover, IPDE-SQ is able to obtain better SA and non-SA classification results than the BIS-11. In addition, SVM outperformed the other classification techniques in both questionnaires.

Plasma kynurenine levels are elevated in suicide attempters with major depressive disorder

BackgroundInflammation has been linked to depression and suicide risk. One inflammatory process that has been minimally investigated in this regard is cytokine-stimulated production of kynurenine (KYN) from tryptophan (TRP). Recent data suggest that KYN increases in cerebrospinal fluid (CSF) are associated with depressive symptoms secondary to immune activation. KYN may alter dopaminergic and glutamatergic tone, thereby contributing to increased arousal, agitation and impulsivity – important risk factors in suicide. We hypothesized that patients with major depressive disorder (MDD) and a history of suicide attempt would have higher levels of KYN than depressed nonattempters, who in turn would have higher levels than healthy volunteers. MethodsPlasma KYN, TRP, and neopterin were assayed by high performance liquid chromatography in three groups: healthy volunteers (n=31) and patients with MDD with (n=14) and without (n=16) history of suicide attempt. Analysis of variance tested for group differences in KYN levels. ResultsKYN levels differed across groups (F=4.03, df=(2,58), and p=0.023): a priori planned contrasts showed that KYN was higher in the MDD suicide attempter subgroup compared with MDD non-attempters (t=2.105, df=58, and p=0.040), who did not differ from healthy volunteers (t=0.418, df=58, and p=0.677). In post hoc testing, KYN but not TRP was associated with attempt status, and only suicide attempters exhibited a positive correlation of the cytokine activation marker neopterin with the KYN:TRP ratio, suggesting that KYN production may be influenced by inflammatory processes among suicide attempters. ConclusionThese preliminary results suggest that KYN and related molecular pathways may be implicated in the pathophysiology of suicidal behavior.

Differential Effects of Executive Functioning on Suicide Attempts

Suicide is common among individuals with psychiatric illness; executive functioning may be associated with suicide risk. The authors examined demographic, clinical, and executive-functioning variables in suicide ideators and suicide attempters, hypothesizing that attempters would demonstrate poorer executive-functioning skills. Seventy-seven participants with psychiatric illness completed a neuropsychological battery while hospitalized or residing in crisis-houses after expressing suicidal ideation (N=40) or making a suicide attempt (N=37). Logistic regression predicted suicide Ideator versus suicide Attempter status; suicide Attempters exhibited poorer inhibition but better problem-solving ability than suicide Ideators. Suicide attempt risk may be associated with better problem-solving skills, but worse inhibitory control.

Differential Effects of Executive Functioning on Suicide Attempts

Suicide is common among individuals with psychiatric illness; executive functioning may be associated with suicide risk. The authors examined demographic, clinical, and executive-functioning variables in suicide ideators and suicide attempters, hypothesizing that attempters would demonstrate poorer executive-functioning skills. Seventy-seven participants with psychiatric illness completed a neuropsychological battery while hospitalized or residing in crisis-houses after expressing suicidal ideation (N=40) or making a suicide attempt (N=37). Logistic regression predicted suicide Ideator versus suicide Attempter status; suicide Attempters exhibited poorer inhibition but better problem-solving ability than suicide Ideators. Suicide attempt risk may be associated with better problem-solving skills, but worse inhibitory control.

Life events as precipitants of suicide attempts among first-time suicide attempters, repeaters, and non-attempters

The aims of this study were to investigate risk factors for suicide attempts and propose a model explaining the associations among life events and suicide status. We assessed 263 subjects admitted following a suicide attempt to the Division of Psychiatry of the Department of Neurosciences of the University of Parma and compared them with 263 non-attempter clinical control subjects. Attempters reported significantly more adverse life events both in the last 6months, and between the ages of 0–15years than non-attempters. A multinomial logistic regression analysis with stepwise forward entry indicated that the best model to explain suicide status was one which included life events in the last 6months, life events during age 0–15years, and their interaction. First-time attempter status (vs. non-attempters) was more likely to be linked to life events in the last 6months, the interaction between life events in the last 6months and life events during age 0–15years, and low social support. Those attempters with one or more prior attempts (repeat attempters) were more likely than non-attempters to be linked to the interaction between life events in the last 6months and life events during age 0–15years, and to higher rates of psychopharmacological treatment before the index admission. Guided by these findings, monitoring the impact of early-life and recent events in vulnerable individuals should be part of risk assessment and treatment.

