Near-lethal Suicide Attempts Research Articles

Associations between childhood abuse, mental health problems, and suicide risk among male prison populations in Spain

There are few studies exploring associations between different types of childhood abuse and mental health problems among adult prisoners. To explore associations between history of childhood abuse, depression or anxiety, and near-lethal suicide attempts among adult prisoners, and test the hypothesis that post-traumatic stress disorder (PTSD) may be a mediator between childhood abuse and adult disorder among prisoners. We enrolled 943 men from three prisons in Spain. Childhood abuse was assessed with the Childhood Trauma Questionnaire at interview and current symptoms were assessed using the 21-item Depression Anxiety and Stress Scale (DASS-21). Self-reported histories of near-lethal suicide attempts were recorded. Overall, 360 (40%) of the men reported at least one type of childhood abuse; 231 (24.5%) described exposure to emotional abuse, 236 (25%) to physical abuse, and 97 (10%) to sexual abuse. Survivors of all types of childhood abuse had over twice the prevalence of severe depression, anxiety, stress disorder, and near-lethal suicide attempts than men who had not been exposed. Survivors of sexual and emotional violence during childhood had more symptoms of PTSD than survivors of physical abuse. Statistically, PTSD had a mediating effect, but it was very small. Although other studies have shown high rates of childhood abuse histories among prisoners, this is the first to link such a history to near-lethal suicide attempts in this population.

Roads less taken: Pathways to care before near-lethal suicide attempts

This study identifies the cultural values affecting near-lethal suicide attempters’ help-seeking behaviours. Six Chinese survivors of intentional near-lethal self-poisoning were interviewed and their medical records examined. Interviewees with strong suicidal intentions had less demand for healthcare services and were resistant to care. Non-contact with services was associated with perceived service irrelevance, unhelpfulness and personal need to maintain self-reliance and dignity. Service providers should be trained to be sensitive to these individual values to allow the delivery of a culturally-appropriate service for this population. Social work empowerment models that focus on users’ self-reliance should be adopted in practice for this high-risk group.

Exploring suicidal behaviours by probation clients-a qualitative near-lethal study.

Existing research emphasizes that offenders serving community based sentences are at an increased risk of suicide compared with the general population, however, there is little understanding about the causes of this risk. The aim of the current research was to understand how to support probation clients and prevent suicide, by exploring the experiences of probation clients who carried out near-lethal suicide attempts whilst under probation supervision. In-depth interviews were carried out with seven probation clients who made near-lethal suicide attempts whilst serving a probation sentence. Data were analysed using Interpretative Phenomenological Analysis. Participants recounted negative experiences which they perceived to be linked to their suicidal feelings and behaviours, such as experiencing bereavements, perceived loss of control over their mental state or situation, and difficulties relating to stages of their probation sentence. Participants expressed severe difficulties with trusting authorities, making disclosure of suicidal feelings problematic. However, participants emphasized the role that purposeful and meaningful activity can play in suicide prevention. Suicide prevention strategies must be tailored to the needs of probation clients across the UK. Mandatory training for probation staff is recommended to help reduce suicides, and support from external agencies should be sought where possible.

Risk Factors Associated With Near-Lethal Suicide Attempts During Incarceration Among Men in the Spanish Prison System.

Studies conducted worldwide indicate that near-lethal suicide attempts are common among incarcerated populations. However, little research attention has been focused on the Spanish prison population. To address this gap in the literature, data were drawn from a sample of men ( N = 2,270) incarcerated in seven prisons in Spain. We compared sociodemographic, criminal/offense, health and mental health, and life events in prison variables between inmates who reported making near-lethal suicide attempts ( n = 616) and those who did not ( n = 1,654) during their current incarceration term. A series of binary and multiple logistic regression analyses indicated that a variety of variables were associated ( p values < .001) with near-lethal suicide attempts, including prior-to-prison employment status, family members in prison, recidivist in prison, childhood trauma, work status in prison, and disciplinary infractions. Our study findings are discussed in light of developing more effective strategies and prevention interventions to reduce attempted suicide in the Spanish Prison System.

