Cri 2016 37 issue 1 by Hogrefe

Volume 37 / Number 1 / 2016

Editor-in-Chief Diego De Leo Associate Editors Maria A. Oquendo Ella Arensman

Crisis The Journal of Crisis Intervention and Suicide Prevention

Published under the auspices of the International Association for Suicide Prevention (IASP)

Helping the bereaved cope after the traumatic death of a loved one “A wonderful synthesis of information on traumatic losses.” Holly Prigerson, Professor of Psychiatry, Harvard Medical School, Director, Center for Psychosocial Epidemiology and Outcomes Research, Boston, MA

Diego De Leo / Alberta Cimitan / Kari Dyregrov / Onja Grad / Karl Andriessen (Editors)

Bereavement After Traumatic Death Helping the Survivors

2014, xiv + 208 pp. US $39.80 / € 27.95 ISBN 978-0-88937-455-3 Also available as an eBook Unless forced by circumstances, people in modern societies go to great lengths to deny death, to the extent that even death of a loved one from natural causes tends to catch us unprepared and unable to cope with its consequences. Death as the result of a sudden, catastrophic event (traffic accident, suicide, a natural disaster, etc.) can have even more extreme effects, sometimes striking survivors so violently and painfully that it leaves an indelible mark. This book speaks about the consequences of such traumatic deaths in

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a wonderfully simple and straightforward way. The authors describe, step by step, what happens to people after the sudden death of a family member or close friend, the difficulties they face in coping, and how professionals and volunteers can help. With their wide experience, both personally and as internationally renowned authorities, they have written a book for professionals and volunteers who deal with bereavement in language that is accessible to all, so it will also help those who have suffered a traumatic loss themselves to understand what to expect and how to get help.

Crisis The Journal of Crisis Intervention and Suicide Prevention

Volume 37, No. 1, 2016 Published under the Auspices of the International Association for Suicide Prevention (IASP)

Editor-in-Chief

Diego De Leo, MD, PhD, DSc, FRANZCP, Australian Institute for Suicide Research and Prevention, WHO Collaborating Centre on Research and Training in Suicide Prevention, Griffith University, Mt. Gravatt Campus, 4122 Queensland, Australia (Tel. +61 7 3735-3382, Fax +61 7 3735-3450, E-mail D.DeLeo@griffith.edu.au)

Associate Editors

Maria A. Oquendo, MD, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, USA (Tel. +1 212 543-5835, Fax +1 212 543-6017, E-mail mao4@columbia.edu) Ella Arensman, PhD, National Suicide Research Foundation, Department of Epidemiology and Public Health, University College Cork,Western Gateway Building, Room 4.34,Western Road, Cork, Ireland (Tel. +353 21 420-5551 or +353 87 052-2284, E-mail earensman@ucc.ie)

Editorial Board

A. Apter, Tel Aviv, Israel R. Battegay, Basel, Switzerland M. P. Battin, Salt Lake City, UT, USA A. L. Beautrais, Christchurch, New Zealand A. L. Berman, Washington, DC, USA S. S. Canetto, Fort Collins, CO, USA J. Cutcliffe, Tyler, TX, USA O. Ekeberg, Oslo, Norway A. Erlangsen, Aarhus, Denmark M. Goldblatt, Boston, MA, USA D. Gunnell, Bristol, UK K. Hawton, Oxford, UK L. M. Hayes, Mansfield, MA, USA K. van Heeringen, Gent, Belgium H. Hjelmeland, Trondheim, Norway E. Isometsa, Helsinki, Finland G. Jessen, Odense, Denmark N. Kapur, Manchester, UK N. Kapusta, Vienna, Austria A. J. F. M. Kerkhof, Amsterdam, The Netherlands M. M. Khan, Karachi, Pakistan

Past Editors-in-Chief

Raymond Battegay, Annette L. Beautrais, David C. Clark, John F. Connolly, Ad J. F. M. Kerkhof, Hermann Pohlmeier

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The journal is published under the auspices of the International Association for Suicide Prevention (IASP) (IASP Central Administrative Office, National Centre for Suicide Research and Prevention, Sogsvannsveien 21, Building 12, N-0372 Oslo, Norway, Tel. +47 22 923715, E-mail admin@iasp.info, www.iasp.info).

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Crisis (2016) 37(1)

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Published in 6 issues per annual volume.

Contents Editorial

Suicide Among Refugees – A Mockery of Humanity

Lakshmi Vijayakumar

Research Trends

Emergency Department Visits Prior to Suicide and Homicide: Linking Statewide Surveillance Systems

Julie Cerel, Michael D. Singleton, Margaret M. Brown, Sabrina V. Brown, Heather M. Bush, and Candice J. Brancado

Suicide in Northern Ireland: An Analysis of Gender Differences in Demographic, Psychological, and Contextual Factors

Siobhan O’Neill, Colette Corry, Danielle McFeeters, Sam Murphy, and Brendan Bunting

Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

Francisco Bustamante, Valeria Ramirez, Cinthya Urquidi, Vicente Bustos, Zimri Yaseen, and Igor Galynker

Does Social Belonging to Primary Groups Protect Young People From the Effects of Pro-Suicide Sites? A Comparative Study of Four Countries

Jaana Minkkinen, Atte Oksanen, Matti Näsi, Teo Keipi, Markus Kaakinen, and Pekka Räsänen

General Practitioners’ Accounts of Patients Who Have Self-Harmed: A Qualitative, Observational Study

Amy Chandler, Caroline King, Christopher Burton, and Stephen Platt

Dating Violence Victimization, Interpersonal Needs, and Suicidal Ideation Among College Students

Caitlin Wolford-Clevenger, JoAnna Elmquist, Meagan Brem, Heather Zapor, and Gregory L. Stuart

Too Much to Bear: Psychometric Evidence Supporting the Perceived Burdensomeness Scale

Nicole J. Peak, James C. Overholser, Josephine Ridley, Abby Braden, Lauren Fisher, James Bixler, and Megan Chandler

Clinical Insights

Self-Injury, Help-Seeking, and the Internet: Informing Online Service Provision for Young People

Mareka Frost, Leanne Casey, and Natalie Rando

Erratum

Correction to Youssef et al., 2015

News, Announcements, and IASP

Obituary: Norman Farberow, 1918–2015 Announcements International Association for Suicide Prevention

78 80 81

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Editorial Suicide Among Refugees – A Mockery of Humanity Lakshmi Vijayakumar SNEHA Suicide Prevention Centre, Voluntary Health Services, Chennai, India

The United Nations High Commissioner for Refugees (UNHCR) report “World at War” released in June 2015 states that in 2014 there were 19.5 million refugees, 38.2 million were displaced inside their own countries, and 1.8 million people were asylum seekers. Worldwide displacement was at the highest level recorded. The majority (86%) of refugees were in developing countries, with Turkey, Pakistan, Lebanon, and the Islamic Republic of Iran being the top four refugee-hosting nations. The least developed nations provided asylum to 3.6 million refugees. Being a refugee or seeking asylum radically transforms one’s life often by circumstances beyond one’s control. A majority of the refugees have experienced genocide, imprisonment, violence, trauma of war, and bereavement, all of which make life intolerable. The process of seeking asylum can involve hazardous journeys, separations, exposure to inhuman conditions, constant fear of being apprehended, and death. Postmigration difficulties, such as detention, discrimination, dispersal, destitution, denial of rights to health care or work etc., also haunt them. It is sometimes referred to as a grief process that comprises seven losses: family and friends, language, culture, homeland, status, contact with community, and exposure to physical risk (Carta, Bernal, Hardoy, & Haro-Abad, 2005). Low- and middle-income countries (LAMIC) are the major host nations for the refugees and, often, they have poor infrastructure and health care as well as political and economic instability. Hence, the arrival of refugees can threaten the availability of scarce local resources leading to tensions in the host country (Farwell, 2003; Pedersen, 2002). Efforts to provide care to the refugees have focused on tangible issues such as safety and shelter, whereas the psychological and emotional needs are often ignored. There is overwhelming evidence that being a refugee and seeking asylum are both directly and indirectly a stressful and disturbing experience and such experience is closely related to suicide and self-harm (Procter, 2004). There is a dearth of information in the literature about suicide among refugees and asylum seekers. This could be because of lack of reliable data, limited access to official © 2016 Hogrefe Publishing

archives, and under-reporting of suicidal behavior. Being a politically sensitive issue, permission to study suicidal behavior among refugees is often denied in LAMICs. The prevalence of suicidal behavior among refugees ranged from 3.4 to 34% accordingly to a recent review (Vijayakumar & Jotheeswaran, 2010). Three recent population-based studies reported on the suicide rate among refugees. Goosen et al. (2011) analyzed death registries from Dutch asylum-seeker reception centers between the years 2002 and 2006 and found a suicide rate of 25.6/100,000 for men and 4.0 for women. Suicide rates and hospital-treated attempts were higher among men but not among women when compared with Dutch nationals. Van Oostrum, Goosen, Uitenbroek, Koppenaal, and Stronks (2011) found a suicide rate of 16.38 for male and 3.41 for female asylum seekers in detention centers from 2002 to 2005 in The Netherlands. Cohen (2008) found an increase in suicide rates from 42 (1997–1999) to 211 (2003–2005) in the United Kingdom. However, the small number of cases implies that the results should be interpreted cautiously. A population-based study from Denmark revealed contrasting results, with suicide rates being lower among male refugees when compared with males in the general population; no difference in the rates was observed for females (Norredam, Olsbjerg, Petersen, Laursen, & Krasnik, 2012). In the US, suicide rates among Bhutanese refugees (24.4) were significantly higher than those of the US residents. Procter, De Leo, and Newman (2013) state that suicide is the leading cause of premature death for people in the Australian immigration detention network. Kalt, Hossain, Kis, and Zimmerman (2013) reviewed violence and health in asylum seekers and found the enormous gap in evidence to be the most robust finding. The universally accepted association between suicide and psychological disorders has not been studied adequately in this special population. Most of the work in this area has focused on the association between posttraumatic stress disorder (PTSD) and suicidal behavior in refugees. Ferrada-Noli, Asberg, Ormstad, Lundin, and Sundbom (1998) studied 65 refugees diagnosed with PTSD and found Crisis 2016; Vol. 37(1):1–4 DOI: 10.1027/0227-5910/a000385

Editorial

that 40% had made suicidal attempts, 29% had a detailed suicidal plan, and 31% had recurrent suicidal thoughts. Suicidal behavior was significantly greater in refugees with a principal PTSD diagnosis than among the others. Patients with PTSD and comorbid depression reported a higher frequency of suicidal thoughts and nondepressive patients with PTSD had an increased frequency of suicide attempts. Fazel, Wheeler, and Danesh (2005) studied the prevalence of serious mental disorders in 6,743 refugees resettled in Western countries. In adults, a prevalence rate of 9% for PTSD and 5% for major depression was found. The prevalence of PTSD in children and adolescents (below 18 years) was found to be 11%. Comorbidity studies revealed 71% of those diagnosed with major depression had a diagnosis of PTSD and 44% of those diagnosed with PTSD also had a diagnosis of major depression. Other studies suggest that there may be a more somatic presentation of psychological problems among asylum seekers and refugees (Tribe, 2002; Van Ommeren et al., 2002). Loss, trauma, violence, physical abuse, torture, and economic hardships, through mediating factors such as stressors and hopelessness, have been linked to suicidal behavior. Nearly all refugees experience losses and many have suffered multiple traumatic experiences. Postmigration factors such as detention, discrimination, dispersal, and destitution can create stress and cause ideas of hopelessness. Problems with the process of acculturation in a new society have been linked to a higher prevalence of mental health problems (Bhugra, 2005). There is also evidence to suggest that these postmigration factors play an important role both in the development and perpetuation of mental disorders such as anxiety disorders, somatization disorders, and depression (Kivling-Boden & Sundbom, 2002; Knipscheer & Kleber, 2006). Alcohol misuse, a known risk factor for suicidal behavior, is also common in the refugee population. A study reviewing alcohol use patterns among refugees found that younger men with a binge-drinking pattern, unemployment, lower language proficiency, and exposure to traumatic events had an increased risk for alcohol-related problems (Weaver & Robert, 2010). There are a few studies that have looked at the prognostic factors and mental health outcomes in this population. One study found pre-displacement factors such as being older, female, better educated, from a rural background, and higher socioeconomic status predicted worse mental health outcomes. Morbidity was significantly associated with postmigration factors such as a lack of permanent accommodation and restricted opportunity to work (McColl, McKenzie, & Bhui, 2008). Although an increased prevalence of psychological disorders has been found in refugees, assessment and diagnosis of psychological problems pose unique challenges in this population. Psychological assessments in refugees can be complicated by issues such as language and culture. Van Ommeren et al. (2002) found that issues of validity occur within transcultural epidemiology, and describing the extent of psychopathology in asylum seekers and refugees can be problematic. Crisis 2016; Vol. 37(1):1–4

Refugee women face many dangers while fleeing or in places of settlement including physical and sexual violence, abduction, forced prostitution, and forced sale of children. For many female refugees, the violent situations that cause them to flee their home countries are only the beginning. When women and girls are separated from male family members during flight or are widowed during war, they are especially susceptible to physical abuse and rape. A cross-sectional survey of 297 Afghan mothers in two refugee camps in the North-West Frontier Province of Pakistan revealed that 36% of women in the sample (n = 106) screened positive for common mental disorders. Of those who screened positive, 96 (91%) had suicidal thoughts in the previous month and nine (8.1%) rated suicidal feelings as their top-most concern (Rahman & Hafeez, 2003). A study from Jordan revealed that Lebanese refugee women who were victims of intimate-partner violence (IPV) had more suicidal thoughts and attempts (Al-Modallal, 2012). Women living in camps along the Thai–Burma border reported a prevalence of 7.4% for suicide ideation in the previous month, and 50% of women who experienced conflict criminalization and IPV reported suicidal ideation (Falb, McCormick, Hemenway, Anfinson, & Silverman, 2013). About half (51%) of the refugee population are children below the age of 18 years. The combined weight of socioeconomic adversity and exposure to violence in their countries of origin followed by migration and resettlement into a new environment exposes them to several risks to their physical, emotional, and social development (Fazel, Reed, Panter-Brick, & Stein, 2012). The adversities and negative experiences they endure at a formative age may have long-term consequences. It is known that childhood physical and sexual abuse is linked to suicidal behavior in later years. Considering the magnitude of refugee children exposed to physical and sexual violence, there is a greater likelihood of them having a higher prevalence for suicidal behavior in adolescence. Studies that reviewed the mental health of refugee children found exposure to violence to be a major risk factor for poor mental health (Fazel et al., 2012; Reed, Fazel, Jones, Panter-Brick, & Stein, 2012). There is an increased risk of suicide during the early period of displacement and when refugees stay for long durations in refugee camps or detention centers. Staehr and Munk-Anderson (2006), in their study of asylum seekers, found that those who were rejected asylum after a long waiting time (average 20.8 months) rapidly developed suicidal ideations. It was also found that 44% of suicidal attempts occur within 6 months of arrival. Another study also found an association between threat of rejection of status as refugee and suicidal attempts (Yilmaz & Riecher-Rössler, 2012). A unique finding was observed in refugees with a history of torture. An association was found between the torture method and the method of suicidal attempt. For example, water torture was associated with drowning and sharp force torture with self-cutting or stabbing (Ferrada-Noli, Asberg, & Ormstad, 1998). There is little information on the protective factors for reducing suicide among refugees. Jahangir, Rehman, and Jan (1998) reported that Afghan refugees with a higher de© 2016 Hogrefe Publishing

Editorial

gree of religiosity had a lower rate of suicidal plans and attempts. Prevention and intervention programs to reduce suicidal behavior in refugees and asylum seekers have not been reported in a single study. Suicide prevention strategies that show promise in the general population may not be generalizable to the refugee population because of the different context within which these interventions have been implemented. Some of the risk factors are the same but others are different, and this has implications in suicide prevention efforts. Priority should be given to developing a culturally and contextually appropriate tool for assessment of suicide ideation and behavior in refugees and asylum seekers. Procter et al. (2013) suggest that articulated and coordinated approaches based on cultural explanatory models must be considered as the starting point of designing a suicide prevention strategy for immigrant detainees. The intervention guidelines most commonly used among refugees in camps are the “Inter-Agency Standing Committee (IASC) Guidelines for Mental Health and Psychological Support in Emergency Settings” (2007). These are general guidelines and not specific to reducing suicidal behavior. Certain specific programs may have additional value: 1. Counseling and provision of emotional support both at the time of arrival and more importantly at the time of relocation or repatriation; 2. Early education on the language and culture of the host country; 3. Early provision for economic activity; 4. Ensuring communication and connections to the family, friends, NGOs, and ethnic groups; and 5. Media efforts to portray the refugees in a positive framework. There is an urgent need to acknowledge the magnitude of the problem, and this requires easy access to accurate and transparent data. The process must occur at all levels of service. At the individual level, refugees must be provided a compassionate and caring environment to express their suicidal thoughts/plans without fear of marginalization and stigmatization. Mental health professionals, health and media personnel, policy makers, and NGOs must be sensitized to the needs of the refugees and the context of their circumstances. Ignoring suicides among refugees is a mockery of humanity.