Effect of Exposure to Suicidal Behavior on Suicide Attempt in a High-Risk Sample of Offspring of Depressed Parents

Exposure to suicidal behavior in peers and relatives is thought to increase risk for suicidal behavior in vulnerable individuals, possibly as a result of imitation or modeling. This study examines exposure to suicidal behavior and likelihood of suicide attempt in a high-risk cohort of offspring of a depressed parent.A total of 449 offspring of 255 probands with a mood disorder were enrolled in a family study. Probands and offspring were assessed for psychopathology and suicide attempt history, and offspring for suicide exposure. Generalized estimating equations (GEE) and generalized least squares models were used to compare suicide attempt history in exposed and nonexposed offspring as well as characteristics of exposure in exposed offspring suicide attempters and exposed nonattempters. GEE was used to compare exposure occurring before first attempt in attempter offspring and exposure occurring before the same age in matched nonattempter offspring.Offspring reporting exposure to suicidal behavior were four times more likely to report a lifetime suicide attempt compared with unexposed offspring, controlling for age. Suicide attempt status was not associated with age at first exposure, total number or degree (attempt or threat) of exposures, or relationship. Analysis of exposure occurring before age at first suicide attempt found no association between exposure and suicide attempt.Offspring exposed to suicidal behavior are more likely to report a lifetime suicide attempt than nonexposed offspring. However, when examining the temporal sequence of exposure and attempt, the association is no longer significant, suggesting that imitation is not sufficient explanation.

Effect of Exposure to Suicidal Behavior on Suicide Attempt in a High-Risk Sample of Offspring of Depressed Parents

Exposure to suicidal behavior in peers and relatives is thought to increase risk for suicidal behavior in vulnerable individuals, possibly as a result of imitation or modeling. This study examines exposure to suicidal behavior and likelihood of suicide attempt in a high-risk cohort of offspring of a depressed parent. A total of 449 offspring of 255 probands with a mood disorder were enrolled in a family study. Probands and offspring were assessed for psychopathology and suicide attempt history, and offspring for suicide exposure. Generalized estimating equations (GEE) and generalized least squares models were used to compare suicide attempt history in exposed and nonexposed offspring as well as characteristics of exposure in exposed offspring suicide attempters and exposed nonattempters. GEE was used to compare exposure occurring before first attempt in attempter offspring and exposure occurring before the same age in matched nonattempter offspring. Offspring reporting exposure to suicidal behavior were four times more likely to report a lifetime suicide attempt compared with unexposed offspring, controlling for age. Suicide attempt status was not associated with age at first exposure, total number or degree (attempt or threat) of exposures, or relationship. Analysis of exposure occurring before age at first suicide attempt found no association between exposure and suicide attempt. Offspring exposed to suicidal behavior are more likely to report a lifetime suicide attempt than nonexposed offspring. However, when examining the temporal sequence of exposure and attempt, the association is no longer significant, suggesting that imitation is not sufficient explanation.

Toxoplasma gondii Antibody Titers and History of Suicide Attempts in Patients With Recurrent Mood Disorders

Toxoplasma gondii (T.gondii) is an obligate intracellular protozoan parasite infecting one-third of the world population, residing relatively silently in the brain of the immunocompetent host. We hypothesized that T.gondii seropositivity and serointensity are associated with having a history of attempting suicide and, in those attempting suicide, a greater number of attempts. T.gondii seropositivity and antibody titers were compared between (a) patients with recurrent mood disorders with history of suicide attempt (99 individuals) versus (b) patients with recurrent mood disorders without history of suicide attempt (119 individuals), and (c) healthy controls (39 individuals). Diagnosis was made using the Structured Clinical Interview for DSM-IV. Statistical methods included chi square, analysis of variance, and linear and logistic regression analyses. Suicide attempters had higher T.gondii antibody titers than nonsuicide attempters (p = 0.004). The logistic regression analysis revealed a predictive association between titers of anti- T.gondii antibodies and history of suicide attempt with OR = 1.55 (1.14-2.12), p = 0.006. No significant relationship was found between T.gondii seropositivity and suicide attempt status, number of prior suicide attempts, and recurrent mood disorder diagnosis. Although preliminary and bearing replication, this is the first report, to our knowledge, of an association between attempting suicide and T. gondii.

Predictors of multiple suicide attempts among suicidal black adolescents.