Prevention of Suicidal Behavior in Prisons

. Background: Worldwide, prisoners are at high risk of suicide. Research on near-lethal suicide attempts can provide important insights into risk and protective factors, and inform suicide prevention initiatives in prison. Aims: To synthesize findings of research on near-lethal attempts in prisons, and consider their implications for suicide prevention policies and practice, in the context of other research in custody and other settings. Method: We searched two bibliographic indexes for studies in any language on near-lethal and severe self-harm in prisoners, supplemented by targeted searches over the period 2000–2014. We extracted information on risk factors descriptively. Data were not meta-analyzed owing to heterogeneity of samples and methods. Results: We identified eight studies reporting associations between prisoner near-lethal attempts and specific factors. The latter included historical, prison-related, and clinical factors, including psychiatric morbidity and comorbidity, trauma, social isolation, and bullying. These factors were also identified as important in prisoners' own accounts of what may have contributed to their attempts (presented in four studies). Conclusion: Factors associated with prisoners' severe suicide attempts include a range of potentially modifiable clinical, psychosocial, and environmental factors. We make recommendations to address these factors in order to improve detection, management, and prevention of suicide risk in prisoners.

Understanding Access to Means of Suicide Opens Door to Prevention

Back to table of contents Previous article Full AccessUnderstanding Access to Means of Suicide Opens Door to PreventionAaron LevinAaron LevinSearch for more papers by this authorPublished Online:15 Jan 2015https://doi.org/10.1176/appi.pn.2015.1b17AbstractKnowledge, familiarity, and comfort with a particular method of suicide will likely direct a person’s choice of lethal means.Suicide is most often an unpremeditated, impulsive act, so if that moment can be staved off, the individual is likely not to try suicide again, Alan Berman, Ph.D., of Washington, D.C., told attendees at a workshop on the means of violence at the Institute of Medicine last December in Washington, D.C.“Most often, suicide is attempted by someone with immediate access to agents in the context of a temporary crisis,” said Berman, former executive director of the American Association of Suicidology. A study conducted in Houston, he said, found that 24 percent of near-lethal suicide attempts occurred within five minutes of thinking about suicide, and 70 percent happened within an hour.“Yet 90 percent of those who survive an attempt do not go on to die by suicide,” said Berman. “We need to give them the chance for a change of mind, a change of circumstances, or some therapeutic intervention.”Attention to and control of access to the means used for suicide offer one avenue of lessening risk for an act that takes the lives of at least 800,000 individuals worldwide each year. Globally, most people kill themselves by hanging, although firearms are the most common method in the United States. Pesticide poisoning is a very common method in China and other parts of Asia, he said.All of these methods share common factors in the context of their cultures: they are accessible yet lethal, said Berman. People have a knowledge of and familiarity and comfort with the means.Pesticides in China (especially in rural areas) are found commonly in the home, as are guns in America. Easy access to means is often compounded in poor or remote areas by distance from medical intervention, making rescue difficult.Attempts to remind Chinese villagers of the dangers of pesticides or to delay access to the poisons have met with only mixed success, he said.One antisuicide success story occurred in Great Britain. A shift from coal gas (which contains a large percentage of carbon monoxide) to natural gas cut the number of suffocation suicides from 2,500 in 1960 to just eight in 1977, contributing to an overall decline in that country’s suicide rates. Natural gas, a mixture of methane and ethane, contains far less carbon monoxide and hence is less lethal. In the United States, efforts to restrict access to the means of suicide have met with numerous challenges. “Auto manufacturers have resisted installing engine shutoff switches to prevent carbon monoxide poisoning, and the rail industry won’t spend the money to fence off tracks, even though a majority of rail suicides occur within five miles of a station,” said Berman. Firearms restrictions are consistently resisted by the National Rifle Association, one of the most powerful lobbies in Washington, D.C.David Hemenway, Ph.D., went on to detail research into the epidemiology of gun ownership.“Overwhelmingly, the evidence from case control and ecological studies shows that the presence of a gun in the home increases the risk of suicide,” said Hemenway, a professor of health policy in the Harvard School of Public Health and director of the Harvard Injury Control Research Center. “Everyone in the family—not only the gun owner but the also the spouse and the children—is at increased risk.” He also cautioned against assuming that mental illness, rather than easy access to firearms, is at fault when a person uses a gun to take his or her own life.A gun in the home increases the risk of death for women, who are less likely to own guns but more likely to be a victim of domestic violence. It also increases the risk of child suicide by a factor of 10 and of unintentional injury by a factor of nine. Gun owning also raises the risk of suicide for adult men.Stronger gun laws appear to reduce risk of homicide and suicide, but those effects cannot be attributed to any specific law, complicating policy planning, said Hemenway. Updated and better-quality research with greater statistical power is needed to clarify associations between gun laws and risks for firearms suicide, homicide, and injury. ■More information on the Institute of Medicine’s Means of Violence workshop can be accessed here. ISSUES NewArchived