References Al-Modallal, H. (2012). Patterns of coping with partner violence: Experiences of refugee women in Jordan. Public Health Nursing, 29(5), 403–411. Bhugra, D. (2005). Cultural identities and cultural congruency: A new model for evaluating mental distress in immigrants. Acta Psychiatrica Scandinavica, 111(2), 84–93. Carta, M. G., Bernal, M., Hardoy, M. C., & Haro-Abad, J. M. (2005). Migration and mental health in Europe (The state of mental health in Europe working group: Appendix I). Clin© 2016 Hogrefe Publishing

ical Practice and Epidemiology in Mental Health, 1, 13. doi:10.1186/1745-0179-1-13 Cohen, J. (2008). Safe in our hands? A study of suicide and selfharm in asylum seekers. Journal of Forensic and Legal Medicine, 15(4), 235–244. Falb, K. L., McCormick, M. C., Hemenway, D., Anfinson, K., & Silverman, J. G. (2013). Violence against refugee women along the Thai–Burma border. International Journal of Gynecology & Obstetrics, 120(3), 279–283. doi:1016/j.ijgo. 2012.10.015 Farwell, N. (2003). In war’s wake: Contextualization trauma experiences and psychosocial well-being among Eritrean youth. International Journal of Mental Health, 32, 20–50. Fazel, M., Reed, V. R., Panter-Brick, C., & Stein, A. (2012) Mental health of displaced and refugee children resettled in high-income countries: Risk and protective factors. Lancet, 379, 266–282. doi:10.1016/S0140-6736(11)60051-2 Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. Lancet, 365, 1309–1314. Ferrada-Noli, M., Asberg, M., & Ormstad, K. (1998). Suicidal behaviour after severe trauma. Part 2: The association between methods of torture and of suicidal ideation in posttraumatic stress disorder. Journal of Traumatic Stress, 11(1), 113–124. Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behaviour after severe trauma. Part one: PTSD diagnosis, psychiatric comorbidity, and assessments of suicidal behaviour. Journal of Traumatic Stress, 11, 103–112. Goosen S, Kunst A. E., Stronks, K., van Oostrum I. E. A., Uitenbroek, D. G., & Kerkhof, A. J. (2011). Suicide death and hospital treated suicidal behaviour in asylum seekers in the Netherlands: A national registry-based study. BMC Public Health, 11, 484. Inter-Agency Standing Committee. (2007). IASC guidelines on mental health and psychosocial support in emergency settings. Geneva, Switzerland: Author. Jahangir, F., Rehman, H., & Jan, T. (1998). Degree of religiosity and vulnerability to suicidal attempt/plans in depressive patients among Afghan refugees. International Journal for the Psychology of Religion, 8(4), 265–269. Kalt, A., Hossain, M., Kis, L., & Zimmerman, C. (2013). Asylum seekers, violence and health: A systematic review of research in high-income host countries. American Journal of Public Health, 103, e30–e42. doi:10.2105/AJPH.2012 Kivling-Boden, G., & Sundbom, E. (2002). The relationship between post-traumatic symptoms and life in exile in a clinical group of refugees from the former Yugoslavia. Acta Psychiatrica Scandinavica, 111(5), 351–357. Knipscheer, J. W., & Kebler, R. J. (2006). The relative contribution of posttraumatic and acculturative stress to subjective mental health among Bosnian refugees. Journal of Clinical Psychology, 62(3), 339–335. McColl, H., McKenzie, K., & Bhui, K. (2008). Mental health care of asylum seekers and refugees. Advances in Psychiatric Treatment, 14, 452–459. Norredam, M., Olsbjerg, M., Petersen, J. H., Laursen, B., & Krasnik A. (2012). Are there differences in injury mortality among refugees and immigrants compared with native-born? Injury Prevention. Advance online publication. doi:10.1136/ injuryprev-2012-040336 Pedersen, D. (2002) Political violence, ethnic conflict, and contemporary wars: Broad implications for health and social well-being. Social Science & Medicine, 55, 175–190. Procter, N. (2004). Emergency mental health nursing for refugees and asylum seekers. Australian Nursing Journal, 12, 21–23. Procter, N. G., De Leo, D., & Newman L. (2013) Suicide and self-harm prevention for people in immigration detention. Medical Journal of Australia, 199(11), 730–732. Crisis 2016; Vol. 37(1):1–4

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Rahman, A., & Hafeez, A. (2003). Suicidal feelings run high among mothers in refugee camps: A cross sectional survey. Acta Psychiatrica Scandinavica, 108, 392–393. Reed, V. R., Fazel, M., Jones, L., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. Lancet, 379, 250–265. doi:10.1016/ S0140-6736(11)60050-0 Staehr, M. M., & Munk-Anderson, E. (2006). Suicide and suicidal behaviour among asylum seekers in Denmark during the period 2001–2003. A retrospective study. Ugeskr Laeger, 168(17), 1650–1653. Tribe, R. (2002). Mental health of refugees and asylum seekers. Advances in Psychiatric Treatment, 8(4), 240–246. UNHCR. (2015). World at war – Global forced displacement trends. Geneva, Switzerland: Author. Van Ommeren, M., Sharma, B., Sharma, G. K., Komproe, I., Cardena, E., & de Jong, J. T. (2002). The relationship between somatic and PTSD symptoms among Bhutanese refugee torture survivors: Examination of comorbidity with anxiety and depression. Journal of Traumatic Stress, 11(1), 113–124. Van Oostrum, I. E. A., Goosen, S., Uitenbroek, D. G., Koppenaal, H., & Stronks, K. (2011). Mortality and causes of death among asylum seekers in the Netherlands, 2002–2005. Journal of Epidemiology and Community Health, 65(4), 376–383. Vijayakumar, L., & Jotheeswaran, A. T. (2010). Suicide in refugees and asylum seekers in mental health of refugees and asylum seekers. In D. Bhugra, T. Craig, T., & K. Bhui (Eds.), Mental health of refuges and asylum seekers (pp. 195–210). Oxford, NY: Oxford University Press.

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Weaver, H., & Roberts, B. (2010). Drinking and displacement – a systematic review of the influence of forced displacement on harmful alcohol use. Substance Use and Misuse, 45(13), 2340–2355. Yilmaz, T. A., & Riecher-Rössler, R. A. (2012). Attempted suicide in immigrants from Turkey: A comparison with Swiss suicide attempters. Psychopathology, 45, 366–373. doi:10.1159/000337266

Accepted November 3, 2015 Published online April 1, 2016 About the author Dr. Lakshmi Vijayakumar is the founder of SNEHA, an NGO for the prevention of suicide. She is head of the Department of Psychiatry, Voluntary Health Services (VHS), Chennai. She is an Honorary Associate Professor at the University of Melbourne, Australia, and a member of the WHO’s International Network for Suicide Research and Prevention. Lakshmi Vijayakumar 25, Ranjith Road, Kotturpuram Chennai 600 085 India lakshmi@vijayakumars.com

Research Trends

Emergency Department Visits Prior to Suicide and Homicide Linking Statewide Surveillance Systems Julie Cerel1, Michael D. Singleton2, Margaret M. Brown3, Sabrina V. Brown3, Heather M. Bush4, and Candice J. Brancado5 1

University of Kentucky, College of Social Work, Lexington, KY, USA University of Kentucky, Department of Biostatistics and the Kentucky Injury Prevention and Research Center, Lexington, KY, USA 3 University of Kentucky, Department of Epidemiology and Kentucky Injury Prevention and Research Center, College of Public Health, Lexington, KY, USA 4 University of Kentucky, Department of Biostatistics, Lexington, KY, USA 5 University of Kentucky , Department of Statistics/DATAQUeST, Lexington, KY, USA

Abstract. Background: Emergency departments (EDs) serve a wide range of patients who present at risk of impending suicide and homicide. Aims: Two statewide surveillance systems were probabilistically linked to understand who utilizes EDs and then dies violently within 6 weeks. Method: Each identified case was matched with four randomly selected controls on sex, race, date of birth, resident zip code, and date of ED visit vs. date of death. Matched-pair odds ratios were estimated by conditional logistic regression to assess differences between cases and controls on reported diagnoses and expected payment sources. Results: Of 1,599 suicides and 569 homicides in the 3-year study period, 10.7% of decedents who died by suicide (x ̅= 13.6 days) and 8.3% who died by homicide (x ̅= 16.3 days) were seen in a state ED within 6 weeks prior to death. ED attendees who died by suicide were more likely to have a diagnosis of injury/ poisoning diagnosis or mental disorder and more likely to have Medicare. Those who died by homicide were more likely to have a diagnosis of injury/poisoning and less likely to have commercial insurance. Conclusion: It is essential for research to further explore risk factors for imminent suicide and homicide in ED patients who present for psychiatric conditions and general injuries. Keywords: suicide, homicide, linkage, violent deaths, emergency

Each year, about 55,000 violent deaths occur in the United States (Walsh, Dignan, & Caldwell, 2007). In 2005, violent deaths, including homicides and suicides, cost the US more than $60 billion in medical care and lost productivity (Centers for Disease Control and Prevention [CDC], 2013). Injury-related fatality accounted for over 50% of all deaths from 1999 to 2010; violent death accounted for 30% of all injury-related deaths. Overall, violent deaths accounted for 17% of all deaths in the US yearly from 1999 to 2010. Nationally, suicides outnumbered homicides by nearly two to one between 1999 and 2010 (CDC, 2013). The Commonwealth of Kentucky’s suicide rate exceeded the national rate of suicides by an average of 8% during that period, and, in 2007, suicides outnumbered homicides by almost three to one (CDC, 2013). It is of vital importance to determine places where identification of individuals at risk can be made prior to a violent death. For every death by suicide in the US, there are an estimated 25–100 suicide attempts (McIntosh, 2010). In 2007, almost 400,000 people were treated © 2015 Hogrefe Publishing

in emergency departments (EDs) for self-inflicted injuries (McCaig & Nawar, 2006). That same year, 165,997 people were hospitalized because of self-inflicted injury (CDC, 2013). The ED, then, becomes a site to identify people at risk of future suicide. The Joint Commission National Patient Safety Goal 15 has now explicitly instructed organizations “to identify patients at risk for suicide.” Despite this, current screening does not seem to detect even the individuals with current suicidal ideation or previous suicide attempts (Allen et al., 2013). Suggestions for brief screening of all patients, even those with nonpsychiatric diagnoses, has been suggested as up to 4.1% patients with nonpsychiatric medical/surgical concerns have been shown to be at risk for suicide (Horowitz et al., 2012). In a study of suicide decedents in the United Kingdom, about a quarter had some contact with mental health services in the year prior to their death, most notably a hospital visit owing to a suicide attempt (Owens & House, 1994). In a more recent study, 39% of a sample of 200 Crisis 2016; Vol. 37(1):5–12 DOI: 10.1027/0227-5910/a000354

J. Cerel et al.: ED Visits Prior to Suicide and Homicide

consecutive suicide decedents had attended an ED in the year prior to their death with final visits, on average, 38 days before the death (Gairin, House, & Owens, 2003). Approximately one third of that sample (15% of all deaths by suicide in the cohort) had visited an ED because of a suicide attempt in that year. Despite this, these suicide attempts often did not result in treatment by mental health professionals outside the ED. One study in the US has linked data from ED with violent death data (Weis, Bradberry, Carter, Ferguson, & Kozareva, 2006). Of the 491 people who died by suicide in South Carolina in 2004, 282 (57.4%) had been treated at a hospital or ED in the previous year. Of these, 24.8% of visits were for suicide attempts prior to the final death by suicide. The median number of days between the final hospital encounter and death by suicide (excluding those who had less than 1 day elapsed, indicating the final visit most likely resulted in the fatality) was 110 days. In another study, in which 1,590 patients were screened in an ED over a 45-day period, 11.6% of patients acknowledged suicidal ideation and 2% reported planning to kill themselves (Claassen & Larkin, 2005). Suicide plans were undetected during the ED visit in 80% of the patients who screened positive for a suicide plan. Suicidal patients were not distinguishable by age, sex, or ethnicity. Suicide risk in patients in the ED is, therefore “occult” and “insidious” and Claassen and Larkin (2005) recommend the need for research to “consider strategies for unmasking this largely undetected threat to public health” (p. 353). There are fewer data regarding ED attendance by people who then go on to die by homicide. Nearly half of all women (n = 34) who were victims of intimate partner violence-related homicide had been in the ED within 2 years before their deaths (Wadman & Muelleman, 1999) In a matched case-control study of homicide victims (N = 124) and offenders (N = 138) matched to controls, Crandall, Jost, Broidy, Daday, and Sklar (2004) found that victims and offenders were more than four times more likely to have had an ED visit within 3 years of the homicide compared with controls. These ED visits were most likely to be for assault, firearm injury, or substance abuse and were more likely to be closer to the death than the visits of control subjects. On January 1, 2008, the Office of Health Policy of the Cabinet for Health and Family Services and the Kentucky Hospital Association initiated statewide collection of electronic billing records for all visits to Kentucky hospital EDs. The Kentucky Violent Death Reporting System (KVDRS) collects information from multiple investigative sources statewide, as part of the National Violent Death Reporting System (NVDRS), and in this study we used state-based data to move beyond what has been previously reported. Linking violent death data with ED information provides a more comprehensive examination of the death, allowing for an improved understanding and ultimately more focused prevention efforts. The purpose of this study was to link these two statewide surveillance systems with the goal of identifying markers of increased short-term risk of violent death among ED attendees. Crisis 2016; Vol. 37(1):5–12

Method Kentucky Violent Death Reporting System The Office of Vital Statistics provides a monthly electronic death certificate file to the KVDRS. Violent deaths are extracted using The International Statistical Classification of Diseases and Related Health Problems: Tenth Revision (ICD-10) codes meeting the CDC’s definition of homicide and suicide from January 1, 2008, to December 31, 2010. ICD-10 codes for suicide include X60-X84, Y87.0, and *U03, and codes for homicide include X85-Y09, Y87.1, *U01, and *U02. This study includes deaths where an investigation occurred within Kentucky. Electronic death certificate data and coroners’ reports were linked by name, date of death, and county of death and then combined in the KVDRS database for statewide analysis.

Kentucky Outpatient Services Claims Files (KOSCF) Effective January 1, 2008, under Kentucky Revised Statute 216.292, the Commonwealth of Kentucky has required all licensed providers of ED services to report copies of health claims submitted for provision of ED services (Veterans’ Administration hospitals are exempt from this requirement). The required data elements include patient demographics (age, sex, race, ethnicity), admission and discharge dates, diagnostic and procedure codes (up to 25), charges billed, patient disposition, external cause of injury codes (E-codes), expected source of payment (up to 3), and more. All reported ED records, including observation visits, for calendar years 2008 through 2010 were selected for linkage with the KVDRS file. There were 6,067,525 total reported visits during the 3-year period, with an annual rate of 45 visits per 100 Kentucky residents. (Note, this does not imply that 45% of Kentucky residents visited an ED during the period because we were unable to identify repeat or multiple visits by the same individual.) In most cases, if a patient is admitted as an inpatient to the same facility from which ED services were received, the facility will submit charges for ED services on the inpatient bill. Such patients are therefore not included in the present study. We made use of both datasets as deidentified data are approved by the University IRB.