Psychopathology, social support, and interpersonal orientation were studied in relation to suicide attempt status in acutely suicidal, psychiatrically hospitalized Black adolescents and a matched sample of White adolescents. In the total sample, multiple attempters were differentiated by lower perceived support. Within the Black youth subsample, social comparison and positive stimulation from others differentiated multiple attempters from single attempters/ideators. Only suicidal ideation predicted multiple attempts among White youth and only higher interpersonal orientation predicted multiple suicide attempts within Black adolescents.

Self-regulation of unattainable goals in suicide attempters: The relationship between goal disengagement, goal reengagement and suicidal ideation

There is growing interest in models of adaptive self-regulation. Recent research suggests that goal disengagement and goal reengagement (i.e., goal adjustment) are implicated in the self-regulation of emotion. This study extends the self-regulation research to investigate the utility of goal adjustment in understanding suicidal risk. To this end, two hundred adults hospitalised following a suicidal episode completed a range of clinical and psychological measures in hospital and were followed up approximately 2.5 months after discharge (Time 2). Hierarchical regression analyses showed that goal reengagement predicted suicidal ideation at Time 2. In addition, the lack of goal reengagement was especially pernicious when reported concomitantly with high disengagement. These predictive effects were independent of baseline mood, attempt status and suicidal intent. The theoretical and clinical implications are discussed.

Mediators of the Relationship Between Childhood Sexual Abuse and Suicidal Behavior in Borderline Personality Disorder

A history of childhood sexual abuse (CSA) increases the risk of suicidal behavior and the lifetime number of suicide attempts in adults with BPD. Despite a strong association, specific variables mediating the relationship between CSA and adult suicidal behavior in BPD have not been identified. This study examined risk factors for suicidal behavior as potential mediators of the relationship between CSA and suicide attempts in 151 men and women with BPD. Diagnostic, clinical, and psychosocial risk factors, as well as CSA, and suicidal behaviors, were assessed by standardized interviews or self-rated measures. Psychotic and schizotypal symptoms, and poor social adjustment, were associated with both CSA and suicidal behavior, and partially mediated the relationship between CSA and attempter status. Psychotic and schizotypal symptoms in BPD define a vulnerability to cognitive and perceptual distortions under stress. They increase the likelihood of suicidal behavior in BPD, especially in the absence of mitigating social support. A theoretical model for suicidal behavior in BPD is presented which integrates direct, mediated, and moderated pathways between childhood sexual abuse and temperament, adolescent and adult risk factors, and suicidal behavior.

The tryptophan hydroxylase‐1 A218C polymorphism is associated with diagnosis, but not suicidal behavior, in borderline personality disorder

While there is some preliminary evidence that the tryptophan hydroxylase I (TPH1) polymorphisms are related to Borderline Personality Disorder (BPD), it is not clear if this association is due to the high rates of suicidal behavior in this patient group. Because of the reported association between TPH1 polymorphisms and suicidal behavior, determining whether TPH1 is related to BPD independent of suicidal behavior is of particular importance. One hundred patients diagnosed with BPD and 101 healthy controls were genotyped for TPH1 intron 7 A218C polymorphism and assessed for impulsiveness and hostility. The BPD patient group had a higher frequency of A allele carriers (AA/AC genotypes) than the control group (chi(2) = 6.12, df = 1, P = 0.01), and differed by genotype frequencies (P = 0.03). Suicide attempter status in the patient group was not related to genotype. Logistic regression analysis controlling for age and gender predicted BPD diagnosis from TPH1 allele group (AA/AC vs. CC, P = 0.03), and TPH1 heterozygotes (AC) appeared to have the highest risk for BPD (P = 0.03). In the full sample, participants with the AC genotype had higher impulsiveness and hostility scores. However, TPH1 did not predict these traits in either of the groups independently, suggesting the association may be an artifact of the association between TPH1 and BPD. Results suggest that the A allele of the tryptophan hydroxylase-1 A218 polymorphism may be associated with BPD, and that it does not appear to be related to suicidal behavior in this population. An aspect of BPD pathology may be due to serotonergic dysfunction.

5-ht2c receptor and mao-a interaction analysis: no association with suicidal behaviour in bipolar patients

The serotonin 2C (HTR2C) receptor has been implicated in suicide-related behaviours, however there are not many studies to date about HTR2C and suicidality. We studied HTR2C haplotypes in suicide attempters, where our sample composed of 306 families with at least one member affected by bipolar disorder. HTR2C (Cys23Ser and a common STR in the promoter) variants were analyzed with respect to attempter status and the severity of suicidal behaviour. The X-linked haplotype analysis in relation to suicide attempt did not reveal any significant association. Furthermore, we performed a particular gene-gene interaction for the X-linked serotonergic genes (HTR2C and MAOA), and found no association among this intergenic haplotype combination and suicidal behaviour in bipolar disorder.

