Introduction
This subject of this post is adolescents with suicidal thoughts. It addresses the question posed in a recent paper by Mars and colleagues [1] in the UK in 2018:
What distinguishes adolescents with suicidal thoughts from those who have attempted suicide?
This paper explains that one in three young people who experience suicidal ideation attempt suicide. Thoughts of suicide (‘suicidal ideation’) are common in adolescents and are a well-established risk factor for suicidal behaviour. Therapists and researchers have identified many such risk factors – and protective factors too. But we still know much less about which factors differentiate those most likely to attempt suicide from those who think about it, but do not attempt it.
How do we know which young people with suicidal thoughts are most at risk?
Many well-established risk factors for suicide, for example depression, hopelessness and impulsivity, strongly predict the development of suicidal ideation. But these factors only weakly predict attempts among those thinking about suicide. The authors sets out recent theories relating to suicide. They then investigate what differentiates those who attempt suicide from those who experience suicidal ideation but don’t act on it. The identifying factors that best distinguish between these groups of adolescents have important implications for clinical practice.
This blogpost contains brief notes on the paper from a clinical perspective by me (Juline) made on 2 March 2018. I made these for my personal use, but am publishing them here in case they are of use to others.
Recent theoretical models of suicide
The paper reviews recent models. These all fit within an ‘ideation to action’ framework. In other words, they assume the development of suicidal ideation and the progression from ideation to attempts are distinct processes. And that these distinct processes have separate risk factors and explanations. The models cited are:
- the interpersonal theory (IPT)
- the integrated motivational–volitional (IMV)
- the three-step theory (3ST)
IPT: perceptions of low ‘belongingness’ and high ‘burdensomeness’ contribute to a desire for suicide, but acquired capability for suicide is required for a potentially lethal attempt.
IMV: defeat and entrapment (termed ‘motivational factors’) increase the likelihood of ideation emerging; a collection of ‘volitional’ factors (e.g. acquired capability, access to lethal means, exposure to suicidal behaviour, or impulsivity) explains the likelihood of young people with suicidal thoughts acting on them.
3ST: suicidal ideation and attempts are explained by a combination of: pain, hopelessness, connectedness and suicide capability (dispositional, learned and practical).
Suicide capability (i.e. the degree to which an individual feels able to make a suicide attempt) is a key determinant in each of the three models. Factors related to increased suicide capability are consistently associated with attempts amongst those with ideation.
Possible factors linked to this concept:
- increased fearlessness about death
- persistence through pain and distress
- exposure to self-harm in others
- knowledge about and access to lethal means
- previous non-suicidal self-harm.
In the literature, exposure to self-harm in others is increasingly seen as a factor reliably distinguishing between young people with suicidal ideation and those making an attempt.
Results / findings of the paper regarding young people with suicidal thoughts
This is a UK population-based study (N = 4,772). Factors that most clearly differentiated between those adolescents with a history of suicidal thoughts and attempts at age 16 years were:
- depressive disorder (OR 3.63)
- behavioural disorder (OR 2.9)
- anxiety disorder (OR 2.20)
- exposure to self-harm in others (either family/friend self-harm) (OR 3.21)
- both friend and family self-harm OR 5.26
- smoking (OR 2.54)
The extent of exposure to self-harm in others and the presence of psychiatric disorder most clearly differentiate adolescents who attempt suicide from those young people who experience suicidal ideation only.
Other risk factors included female gender, lower IQ, higher impulsivity, higher intensity seeking, lower conscientiousness, a greater number of life events, body dissatisfaction, hopelessness, smoking and illicit drug use (excluding cannabis). However, there is a need for further longitudinal research to explore whether these risk factors predict progression from suicidal ideation to attempts over time.
Discussion in the paper
Recent theoretical models all emphasise the role of ‘suicide capability’ in adolescents with suicidal thoughts in the progression from ideation to attempts. This capability is thought to develop and grow through exposure to painful and provocative events, which lead to an increased tolerance to pain, fear and death.
The authors consider their findings to be consistent with the idea of suicide capability as one of the factors most clearly differentiating between ideation and attempts. The amount of exposure to self-harm seems to increase the risk of moving to a suicide attempt (‘dose effect’). Other factors noted (in other research) are non-suicidal self-harm and family history. The paper briefly speculates on potential mechanisms underlying these relationships.
The paper also discusses the following:
- The role of smoking and illicit drug use
- The link to psychiatric disorders
- Variables in the literature such as hopelessness and impulsivity.
Other clinical implications for young people with suicidal thoughts
Some other clinical implications noted in the paper are as follows.
- The possibility of differentiating between those with suicidal ideation and attempts to help improve risk assessment and identify targets for intervention.
- The importance of considering the social context in which attempts occur and “the possibility of modelling, contagion and environmental reinforces of self-harm behaviour”, given that young people who make suicide attempts are likely to have had exposure to self-harm in others.
- The need to identify and treat mental health problems – and not just depression – given their link to the development of suicidal ideation and likely role in progression to attempts.
- Future research is needed to explore whether those who are hospitalised for mental health problems are more likely to be exposed to self-harm, as this would have important implications for treatment.