A Typology of Male Prisoners Making Near-Lethal Suicide Attempts

Prisoners are at high risk of suicide. This study aimed to develop a typology of prison suicide. We interviewed 60 male prisoners who made near-lethal suicide attempts in prison to obtain quantitative and qualitative data regarding psychiatric, psychological, social, and criminological factors. We analyzed this information to develop a typology to classify suicidal prisoners and validated it by having a prison psychiatrist independently rate each interview transcript. We developed a typology of five subgroups: attempts that (1) were due to a prisoner being unable to cope in prison, (2) were motivated by psychotic symptoms, (3) had instrumental motives, (4) were "unexpected" by the prisoners themselves, and (5) were associated with withdrawal from drugs. The interrater reliability as measured by Cohen's was good to excellent at 0.81 (p < .001), 95% CI (0.69, 0.93). With further validation in other samples, this typology may assist suicide prevention initiatives in prisons as well as other forensic institutions by informing the assessment and formulation of suicide risk.

Psychosocial characteristics and social networks of suicidal prisoners: towards a model of suicidal behaviour in detention.

Prisoners are at increased risk of suicide. Investigation of both individual and environmental risk factors may assist in developing suicide prevention policies for prisoners and other high-risk populations. We conducted a matched case-control interview study with 60 male prisoners who had made near-lethal suicide attempts in prison (cases) and 60 male prisoners who had not (controls). We compared levels of depression, hopelessness, self-esteem, impulsivity, aggression, hostility, childhood abuse, life events (including events occurring in prison), social support, and social networks in univariate and multivariate models. A range of psychosocial factors was associated with near-lethal self-harm in prisoners. Compared with controls, cases reported higher levels of depression, hopelessness, impulsivity, and aggression, and lower levels of self-esteem and social support (all p values <0.001). Adverse life events and criminal history factors were also associated with near-lethal self-harm, especially having a prior prison spell and having been bullied in prison, both of which remained significant in multivariate analyses. The findings support a model of suicidal behaviour in prisoners that incorporates imported vulnerability factors, clinical factors, and prison experiences, and underscores their interaction. Strategies to reduce self-harm and suicide in prisoners should include attention to such factors.

Studying survivors of near-lethal suicide attempts as a proxy for completed suicide in prisons

Suicides in prisons are common. There is a pressing need to understand more about the causes and prevention of prisoner suicides. A particularly informative approach is through studying survivors of near-lethal suicide attempts. However, the extent to which this approach is a good proxy for completed suicide requires verification. In this article we aimed to assess (1) the extent to which male and female prisoners who made near-lethal suicide attempts in prison are similar to prisoners who die by suicide; (2) the suicidal intent of those making near-lethal suicide attempts; and (3) the applicability of the Suicide Intent Scale in prisons. Survivors of near-lethal suicide attempts and prisoners who died by suicide were compared on sociodemographic and criminological characteristics. The suicidal intent of prisoners engaging in near-lethal self-harm was assessed using Beck's Suicide Intent Scale. There were no significant differences when the sociodemographic and criminological profiles of prisoners who made near-lethal suicide attempts and those who died by suicide were compared, except that male prisoners who made near-lethal suicide attempts were somewhat younger. Most prisoners carrying out near-lethal acts had high suicidal intent. However, some questions in the Suicide Intent Scale were inappropriate for assessing intent in prisoners. Prisoners who survive near-lethal self-harm would appear to be a valid proxy for those who die by suicide in prison. The Suicide Intent Scale requires some modifications for use in prisons.

