Self-directed Violence Research Articles

The Association of Multiple Identities with Self-Directed Violence and Depression among Transgender Individuals.

Transgender individuals have a high prevalence of self-directed violence; however, there is scant literature focusing on their unique experiences. The differences in self-harm, suicidal ideation, suicide attempt, and depression based on racial/ethnic identity and sexual orientation were examined among transgender individuals. Data were gathered from the Fall 2008 and Spring 2009 National College Health Assessment. Across racial/ethnic identities, greater proportions of transgender students endorsed self-directed violence than their cisgender peers. Among transgender individuals, sexual minorities were more likely to report suicidal ideation than their heterosexual peers, and racial/ethnic minorities had higher odds of attempting suicide than non-Hispanic White individuals.

The Validity of a Brief Risk Assessment Tool for Predicting Suicidal Behavior in Veterans Utilizing VHA Mental Health Care.

Suicide risk among military veterans is an important and ongoing concern. The Veterans Administration (VA) mandates suicide risk screening of all veterans seen for mental health issues, but little is known about the effectiveness of this screening. A retrospective chart review to examine all suicide risk screens at VA San Diego between October and December 2012 (n=3,365) was conducted to assess whether results were associated with suicidal behavior over the subsequent 12months. Patients judged to be at increased risk for suicide were 3 to 16 times more likely to attempt suicide and 7 to 25 times more likely to engage in self-directed violence over the next 12months compared with others. The screening tool may be a useful addition to clinical practice.

Mental Health of Transgender Veterans in US States With and Without Discrimination and Hate Crime Legal Protection.

To examine whether indicators of community- and state-level lesbian, gay, bisexual, and transgender equality are associated with transgender veterans' mental health. We extracted Veterans Administration data for patients who were diagnosed with gender identity disorder, had at least 1 visit in 2013, and lived in a zip code with a Municipality Equality Index score (n = 1640). We examined the associations of whether a state included transgender status in employment nondiscrimination laws and in hate crimes laws with mood disorders; alcohol, illicit drug, and tobacco use disorders; posttraumatic stress disorder; and suicidal ideation or attempt. Nearly half (47.3%) of the sample lived in states with employment discrimination protection, and 44.8% lived in states with hate crimes protection. Employment nondiscrimination protection was associated with 26% decreased odds of mood disorders (adjusted odds ratio [AOR] = 0.74; 95% confidence interval [CI] = 0.59, 0.93) and 43% decreased odds of self-directed violence (AOR = 0.57; 95% CI = 0.34, 0.95). Understanding lesbian, gay, bisexual, and transgender social stressors can inform treatment and care coordination for transgender populations.

What Every ED Nurse Should Know About Suicide Risk Assessment

Suicide is internationally recognized as a major cause of preventable death, particularly among older adults and persons with a history of psychiatric and/or substance use disorders. Historical perceptions of suicide still have an impact on modern attitudes, assumptions, and practices. Perceptions about suicide are generally defined by spiritual, cultural, ethnic, and social factors. The Centers for Disease Control and Prevention (CDC) defines suicide as “death caused by self-directed injurious behavior with any intent to die as a result of the behavior” (p. 25). 1 Crosby AE Ortega L Melanson C Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements. Version 1.0. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA2011 Google Scholar Deborah Antai-Otong is Continuous Readiness Officer and Psychiatric Mental Health Nurse Practitioner, Department of Veterans Affairs, Arlington, TX.

Association of Cigarette Smoking With Interpersonal and Self-Directed Violence in a Large Community-Based Sample.