Record Linkage We linked the KVDRS and ED files for calendar years 2008–2010 using probabilistic methods that have been described in detail in the literature (Fellegi & Sunter, 1969; Jaro, 1995). Briefly, probabilistic data linkage (PDL) matches observations on administratively unrelated datasets by comparing the values of common data elements, and calculating the probability that pairs of observations represent the same individual. Common variables on the © 2015 Hogrefe Publishing

J. Cerel et al.: ED Visits Prior to Suicide and Homicide

KVDRS and ED files included date of birth, sex, race, resident zip code, and date of event (death vs. ED visit). Agreement on the first four of these variables was defined as an exact match, whereas agreement on date of event was defined as an ED admit date within 42 days of death date. We used LinkSolv version 8.3 (Strategic Matching, Inc., 2013) to link the KVDRS and ED data files. Decedents whose KVDRS record linked to an ED record with a total match probability of at least 90% were considered for the purposes of this study to have visited an ED within 6 weeks (42 days) of their death. In this paper, decedents linked to an ED visit within 6 weeks of death will be referred to as the “cases.” If multiple distinct ED records linked to the same KVDRS record with a match probability of 90% or greater, all such matches were kept. This allows us to identify cases in which a decedent visited an ER on multiple occasions within 6 weeks of death. Cases in which the ED admit date and death date were identical were excluded from the analysis.

Data Analysis Counts and percentages were used to characterize decedents by manner of death (homicide or suicide) in terms of age (minors vs. adults), education (whether the decedent had earned a high school diploma), marital status, sex, race, and residence (rural vs. urban). Diagnostic codes and expected sources of payment for the most recent ED visit prior to death were summarized as categorical variables. Diagnostic code groups corresponded to the major groupings in the International Classification of Diseases (9th ed.), Clinical Modification (6th ed.; ICD-9-CM). Payment source codes were grouped into commercial payers, Medicaid, Medicare, and self-pay or charity care. The proportions of cases belonging to each diagnostic code and expected payer group were calculated by scanning all reported diagnostic codes and expected payer codes. Four controls were matched to each case based on age (± 2 years), sex, and date of discharge (± 10 days). For each case, the controls were selected at random from the set of all ED patients who met the matching criteria and did not die violently within 6 weeks of discharge from the ED. Matched pair odds ratios, 95% confidence intervals, and p values were estimated by exact conditional logistic regression to account for the matching of controls to cases and for the possibly small numbers of discordant diagnoses and payment sources between cases and controls. These statistics quantify the increased (or decreased) odds of the presence of a particular diagnostic code group or expected source of payment on the ED records of patients who died violently within 6 weeks of discharge, relative to comparable patients who did not. All data management and statistical analyses were performed with SAS version 9.2. Statistical significance was defined as p values less than or equal to .05.

Results The KVDRS includes 1,599 suicides and 569 homicides from January 1, 2008, to December 31, 2010. Decedent characteristics by manner of death are summarized in Table 1. Suicide victims were overwhelmingly Caucasian adults, with 82% being male. Nearly 60% were unmarried, 16% were veterans, 62% had not earned a high school diploma, and 56% resided in urban areas. Homicide victims were also mostly adults (93%), but in other respects their profile differed somewhat from that of suicides. Homicide victims were more commonly female (29%), markedly more likely to be non-Caucasian (27%), and considerably less likely to be veterans (1.8%). Among these individuals, there were 218 who visited an ED in the 6 weeks prior to their violent death – 171 (10.7% of 1,599) suicides and 47 (8.3% of 569) homicides. The difference in mean number of days from ED visit to violent death was not statistically significant between suicides (13.6 days, SD = 12.13) and homicides (16.3 days, SD = 12.2). Table 2 presents the distribution of days from the most recent ED visit to violent death for these 218 decedents. Twenty-two percent of suicides and 17% of homicides occurred within 2 days of the ED visit. Forty percent of suicides occurred between 2 days and 2 weeks after the ED visit, whereas 40% of homicides occurred within 2 weeks and 2 months after. Table 3 presents the comparison of diagnostic codes and expected payment sources between cases and matched controls. ED patients who died by suicide within 6 weeks of discharge had increased odds of having a diagnosis in ^ several categories including injury and poisoning, OR = ^ 1.40 (1.10, 1.78), p = .006, mental disorders, OR = 1.93 (1.52, 2.45), p = .014, and symptoms, signs, and ill-defined conditions, ^ OR = 1.32 (1.06, 1.66), p < .0001. ED patients who died by homicide within 6 weeks of discharge had strongly increased odds of having a diagnosis in the injury ^ and poisoning group, OR = 2.96 (1.86, 4.86), p < .0001. With regard to payment source, ED patients who died by suicide within 6 weeks of discharge had increased odds of having Medicare listed as an expected source of payment, ^ OR = 1.47 (1.06, 2.04), p = .02, and decreased odds of having Medicaid listed, ^ OR = 0.76 (0.58, 0.99), p = .04. Note that cases and controls were matched on age, so the increased odds for Medicare is not a result of the cases being older, on average, than controls. ED patients who died by homicide within 6 weeks of discharge had decreased odds of having commercial insurance listed as an expected ^ source of payment, OR = 0.36 (0.21, 0.62), p < .0001. The estimated odds of self-pay or charity were increased in the homicide group, but this result fell short of being statistically significant, ^ OR = 1.50 (0.94, 2.43), p = .09. Table 4 presents prevalence rates per 100 individuals for the most commonly reported diagnostic codes and external cause of injury codes for cases and controls, for selected diagnostic categories. Several differences are noteworthy owing to their magnitude. Among cases who died by suicide: 9.9% had an external cause of injury code for self-inflicted injury on their ED record compared with Crisis 2016; Vol. 37(1):5–12

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Table 1. Decedent characteristics by manner of death Suicide (N = 1,599) Characteristic

Homicide (N = 569)

Number

Percent

Number

Percent

< 18

2.4

7.4

â&#x2030;Ľ 18

1,561

97.6

527

92.6

Age

Sex Female

287

17.9

166

29.3

1,312

82.1

401

70.7

White

1,535

96.2

412

73.3

Other

3.8

150

26.7

No diploma

597

62.3

251

72.5

High school diploma or higher

362

37.7

27.5

Not married

594

59.7

253

69.7

Married

401

40.3

110

30.3

84.1

98.2

Male Race

Education

Marital status

Veteran status Nonveteran Veteran

15.9

Rural

703

44.2

228

40.5

Urban

887

55.8

335

59.5

1.8

Urbanization

Note. aAt least 1 but less than 5.

Table 2. Time from ED discharge to violent death, by manner of death

Time

Number (%) died by suicide (N = 171)

Number (%) died by homicide (N = 47)

2 Days

38 (22%)

8 (17%)

2 Weeks

69 (40%)

13 (28%)

1 Month

42 (25%)

19 (40%)

6 weeks

22 (13%)

7 (15%)

Note. ED = emergency department.

only 0.3% of controls; 10.5% had a diagnosis of depressive disorder compared with 1.1% of controls; and 5.3% had a diagnosis of alcohol abuse compared with 0.7% of controls. Interestingly, only one of the cases with a depression diagnosis (311), and none of the cases with an alcohol abuse diagnosis (305.00) also had an external cause of injury code indicating self-injury. In other words, it is not the case that patients who self-injured were the same patients who received the depression and alcohol abuse codes. This implies that depression and alcohol abuse diagnoses may be independent markers of increased short-term suicide risk following ED discharge. Among cases who died by Crisis 2016; Vol. 37(1):5â&#x20AC;&#x201C;12

homicide, 10.6% had an external cause of injury code for assault on their ED record compared with only 0.9% of controls.

Discussion Nearly 10% of persons who died by suicide or homicide in a 2-year period were treated in an ED in Kentucky in the 6 weeks before their death. Those who died by suicide were seen an average of 13.6 days before their death and people who died by homicide were seen, on average, 16.3 days before their death. It should be noted that these estimates are influenced by the length of the follow-up period. Nevertheless, it is apparent that the weeks immediately following an ED discharge are a critical time for certain individuals at risk of violent death, and that the ED visit represents an opportunity for screening and prevention. We identified several groups of diagnostic codes and expected payment sources on the ED record that may be considered markers of increased risk of violent death in the 6 weeks following discharge. Injury and poisoning diagnoses (particularly self-inflicted injury), mental disorder diagnoses (particularly depressive disorder and alcohol ÂŠ 2015 Hogrefe Publishing

Symptoms, signs and ill-defined conditions (780–7999)

Mental disorders (290–319)

Diseases of the circulatory system (390–459)

Factors influencing health status and contact with health services (V01–V89)

Endocrine, nutritional and metabolic diseases, and immunity disorders (240–279)

34 (20.0%) 69 (40.4%) 54 (31.6%)

Medicaid

Medicare

Self-pay or charity

21 (44.7%)

8 (17.0%)

14 (29.8%)

8 (17.0%)

10 (21.3%)

15 (31.9%)

13 (27.7%)

24 (51.1%)

Homicide (N = 47)

276 (31.7%)

274 (31.4%)

222 (25.5%)

310 (35.6%)

141 (16.2%)

220 (25.3%)

245 (28.1%)

237 (27.2%)

319 (36.6%)

227 (26.3%)

Controlsd (N = 872)

p = .67

p = .09

1.50 (0.94, 2.43)

p = .74

p = .02 1.06 (0.83, 1.35)

1.18 (0.59, 2.39)

1.47 (1.06, 2.04)

p = .9

p = .04

p < .0001 1.07 (0.63, 1.82)

p = .16 0.76 (0.58, 0.99)

0.36 (0.21, 0.62)

p = .007 1.19 (0.94, 1.51)

0.24 (0.06, 0.72) p = .0005

p = .25

p = .04 0.56 (0.39, 0.78)

0.72 (0.42, 1.23)

0.76 (0.59, 0.98)

p = .68

p = .44

p = .55 1.17 (0.65, 2.10)

0.90 (0.69, 1.17)

p < .0001

p = .11 1.19 (0.72, 1.96)

1.93 (1.52, 2.45)

p = .014

p < .0001 0.69 (0.43, 1.08)

p = .006 1.32 (1.06, 1.66)

2.96 (1.86, 4.86)

Homicide

1.40 (1.10, 1.78)

Suicide

Matched pairse odds ratio (95% CI)

Note. All 25 reported diagnostic code variables were searched for each ED visit. As a result, the same patient may be counted in multiple payment categories. All three reported expected payment source variables were searched for each ED visit. As a result, the same patient may be counted in payment categories. cKentucky-resident ED attendees who died violently within 6 weeks of an ED visit. dKentucky-resident ED attendees who did not die violently within 6 weeks of an ED visit. Four controls were randomly matched to each case on patient sex, age (± 2 years), and date of discharge (± 10 days). e Matched pair odds ratios, 95% confidence intervals, and p values were estimated by exact conditional logistic regression to account for the matching of controls to cases and the possibly small numbers of discordant diagnoses and payment sources between cases and controls. fAt least 1 but less than 5.

67 (39.2%)

Commercial

Expected source of payment

57 (33.3%)

Injury and poisoning (800–999)

Diagnosis

Suicide (N = 171)

Casesc

Table 3. Reported emergency department diagnosesa and primary expected source of paymentb by manner of death

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Table 4. Prevalence rates per 100 individuals of most commonly reported diagnostic codes and external cause of injury codes among cases and controls within selected diagnostic categories ICD-9-CM code

Description

Suicide (N = 171)

Homicide (N = 47)

Controls (N = 872)

Mental disorders 305

Nondependent abuse of drugs

31.6

34.0

21.3

305.1

Tobacco use disorder

22.2

29.8

19.3

305.00

Alcohol abuse

5.3

2.1

0.7

311

Depressive disorder, not elsewhere classified

10.5

2.1

1.1

300

Anxiety, dissociative and somatoform disorders

6.4

0.0

4.6

Injury and poisoning E800-E869, E880-E829

Unintentional injury

12.9

27.7

18.5

E950-E959

Self-inflicted injury

9.9

0.0

0.2

E960-E969

Assault

1.2

10.6

0.9

Symptoms, signs, and ill-defined conditions 780

General symptoms

14.6

4.3

11.8

786

Symptoms involving respiratory system and other chest symptoms

12.3

12.8

17.7

789

Other symptoms involving abdomen and pelvis

9.9

6.4

8.4

Factors influencing health status and contact with health services V58

Encounter for other and unspecified procedures and aftercare

11.7

2.1

14.8

V58.6

Long-term (current) drug use

11.1

2.1

13.8

abuse), and Medicare membership were associated with greater risk of subsequent suicide. Injury and poisoning diagnoses (particularly assault) and lack of commercial health insurance were associated with greater risk of subsequent homicide. The identification of these risk markers suggests that there might be ways in the future to narrow down which ED patients are at highest risk and may warrant additional screening. On the basis of the computerized ED claim records we cannot infer suicidal intent, only that self-injury was reported. Nevertheless, Nordström and colleagues (1995) reported elevated risk of completed suicide following hospitalization for a suicide attempt in a Swedish cohort. In their study the risk was particularly high in the first year following the attempt and was nearly twice as high in men as in women. In a 40-year follow-up study of 40,000 Norwegian military conscripts, Rossow and Amundsen (1995) reported a relative risk of lifetime suicide of 6.9 among alcohol abusers, relative to nonabusers, with the relative risk being substantially higher among persons aged 40 or older (12.8–4.5). Blair-West and colleagues (1999) have reported that suicide in persons with major depression occurs predominantly among males, and “the male experience of depression that leads to suicide is often not identified as a legitimate medical complaint by either sufferers or professionals” (p. 171). With regard to insurance status, Friedman and colleagues (2005) reported markedly higher levels of suicidal ideation and behaviors in a population of Medicare primary care patients under age 65 with significant functional impairments and health services use, relative to the general population of nonelderly US adults. Crisis 2016; Vol. 37(1):5–12

There is compelling evidence that people who have made suicide attempts report that ED staff do not always treat them in ways that decrease their suicidal ideation or plans (Cerel, Currier, & Conwell, 2006). Coupled with the current findings, there is a need for research on screening and training so that ED staff can be in the best position to detect people at risk of dying violently in the near future and know how to refer them to life-saving help. We are unaware of previous studies linking recent experience of assault with subsequent homicide. Similarly, the relationship between insurance status and homicide risk requires further study. It may be that insurance status is serving as a proxy for socioeconomic factors. Cubbin and colleagues (2000) reported a twofold increased risk of homicide for residents of low-socioeconomic-status neighborhoods. It is likely that not only suicide risk (Claassen & Larkin, 2005) but also homicide risk is occult in ED victims. Screening of suicide risk and violence risk in EDs may be one means of determining how to prevent these deaths. Insurance status may provide information for targeting screening efforts toward high-risk patients.

Limitations Several limitations of the current study need to be noted. The first is sample size. We linked 218 decedents with at least one ED visit. This small sample size makes it more difficult to detect differences or conduct multivariate analyses. Future research should utilize larger samples in order © 2015 Hogrefe Publishing

J. Cerel et al.: ED Visits Prior to Suicide and Homicide

to examine more variables about the decedent, their death, and the emergency visit. Second, in Kentucky, as in many other states, administrative health claim records available to researchers do not contain unique personal identifiers. This necessitates the use of methods such as probabilistic record linkage. The cost of validating linkage results is generally prohibitive. National health-care identifiers would make this type of research more exact and expand the ability to interpret results. Finally, this study may not include persons who were admitted to the same hospital from which they received ED services. This means that people with more serious injuries or those who had admissions to psychiatric facilities were not included in the current data. Linking ED data with inpatient and death data will be an important future step toward better understanding of how to intervene in these violent deaths. These data are increasingly becoming available and will assist in future investigations.