The suicidal process in male prisoners making near-lethal suicide attempts

Most investigations of factors contributing to prisoner suicide have focused on suicidal behaviour as a discrete event and used official records or ‘psychological autopsy’ methodology. A potentially more informative approach is to study survivors of near-lethal suicide attempts about their suicidal process. We have investigated the suicidal process in male prisoners through semi-structured interviews with 60 prisoners who made near-lethal suicide attempts. The suicide attempts often followed adverse life events (especially broken relationships or bereavement), criminal justice/prison-related factors (e.g. concerns about sentencing) and psychiatric or psychological factors (e.g. drug/alcohol withdrawal, depression/anxiety and hearing voices). The majority of prisoners said they intended to die (73%), although many acts had been impulsive (40%). Most described visual images about their suicidal acts (82%). Limited access to methods of suicide had clearly influenced method choice (most commonly hanging/ligaturing 67%), along with expectations about the anticipated speed, painfulness and lethality. Half the prisoners believed their acts could have been prevented, often with relatively simple solutions. The suicidal process in prisoners is a complex interplay of background factors, adverse life events, mental health and psychological problems and cognitive processes. Understanding and recognising these various aspects of the process is likely to improve suicide prevention in prisons.

Impact on prisoners of participating in research interviews related to near-lethal suicide attempts

Prisoners have a high risk of suicide. Research studies have investigated factors contributing to this, some through interviews with survivors of suicide attempts, others with informants such as family and friends of suicide victims. However, there is little information regarding the effects of participating in such interviews. To investigate the effects on participants of taking part in detailed interviews about suicidal behaviour and contributory factors. Case-control studies of 120 prisoners who made near-lethal suicide attempts (cases) and 120 prisoners who had never carried out near-lethal suicide attempts in prison (controls) were conducted. Information regarding effects on prisoners of participating in the interviews was collected using quantitative and qualitative methods. For both male cases and controls, and female controls, self-reported mood levels improved significantly by the end of the interviews. For female cases, the interviews had no negative effect on their self-reported mood. Whilst some prisoners found the interviews upsetting, nearly all said they were pleased to have participated. The same researchers carried out the interviews and collected data on the effects of participation. Also, several potential participants were excluded from the study and the likely effect of the interview on them is unknown. We found little evidence that participation of prisoners in interview-based research on suicidal behaviour has negative effects on them; indeed, it can be beneficial. Inclusion of similar instruments to measure the effects of research participation in future investigations could provide valuable feedback to researchers and ethics committees.

Appraisal of Suicidal Risk Among Adolescents and Young Adults Through the Rorschach Test

The aims of this study are to investigate suicidal behaviors among adolescents and young adults and to test an index composed using Rorschach test responses related to an increased risk of suicide. Using a cross-sectional design, 4 groups were studied (according to criteria of the Columbia Classification Algorithm of Suicide Assessment [Posner, Oquendo, Gould, Stanley, & Davies, 2007]): A group with suicidal ideation (n = 30), a group with parasuicidal behavior (n = 30), a group with near-lethal suicide attempts (n = 26), and a control group (n = 30). Responses to the Rorschach test yielded 6 potential indicators of suicidal behavior (scored according to Exner's Comprehensive System and the Suicidal Index for Adolescents; Silberg & Armstrong, 1992). Rorschach scores including at least 4 of these 6 indicators selected 69% of the people who had committed serious suicide attempts. The Rorschach Suicidal Index reached an acceptable reliability and was related to other criteria of suicide risk, such as the Beck Depression Inventory (BDI; Beck, Ward, Mendelsohn, Mock, & Erbaugh, 1961) and Linehan Reasons for Living Inventory (RFL–I; Linehan, Goodstein, Nielsen, & Chiles, 1983). Moreover, the Rorschach Suicidal Index showed incremental validity over the BDI and the RFL–I to predict suicidal behavior. A path analysis additionally showed that low social support was an important mediator between the Rorschach Suicidal Index and the number of suicide attempts committed by participants.