Substance use is a major risk factor for various forms of violence, yet how cigarette smoking influences violence outcomes is incompletely understood. We investigated associations between cigarette smoking and three types of violence in a large, nationally representative, community-based sample. Adult subjects participating in both Wave 1 (2001-2002; N = 43 093) and Wave 2 (2004-2005; N = 34 653) of the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) were stratified by daily cigarette smoking status at Wave 1, and individuals with unchanged smoking status between waves were analyzed (nonsmokers [consisting of never and former daily smokers]: N = 22 529; daily smokers: N = 7442). We created composites of other- and self-directed violence and victimization occurring between Waves 1 and 2, and performed logistic regression models, controlling for psychiatric diagnoses, alcohol and substance use, and relevant demographic covariates. Daily smokers at Wave 1 were 2.1 (95% CI: 1.5-3.0), 2.5 (2.1-2.9), and 1.7 (1.5-2.1) times more likely than nonsmokers to report self-directed violence, other-directed violence, or victimization between Waves 1 and 2, respectively. Former daily smokers were significantly less likely to report other-directed violence than individuals who were never daily smokers. Daily cigarette smoking is temporally associated with multiple forms of violence compared to never and former cigarette smokers, even when common covariates associated with violence are controlled. Smoking status should be carefully controlled for in studies designed to identify risk factors for violence, and may be a useful component of violence risk assessment. The findings suggest that cigarette smoking status should be carefully and systematically controlled for in studies of violence risk factors. The findings also support further investigation of the utility of cigarette smoking status for violence risk assessment, and whether smoking cessation strategies mitigate violence risk.

Examining challenging behaviors of clients with borderline personality disorder

Few studies have examined effects of challenging behaviors of clients with borderline personality disorder (BPD) on psychotherapy outcomes. Dialectical behavior therapy (DBT) is an evidence-based treatment designed to treat chronic suicidality, self-directed violence (SDV), and emotion dysregulation, while targeting challenging behaviors. DBT has been shown to be effective with clients with BPD. We evaluated whether therapist reported challenging behaviors, such as high volume phone contacts or violating the therapist's limits, during DBT would be associated with dropping out of DBT, severity and frequency of SDV, emotion regulation deficits, psychological symptom severity and client's and therapist's satisfaction of treatment. The current study examined challenging behaviors reported by therapists in a sample of 63 psychiatrically disabled outpatient DBT clients diagnosed with BPD (73% women, average age 37 years). More frequent phone contacts were associated with a decrease in dropout and psychological symptoms, and an increase in client and therapist satisfaction. More avoidance/disengagement behavior was associated with more than twice the risk of SDV and a decrease in therapist satisfaction. Findings suggest that the phone coaching might serve to maximize client satisfaction and reduce the likelihood of dropout.

The second wave of violence scholarship: South African synergies with a global research agenda

Violence is a serious public health and human rights challenge with global psychosocial impacts across the human lifespan. As a middle-income country (MIC), South Africa experiences high levels of interpersonal, self-directed and collective violence, taking physical, sexual and/or psychological forms. Careful epidemiological research has consistently shown that complex causal pathways bind the social fabric of structural inequality, socio-cultural tolerance of violence, militarized masculinity, disrupted community and family life, and erosion of social capital, to individual-level biological, developmental and personality-related risk factors to produce this polymorphic profile of violence in the country. Engaging with a concern that violence studies may have reached something of a theoretical impasse, ‘second wave’ violence scholars have argued that the future of violence research may not lie primarily in merely amassing more data on risk but rather in better theorizing the mechanisms that translate risk into enactment, and that mobilize individual and collective aspects of subjectivity within these enactments. With reference to several illustrative forms of violence in South Africa, in this article we suggest revisiting two conceptual orientations to violence, arguing that this may be useful in developing thinking in line with this new global agenda. Firstly, the definition of our object of enquiry requires revisiting to fully capture its complexity. Secondly, we advocate for the utility of specific incident analyses/case studies of violent encounters to explore the mechanisms of translation and mobilization of multiple interactive factors in enactments of violence. We argue that addressing some of the moral and methodological challenges highlighted in revisiting these orientations requires integrating critical social science theory with insights derived from epidemiology and, that combining these approaches may take us further in understanding and addressing the recalcitrant range of forms and manifestations of violence.