Conclusion This study shows that almost 10% of people who died by suicide and homicide had an ED visit in the 6 weeks prior to their death. Most of these visits occur in the month prior to the death, thus narrowing the potential window for intervention even further. Determining how to screen and identify potential violent death victims within the ED setting may maximize the effectiveness of prevention efforts given the immediacy of violent death following ED discharge. The overall homogeneity of characteristics among violent death victims lends itself to universal screening tools and prevention rather than demographically defined efforts. More importantly, diagnosis codes may better identify individuals at higher risk of violent death so as to provide a targeted screening pool. While screening might lead to false-positive cases, our current investigation was unable to determine whether any mental health or violence risk assessment had taken place. It is likely that even if screening overidentified people at potential risk for violent death, these individuals may benefit from services that might not have been offered if screening had not taken place. To facilitate studies of this kind – linking statewide surveillance systems to identify health-care links to violent death outcomes – the surveillance systems must be in place. Increasing NVDRS coverage to all 50 states will help to facilitate the availability of violent death data within states. Additionally, research will be furthered by increasing the accessibility of medical billing and diagnosis records within the bounds of patient confidentiality. More research is needed to understand people who die violently and to develop screening and prevention strategies that can utilize this window and save lives. Recommendations for future research include more precise examination of precipitating suicide and homicide circumstances so as to identify risk factors that might be apparent though screening at an ED visit that could prevent violent death outcomes. © 2015 Hogrefe Publishing

References Allen, M. H., Abar, B. W., McCormick, M., Barnes, D. H., Haukoos, J., Garmel, G. M., & Boudreaux, E. D. (2013). Screening for suicidal ideation and attempts among emergency department medical patients: Instrument and results from the Psychiatric Emergency Research Collaboration. Suicide and Life-Threatening Behavior, 43(3), 313–323. doi:10.1111/ sltb.12018 Blair-West, G. W., Cantor, C. H., Mellsop, G. W., & Eyeson-Annan, M. L. (1999). Lifetime suicide risk in major depression: sex and age determinants. Journal of Affective Disorders, 55(2), 171–178. Centers for Disease Control and Prevention. (2013). Web-based injury statistics query and reporting system (WISQARS). Retrieved from http://www.cdc.gov/injury/wisqars/index.html Cerel, J., Currier, G. W., & Conwell, Y. (2006). Consumer and family experiences in the emergency department following a suicide attempt. Journal of Psychiatric Practice, 12(6), 341–347. Claassen, C. A., & Larkin, G. L. (2005). Occult suicidality in an emergency department population. British Journal of Psychiatry, 186, 352–353. doi:10.1192/bjp.186.4.352 Crandall, C. S., Jost, P. F., Broidy, L. M., Daday, G., & Sklar, D. P. (2004). Previous emergency department use among homicide victims and offenders: A case-control study. Annals of Emergency Medicine, 44(6), 646–655. doi:10.1016/ S0196064404006353 Cubbin, C., LeClere, F. B., & Smith, G. S. (2000). Socioeconomic status and injury mortality: individual and neighbourhood determinants. Journal of Epidemiology and Community Health, 54(7), 517–524. Fellegi, I., & Sunter, A. (1969). A theory for record linkage. Journal of the American Statistical Association, 64(328), 1183–1210. Friedman, B., Conwell, Y., Delavan, R. R., Wamsley, B. R., & Eggert, G. M. (2005). Depression and suicidal behaviors in Medicare primary care patients under age 65. Journal of General Internal Medicine, 20(5), 397–403. Gairin, I., House, A., & Owens, D. (2003). Attendance at the accident and emergency department in the year before suicide: Retrospective study. British Journal of Psychiatry, 183, 28–33. Horowitz, L. M., Bridge, J. A., Teach, S. J., Ballard, E., Klima, J., Rosenstein, D. L., … Pao, M. (2012). Ask Suicide-Screening Questions (ASQ): A brief instrument for the pediatric emergency department. Archives of Pediatric and Adolescent Medicine, 166(12), 1170–1176. doi:10.1001/archpediatrics.2012.1276 Jaro, M. A. (1995). Probabilistic linkage of large public health data files. Statistics in Medicine, 14(5–7), 491–498. LinkSolv (v. P.3) [Computer sotware]. Morrisonville, NY: Strategie Matching, Inc. McCaig, L. F., & Nawar, E. N. (2006). National hospital ambulatory medical care survey: 2004 emergency department summary (Advance Data From Vital Health Statistics, Report No. 372). Hyattsville, MD: National Center for Health Statistics. McIntosh, J. L. (2010). USA. suicide 2007: Official final data. Retrieved from http://www.suicidology.org/c/document_library/ get_file?folderId=228&name=DLFE-227.pdf Nordström, P., Åsberg, M., Åberg-Wistedt, A., & Nordin, C. (1995). Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatrica Scandinavica, 92(5), 345–350. Owens, D., & House, A. (1994). General hospital services for deliberate self-harm. Haphazard clinical provision, little research, no central strategy. Journal of the Royal College of Physicians of London, 28(4), 370–371. Rossow, I., & Amundsen, A. (1995). Alcohol abuse and suicide: A 40-year prospective study of Norwegian conscripts. Addiction, 90(5), 685–691. Crisis 2016; Vol. 37(1):5–12

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Wadman, M. C., & Muelleman, R. L. (1999). Domestic violence homicides: ED use before victimization. The American Journal of Emergency Medicine, 17(7), 689–691. Walsh, S., Dignan, M., & Caldwell, G. (2007). The PAPM, diffusion theory, and violent death surveillance. American Journal of Health Behavior, 31(5), 451–461. doi:10.5555/ ajhb.2007.31.5.451 Weis, M. A., Bradberry, C., Carter, L. P., Ferguson, J., & Kozareva, D. (2006). An exploration of human services system contacts prior to suicide in South Carolina: An expansion of the South Carolina Violent Death Reporting System. Injury Prevention, 12 Suppl 2, ii17–ii21. doi:10.1136/ip.2006.012427

Received June 18, 2014 Revision received July 6, 2015 Accepted July 9, 2015 Published online December 1, 2015 About the authors Julie Cerel, PhD, is a licensed psychologist and Associate Professor in the College of Social Work at University of Kentucky, USA. She is President-Elect of the American Association of Suicidology. Follow her on twitter@juliecerel Michael Singleton, PhD, is Assistant Professor in the Department of Biostatistics, College of Public Health, and the Kentucky Injury Prevention and Research Center at the University of Kentucky, KY. Margaret Melissa Brown, MPH, is a DrPH candidate in the Health Management and Policy Department, Public Health Services and

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Systems Research in the College of Public Health, University of Kentucky, KY. Her research focuses on suicide and violence fatalities. She currently serves as Research Administrative Coordinator for the CDC-funded Kentucky Violent Death Reporting System (KVDRS). Sabrina V. Brown, DrPH, is Assistant Professor in the Department of Epidemiology, College of Public Health, at the University of Kentucky, KY. Dr. Brown developed the Centers for Disease Control and Prevention-funded Kentucky Violent Death Reporting System, and currently serves as principal investigator. Candace J. Brancato, MS, is Statistical Programming Manager with the Department of Statistics/DATAQUeST at the University of Kentucky. KY. Her primary roles include data analysis, data management, and statistical programming. Heather M. Bush, PhD, is Associate Professor of Biostatistics at the University of Kentucky, KY. Dr. Bush holds the Kate Spade & Company Endowed Professorship in the Center for Research on Violence Against Women. Her research focuses on utilizing statistical methodology and data visualization to better understand complex relationships in violence control.

Julie Cerel University of Kentucky College of Social Work 627 Patterson Office Tower Lexington, KY 40502 USA E-mail julie.cerel@uky.edu

Research Trends

Suicide in Northern Ireland An Analysis of Gender Differences in Demographic, Psychological, and Contextual Factors Siobhan O’Neill1, Colette Corry2, Danielle McFeeters1, Sam Murphy1, and Brendan Bunting1 1

Psychology Research Institute, Ulster University, Londonderry, UK National Suicide Research Foundation, University College Cork, Ireland

Abstract. Background: The circumstances surrounding death by suicide can give us insight into the factors affecting suicide risk in particular regions. Aims: This study examined gender and circumstances surrounding death by suicide in Northern Ireland from 2005 to 2011. Method: The study analyzed 1,671 suicides (77% male and 23% female cases) using information contained from the coroner’s files on suicides and undetermined deaths. Results: Hanging was the most common method and more than one third of the deceased had prior suicide attempts. There was evidence of alcohol use in 41% of the cases. Only, 61% of cases had recorded adverse events; most had multiple and complex combinations of experiences. Relationship and interpersonal difficulties were the most common category of adverse event (40.3%). However, illness and bereavement, employment /financial crisis, and health problems were also common. One third of those who died by suicide were employed, compared with 50.3% who were not in employment. Just over half (50.1%) were known to have a mental health disorder. Conclusion: The results provide the first profile of deaths by suicide in Northern Ireland. They highlight the need to target people who have difficult life experiences in suicide prevention work, notably men, people with employment, financial and relationship crises, and those with mental disorders. Keywords: suicide, gender, life events, alcohol, occupation

Suicide is an important and potentially preventable cause of mortality. In contrast to constituent countries of the United Kingdom, Northern Ireland (NI) comprises a single coronial district, amalgamated in 2004, and is currently the only region of the UK where coronial files have been examined to establish a database of deaths by suicide. The construction of this database therefore offers a unique opportunity to collate and examine demographic, psychological, and contextual factors at play prior to death by suicide. Thus far, distinct psychological, physical, pharmacological, and service use profiles have been useful in helping to distinguish those individuals at risk of suicidal behaviors (Benson, O’Neill, Murphy, Ferry, & Bunting, 2014; O’Neill, Corry, Murphy, Brady, & Bunting, 2014). High levels of mental disorders have been noted previously in the NI population (Bunting, Murphy, O’Neill, & Ferry, 2012). In addition, mental disorders, particularly depression, have been shown to be an important precipitating factor in suicides in NI (Foster, Gillespie, & McClelland, 1999; O’Connor, Sheehy & O’Connor, 1999). Yet most people with mental disorders do not go on to die by suicide, and the analysis of service use prior to death by suicide in NI demonstrates that many of those who die by suicide are not known to mental health services (O’Neill, Corry, et al. 2014). In addition, alcohol and substance use has been implicated in suicide in terms of its association with im© 2015 Hogrefe Publishing

pulsive behavior and as comorbid mental disorders. Finally, as previous suicide attempts remain a key indicator of subsequent fatal suicidal behavior, information about prior suicidal behavior may assist in identifying individuals at highest risk (Hawton, Saunders, & O’Connor, 2012). In addition, a number of contextual factors have been implicated in a heightened risk of suicidality. Analyses of suicidal behavior in NI demonstrate associations with conflict-related traumatic events (O’Neill, Ferry, et al. 2014b). In NI suicide rates have steadily increased over the past number of years, which has been partly attributed to the recent relative stability (Tomlinson, 2012). Case–control studies consistently show that people who die by suicide have experienced a higher number of stressful life events (Kumar & George, 2013; Overholser, Braden, & Dieter, 2012). Studies of suicide in specific populations indicate that interpersonal difficulties (Bagge, Littlefield, Conner, Schumacher, & Lee, 2013) and offending behavior (Webb et al., 2013) are common. Employment and occupational factors are among the life events associated with suicide (Schneider et al., 2011; Tsutsumi, Kayaba, Ojima, Ishikawa, & Kawakami, 2007). This has given rise to concern about the association between the recent economic recession in the UK and Ireland and increased suicide rates. Understanding how life events can increase suicide risk may help us identify additional opportunities for intervenCrisis 2016; Vol. 37(1):13–20 DOI: 10.1027/0227-5910/a000360

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tion. In addition, theories of suicide conceptualize this behavior as a consequence of an interaction between a range of social and cognitive processes that, along with acquired capability, result in death (Joiner, 2005; O’Connor, 2011). Indeed, contextual factors may also contribute to the method of death in certain instances. Skegg, Firth, Gray, and Cox (2010) found that while access to and familiarity with particular means of suicide did not heighten the risk of death it shaped the method used. Thus there appears to be some utility in analyzing the methods of deaths as a means of informing intervention strategies. Suicide profiles in different regions are influenced by and therefore reflect social and cultural trends as well as the effects of legislation around access to means (such as firearm control, medication packaging). It is therefore vital that the circumstances surrounding deaths by suicide are examined in order to understand the factors associated with suicides in individual regions and to inform suicide prevention initiatives. However, data on events prior to death tend to be unreliable owing to the reliance on secondary sources of evidence. Few studies have collected this information in any systematic way at a population level. The National Confidential Inquiry Into Suicide and Homicide by People with Mental Illness (2014) and the data collected by the Office for National Statistics (ONS; 2015) do not provide information on life events and occupational factors that may precipitate death. In an attempt to address these issues, the current study uses qualitative data from coronial files, based on a range of sources, to analyze the events prior to death by suicide in NI from 2005 to 2011.

Method Approval was obtained from Ulster University’s research ethics committee to undertake the research. Cases were recorded by year of death; recorded deaths by suicide and undetermined intent were generated by staff from the NI Coroner’s Service (CSNI), which subsequently directed file selection and inclusion. Undetermined deaths were examined; those cases that were clearly not related to selfharm and demonstrated no indication of suicidal intent, such as fishing boat accidents, sudden death, or deaths in early childhood, were excluded from the final sample. The decisions regarding these cases were made by the researcher and validated by staff at the coronial service. Case validation was undertaken with the assistance of NI Statistics and Research Agency (NISRA) personnel to ensure that the cases in the database were those included in the official NISRA statistics on deaths by suicide. In keeping with NISRA policy, only those deaths that had been subject to the full rigor of the coronial process and officially classified as “closed files” were considered. Cases that were within the research timeframe but remained open for enquiry, such as an inquest, were deemed beyond the remit of the study protocol and duly excluded. Data were extracted from the hard files stored in CSNI archives and electronically recorded in a database in a secure setting. To proCrisis 2016; Vol. 37(1):13–20

tect the bereaved, all information was encrypted at source; address information was replaced by XY coordinates and names changed to unique identifying codes. The master computer remained in a locked facility within the CSNI offices for the duration of the project. Data on established risk factors including prior suicidal behavior, diagnosed mental and physical health conditions, pharmacological profiles, demographics, substance use, and prior adverse events were extracted. Health disorders and service use were assessed via medical notes (where available), police reports, and next-of-kin statements. Socioeconomic indicators were identified through the same sources as well as information included in pathology reports regarding occupation and geographical position, which was linked with NISRA deprivation indices. Qualitative information on events prior to death was obtained mainly from the witness statements collected by police officers at the time of death. These were interviews with those present at the scene of death, usually family members or friends of the deceased. In some cases adverse events were evident in communications from the deceased (such as suicide notes) and sometimes in medical reports provided as part of the coronial investigation. The quantity of information varied enormously from case to case. The database contained a series of mutually exclusive variables and variable categories pertaining to adverse events prior to death. The project research officer (C.C.) coded each case and also developed a qualitative summary statement outlining the adverse events and the circumstances of the deceased. A second researcher (S.O.) independently coded each case, based on the statement of adverse events prior to death, to triangulate the coding of the data. In this analysis, the categories of adverse events were developed based on those identified in Foster’s (2011) synthesis of psychological autopsy studies on events prior to suicide. Given the limitations of the data, several categories of “missing” data were developed. Cases where the circumstances prior to death were only described in terms of the person’s mental health condition (such as “escalating depression”) or related only to the treatment of a mental health condition (such as “discharged from hospital”) were not included in the analysis. However, this information was incorporated into the data on the person’s mental disorder profile. Cases where alcohol or drugs were believed to have played a prominent role in the death, or where the deceased was reported to have a substance disorder, were coded as 1 in a binary “Disordered Substance Use” category. This was assessed using information in the witness statements or medical reports, such as a note that the person was known to be addicted to alcohol or drugs, or more general information, such as descriptions of the person as a heavy drinker or that they had drunk a large amount of alcohol in the days and weeks prior to death. The presence of alcohol in the toxicology report was not used in this variable; hence, there are major differences between the figures for disordered substance use and the presence of alcohol. The legal driving limit in NI is 80 mg of alcohol in 100 ml of blood or 107 mg of alcohol per 100 ml of urine. This was chosen as a means by which to assess intoxication levels © 2015 Hogrefe Publishing

S. O’Neill et al.: Suicide in Northern Ireland

prior to death. This variable was based on the data in toxicology reports. Information concerning the individual’s job title prior to death was available from case notes. Each title was supplemented by a quantitative code demarcating the role and responsibilities of the job based on information provided by the ONS. This enabled the reformatting of the groups into nine standardized occupational groups in accordance with SOC 2011 guidelines (ONS, 2010). Descriptive statistics (frequencies and percentages) have been used throughout the report, and tests of statistical significance have been kept to a minimum. Given the limited use of statistical tests, and the exploratory nature of the analysis, no adjustment was applied to the p values.