Hypomanic symptoms among first‐time suicide attempters predict future multiple attempt status

Past conceptual and empirical works have identified unique differences between multiple suicide attempters, single attempters, and zero attempters, but have overlooked two distinct subgroups of single attempters: true single attempters who will not attempt suicide again, and future multiple attempters who will. Consistent with fluid vulnerability theory, the authors hypothesized that subgroups should have differences in personality traits that can predict if a first-time attempter is likely to attempt suicide again. In a sample of 127 military members (81% male, 19% female) participating in a clinical intervention study for suicidal behaviors, hypomanic symptoms -- not personality traits -- predicted future multiple attempters, and future multiple attempters more frequently met criteria for a bipolar-spectrum disorder. Clinical implications and convergence of findings with fluid vulnerability theory and existing research are discussed.

Dissociative Disorders and Suicidality in Psychiatric Outpatients

Although it is common for patients with dissociative disorders to report a history of suicide attempts, there is very little data systematically comparing suicidality in patients with dissociative disorders versus patients without these disorders. The subjects in our study were 231 patients consecutively admitted to an inner-city, hospital-based outpatient psychiatric clinic. Eighty-two of these patients completed structured interviews for dissociative disorders, borderline personality disorder, and trauma history (dissociative disorders interview schedule) and for posttraumatic stress disorder and substance abuse (Structured Clinical Interview for DSM-IV). Patients receiving a dissociative disorder diagnosis were compared with nondissociative patients on measures of self-harm and suicidality. Presence of a dissociative disorder was strongly associated with all measures of self-harm and suicidality. When we focused on patients with a history of multiple suicide attempts, significant associations were found between several diagnoses (dissociative disorder; borderline personality disorder; posttraumatic stress disorder; alcohol abuse/dependence) and multiple suicide attempter status. When these diagnoses were entered in a logistic regression, a highly significant association remained for dissociative diagnosis and multiple suicide attempter status (odds ratio, 15.09; 95% confidence interval, 2.67-85.32; p = 0.002). Dissociative disorders are commonly overlooked in studies of suicidality, but in this population they were the strongest predictor of multiple suicide attempter status.

No association between a TPH2 promoter polymorphism and mood disorders or monoamine turnover

Background Tryptophan hydroxylase (TPH) is the rate-limiting enzyme in serotonin synthesis. TPH2 is a recently discovered isoform that is expressed predominantly in serotonin neurons. Associations are reported of TPH2 polymorphisms with MDD, bipolar disorder and suicidal behavior. This study examines a single nucleotide polymorphism in the putative promoter region of the TPH2 gene. Methods One hundred nine bipolar, 324 major depressive disorder, and 130 healthy volunteers were genotyped for the rs4131347 (−C8347G) promoter SNP. Association was assessed with diagnosis, suicide attempt status, severity of psychopathology and cerebrospinal fluid monoamine metabolite levels of 5-HIAA, HVA, and MHPG. General linear models and logistic regression tested the effect of genotype ⁎ childhood abuse interactions on psychopathology severity and suicide attempt. Results There was no association between genotype and either mood disorder, suicide attempt status, psychopathology severity or CSF monoamine metabolite levels. Conclusions No association was detected between the rs4131347 (−C8347G) SNP in the promoter region of the TPH2 gene and mood disorders, suicidal behavior or monoamine function.

Change in “resolved plans” and “suicidal ideation” factors of suicidality after participation in an intensive outpatient treatment program

Background This study aims to investigate factors related to suicide in a unique clinical population with more chronic psychopathology than many outpatient samples. Method One hundred and five adult outpatients were included in the current study. We predicted that higher scores on the resolved plans and preparation (RPP) factor of the Beck Suicide Scale [Beck, A.T., Kovacs, M., Weissman, M., (1979). Assessment of suicidal intention: The scale for suicidal ideation. Journal of Consulting and Clinical Psychology 47, 343–352] would predict multiple attempter status even after accounting for co-morbid diagnoses and suicidal ideation (SI) factor scores. Additionally, we predicted that the scores on the RPP factor would decrease less over time than scores on the SI factor. Results and conclusions Results were consistent with both hypotheses, suggesting that RPP factor scores were uniquely predictive of status as a multiple attempter and were more stable over time. Limitations Mental health diagnoses were rendered without the use of a structured interview and therefore no reliability data were collected.