Combined Toxoplasma gondii seropositivity and high blood kynurenine – Linked with nonfatal suicidal self-directed violence in patients with schizophrenia

Toxoplasma gondii (T. gondii) chronic infection and elevated kynurenine (KYN) levels have been individually associated with non-fatal suicidal self-directed violence (NF-SSDV). We aimed to test the hypothesis that the association between T. gondii seropositivity and history of NF-SSDV would be stronger in schizophrenia patients with high plasma KYN levels than in those with lower KYN levels. We measured anti-T. gondii IgG antibodies and plasma KYN in 950 patients with schizophrenia, and used logistic regression to evaluate the relationship between NF-SSDV and KYN in patients who were either seropositive or seronegative for T. gondii. For those with KYN levels in the upper 25th percentile, the unadjusted odds ratio for the association between NF-SSDV history and KYN in T. gondii seropositive patients was 1.63 (95% CI 1.01 to 2.66), p = 0.048; the adjusted odds ratio was 1.95 (95% CI 1.15 to 3.30), p = 0.014. Plasma KYN was not associated with a history of NF-SSDV in T. gondii seronegative patients. The results suggest that T. gondii and KYN may have a nonlinear cumulative effect on the risk of NF-SSDV among those with schizophrenia. If confirmed by future longitudinal studies, this result is expected to have both theoretical and clinical implications for the prevention and treatment of suicidal behavior.

How Parental Reactions Change in Response to Adolescent Suicide Attempt

This study examined parental reactions to adolescents’ suicide attempts and the association of reactions with future suicidal self-directed violence. Participants were 81 mothers and 49 fathers of 85 psychiatric inpatient adolescents. Maternal hostility and paternal anger and arguing predicted future suicide attempts. From pre- to post-attempt, mothers reported feeling increased sadness, caring, anxiety, guilt, fear, and being overwhelmed; fathers reported increased sadness, anxiety, and fear. Findings have clinical implications; improving parent-child relationships post-suicide attempt may serve as a protective factor for suicide.

Mortality Among OEF/OIF/OND Veterans Diagnosed with Traumatic Brain Injury (TBI) and/or Post Traumatic Stress Disorder (PTSD) Using VA Health Care System

To examine mental health indicators, in aggregate and stratified by sex, among a population-based sample of U.S. military veterans.Data are from veteran who completed the Veterans Health Module (VHM) of the 2011 and 2012 Behavioral Risk Factor Surveillance System (n = 10,406). VHM items included lifetime diagnoses of mental illnesses, service in a combat zone, sources of mental health care, and past 12-month suicidal ideation and attempt. We used weighted, multiple logistic regression models, adjusted for sociodemographics, to examine differences in suicidal ideation and attempt among men and women.Overall, 5.0% of the sample reported recent suicidal ideation and 1.0% reported attempting suicide. Among men, unemployment was positively associated with suicidal ideation, and combat exposure was negatively associated with suicidal ideation. Being separated, divorced, or widowed was positively associated with suicidal ideation among women. After adjusting for sociodemographic and VHM variables, veterans who sought mental health treatment from both Veterans Affairs (VA) and non-VA facilities had more than fourfold increased odds of suicidal ideation than veteran who sought mental health treatment from only VA facilities (adjusted odds ratio = 4.02; 95% confidence interval 1.23–13.13).Correlates of suicidal ideation differ between male and female veterans. Veterans who use both non-VA and VA facilities for mental health services may have greater risk of self-directed violence.