Prior Suicide Attempts

Results

Communication of Suicidal Intent

Method of Suicide

Over two thirds of the deceased (69.4%) had not provided a suicide note or any communication regarding their plans for suicide (see Table 3). The most common means of communication was a handwritten suicide note (26.6%). Text messages were sent by 4.5% of the cohort (the majority of these were sent by people aged less than 40 years). Almost an equal proportion of males and females communicated a prior suicidal intent and most did so by means of a handwritten note (22.8% and 23.1%, respectively). Males were more likely to send a text message prior to death than females, with 4.5% choosing this option in comparison with 1.9%. Females, however, were more likely than males to make a telephone call prior to their demise (0.8% vs. 0.5%, respectively).

A total of 1,667 deaths were included in the analysis (77% male and 23% female cases). The age, gender, marital status, health profiles, and use of services prior to death are reported elsewhere (O’Neill et al., 2014a). More than half of those who died by suicide did so through hanging (60.5%), of whom 83.3% were male. A further 18.7% died following overdose, a higher proportion of these cases (31.6%) being female. Drowning accounted for 7.9% of all suicides with men more than twice as likely as women to choose this method of death (71% and 29%, respectively). Of the 3.4% who died using a firearm, 95% were male. The smallest proportion of deaths (2.6%) was attributed to carbon monoxide poisoning or gassing. Those who died by other means included jumping from a height, stepping in front of a train, and cutting (see Table 1).

Almost half (47.2%) of the deceased had prior suicide attempts recorded in an official capacity, either through medical or police records or via witness statements in the aftermath (see Table 2). Of these, almost one fifth (18%) were known to have made two or more suicide attempts prior to the fatal event. Statistically significant gender differences were identified with regard to number of previous suicide attempts. Females were more likely than males to have nonfatal attempts prior to death by suicide. Of those who had recorded previous attempts, females were more likely than males to have multiple attempts. More men than women had only one previous attempt (17.3% and 15.4%, respectively).

Table 1. Gender and method of suicide Female

Male

Total

Hanging

45.0% (168)

65.0% (840)

60.5% (1,008)

Drowning

10.2% (38)

7.2% (93)

7.9%

(131)

Overdose

31.6% (118)

14.9% (193)

18.7%

(311)

Gassing

1.6%

(6)

2.9% (38)

2.6%

(44)

Firearm

0.8%

(3)

4.1% (53)

3.4%

(56)

Cutting

1.1%

(4)

1.2% (16)

1.2%

(20)

Jumping from height

1.5%

(6)

1.2% (15)

1.3%

(21)

Railway tracks

0.3%

(1)

0.5%

(6)

0.4%

(7)

Other

7.8% (29)

2.9% (38)

4.0%

(67)

Table 2. Gender and prior attempt Female

Male

Total

Any prior attempt

37.3% (116)

49.9% (579)

47.2% (695)

No prior attempt

62.7% (195)

50.1% (581)

52.8% (776)

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Table 3. Gender and communication of suicidal intent Female

Male

Total

Any communication

29.9% (112)

20.8% (399)

30.6%

No communication

70.1% (263)

69.2% (897)

69.4% (1,160)

Female

Male

Total

No alcohol

46.4% (174)

43.4% (562)

44% (736)

Alcohol

53.6% (201)

56.6% (734)

56% (935)

(511)

Table 4. Gender and alcohol intake prior to death by suicide

Table 5. Recorded life events prior to death by suicide Female

Male

Total

Relationship difficulties, arguments, or break-up

32.2% (77)

42.6% (367)

40.3% (444)

Death/illness of another

17.2% (41)

10.6% (91)

12.0% (132)

Fears for own health

8.8% (21)

7.7% (66)

7.9% (87)

Financial/employment crisis

7.6% (18)

14.2% (122)

12.8% (140)

Disordered substance use

9.7% (25)

7.8% (72)

8.2% (97)

Alcohol Intoxication at the Time of Death There was evidence of alcohol in the systems of 56% of the deceased at the time of postmortem examination (see Table 4). Males were more likely to have taken alcohol (46%) than females (33.9%). In certain cases, for example, death by drowning, it would not have been possible to assess postmortem alcohol levels. 44% of the deceased did not have alcohol present at the time of death, particularly those in older age categories (61.3% aged between 60 and 69 years, and 67.5% aged 70 years and over). Those aged between 20 and 29 years were less likely to have a zero blood/urine alcohol reading (36.3%) than other age cohorts. The youngest age group (between 10 and 19 years) had the highest proportion of individuals with twice the legal limit of alcohol in their system (19.8%). Among this group of individuals, a substantial number had over three times the legal driving limit (16.7%) of alcohol in his/her system. Those aged 20–29 years and 40–49 years were most likely to have blood/ urine alcohol levels of up to four times the legal driving limit (7.7% in both groups). This pattern was similarly observed for the 40–49-year cohort with readings of up to five times the NI drink driving limit (2.5%).

Life Events Prior to Death Either singly or in combination, 61% of cases had recorded adverse events prior to suicide. The events prior to death in each case were recorded in a different manner and, of those with recorded adverse events, many had multiple and complex combinations of events and experiences. Relationship and interpersonal difficulties were noted as the most common adverse event experienced by the deceased (40.3%). This Crisis 2016; Vol. 37(1):13–20

category included romantic relationships for those who were married or cohabiting, dating relationships, as well as peer relationships. The death/illness category (12%) included the deaths or illnesses of, among others, spouse, family members, and romantic partners. This category also included the deaths of others by suicide. The “fears for own health” category (7.9%) included those with chronic health conditions, accidents, disability, or a recent diagnosis. Financial/ employment crisis (12.8%) included reports of recent job loss or bankruptcy, debt worries, and business failure or employment difficulties related to issues such as fear of redundancy and pending disciplinary action (see Table 5).

Employment and Occupation Approximately 35% (N = 583) of those who died by suicide were employed at the time of death compared with 50.3% who were classified as unemployed (including unemployed, retired, student, homemaker). For the remainder of the sample, no information concerning the employment status of the deceased was available. Descriptive statistics relating to employment status, gender, and mental disorders for individuals who were in employment at the time of suicide in NI are presented in Table 6. The mean age of deceased employees was 37.46 years (SD = 12.5). Of those who were employed, males represented the highest proportion of suicides, equating to 84% of the sample compared with 16% of female employee suicides, and the highest proportion were either married/cohabiting or single (40.8% and 40.3%, respectively). Just over half (50.1%) had at least one mental disorder prior to death. Table 7 provides the occupational breakdown of employee suicides disaggregated by gender from 2005 to © 2015 Hogrefe Publishing

S. O’Neill et al.: Suicide in Northern Ireland

Table 6. Demographic characteristics of employees who died by suicide Employed (Y/N)

(34.8% / 50.3%)

Gender (F/M)

(16.0% / 84.0%)

Mental health (Y/N)

(50.9% / 49.1%)

Married

28.1%

Separated

11.8%

Divorced

5.5%

Widowed

contrast, the percentage of suicides denoted by professional occupations was lowest in 2005 accounting for 2.4% of suicides within this category. However, this increased to 16.5% of suicides in 2011, yet professional occupations represented a smaller proportion of suicides overall (7.6%). In 2008, for both skilled and elementary workers, there was a sharp fall in deaths from the previous year (skilled 18.8 vs. 29.1, elementary 16.3% vs. 31.4%, respectively) and the decline continued from that year onward.

1.0%

Cohabiting

12.7%

Single

40.3%

Discussion

Note. Y = yes. N = no. F = female. M = male.

2011. For the combined years, skilled and elementary workers represented the highest proportion of employee suicides accounting for 26% and 20.1%, respectively. In all, 30.1% of male employee suicides were involved in skilled occupations at the time of death compared with 4.3% of female employees. Comparably, 21.9% of employed males who died by suicide and 10.8% of employed females were working in elementary occupations prior to death. The highest proportion of female suicides was documented for those employed in professional occupations (21.5%). In addition, the greatest proportion of mental disorders was noted for individuals employed in skilled and elementary occupations (20.9% and 18.5%, respectively). In each year, the findings revealed a consistently higher proportion of suicides within skilled and elementary occupational groups. For instance, in 2008, elementary and skilled occupations represented 31.4% and 29.1%, respectively, of employee suicides in that year. Within each occupational group, the percentage of suicides varied by year. The percentage of suicides within managerial groups peaked in 2007 at 7.5% and gradually declined until 2011. At this time, the observed percentage was the lowest documented for all of the occupational groups at 1.3%. Similarly rates declined for associate professional occupations. By

In NI hanging was the most common method of suicide, particularly among males and among the younger age groups; this was followed by overdoses as the second most common method. The patterns of suicide methods in NI are broadly similar to those reported for the UK, and the gender breakdown in NI is almost the same as in the UK as a whole (78% male and 22% female in the UK). The proportions of males who die by hanging in NI are higher (65% in NI, compared with 56% for the UK as a whole; ONS, 2013). This may be a consequence of contagion effects; however, it is important to note that the proportions of “narrative verdicts” vary across the regions in the UK, thus affecting the comparability of the figures (ONS, 2013). These findings offer few obvious options for suicide prevention interventions. However, they highlight the need for continued vigilance of very high risk individuals and consideration of the ways in which to restrict access to items that may be used as ligatures. As Kosky and Dundas (2000) indicated, the private nature of hanging restricts the opportunities for prevention. As a result, there is a need to understand and identify the factors that may precipitate suicidal behaviors. In addition there is evidence that restricting access to detailed information about means of suicide, such as information from the Internet about specific methods of hanging, may influence rates and methods used. The

Table 7. Occupation breakdown by year of death, mental health diagnosis, and gender Year

Manag.

Profes.

Assoc. P.

Admin.

Skill

Service

Sales

Process

Element.

2005

7.2

2.4

13.3

7.2

34.9

4.8

3.6

10.8

15.7

2006

7.1

10.7

4.8

26.2

4.8

3.6

11.9

2007

7.5

8.8

6.3

18.8

8.8

12.5

16.3

2008

5.8

4.7

2.3

29.1

2.3

5.8

31.4

2009

6.3

27.5

13.8

16.3

2010

6.7

5.6

4.5

5.6

24.7

7.9

21.3

14.6

2011

1.3

16.5

2.5

5.1

20.3

6.3

10.1

16.5

21.5

Total

5.9

7.6

7.2

5.3

5.9

7.6

14.5

20.1

Male

5.9

4.9

2.9

30.1

3.3

6.6

16.4

21.9

Female

5.4

21.5

3.2

18.3

4.3

19.4

12.9

4.3

10.8

Mental health

8.1

9.1

6.7

8.8

20.9

7.7

8.1

12.1

18.5

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media reporting of methods used in high-profile suicides has been shown to influence suicide methods in the period following the death (Suh, Chang, & Kim, 2015). The low proportion of deaths by firearms in comparison with other Western cultures (e.g., the US) may reflect the restrictions on the ownership of these weapons in the UK. In addition, the reduced rates of suicide following means restriction suggest that substitution of method is not common (Barber & Miller, 2014). This also suggests that efforts to restrict access to detailed information about hanging and other methods remain important and that the media have a central role to play in this regard. Presence of alcohol was noted in 56% of cases and was more common among males and young people. In addition, at least 8.2% appear to have had difficulties with substance use. The involvement of alcohol in suicide and self-harm has been reported in other parts of the UK (Ness et al., 2015); however, the rates for NI appear to be slightly higher (although the studies use different methods). There are numerous explanations for this pattern. Mental disorders are common in NI in comparison with the UK and other countries, and at 14.1% the rates of substance disorders are also high (Bunting et al., 2012). A proportion of the deceased would therefore have had substance disorders including alcohol addiction. Many would have used alcohol to deal with stress or manage mental health problems. In certain cases the impulsivity associated with the effects of alcohol intoxication may have contributed to the suicide. Alternatively, individuals may have taken alcohol to reduce the fear or pain associated with the suicidal act. Alcohol use is common in NI culture and the abuse of alcohol has widely been regarded as the population’s way of managing the stress and mental health effects of the conflict (Bunting et al., 2012). It is therefore important that future research considers the impact of public health alcohol interventions on suicide rates. The fact that almost half of those who died by suicide had a previous recorded suicide attempt indicates that attempt remains one of the biggest predictors of suicide. Self-harm is a highly prevalent behavior in the UK and Ireland (Griffin et al., 2014; O’Connor, Rasmussen, & Hawton, 2014; Perry et al., 2012). It is therefore necessary to explore the factors predicting future attempts among people who self-harm through the linkage of suicide and self-harm databases. Handwritten notes remain the most common means of communication of suicidal intent. In this study 30.6% had communicated their intent and 26.6% had left a written suicide note. The figures are lower than the 38% reported in O’Connor and Sheehy’s (1997) study of suicides in NI and this may reflect the increase in suicide rates and changing age profiles of suicides in NI over time. The rates are similar to the proportions for Greece (26.1%; Parachakis et al., 2012) and lower than the 33% reported in an Australian study (Haines, Williams, & Lester, 2011). They are somewhat higher than those reported in a recent US study (18.25%; Cerel, Moore, Broen, Van De Venne, & Brown, 2015). While O’Connor et al. (1999) found that men were more likely to leave notes than women, the figures in our study concur with those from Foster’s study (2003), which show that the proportions of men and women who comCrisis 2016; Vol. 37(1):13–20

municated their intent were similar. Internationally, studies show that the proportion of those who die by suicide and leave notes has not changed (Shioiri et al., 2005). However, the increasing use of electronic means of communication of intent reflects changes in the ways in which people communicate generally and the increased use of text messaging and other electronic communications among younger people. Electronic communications, particularly public posts on social media, may offer opportunities for analysis to establish linguistic markers and predictors of suicide. These should perhaps be examined to identify possible areas for suicide prevention interventions. Etiological theories of suicide acknowledge the role of life stress in leading to the development of suicide behaviors (Foster, 2011; O’Connor, 2011). Previous studies of suicide in NI have also highlighted the associations with stressful life events (O’Connor & Sheehy, 1997). In this study the types of life events that are associated with suicide are also those that are, in an indirect way, associated with mental disorders generally and the legacy of the conflict. Employment status is likely to represent one such factor since several studies have demonstrated a link between unemployment (e.g., job loss or long-term unemployment) and suicidality (Eliason & Storrie, 2009; Lundin & Hemmingsson, 2009; Schneider et al., 2011). This is particularly the case for males, and is reflected in these data showing us that at least half of those who died by suicide were known to be unemployed, and employment-related problems or financial concerns were recorded prior to the death in at least 12.8% of cases. These figures suggest a continuing need to direct suicide prevention efforts to those affected by the economic recession and to be cognizant of the potential impact of economic and social policy decisions on mental health and suicide rates. Epidemiologists should continue to monitor the associations between social and economic policies and suicide rates and monitor the cost effectiveness of public health interventions as suicide prevention initiatives. The largest category of adverse event, experienced by one third of those who died by suicide, is that of relationship breakdown or discord. Efforts to support people with relationship difficulties and to help people manage conflict in relationships are therefore to be encouraged in terms of suicide prevention. Finally, more than 1 in 10 (12%) of those who died by suicide had recorded events relating to experiences of death and grief or serious illness. This again emphasizes the need to support people in coping with illness and loss and the need to research the impact of interventions for these groups on suicidal behavior and thoughts. The findings for occupation re-affirm that particular groups are likely to have a higher risk of suicide; the results also support a possible skill level gradient in risk, with lower–middle-skilled occupations encountering the greatest threat. Since previous research has failed to establish that lower socioeconomic status may account for this finding (Milner, Spittal, Pirkis, & La Montagne, 2013), alternative explanations should be explored. For instance, the contribution of work stress may be one avenue of further investigation that may help clarify the risk differential between © 2015 Hogrefe Publishing

S. O’Neill et al.: Suicide in Northern Ireland

these groups. Indeed, several studies have demonstrated associations between work stress (e.g., high demand and low control) and suicide outcomes (Ostry et al., 2007; Tsutsumi et al., 2007) and this is known to fluctuate by occupation (Bültmann, Kant, Schröer, & Kasl, 2002). Further research should also consider harassment at work as a possible stressor that may contribute to suicide risk, given that negative acts at work have been implicated in stress responses previously (Hogh, Hansen, Mikkelsen, & Persson, 2012).

