The current American Journal of Psychiatry offers an editorial by J.John Mann, MD, who describes several articles in this AJP that contribute toward furthering our understanding about suicide and suicidal behavior. He points out that not only is suicide a major cause of death in the United States and around the world but that it is the third leading cause of death in young people in the US and the leading cause of death in young adults in China, Sweden, Australia, and New Zealand and other countries. For every suicide, there are approximately 10 suicide attempts. There continues to be an urgent need for research into the causes of suicide and suicide attempts and to strive toward the development of a scientific basis for designing national plans for suicide prevention.
One of the articles in this AJP looks at individuals with multiple suicide attempts to look for predictive markers for severe psychopathology. Researchers compared those who made a single suicide attempt to individuals who had made multiple suicide attempts using a series of self-report questionnaires and clinician-completed rating scales. Although the groups were similar in age, the multiple-attempt group occurred at a significantly earlier age than the suicide attempt in the single-attempt group. The multiple-attempt group also had greater severity of psychopathology, greater psychiatric comorbidity, and poorer functioning in terms of problem solving and interpersonal relationships.
This result is inconsistent with previous research that suggests that it is the subjective severity of depression that distinguishes suicide attempters from nonattempters and the authors suggest a kindling effect. That each time the suicidal mode becomes activated, it becomes increasingly accessible in memory and requires less triggering stimuli to become activated the next time.
Race as a Variable
The other studies continued to look at the factors related to suicide from Health studies. Data from the US National Mortality Followback Survey was used to compare factors related to completed suicide in African Americans versus Caucasians. In addition to demographic variables, clinical variables in the assessment included antisocial behavior, substance abuse, depressive symptoms, and psychotic symptoms. The results found very few differences between white and black suicide groups. Four items distinguished suicides in both groups from accidents: death ideation, suicidal ideation, bizarre behavior, and withdrawn behavior. The use of marijuana, community complaints about antisocial behavior and problem drinking, were more frequent in white than in black subjects.
Dr. Mann suggests that 'this study is an important step forward in that problems with alcoholism and antisocial behavior emerge as more important for suicide in white than in black subjects. Such a finding merely highlights how little we know about the factors that are important in suicide in black subjects.'
Internalizing versus Externalizing
The third article on suicide looks at data from the Colorado Social Health Survey to evaluate two dimensions of psychopathology: internalizing and externalizing behavior related to suicide attempts. The internalizing factor was related to mood and anxiety disorders, and the externalizing factor was related to conduct disorder and antisocial personality disorder. The researchers did a symptom count and factor analysis of these dimensions. "The major finding was that both in men and in women, the investigators confirmed a long-demonstrated role for internalizing symptoms being related to suicide attempts. Also for both men and women, an independent relationship to suicidality was demonstrated for externalizing psychopathology." Comorbidity was also predictive of suicidal behavior but more so among women.
The goal of such a study is to help guide clinicians in the screening of individuals for risk for suicidal behavior and offers new targets for therapeutic intervention. Different approaches can be devised for individuals screened for those who tend to internalize affects as opposed to those who are more aggressive or impulsive. Hopefully. continued research can provide further tools for the clinician in detecting high-risk patients and guiding treatment.
Recent studies by JJ Mann, MD
A recent Medscape Interview with Maria Oquendo, MD on suicide in families
(registration free but required)
Suicide Survivors: Tips for Health Professionals
(fromMedGenMed Psychiatry & Mental Health)
American Foundation for Suicide Prevention
Center for Suicide Prevention
Suicide and Suicide Prevention
(from Depression Central)