Choice, deliberation, violence: Mental capacity and criminal responsibility in personality disorder

Personality disorder is associated with self-harm and suicide, as well as criminal offending and violence towards others. These behaviours overlap when the means chosen to self-harm or attempt suicide put others at risk. In such circumstances, an individual's mental state at one and the same time may be deemed to meet the conditions for criminal responsibility, and to warrant involuntary hospital admission. I explore this tension in how people with personality disorder are treated at the hands of the criminal and civil law respectively in England and Wales: they may be deemed sufficiently mentally well to be punished for their crimes, but not deemed sufficiently mentally well to retain the right to make their own decisions about matters of serious importance to their own lives, including whether or not to continue them. The article divides into four sections. After introducing this tension, Section 2 sketches the nature of personality disorder and the psychology underlying self-directed and other-directed violence. Section 3 addresses the questions of whether people with personality disorder who are violent, whether towards self or others, typically meet the conditions for criminal responsibility and mental capacity respectively, considering in particular whether their underlying desires and values, or their emotional distress, affect their mental capacity to make treatment decisions. Section 4 then considers what we might do to address the tension, within the confines of current legislation. Drawing on The Review of the Mental Health Act 1983, I argue that we are ethically justified in involuntarily admitting to hospital people with personality disorder who pose a serious risk to themselves only if we simultaneously undertake to offer genuine help for their future, in the form of appropriate treatment, social support, and better life opportunities — a provision which, as things stand in England and Wales, is sorely lacking.

Alcohol misuse, firearm violence perpetration, and public policy in the United States

ObjectiveFirearm violence is a significant public health problem in the United States, and alcohol is frequently involved. This article reviews existing research on the relationships between alcohol misuse; ownership, access to, and use of firearms; and the commission of firearm violence, and discusses the policy implications of these findings. MethodNarrative review augmented by new tabulations of publicly-available data. ResultsAcute and chronic alcohol misuse is positively associated with firearm ownership, risk behaviors involving firearms, and risk for perpetrating both interpersonal and self-directed firearm violence. In an average month, an estimated 8.9 to 11.7 million firearm owners binge drink. For men, deaths from alcohol-related firearm violence equal those from alcohol-related motor vehicle crashes. Enforceable policies restricting access to firearms for persons who misuse alcohol are uncommon. Policies that restrict access on the basis of other risk factors have been shown to reduce risk for subsequent violence. ConclusionThe evidence suggests that restricting access to firearms for persons with a documented history of alcohol misuse would be an effective violence prevention measure. Restrictions should rely on unambiguous definitions of alcohol misuse to facilitate enforcement and should be rigorously evaluated.

Executive Functioning and Suicidal Behavior Among Veterans With and Without a History of Traumatic Brain Injury

ObjectiveTo examine the relationship between executive dysfunction, as a multidimensional construct (ie, decision-making, impulsivity, aggression, concept formation), and suicide attempt (SA) history in a high-risk sample of veterans with moderate to severe traumatic brain injury (TBI). DesignObservational, 2×2 factorial design. To estimate group differences, linear regression was used to model the primary and secondary outcomes of interest as a function of history of SA, TBI, and the interaction between the 2 variables. Additionally, to determine the pattern of performance over the course of the Iowa Gambling Test (IGT), scores were modeled across the 5 IGT blocks by using a varying-coefficient model. SettingVeterans Health Administration. ParticipantsVeterans (N=133; no SA/no TBI, n=48; no SA/yes TBI, n=51; yes SA/no TBI, n=12; yes SA/yes TBI, n=22) completed the study measures. InterventionsNot applicable. Main Outcome MeasuresIGT, Immediate and Delayed Memory Test, State-Trait Anger Expression Inventory-2, Wisconsin Card Sorting Test. ResultsAll groups demonstrated learning over the course of the IGT, except for veterans with a history of both SA and TBI. No group differences were identified on other measures of executive functioning. ConclusionsThese findings highlight the potential, unique decision-making challenges faced by veterans with a history of TBI and SA. Specialized interventions focused on overall distress reduction and means restriction may be required to prevent future self-directed violence.

Self-reported Usual Care for Self-directed Violence During the 6 Months Before Emergency Department Admission.