Psychiatric disorders in male prisoners who made near-lethal suicide attempts: case–control study

Although male prisoners are five times more likely to die by suicide than men of a similar age in the general population, the contribution of psychiatric disorders is not known. To investigate the association of psychiatric disorders with near-lethal suicide attempts in male prisoners. A matched case-control study of 60 male prisoners who made near-lethal suicide attempts (cases) and 60 prisoners who had never carried out near-lethal suicide attempts in prison (controls) was conducted. Psychiatric disorders were identified with the Mini International Neuropsychiatric Interview (MINI), and information on sociodemographic characteristics and criminal history was gathered using a semi-structured interview. Psychiatric disorders were present in all cases and 62% of controls. Most current psychiatric disorders were associated with near-lethal suicide attempts, including major depression (odds ratio (OR) = 42.0, 95% CI 5.8-305), psychosis (OR = 15.0, 95% CI 2.0-113), anxiety disorders (OR = 6.0, 95% CI 2.3-15.5) and drug misuse (OR = 2.9, 95% CI 1.3-6.4). Lifetime psychiatric disorders associated with near-lethal attempts included recurrent depression and psychoses. Although cases were more likely than controls to meet criteria for antisocial personality disorder, the difference was not statistically significant. Comorbidity was also significantly more common among cases than controls for both current and lifetime disorders. In male prisoners, psychiatric disorders, especially depression, psychosis, anxiety and drug misuse, are associated with near-lethal suicide attempts, and hence probably with suicide.

Two Studies that Challenge “Conventional Wisdom”

Source: Mercy JA, Kresnow M, O’Carrol PW,et al. Is suicide contagious? A study of the relation between exposure to the suicidal behavior of others and nearly lethal suicide attempts. Am J Epidemiol. 2001;154:120–127.The authors conducted a population-based case-control study in Houston to examine the association between adolescents’ nearly lethal suicide attempts and exposure to suicidal behavior of parents, relatives, friends, or acquaintances, and to accounts of suicide in the media. They interviewed 153 victims, 83 male, aged 13–34 who had been treated at 3 area hospital emergency departments between 1992 and 1995 for nearly lethal suicide attempts, and 513 control subjects identified by random digit dialing. Nearly lethal events were defined as those in which the attempter probably would have died without emergency medical or surgical intervention or those in which the attempter sustained any injury from a method with a high case fatality ratio (ie, gun or noose). Interviews were successfully completed with 63% of eligible cases and 60% of eligible controls. After controlling for possible confounding variables, nearly lethal suicide attempts were not significantly associated with suicidal behavior of a parent (OR=1.5; 95% CI, .6–3.6, P=.42) or a non-parent relative (OR=1.2; 95% CI, .7–2.0, P=.55). Suicidal behavior of a friend or acquaintance (OR=.6; 95% CI, .4–1.0, P=.05) and exposure to media accounts of suicide (OR=.2; 95% CI, .1–.3; P=.00) were both associated with a lower risk of nearly lethal suicide attempts. The authors conclude that exposure to suicide in the media and, to a lesser extent, exposure to suicide behavior of friends or acquaintances may protect against nearly lethal suicide attempts.Source: Takemura Y, Sakurai Y, Honjo S, et al. Relation between breastfeeding and the prevalence of asthma: The Tokorozawa Childhood Asthma and Pollinosis Study. Am J Epidemiol. 2001;154:115–119.These investigators at Japan’s National Defense Medical College studied the relationship between breastfeeding and the prevalence of asthma among children. They enrolled all public elementary and junior high school students in Tokorozawa, Japan (ages 6–15 years). Subjects included 2,315 students with asthma and 21,513 controls. Parents completed a standardized questionnaire. After adjustment for age, gender, parental smoking, and parental history of asthma, a higher prevalence of asthma was noted among children who had been breastfed (OR=1.198; 95% CI, 1.054–1.363; P<.01). The authors suggest that breastfeeding may be a risk factor for asthma in school-age children.Conventional wisdom tells us that suicide attempts by schoolmates and media exposure to suicide events are important risk factors for suicide in psychologically vulnerable adolescents and young adults.1 Mercy et al show the opposite: exposure to suicide behavior by acquaintances and media accounts of suicide appear to have a protective effect against nearly lethal suicide attempts. Many pediatricians also believe that breastfeeding protects against asthma.2,3 The study by Takemura et al suggests that, on the contrary, breastfeeding may be a risk factor for asthma. What gives?In the suicide study, the authors point out that conventional wisdom is derived from reports of clusters of suicide attempts in communities rather than isolated cases. They also suggest that recent media portrayals of suicide are more realistic and less glamorous than in the past. However, it is also important to note that this study examined near-lethal suicide attempts, which may differ in important ways from clusters of so-called “suicide gestures.” Also, the risk factors for completed suicides may differ from the factors influencing the attempts in this study. Clearly, the causes of the spectrum of suicidal behaviors in various contexts need further elucidation.Contrary to popular wisdom, studies of the relationship between breastfeeding and asthma have yielded disparate results. Similar numbers of studies have shown benefit, risk, or no effect at all. Takemura et al note that their study is limited by the potential for faulty recall of past events and by lack of information on parental smoking prior to the onset of asthma. They conclude only that their findings show the possibility of an undesirable effect. The etiology of asthma is almost certainly multifactorial. It is possible that what appears to be a protective factor in one study might appear as a contributory factor in another due to confounding. These 2 studies show the utility of epidemiologic investigations in both raising questions about our common beliefs and assisting us to formulate the next research questions.

