This blogpost contains brief notes by me (Juline) made on 2 March 2018 from a clinical perspective on the following paper cited below. The notes are made for my personal use but are published here in case they are of use to others.
Mars, B., Heron, J., Klonsky, E. D., Moran, P., O’Connor, R. C., Tilling, K., Wilkinson, P. and Gunnell, D. (2018), What distinguishes adolescents with suicidal thoughts from those who have attempted suicide? A population-based birth cohort study. J Child Psychol Psychiatr. doi:10.1111/jcpp.12878. First published: 1 March 2018. Retrieved, 2 March 2018 from: http://onlinelibrary.wiley.com/doi/10.1111/jcpp.12878/full (Creative Commons licence.)
Context from the paper
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. Although many risk and protective factors for suicidal behaviour have been identified, little is known about the factors that differentiate those most likely to attempt suicide from those who think about suicide, but do not attempt it.
Many well-established risk factors for suicide (including depression, hopelessness and impulsivity) strongly predict the development of suicidal ideation, but only weakly predict attempts among those thinking about suicide. It is important to identify factors which differentiate those who attempt suicide from those who experience suicidal ideation but do not act on these thoughts. Identifying factors that best distinguish between these groups of adolescents have important implications for clinical practice.
Recent theoretical models of suicide
The paper reviews recent models. These all fit within an ‘ideation to action’ framework, i.e. development of suicidal ideation and progression from ideation to attempts are distinct processes with separate risk factors and explanations. Models cited:
- the interpersonal theory (IPT)
- the integrated motivational–volitional (IMV)
- the three-step theory (3ST)
IPT: perceptions of low belongingness and high burdensomeness contribute to 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, impulsivity) explains the likelihood of acting on ideation.
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 making an attempt.
Results / findings
This is a UK population-based study (N = 4,772). Factors that most clearly differentiated between those with a history of ideation 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 who only experience suicidal ideation.
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, further longitudinal research is needed 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 the progression from suicidal ideation to attempts. This capability is thought to be developed and enhanced through exposure to painful and provocative events, which lead to an increased tolerance to pain, fear and death.
The authors state their findings are consistent with the idea of suicide capability as one of the factors which 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 potential mechanisms underlying these relationships are briefly speculated upon.
The following are also discussed:
- 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 noted in the paper
- 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.