The literature describing the health services individuals receive before and following self-directed violence (SDV) is limited. This study examines services received for the 6 months preceding admission to an urban county medical center emergency department (ED) for SDV. We predicted that individuals with at least 1 prior act of SDV in the past 6 months would have received more services than those for whom the index admission was their only recent act. Participants were recruited from ED admissions during shifts selected to maximize representativeness. Participants (n=202) were interviewed using the Suicide Attempt Self-Injury Interview, Suicide Attempt Self-Injury Count, Treatment History Interview, Mini International Neuropsychiatric Interview, Brief Symptom Index, and SF-12. The majority of index acts of SDV (79%) were suicide attempts. The participants were characterized by low socioeconomic status, substantial symptomatology, low physical and mental health functioning, and multiple psychiatric diagnoses. In the preceding 6 months, 34% were admitted to a hospital and 56% received crisis services (including 44% in the ED). Although three quarters (76%) had seen an outpatient medical provider and most (70%) received psychotropic medications, less than half of the sample received psychiatric services (40%) or outpatient psychosocial treatment (48%). As predicted, utilization for most types of usual care was higher for those engaging in SDV in the 6 months preceding the index admission. Individuals admitted to this ED for SDV received inadequate outpatient psychosocial and psychiatric services despite severe illness and disability.

A factor analysis and exploration of attitudes and beliefs toward complementary and conventional medicine in veterans.

Although Veterans utilize complementary and alternative medicine (CAM) at rates comparable with civilians, little is known about Veterans' attitudes and beliefs toward CAM. Measures to increase such knowledge may help to identify treatment preferences, particularly among those with signature conditions from the recent conflicts [ie, traumatic brain injury (TBI), posttraumatic stress disorder (PTSD)]. This exploratory study aimed to: (1) determine the factors of the Complementary, Alternative, and Conventional Medicine Attitudes Scale (CACMAS); and to utilize the resulting factors to describe (2) attitudes and beliefs toward CAM; (3) their association with TBI, PTSD, and history of self-directed violence. Patterns of CAM use were also obtained. Factor analysis. Observational study. Participants were 97 Veterans seeking care at a Mountain State Veterans Affairs Medical Center. Participants completed the CACMAS, clinical interviews, and self-report measures during a single visit. CACMAS factors identified were: acceptability of (1) CAM and (2) conventional medicine; (3) mind-body integration; and (4) belief in CAM. Acceptability of CAM was significantly associated with history of mild TBI (mTBI) or PTSD symptom severity. Veterans endorsed a wide range of CAM use. Veterans in this sample were open to CAM and conventional medicine, believed in CAM, and believed that treatments should incorporate the mind and body. Veterans with a history of mTBI or PTSD symptoms may be more accepting of CAM. Understanding Veterans' beliefs and attitudes regarding CAM may help providers deliver patient-centered treatments, particularly among those with conditions for which evidence-based interventions are limited (eg, mTBI).

Confronting death from drug self-intoxication (DDSI): prevention through a better definition.

Suicide and other self-directed violence deaths are likely grossly underestimated, reflecting inappropriate classification of many drug intoxication deaths as accidents or unintentional and heterogeneous ascertainment and coding practices across states. As the tide of prescription and illicit drug-poisoning deaths is rising, public health and research needs would be better satisfied by considering most of these deaths a result of self-intoxication. Epidemiologists and prevention scientists could design better intervention strategies by focusing on premorbid behavior. We propose incorporating deaths from drug self-intoxication and investigations of all poisoning deaths into the National Violent Death Reporting System, which contains misclassified homicides and undetermined intent deaths, to facilitate efforts to comprehend and reverse the surging rate of drug intoxication fatalities.