Conclusion and Limitations Building on studies from Foster et al. (1999), O’Connor and Sheehy (1997), and O’Connor et al. (1999), this study offers insight into the circumstances surrounding deaths by suicide in NI, a region of the UK with a history of civil conflict, high rates of mental disorders (Bunting et al., 2012), and rising suicide rates (Snowcroft, 2013). In NI many of those who die by suicide have mental disorders, and disengagement from services prior to death is common (O’Neill, Corry, et al., 2014) making it important to examine the other contextual factors so as to inform prevention initiatives. The findings with regard to means of suicide suggest that restricting access to ligatures for those at high risk and limiting access to information on methods are important. Efforts to identify predictors of suicide among those who use electronic forms of communication and among people who attempt suicide or self-harm may also be useful. Suicide prevention initiatives should target people who are unemployed or in low-status occupations, and those who have had life crises and relationship difficulties. Although these data offer clues about the factors associated with suicides in this population, the analysis of these types of qualitative data is expensive and time consuming and the unreliability of the data, particularly in relation to adverse events, remains a major limitation. For example, in many cases no information was provided about the proximity of the life event to the death and indeed those events occurring close to the time of death; moreover, events with a known link to suicide or mental health are probably more likely to have been reported. In addition, communications about suicidal intent and suicide notes are not always disclosed to the authorities, therefore the figures for these may be an underestimation. Furthermore, many of the events and experiences that precipitate suicide may be perceived as stigmatizing, and such factors may therefore be less likely to be reported in coronial files or may remain known only to the deceased. Caution should therefore be exercised when interpreting these findings and the results should not be used to make definitive statements about the causes of suicide. While this study included undetermined deaths that were probable suicides, the difficulties in establishing whether a death was in fact suicide also affect the reliability of the statistics. It is only through the accurate coding of deaths as suicide and through the thorough and systematic collection of data pertaining to each suicide that researchers can uncover the © 2015 Hogrefe Publishing

depth of information required to understand what measures could have been taken to prevent any of these deaths.

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Lundin, A., & Hemmingsson, T. (2009). Unemployment and suicide. The Lancet, 374(9686), 270–271. Milner, A., Spittal, M.J., Pirkis, J., & La Montagne, A. D. (2013). Suicide by occupation: Systematic review and meta-analysis. British Journal of Psychiatry, 203(6), 409–416. Ness, J., Hawton, K., Bergen, H., Cooper, J., Steeg, S., Kapur, N., …Waters, K. (2015). Alcohol use and misuse, self-harm and subsequent mortality: An epidemiological and longitudinal study from the multicentre study of self-harm in England. Emergency Medicine Journal. Advance online publication. doi:10.1136/emermed-2013-202753. O’Connor, R. C. (2011). The integrated motivational-volitional model of suicidal behaviour. Crisis, 32(6), 295–298. O’Connor, R. C., Rasmussen, S., & Hawton, K. (2014). Adolescent self-harm: A school-based study in Northern Ireland. Journal of Affective Disorders, 159, 46–52. O’Connor, R. C., & Sheehy, N. P. (1997). Suicide and gender. Mortality, 2, 239–254. O’Connor, R. C., Sheehy, N. P., & O’Connor, D. B. (1999). A thematic analysis of suicide notes. Crisis, 20(3), 106–114. Office for National Statistics (ONS). (2010). Standard occupational classification 2010. Retrieved from http://www. ons.gov.uk/ons/guide-method/classifications/current-standard-classifications/soc2010/soc2010-volume-2-the-structure-and-index/index.html Office for National Statistics (ONS). (2015). Suicides in the United Kingdom, 2013 registrations. http://www.ons.gov.uk/ons/rel/ subnational-health4/suicides-in-the-united-kingdom/2013registrations/suicides-in-the-united-kingdom--2013-registrations.html O’Neill, S., Corry, C. V., Murphy, S., Brady, S., & Bunting, B.P. (2014). Characteristics of deaths by suicide in Northern Ireland from 2005 to 2011 and use of health services prior to death. Journal of Affective Disorders, 168, 466–471. O’Neill, S., Ferry, F., Murphy, S., Corry, C., Bolton, D., Devine, B., … Bunting, B. (2014). Patterns of suicidal ideation and behaviour in Northern Ireland and associations with conflict related trauma. Plos ONE 9(3), e91532. Ostry, A., Maggi, S., Tansey, J., Dunn, J., Hershler, R., Chen, L., … Hertzman, C. (2007). The impact of psychosocial work conditions on attempted and completed suicide among western Canadian sawmill workers. Scandinavian Journal of Public Health, 35(3), 265–271. Overholser, J. C., Braden, A., & Dieter, L. (2012). Understanding suicide risk: Identification of high-risk groups during highrisk times. Journal of Clinical Psychology, 68(3), 349-61. Parachakis, A., Michopolous, I., Douzenis, A., Christodoulou, C., Koutsaftis, F., & Lykouras, L. (2012). Differences between suicide victims who leave notes and those who do not: A 2-year study in Greece. Crisis, 33(6), 344–349. Perry, I. J., Corcoran, P., Fitzgerald, A. P., Keeley, H. S., Reulbach, U., & Arensman E. (2012). The incidence and repetition of hospital-treated deliberate self harm: Findings from the world’s first national registry. PLoS One, 7(2), e31663. Schneider, B., Grebner, K., Schnabel, A., Hampel, H., Georgi, K., & Seidler, A. (2011). Impact of employment status and work-related factors on risk of completed suicide: A case– control psychological autopsy study. Psychiatry Research, 190(2–3), 265–270. Shioiri, T., Nishimura, A., Acazawa, K., Abe, R., Nushida, H., Ueno, Y., … Someya, T. (2005). Incidence of note-leaving remains constant despite increasing suicide rates. Psychiatry and Clinical Neuroscience, 59(2), 226–228. Skegg, K., Firth, H., Gray, A., & Cox, B. (2010). Suicide by occupation: Does access to means increase the risk? Australia and New Zealand Journal of Psychiatry, 44(5), 429–434.

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Snowcroft, E. (2013). Samaritans suicide statistics report 2013. Data for 2009–2011. Retrieved from http://www.samaritans. org/sites/default/files/kcfinder/files/research/Samaritans%20 Suicide%20Statistics%20Report%202013.pdf Suh, S., Chang, Y., & Kim, N. (2015). Quantitative exponential modelling of copycat suicides: Association with mass media effect in South Korea. Epidemiology and Psychiatric Sciences, 24(2), 150–157. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. (2014). Annual report 2014: England, Northern Ireland, Scotland and Wales. July 2014. Manchester, UK: University of Manchester. Tomlinson, M. W. (2012). War, peace and suicide: The case of Northern Ireland. International Sociology, 27(4), 464–482. Tsutsumi, A., Kayaba, K., Ojima, T., Ishikawa, S., & Kawakami, N. (2007). Low control at work and the risk of suicide in Japanese men: A prospective cohort study. Psychotherapy Psychosomatics, 76(3), 177–185. Webb, R. T., Qin, P., Stevens, H., Shaw, J., Appleby, L., & Mortensen, P. B. (2013). National study of suicide method in violent criminal offenders. Journal of Affective Disorders, 150(2), 237–244.

Received March 14, 2015 Revision received July 20, 2015 Accepted July 20, 2015 Published online December 23, 2015 About the authors Siobhan O’Neill, MPsychSc and PhD, is a professor of Mental Health Sciences at Ulster University, Londonderry, UK, and a chartered health psychologist. She was a coordinator of the study. Dr. Colette Corry is a senior research psychologist with the National Suicide Research Foundation at University College Cork, Ireland. She developed the NI suicide database and collected the data for this study. Dr. Danielle McFeeters is a postdoctoral researcher at Ulster University, Londonderry, UK. Her dissertation examined occupational factors and suicidal behavior. Dr. McFeeters developed and analyzed the occupational variables for the study. Dr. Sam Murphy is a lecturer in psychology at Ulster University, Londonderry, UK. He is also a chartered ergonomist and coordinator of the suicide study. Brendan Bunting is a professor of psychology at Ulster University, Londonderry, UK, and specialist in statistical analysis and epidemiology. He was principal investigator of the study. Siobhan O’Neill Psychology Research Institute Ulster University Northland Road Londonderry, BT48 7JL UK E-mail sm.oneill@ulster.ac.uk

Research Trends

Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010 Francisco Bustamante1, Valeria Ramirez2, Cinthya Urquidi2, Vicente Bustos3, Zimri Yaseen4, and Igor Galynker4 1

Mental Health Department, Universidad de los Andes, Clínica Universidad de los Andes, Santiago, Chile 2 Public Health Department, Faculty of Medicine and Faculty of Odontology, Universidad de los Andes, Santiago, Chile 3 Faculty of Medicine, Universidad de los Andes, Santiago, Chile 4 Department of Psychiatry and Behavioral Sciences, Beth Israel Medical Center, New York, NY, USA Abstract. Background: Despite the many studies trying to evaluate the magnitude of suicide in Chile, none of them include the new valid data, recently published by the DEIS of the Chilean Health Ministry. Aim: This paper sought to describe how suicide rates changed among Chileans who were at least 15 years of age during the period of 2001–2010; these rates were stratified by sex, age, urban/rural status, and region of the country. Method: An exploratory and temporal study was conducted. Suicide mortality rates were calculated by collecting information from the Chilean Ministry of Health’s death registry between 2001 and 2010 among subjects who were at least 15 years of age. Crude and age-adjusted mortality rates were computed. Results: The standardized suicide rate in Chile during 2001–2010 was 14.7 deaths per 100,000, the highest in South America. The minimum age-adjusted suicide rate observed during the examined period was 13.49 per 100,000 in 2005, and the maximum, 16.67 per 100,000 in 2008. Suicide rates among men were up to 4.8 times the suicide rates among women. In addition, rates in rural areas were double compared with urban areas. Hanging was the most common suicide method, followed by use of firearms and explosives in men and poisoning in women. Finally, there was a progressive increase in suicide rates in the southernmost regions of the country. Conclusion: Suicide rates in Chile are relatively high among male subjects in rural areas. There is a disturbing increase in suicide rates among younger individuals and women, although these rates remain lower among younger individuals and women than among adults in general. Keywords: suicide, epidemiology, prevalence

Suicide is an important public health problem worldwide (World Health Organization [WHO], 2013a). It is the eighth leading cause of death (Bertolote & Fleischmann, 2009) and Chile is the 13th member of the Organization for Economic Cooperation and Development (OECD) with a higher prevalence of death by suicide (OECD, 2013). Therefore, the WHO has proposed public health actions for the prevention of suicide, including to address the incidence trends of suicide, to establish a reliable record and identify the most vulnerable geographical area or subgroup populations, and to identify the most prevalent methods of suicide (WHO, 2013a). Some studies have attempted to assess the magnitude and trends of suicide mortality in Chile (Baader et al., 2011; Mazzei & Cavada, 2004; Méndez, Opgaard, & Reyes, 2001; Retamal, Reszczynki, Orio, Ojeda, & Medina, 1995; Trucco Burrows, 1993). However, all these studies incorporate suicides reported between 1973 and 2000; during that period, the Chilean Ministry of Health’s Department of Health Statistics and Information (DEIS) was © 2015 Hogrefe Publishing

suppressed by the military government, and there was no cross-checking or verification of different reports of the cause of death for the same person. With the return to democracy in 2000, the DEIS resumed its functions, resulting in an important improvement in the reports and records of rates of death by suicide after 2000 (in 1999 the suicide rate was reported as 6.8 per 100,000 inhabitants, while in 2001 the rate was found to be 10.4). For this reason, an authoritative analysis of the rates of suicide in Chile should include only data from 2000 onward. Chile is a country located in South America with an estimated population for 2015 of 18 million people (Instituto Nacional de Estadísticas, 2008). According to the gross domestic product estimated by the International Bank for 2013, Chile ranks in the 38th world position (US $277,199 million), under Argentina (21st position) and above Peru (52nd) and Bolivia (98th), its closest neighbors. It is divided into 13 geopolitical regions where Región Metropolitana accounts for 40.3% of the whole population of the country, followed by Región del Bíobío (11.9%) and ValCrisis 2016; Vol. 37(1):21–30 DOI: 10.1027/0227-5910/a000357

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

paraíso (10.3%; Instituto Nacional de Estadísticas, 2010a). Santiago de Chile, located in Región Metropolitana, is the capital and the most populated city followed by Concepción (Región del Bíobío). About 13% of the population lives in rural areas; however, rurality increases to about 30% in regions further south in the country, such as Región de la Araucanía. According to the data obtained from the Instituto Nacional de Estadísticas and the United Nations CEPAL (Comisión Económica para América Latina y el Caribe), the percentage of the Chilean population classified as rural has not changed dramatically from 2002 to 2010 (Instituto Nacional de Estadísticas 2010b). Therefore, the purpose of this study was to address the lack of sound epidemiological data on suicide and its temporal trends in Chile in the literature. We describe the trends in suicide among Chileans at least 15 years of age over a 10-year period using the official DEIS database data from 2001 to 2010, and identify vulnerable geographical regions and subpopulations. We also by describe the most frequent suicide methods used.

Method An exploratory and temporal study was conducted in which suicide rates and proportional mortality among Chileans who were at least 15 years of age were examined over the period of 2001–2010. In this study, the population under 15 years of age was excluded because the cumulative incidence of suicide in this group was close to zero; in addition, 2001 was chosen as the starting year for information collection because new records were first used by the DEIS in this year. In order to access mortality information by regions for the 2001–2010 period, the death registry compiled by the DEIS was used (Departamento de Estadísticas e Información de Salud, 2013). Chilean population data for the same period were acquired from estimates issued by the Chilean National Statistics Institute (Instituto Nacion-

al de Estadísticas, 2010a), and standard world population information was used to adjust the calculated rates by age as suggested by the WHO (WHO, 2013b). Administrative shapefiles containing boundaries of standard geographic locations were obtained from the website of the US Centers for Disease Control and Prevention (CDC, 2013a) and mortality rates by region were produced using Stata software. Mortality rates were calculated with information on suicide deaths, which were regarded as deaths with ICD10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) codes X60–X84. The deaths from the methods coded Y10–Y34 (events with nondetermined intention) were not registered by the DEIS, and thus they were excluded. The examined variables included the year in which suicides occurred, the age, gender, and urbanicity of the involved individuals, and the suicide methods. The results for the age variable were grouped into the following five categories of programmatic age ranges in Chile, which are defined as “populations of individuals whose ages are typically referenced in the design and implementation of policies, programs and projects related to the education and health sectors” (Instituto Nacional de Estadísticas, 2012): 15–19 years, 20–44 years, 45–64 years, 65–79 years, and 80 years and over. For study of the urban/rural status variable, we used the Chilean National Institute of Statistics definition for urban areas: “An urban entity consists of a cluster of gathered houses with two thousand people or more, with half of its population economically active” (Instituto Nacional de Estadísticas, 2012). In 2000 Chile was divided into 13 regions, but since 2007 15 regions have been demarcated. To analyze the whole 2001–2010 decade, the original 13 regions were used. For statistical analysis, categorical variables were described in terms of absolute frequencies and percentages. Crude rates were calculated by year, gender, age and urban/ rural status, and overall rates were standardized according to world population data (obtained from the WHO). The

Table 1. Numbers of suicides and rates of suicide deaths (per 100,000 population) among Chileans at least 15 years of age, stratified by year and sex Sex

Women

Men

Year

Suicides (n)

Rate (per 100,000 habitants)

Suicides (n)

Rate (per 100,000 habitants)

2001

223

3.85

1,380

24.86

2002

241

4.09

1,336

23.60

2003

248

4.13

1,382

23.95

2004

258

4.22

1,457

24.78

2005

265

4.26

1,375

22.96

2006

291

4.60

1,478

24.25

2007

354

5.50

1,543

24.88

2008

409

6.25

1,727

27.38

2009

413

6.21

1,709

26.65

2010

373

5.52

1,600

24.54

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F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

Figure 1. Suicide rates among Chileans at least 15 years of age: 2001–2010.