The Rorschach Suicide Constellation: Assessing Various Degrees of Lethality

In this article we examine the relation between the Rorschach Comprehensive System's Suicide Constellation (S-CON; Exner, 1993; Exner & Wiley, 1977) and lethality of suicide attempts during the course of patients' hospitalization at the Austen Riggs Center (Stockbridge, MA). Patient records were rated as nonsuicidal (n = 37), parasuicidal (n = 37), or near-lethal (n = 30) based on the presence and lethality of self-destructive acts. Diagnostic efficiency statistics utilizing a cutoff score of 7 or more positive indicators successfully predicted which patients would engage in near-lethal suicidal activity relative to parasuicidal patients (overall correct classification rate [OCC] = .79), nonsuicidal inpatients (OCC = .79), and college students (OCC = .89). Although these predictions were influenced by relatively high base rates in the hospital population (14.5%), base rate estimates were calculated for other hypothetical populations revealing different prediction estimates that should be considered when judging the relative efficacy of the S-CON. Logistic regression analysis revealed that an S-CON score of 7 or more was the sole predictor of near-lethal suicide attempts among 9 psychiatric and demographic variables.

An empirical study of seriously disturbed suicidal patients.

Aspects of unconscious processes in a group of seriously disturbed psychiatric patients are examined in an effort to predict near-lethal suicide attempts and explore psychoanalytic formulations of suicide. The Rorschach Inkblot Test, the most widely used projective measure in suicide research (Bongar 1991), was chosen for its potential to shed light on specific unconscious processes. Psychic states commonly associated with suicide were measured by psychoanalytic Rorschach analog scales and then subjected to a progression of statistical analyses in order to predict future occurrence and lethality of suicide attempts. On the basis of a priori hypotheses, the authors developed a suicide index comprising four psychoanalytic Rorschach signs that predicted, with considerable accuracy, which patients would later make near-lethal suicide attempts. The best predictors were unconscious processes indicative of penetrating affective overstimulation, disturbance in the capacity to maintain adequate ego boundaries, and depressive affective states characterized by a morbid preoccupation with death and inner decay. These findings provide empirical support for several well-known formulations of the unconscious motivations for suicide.