Global development and diffusion of outcome evaluation research for interpersonal and self-directed violence prevention from 2007 to 2013: A systematic review

Through a global review, we identified gaps in the geographical distribution of violence prevention evidence outcome evaluation studies and the types of violence addressed. Systematic literature searches identified 355 articles published between 2007 and 2013 that evaluated programs to prevent interpersonal or self-directed violence; focused on universal or selected populations; and reported outcomes measuring violence or closely related risk factors. The number of studies identified increased annually from 2008 (n = 37), reaching 64 in 2013. Over half (n = 203) of all studies focused on youth violence yet only one on elder maltreatment. Study characteristics varied by year and violence type. Only 9.3% of all studies had been conducted in LMICs. These studies were less likely than those in high income countries (HICs) to have tested established interventions yet more likely to involve international collaboration. Evaluation studies successfully established in LMIC had often capitalized on other major regional priorities (e.g. HIV). Relationships between violence and social determinants, communicable and non-communicable diseases, and even economic prosperity should be explored as mechanisms to increase the global reach of violence prevention research. Results should inform future research strategies and provide a baseline for measuring progress in developing the violence prevention evidence-base, especially in LMICs.

“Latent” infection with Toxoplasma gondii: Association with trait aggression and impulsivity in healthy adults

BackgroundLatent chronic infection with Toxoplasma gondii (T. gondii), a common neurotropic pathogen, has been previously linked with suicidal self-directed violence (SSDV). We sought to determine if latent infection with T. gondii is associated with trait aggression and impulsivity, intermediate phenotypes for suicidal behavior, in psychiatrically healthy adults. MethodsTraits of aggression and impulsivity were analyzed in relationship to IgG antibody seropositivity for T. gondii and two other latent neurotropic infections, herpes simplex virus 1 (HSV1) and cytomegalovirus (CMV). One thousand community-residing adults residing in the Munich metropolitan area with no Axis I or II conditions by SCID for DSM-IV (510 men, 490 women, mean age 53.6 ± 15.8, range 20–74). Plasma samples were tested for IgG antibodies to T. gondii, HSV-1 and CMV by ELISA. Self-reported ratings of trait aggression scores (Questionnaire for Measuring Factors of Aggression [FAF]) and trait impulsivity (Sensation-Seeking Scale-V [SSS-V]) were analyzed using linear multivariate methods. ResultsT. gondii IgG seropositivity was significantly associated with higher trait reactive aggression scores among women (p < .01), but not among men. T. gondii-positivity was also associated with higher impulsive sensation-seeking (SSS-V Disinhibition) among younger men (p < .01) aged 20–59 years old (median age = 60). All associations with HSV-1 and CMV were not significant. ConclusionsAggression and impulsivity, personality traits considered as endophenotypes for SSDV, are associated with latent T. gondii infection in a gender and age-specific manner, and could be further investigated as prognostic and treatment targets in T. gondii-positive individuals at risk for SSDV.

Disparities in adverse childhood experiences among individuals with a history of military service.

Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data. To compare the prevalence of ACEs among individuals with and without a history of military service. Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973. History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex. Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras. Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.

Safety Planning for Military (SAFE MIL): Rationale, design, and safety considerations of a randomized controlled trial to reduce suicide risk among psychiatric inpatients

Mental health related hospitalizations and suicide are both significant public health problems within the United States Department of Defense (DoD). To date, few evidence-based suicide prevention programs have been developed for delivery to military personnel and family members admitted for psychiatric inpatient care due to suicidal self-directed violence. This paper describes the rationale and detailed methodology for a study called Safety Planning for Military (SAFE MIL) which involves a randomized controlled trial (RCT) at the largest military treatment facility in the United States. The purpose of this study is to test the efficacy of a brief, readily accessible, and personalized treatment called the Safety Planning Intervention (Stanley and Brown, 2012). Primary outcomes, measured by blinded assessors at one and six months following psychiatric discharge, include suicide ideation, suicide-related coping, and attitudes toward help seeking. Additionally, given the study's focus on a highly vulnerable patient population, a description of safety considerations for human subjects' participation is provided. Based on this research team's experience, the implementation of an infrastructure in support of RCT research within DoD settings and the processing of regulatory approvals for a clinical trial with high risk suicidal patients are expected to take up to 18–24months. Recommendations for expediting the advancement of clinical trials research within the DoD are provided in order to maximize cost efficacy and minimize the research to practice gap.