Figure 2. Rates of suicide deaths per year (per 100,000 population) in Chile among individuals who were at least 15 years of age, stratified by urban/rural status.

rates by region for the examined decade were depicted using a national choropleth map, which presented rates divided into quartiles (Brewer & Pickle, 2002). Multivariate Poisson models were constructed to identify vulnerable geographical regions using the Región Metropolitana as the reference and controlling for gender and rural status; since the rural population stratified by geographical region and year was not available, the rural population according to the census was used assuming that the percentage of rurality for the decade remained the same (as mentioned). Incidence rate ratios (IRRs) and 95% confidence intervals (95% CI) are reported. Data management, statistical analyses, and map generation were performed using Stata software (version 11.2, StataCorp, TX).

Results In Chile, between 2001 and 2010, 18,062 individuals who were at least 15 years of age died by suicide. Suicide mortality rates per 100,000 in Chile between 2001 and 2010 are depicted in Figure 1; these rates were highest in 2008 and 2009. Age-standardized rates were similar to crude rates over the entire period. Suicide rates stratified by year and sex are presented in Table 1. The suicide rate for men was 4.87 times higher than that for women. Figure 2 shows suicide rates stratified by year and by urban/rural status. Suicide rates for each age group during the 2001–2010 period are presented in Table 2. The rates for each region of Chile during the examined decade are depicted in FigCrisis 2016; Vol. 37(1):21–30

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

Table 2. Suicide rates among Chileans at least 15 years of age during the 2001–2010 period, stratified by age group Age groups

Suicide (n)

Rate (per 100,000 habitants)

15 to 19 years

1,456

10.09

20 to 44 years

9,621

15.4

45 to 64 years

5,027

15.26

65 to 79 years

1,545

14.49

413

15.75

≥ 80 years

ure 3, and the total numbers and proportion of suicides with their respective IRR for each region are summarized in Table 3. The Metropolitana and the Bíobío region of Chile concentrated the greatest number of suicides, 33.8% and 13.6%, respectively; however, after controlling for rurality and gender, the highest IRRs are observed in the region of the Araucanía, Los Lagos, and Aysén (1.36, 1.45, and 1.56, respectively). Regarding the methods by which Chileans suicided, the most common was by hanging, which accounted for 79.50% of the deaths, with a slight predominance in male subjects (81.26% vs. 70.93% in females). In men, it was followed by the use of firearms and explosives in 9.34% and by poisoning in 4.95% of the cases, whereas in women this distribution was inverted (15.35% died by poisoning and 4.59% by the use of firearms or explosives). No differences were found when comparing the rates of deaths by hanging in the different regions of the country; the lowest incidence corresponded to 70.43% in Maule, and the highest was 88.82% in Los Lagos. However, some noteworthy facts were identified when comparing the other methods among regions: for example, in Tarapacá jumping from high places

was the chosen method in 5.18% of the cases, whereas in all the other regions it did not represent more than 1%. In the rural population, poisoning accounted for 7.89% of suicides, followed by the use of firearms and explosives (9.09%) and jumping from high places (0.17%). For the urban population, the percentages were 6.44%, 8.49%, and 1.62%, respectively. Important time trends were also observed: Deaths by hanging presented a progressive increase during the years studied (from 74.92% in 2001 to 81.96% in 2010). The use of firearms and explosives, however, diminished steadily in the same period (11.29 to 7.25 in 2010).

Discussion This is the first study to address suicide rates in Chile by examining data only from the new cross-referenced registration system of the DEIS. Furthermore, these data were age-standardized in accordance with WHO criteria. Because suicide deaths are difficult to register in epidemiological terms (Bertolote & Fleischmann, 2009; Chang, Sterne, Lu, & Gunnell, 2010; Pritchard & Hean, 2008), this new registration system facilitates comparison with other countries that share the same methodology. The standardized suicide rate in Chile over the 2001– 2010 period was 14.7 deaths per 100,000 population. Based on this rate, Chile is the South American nation with the highest suicide rate. By comparison, between 1980 and 2006, the suicide rates in Brazil and Colombia were 4.12 deaths per 100,000 population (Brzozowski, Soares, Benedet, Boing, & Peres, 2010; Lovisi, Santos, Legay, Abelha, & Valencia, 2009) and 5.5 deaths per 100,000 popu-

Table 3. Numbers, mortality percent, and incidence rate ratio (IRR) with 95% confidence interval of suicides by geographical regions of Chile during the 2001–2010 period Geographical region

Suicide number

Mortality (%)

IRR* 95% CI

Tarapacá

483

2.67

1.08 (0.99–1.19)

Antofagasta

529

2.93

1.03 (0.94–1.12)

Atacama

288

1.59

1.11 (0.98–1.25)

Coquimbo

707

3.91

1.12 (1.03–1.21)

Valparaíso

1,837

10.17

1.15 (1.09–1.21)

O'Higgins

1,106

6.12

1.29 (1.20–1.32)

Maule

1,209

6.69

1.21 (1.13–1.29)

Bio Bio

2,462

13.63

1.26 (1.20–1.32)

Araucanía

1,276

7.06

1.36 (1.28–1.45)

Los Lagos

1,708

9.46

1.45 (1.37–1.53)

Aysén

157

0.87

1.56 (1.33–1.83)

Magallanes

202

1.12

1.19 (1.03–1.83)

6,098

33.76

Reference

18,062

100

Metropolitana Chile

–

Note. *Poisson model estimations controlled by rural and sex status. Crisis 2016; Vol. 37(1):21–30

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

lation, respectively (Cendales, Vanegas, Fierro, Córdoba, & Olarte, 2007). However, the WHO 2014 Suicide Report includes Chile, Argentina, and Bolivia in the 10.0–14 per 100,000 population rate segment (Peru, the other closest neighbor, is reported as not having data available), which is much closer to the results obtained in this study. Furthermore, the 14.7 per 100,000 standardized suicide rate for 2001–2010 in Chile calculated in this study is in agreement with the average global suicide rate (14 per 100,000) estimated by Bertolote and Fleischmann for 2008 (Bertolote & Fleischmann, 2009). These researchers identified Lithuania, Russia, Belarus, Kazakhstan, and Slovenia as the countries with the highest suicide rates (Bertolote & Fleischmann, 2009). Still, when compared with other member countries of the OECD, Chile exhibits one of the highest suicide rates, with particularly high relative suicide rates for teens between 15 and 19 years of age (OECD, 2011).

Temporal Trends

Figure 3. The distribution of suicide rates in Chile at the regional level over the 2001–2010 period among individuals who were at least 15 years of age. The colors show the rates divided into quartiles.

Another important finding of this study is that, during the examined period, national suicide rates in Chile increased. The Chilean Ministry of Health reports that suicide rates in Chile increased by 60% between 1999 and 2007 (Ministerio de Salud, 2011), but that conclusion was obtained using the non-DEIS data for 1999. If solely the DEIS information is used for the period 2000–2004, the suicide rate shows only a 5% increase. Increases in suicide rates over the course of the examined period are most clearly evident among adolescents (15–19 years of age) and women, whereas the male group rate remained almost constant. There were 4.87 times as many suicides among males as among females, consistent with literature reports indicating that men complete suicide more frequently than women (Mäkinen, 2009; Nock et al., 2008; Redaniel, Lebanan-Dalida, & Gunnell, 2001; Varnik, 2012), with the exception of Chinese women in the regions of mainland China (Xiong & Lester, 1997). However, as noted, there has been an increase in female suicides in Chile in recent years. This phenomenon has not been examined by Chilean authorities. In fact, greater efforts and resources have been devoted to preventing women’s deaths from intimate partner homicide (Stöckl et al., 2013) than deaths from suicide, despite the fact that in 2010, 49 deaths resulted from intimate partner homicide (Servicio Nacional de la Mujer, 2013) while 373 deaths resulted from suicide. While a rigorous explanation of the differential performance in female and male suicide rates is beyond the scope of this study, it may be worth noting that women’s participation in the workforce has been positively correlated with women’s suicide rates, while parenthood has been found to be a protective factor (Stack, 2000). Thus it is possible that the upward trends seen in women’s suicide rates are due in part to the delayed effects of falling birth rates and increasing work force participation in Chile in the 1990s (Contreras & Plaza, 2010). Such an explanation is consistent with rising suicide rates in urban but not in Crisis 2016; Vol. 37(1):21–30

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

rural areas, where women’s workforce participation is less likely to have increased. We decided not to include adolescents younger than 15 years because there were very few suicides in this population (Cash & Bridge, 2009; Hawton, Saunders, & O’Connor, 2012), as the DEIS data show. Nevertheless, the adolescent population older than 15 years shows a significant increase in suicide rate through the decade, a phenomenon also reported in other countries (Pompili, Vichi, De Leo, Pfeffer, & Girardi, 2012). There are many studies of suicide behavior and its risk factors for this population, but not for completed suicides (McLoughlin, Gould, & Malone, 2015), and Chile is not the exception. This is an important matter, because there are many effective suicide prevention programs for adolescents (Bustamante & Florenzano, 2013). Internationally, several countries have also experienced an increase in deaths from suicide. For example, in the US, suicide rates increased by 15% between 2000 and 2009 (Rockett et al., 2012), with a particularly steep increase of nearly 30% among individuals over 35 years of age (CDC, 2013b). By contrast, Europe has generally exhibited downward trends in suicide rates, whereas countries such as South Korea and the Philippines are experiencing significant increases in suicide rates (Redaniel et al., 2011; Titelman et al., 2013; Varnik, 2012). Among South American nations, Brazil has experienced recent increases in suicide rates, particularly among younger individuals aged between 15 and 19 years (Brzozowski et al., 2010; Lovisi et al., 2009; Mello-Santos & Bertolote, 2005). Nevertheless, Bertolote and De Leo (2012) concluded that a general decline in the worldwide suicide rate was observable in the second half of the 2000s.

Synchronous Geographic Trends Another notable finding from this study relates to the regional distribution of suicide deaths. More than one third of all suicides during the examined decade occurred in the Región Metropolitana (6,098 suicides), with the next highest number of suicides occurring in the Bíobío and Valparaiso regions; these three regions being the most populated areas of Chile. However, the highest suicide rates per 100,000 population were found in rural regions: Aysén (21.56), followed by Los Ríos-Los Lagos (19.73) and La Araucanía (18.46). Rural suicides thus accounted for the majority of suicide deaths nationally. A striking result from the observations of how suicide rates are distributed by latitude (Figure 3) is that these rates tend to increase as one moves south from the O’Higgins region. Although the reasons for this increase are beyond the scope of our study, it is possible that the greater proximity to the South Pole is associated with increased suicide risk because regions closer to the pole experience less light in winter than do regions closer to the equator. This hypothesis has been empirically supported by reports indicating that areas near the poles exhibit higher suicide rates than other regions, in both the northern (Björksten, Kripke, & Bjerregaard, 2009; Davis & Lowell, 2002; Terao, SoeCrisis 2016; Vol. 37(1):21–30

da, Yoshimura, Nakamura, & Iwata, 2002) and southern hemispheres (Lawrynowicz & Baker, 2005). However, the proximity hypothesis fails to explain why the southern region Magallanes exhibited lower suicide rates than northern regions. Although Chile experienced sustained growth in GDP in the last decade, along with diminished poverty and unemployment, there are regional economic disparities, with northern regions being richer than southern ones (Moyano & Barría, 2006). One example, Aysén, which has the highest suicide rate, also has the highest rate of illiteracy in the country and the lowest in schooling (Moyano & Barría, 2006). Therefore, an impoverished environment could explain, in part, these differences. The degree of urbanization is another factor that could explain why suicide rates were higher in southern Chile than in northern Chile. According to our results, there were many more deaths from suicide in rural areas than in urban areas, with nearly twice as many rural suicides as urban suicides during several years. This finding is consistent with observations in other countries (Bertolote et al., 2010; Cendales et al., 2007; Chang et al., 2010; Lovisi et al., 2009; Mello-Santos & Bertolote, 2005). It has been hypothesized that this phenomenon relates to the challenges that rural populations face with respect to accessing health services (Chang et al., 2011). There tend to be higher rural populations in southern than in northern Chile (Instituto Nacional de Estadísticas, 2008); therefore, it could be argued that these rural populations exhibit higher suicide risks due to reduced access to medical care. However, we performed a multivariate Poisson analysis to control the urban/rural variable. As shown in Table 3, in Aysén, Los Lagos, and La Araucanía the rural factor does not explain why these regions have the highest rates of the country. Furthermore, the Aysén rural population decreased over the course of the decade. One explanation could be the low number of psychiatrists in the south of the country, for example, Aysén has only five for the whole region of 100,000 habitants. Further studies are needed to assess the impact of local access to psychiatric care on suicide rates in Chile.

Methods of Suicide The findings of this study were similar to the ones published in previous Chilean investigations (Baader et al., 2011; Madariaga et al., 2010; Otzen, Sanhueza, Manterola, & Escamilla-Cejudo, 2014) regarding the most frequent method of suicide used. In all cases it was hanging (near 79%), followed by the use of firearms and poisoning. Some differences were observed when comparing the methods used by men and women with those reported in the study of Madariaga et al., in which hanging was followed by the use of firearms in both genders. These results are also in agreement with international evidence, which in general describes a preponderance of suicide by hanging (Badiye, Kapoor, & Ahmed, 2014; Dedic, 2014; Im et al., 2011; Thomas, Beech, & Gunnell, 2013; Yoshioka, Hanley, Kawanishi, & Saijo, 2014). The difference in the method chosen by gender also correlates © 2015 Hogrefe Publishing

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

with previous international findings, in which poisoning is more frequently preferred by females, whereas males tend to use more lethal means such as firearms or explosives (Dedic, 2014). The fact that deaths by poisoning were more prevalent in rural than in urban locations was expected, since the same has been observed in other studies in which the population has a more rural lifestyle and the access to insecticides and other chemicals is easier (Badiye et al., 2014; Knipe et al., 2014).

Public Health Implications Given that suicide is considered a multifactorial behavior (Arsenault-Lapierre, Kim, & Turecki, 2004; Hawton & van Heeringen, 2009; Mäkinen, 2009; Nock et al., 2008), it is not easy to explain the causes of the increase in suicide rates, particularly among women and adolescents, and such explanations are beyond the scope of the current study. Chile’s National Plan of Mental Health and Psychiatry was first issued in 2001 to define mental health public policy (Ministerio de Salud, 2001). This plan subsequently came to fruition with the establishment of the National Diagnosis and Treatment of Depression Program, which has been formalized in law since 2005, and is available to every Chilean in the country (Ministerio de Salud, 2009a). Similar programs were also implemented for schizophrenia (Ministerio de Salud, 2009b) and for the management of alcohol and drug abuse among individuals under 20 years of age (Ministerio de Salud, 2007a). The National Suicide Prevention Program, created in 2007 (Ministerio de Salud, 2007b), consists of seven evidence-based interventions: (1) a regional registry of suicide deaths and case study system for every suicide death or attempt; (2) a regional multidisciplinary prevention plan; (3) specialized training in suicide prevention for health professionals in the public health system; (4) prevention programs in schools, a help protocol for local crisis situations (e.g., hotlines, websites, etc.); (5) crisis intervention protocols and follow-up for survivors of an attempt; (6) improvements in mental health treatments; (7) specialized training for media professionals. To date, however, the only intervention actually implemented has been the regional registry of suicide deaths. Therefore, the overall effectiveness of the program could not be evaluated yet. Moreover, initiatives focused on the detection and treatment of psychiatric disorders (like the National Diagnosis and Treatment of Depression Program), conditions that have been directly related to increased suicide risk (Lönnqvist, 2009; Tidemalm, Långström, Lichtenstein, & Runeson, 2008; Wasserman et al., 2012), are effective for suicide prevention. It is therefore necessary to reconsider these policies, and try to find risk factors beyond mental illness to ensure that they can contribute to meaningful reductions in the suicide rate in Chile. Our findings also highlight the urgency of a full implementation of the National Suicide Prevention Program.

