Additional risk factors

High comorbidity is generally associated with greater risk of suicidal behaviour. One particular type of comorbidity that has received attention is comorbid Axis I and Axis II disorders. For example, Foster et al. (1999) found in the Northern Ireland study a much higher risk of suicide in those with Axis I-Axis II morbidity than those with Axis I morbidity only. Personality disorder has also been found to be an additional risk factor in the case of suicide attempts. Soloff et al. (2000) compared the characteristics of suicide attempts in patients who had both borderline personality disorder and major depression with those who had only major depression or only borderline personality disorder. Depressed and borderline patients did not differ from each other in characteristics of suicide attempts (number of attempts, level of lethal intent, medical damage, objective planning, or degree of violence of method), but those with both disorders had higher levels of objective planning and a greater number of attempts. Comorbid depression and alcoholism are also associated with higher rates of suicidality than is depression alone (Cornelius et al., 1995).

A number of studies have examined psychological variables that differentiate depressed suicidal from depressed non-suicidal individuals. Roy (1998) found that depressed patients who had attempted suicide were more introverted than depressed patients who had never attempted suicide. Seidlitz et al. (2001) measured a range of emotion traits in older (over 50) depressed inpatients who either had or had not attempted suicide. Attempters were lower in warmth and positive emotions, but the groups did not differ on other emotions, such as anger, sadness, and guilt. Importantly, the groups did not differ on severity of depression as measured by the Hamilton depression score (excluding the suicide item), ruling out severity of depression as an overriding explanation for both emotions and suicidality. The strategy of comparing suicidal and non-suicidal depressed patients has also been used to look at problem-solving skills. Schotte and Clum (1987) measured problem-solving skills in depressed inpatients with suicidal ideation and inpatients who were equally depressed but did not have any suicidal ideation. The suicidal group performed more poorly than the depressed, non-suicidal group in a number of ways: they thought of fewer relevant steps to solve problems, gave more irrelevant solutions, thought of more drawbacks to their solutions, and said they were less likely to implement their solutions. Williams and colleagues have linked this difficulty with problem solving to the difficulties that suicidal individuals have in recalling specific autobiographical memories (e.g., Williams, 2001).

As well as additional risk factors, lack of factors that protect against suicidality in the face of depression might play an important role. Linehan and colleagues (Linehan et al., 1983) developed the Reasons for Living Inventory (RFL) to assess beliefs that inhibit suicidal behaviour. The scale has six subscales covering survival and coping beliefs (for example, I still have many things left to do—I am curious about what will happen in the future), responsibility to family, child-related concerns, fear of suicide, fear of social disapproval, and moral objections to suicide. Those who have attempted suicide endorse fewer reasons for living than psychiatric controls or the general population (Linehan et al., 1993). In the context of depression and suicidality, Malone et al. (2000) measured reasons for living in patients with major depression who either had or had not attempted suicide. The attempters and non-attempters had comparable Hamilton depression scores, though the attempters were significantly higher on depression as measured by the Beck Depression Inventory. The attempters had lower scores on the RFL generally and particularly on the subscales of responsibility to family, survival and coping beliefs, fear of social disapproval, and moral objections.

The nature of the depressive experience— hopelessness

Are certain features or aspects of the experience of depression linked to suicidality? Perhaps the most obvious question is whether severity of depression is related to suicidal behaviour. Not surprisingly, the evidence suggests that it is. In a large follow-up study, Simon and von Korff (1998) found that the risk of suicide greatly increased with the type of treatment received. The rates in those treated as inpatients were much higher than those treated as outpatients. Assuming that treatment reflects severity, it is reasonable to conclude that rates are related to severity of depression. Alexopoulos et al. (1999) found that suicide ideation and suicide attempts in an elderly depressed sample were predicted by severity of depression, along with low social support and having previous attempts with high intent.

A more interesting question is whether there are particular aspects of depression that link to suicidality. The evidence is very clear that hopelessness about the future is the component of depressive experience that relates to suicidal behaviour (see Nimeus et al., 1997). Studies report that hopelessness mediates the relationship between depression and suicidal intent within parasuicide populations (Salter & Platt, 1990; Wetzel et al., 1980). Furthermore, hopelessness has also been found to be related to repetition of parasuicide 6 months later (Petrie et al., 1988) and completed suicides up to 10 years later (Beck et al., 1989; Fawcett et al., 1990).

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