Limitations The main limitation of our study lies in the study database, which provides no data to establish causes of observed increases in suicide rates. Thus, we could not identify the factors that might explain the observed increases in Chilean suicide rates. These issues could be addressed by future studies. Our rates are different from the ones published by the DEIS because the DEIS data are raw and ours are adjusted and exclude the population under 15 years of age (as explained). Thus, our findings cannot be compared with the DEIS rates. Nevertheless, the trends and the geographical distribution are the same. Another limitation is that the CIE-10 codes Y10–Y34 were not included. Those codes could mask suicides not registered in other codes.

Conclusion In summary, suicide rates increased in Chile during the last decade, especially in women and adolescents, despite the Ministry of Health’s implementation of several mental health policies. These rates are the highest among the South American countries and show an increase in southern regions not explained by decreasing urbanicity. Acknowledgments None of the authors report any conflict of interest.

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Stöckl, H., Devries, K., Rotstein, A., Abrahams, N., Campbell, J., Watts, C., & Moreno, C. G. (2013). The global prevalence of intimate partner homicide: a systematic review. The Lancet, 382(9895), 859–865. doi:10.1016/S0140-6736(13)61030-2 Terao, T., Soeda, S., Yoshimura, R., Nakamura, J., & Iwata, N. (2002). Effect of latitude on suicide rates in Japan. The Lancet, 360(9348), 1892–1892. doi:10.1016/S0140-6736 (02)11761-2 Thomas, K. H., Beech, E., & Gunnell, D. (2013). Changes in commonly used methods of suicide in England and Wales from 1901–1907 to 2001–2007. Journal of Affective Disorders, 144, 235–239. doi:10.1016/j.jad.2012.06.041 Tidemalm, D., Långström, N., Lichtenstein, P., & Runeson, B. (2008). Risk of suicide after suicide attempt according to coexisting psychiatric disorder: Swedish cohort study with long term follow-up. BMJ, 337, a2205. doi:10.1136/bmj.a2205 Titelman, D., Oskarsson, H., Wahlbeck, K., Nordentoft, M., Mehlum, L., Jiang, G. X. … Wasserman, D. (2013). Suicide mortality trends in the Nordic countries 1980–2009. Nordic Journal of Psychiatry, 67, 414–423. doi:10.3109/08039488. 2012.752036 Trucco Burrows, M. (1993). Tendencias del suicidio en Chile, 1971–1990 [Trends in suicide in Chile, 1971–1990]. Revista Chilena de Neuro-Psiquiatría, 31, 5–17. Varnik, P. (2012). Suicide in the world. International Journal of Environmental Research and Public Health, 9(3), 760–771. doi:10.3390/ijerph9030760 Wasserman, D., Rihmer, Z., Rujescu, D., Sarchiapone, M., Sokolowski, M., Titelman, D., … Carli, V. (2012). The European Psychiatric Association (EPA) guidance on suicide treatment and prevention. European Psychiatry: The Journal of the Association of European Psychiatrists, 27(2), 129– 141. doi:10.1016/j.eurpsy.2011.06.003 World Health Organization. (2013a). Suicide. Retrieved from http://www.who.int/mental_health/media/en/382.pdf World Health Organization. (2013b). Health state valuations. Retrieved from http://www.who.int/choice/demography/health_ valuations/en/index.html World Health Organization (2014). Preventing suicide: A global imperative. Retrieved from http://www.who.int/mental_ health/suicide-prevention/world_report_2014/en/ Xiong He, Z., & Lester, D. (1997). The gender difference in Chinese suicide rates. Archives of Suicide Research, 3(2), 81–89. Yoshioka, E., Hanley, S. J., Kawanishi, Y., & Saijo, Y. (2014). Time trends in method-specific suicide rates in Japan, 1990– 2011. Epidemiology and Psychiatric Sciences, 6, 1–11.

Received October 16, 2014 Revision received July 9, 2015 Accepted July 19, 2015 Published online December 1, 2015

About the authors Francisco Bustamante, MD, studied medicine at the Universidad de Chile and specialized in psychiatry at the Universidad de los Andes, Chile. He is a professor at the school of medicine at the Universidad de los Andes as well as a DBT therapist. He treats suicide risk patients in Grupo DBT Chile and Clínica Universidad de los Andes, Chile. Valeria Ramírez, MPH, studied odontology at the Universidad de Chile, and obtained a master’s degree in epidemiology from the same university. Her master’s thesis was on suicide in Chile. Crisis 2016; Vol. 37(1):21–30

F. Bustamante et al.: Trends and Most Frequent Methods of Suicide in Chile Between 2001 and 2010

She currently teaches epidemiology at the Odontology School of Universidad de los Andes, Chile. Cinthya Urquidi, MD, PhD, studied medicine at the Universidad Mayor San Andrés, Bolivia, and worked for the Ministry of Health in Bolivia on epidemiological issues. She obtained a doctorate degree in public health from the Universidad de Chile and now works in the Department of Public Health of the Faculty of Medicine, Universidad de los Andes. Vicente Bustos, MD, received his MD from the Universidad de los Andes. He currently works in a primary care center attending patients at high social risk. Zimri S. Yaseen, MD, completed his psychiatry residency and studied suicide and the interactions between attachment and depression at the Beth Israel Medical Center, NY. Dr. Yaseen is a graduate of the Sackler School of Medicine, and completed his undergraduate studies at the University of Chicago where he majored in mathematics and philosophy.

Crisis 2016; Vol. 37(1):21–30

Igor I. Galynker, MD, PhD, received his MD from the Albert Einstein College of Medicine and completed his psychiatry residency at the Mount Sinai Medical Center, NY. He is Associate Chairman for Research, Director of the Division of Biological Psychiatry at the Beth Israel Medical Center, and Director of the Zirinsky Mood Disorders Center and the Family Center for Bipolar Disorders.

Francisco Bustamante Clínica Universidad de los Andes Avenida Plaza 2501, Las Condes Santiago Chile Tel. +56 (2) 2 618-3171 E-mail fbustamante@uandes.cl

Why understanding the role of culture can help prevent suicide “This book is a wake-up call to suicidologists.” Prof. Michael Kral, PhD, Associate Professor of Psychology and Anthropology University of Illinois at Urbana-Champaign, IL

Erminia Colucci / David Lester (Editors) with Heidi Hjelmeland / B. C. Ben Park

Suicide and Culture Understanding the Context 2013, xiv + 270 pp. US $49.00 / € 34.95 ISBN 978-0-88937-436-2 Also available as an eBook The increasing domination of biological approaches in suicide research and prevention, at the expense of social and cultural understanding, is severely harming our ability to stop people dying – so run the clearly set out arguments and evidence in this lucid book by leading social scientists and suicide researchers. In the first part of this book, instead of simply comparing suicide in different countries, the authors review and examine the fundamental issues of why culture is of vital importance in understanding and preventing suicidal behavior, what the “cultural meaning” of suicide is, and where current research and theory are leading us.

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The second part of the book then presents (and, importantly, also critiques) exemplary recent research, including a quantitative and qualitative study on the meaning of suicide in Australia, India, and Italy, which is reported in detail, as well as other studies on correlates of suicidal behavior in Kuwait and the US, on a culturally specific form of suicide (sati), and on the role of cultural conflict in South Korea. In the concluding section, the editors highlight both the necessity and the challenges of conducting good culturally sensitive studies, as well as suggesting solutions to these challenges. This volume is thus essential reading for anyone involved in suicide research and prevention.

Social Psychology Editor-in-Chief Christian Unkelbach Universität zu Köln, Germany New Editor-in-Chief starting April 1, 2016: Kai Epstude, Groningen, NL

nline free o issue le samp

Associate Editors Julia Becker, Osnabrück, Germany Malte Friese, Saarbrücken, Germany Michael Häfner, Berlin, Germany Hans J. IJzerman, Amsterdam, The Netherlands Markus Kemmelmeier, Reno, USA Ruth Mayo, Jerusalem, Israel Ulrich Kühnen, Bremen, Germany Michaela Wänke, Mannheim, Germany

Editorial Office Juliane Burghardt Universität zu Köln, Germany

ISSN-Print 1864-9335 ISSN-Online 2151-2590 ISSN-L 1864-9335 6 issues per annum (= 1 volume)

Subscription rates (2016) Libraries / Institutions US $464.00 / € 354.00 Individuals US $223.00 / € 159.00 Postage / Handling US $24.00 / € 18.00

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About the Journal Social Psychology publishes innovative and methodologically sound research and serves as an international forum for scientific discussion and debate in the field of social psychology. Topics include all basic social psychological research themes, methodological advances in social psychology, as well as research in applied fields of social psychology. The journal focuses on original empirical contributions to social psychological research, but is open to theoretical articles, critical reviews, and replications of published research. The journal was published until volume 38 (2007) as the Zeitschrift für Sozialpsychologie (ISSN 0044-3514). Drawing on over 30 years of experience and tradition in publishing high-quality, innovative science as the Zeitschrift für Sozialpsychologie, Social Psychology has an internationally renowned team of editors and consulting editors from all areas of basic and applied social psychology, thus ensuring that the highest international standards are maintained.

Manuscript Submissions All manuscripts should be submitted online at www.editorialmanager.com/sopsy, where full instructions to authors are also available. Electronic Full Text The full text of the journal – current and past issues (from 1999 onward) – is available online at http://econtent.hogrefe.com/ loi/zsp (included in subscription price). A free sample issue is also available here. Abstracting Services The journal is abstracted/indexed in Current Contents/Social and Behavioral Sciences (CC/S&BS), Social Sciences Citation Index (SSCI), PsycINFO, PSYNDEX, ERIH, Scopus, and EMCare. Impact Factor (Journal Citation Reports®, Thomson Reuters): 2014 = 1.662

Research Trends

Does Social Belonging to Primary Groups Protect Young People From the Effects of Pro-Suicide Sites? A Comparative Study of Four Countries Jaana Minkkinen1, Atte Oksanen1, Matti Näsi2, Teo Keipi2, Markus Kaakinen1, and Pekka Räsänen2 1

School of Social Sciences and Humanities, University of Tampere, Finland Department of Social Research/Economic Sociology, University of Turku, Finland

Abstract. Background: The Internet has facilitated the existence of extreme and pathological communities that share information about ways to complete suicide or to deliberately harm or hurt oneself. This material is user-generated and easily accessible. Aims: The present study analyzed the buffering effect of social belonging to a primary group in the situation of pro-suicide site exposure. Method: Cross-national data were collected from the US, UK, Germany, and Finland in spring 2013 and 2014 from respondents aged 15–30 years (N = 3,567). Data were analyzed by using linear regression separately for women and men for each country. Results: A higher level of belonging to a primary group buffered the negative association of pro-suicide site exposure with mental health, measured as happiness, although the results were not consistent in the subgroups. US male subjects showed a significant buffering effect of the sense of belonging to family while the belonging to friends had a buffering effect among four other subgroups: British female and male subjects and Finnish female and male subjects. Conclusion: The results underline the positive potential of primary groups to shield young people’s mental health in the situation of pro-suicide site exposure. Keywords: pro-suicide sites, buffering hypothesis, social belonging, social support, happiness

It is estimated that much online material concerning suicide does not advocate it (Kemp & Collings, 2011; Recupero, Harms, & Noble, 2008); however, suicide is endorsed on pro-suicide sites where users share their suicidal ideas, death fantasies and intentions, including concrete advice on how to carry out lethal acts (Becker & Schmidt, 2004; Biddle, Donovan, Hawton, Kapur, & Gunnell, 2008; Kemp & Collings, 2011; Recupero et al., 2008). Although support for coping with social and psychological distress could also be available on pro-suicide websites (Baker & Fortune, 2008), the current research evidence shows that the damage associated with exposure to pro-suicide material is greater than the potential benefits of self-help (Daine et al., 2013). For example, the exposure to online discussion forums with pro-suicidal content had an association with increased suicidal ideation among young people (Dunlop, More, & Romer, 2011), and youth aged 10–17 years were 7 times more likely to have thoughts about killing themselves if they had been exposed to websites that encourage self-harm or suicide (Mitchell, Wells, Priebe, & Ybarra, 2014). The exposure to pro-suicide images and conversations produced by suicide-engaged communities can normalize and romanticize suicide and © 2015 Hogrefe Publishing

push ambivalent users to carrying out lethal acts instead of searching for professional help (Becker, Mayer, Nagenborg, El-Faddagh, & Schmidt, 2004; Daine et al., 2013; Tam, Tang, & Fernando, 2007). Potentially harmful online content has become accessible for everyone with the expansion of the Internet. As such, a motivated online user will find the material he or she wishes for. On the larger scale of online content, pro-suicide material is still relatively uncommon compared with other material on suicide. Recupero et al. (2008), for example, found out that only 11% of the suicide web hits were actually pro-suicide. Similarly, Kemp and Collings (2011) found pro-suicide sites to be a marginal phenomenon compared with sites dedicated to suicide prevention. We do not, however, have enough information about people accessing such sites. Previous research has particularly focused on how suicide-related web forums could have an effect on past suicidal behavior among persons with suicidal risk (Alao, Soderberg, Pohl, & Alao, 2006; Baume, Cantor, & Rolfe, 1997; Becker & Schmidt, 2004; Daine et al., 2013). However, less attention has been paid to the examination of how different online suicide communities could affect the mental health and happiness of teenagCrisis 2016; Vol. 37(1):31–41 DOI: 10.1027/0227-5910/a000356

J. Minkkinen et al.: Does Social Belonging Protect Young People?

ers and young adults more generally. We found no earlier studies considering pro-suicide exposure and subsequent happiness; however, a recent longitudinal Japanese study found that exposure to online suicide material increased depressive symptoms (Sueki, Yonemoto, Takeshima, & Inagaki, 2014). This gives support to the hypothesis that exposure to pro-suicide sites could adversely affect young people’s mental health and create a potential risk for their happiness. Happiness reflects one’s emotional state characterized by positive feelings and the paucity of negative emotional states (Diener, 2000). Longitudinal research in suicide has shown that previous self-reported unhappiness had a strong association with subsequent suicide and that risk factors for suicide could cumulate in the course of life (Koivumaa-Honkanen, Honkanen, Koskenvuo, & Kaprio, 2003). This makes it important to examine both the contributors to young people’s happiness and the potential shielding mechanisms against the loss of subjective well-being. One potential protective factor in the situation of pro-suicide exposure is social support, which can have both direct and buffering effects on mental health in stressful life situations (Cobb 1976; Cohen & Wills, 1985; Joiner, 2005; Maulik, Eaton, & Bradshaw, 2011; Moak & Agrawal, 2009; Mueller, 2006; Takizawa et al., 2006; Thoits, 2011; Uchino, 2006). Enhanced social support has been associated with lower levels of suicidal thoughts and a decreased likelihood of lifetime suicide attempts (Chioqueta & Stiles, 2007; Kleiman & Liu, 2013). Further, social support has been shown to reduce the impact of psychological risk factors, such as life stress and perfectionism, on suicidal ideation (Blankstein, Lumley, & Crawford, 2007; Yang & Clum, 1994). The purpose of this study was to explore whether the sense of belongingness to primary groups of family and friends could protect young people from the negative effect of pro-suicide site exposure on happiness. Social belonging here refers to experiencing acceptance and inclusion by other group members (Thoits, 2011, p. 149), while a low sense of belongingness emerges from alienation from others in a valued group such as family and friends (Joiner et al., 2009, p. 635). According to Joiner’s (2005) theory on suicide, supported by empirical findings, thwarted belongingness is one antecedent factor in suicidal ideation (Joiner et al., 2009; You, Van Orden, & Conner, 2011). Belongingness to family and friends may support one’s mental health by offering emotional sustenance and active help for coping, which may result in enhanced resilience to stress produced by pro-suicide communities. Given previous research, we hypothesize that a higher level of belongingness reduces the negative association of the pro-suicide site exposure with happiness.

Variations by Country and Gender Our data were collected from four countries, namely, the US, the UK, Germany, and Finland – all of which are technologically highly advanced countries with high living standards. The countries are among the world’s happiest countries according to the World Happiness Report: Crisis 2016; Vol. 37(1):31–41

Finland being in seventh position while the others are ranked between 17 and 26 (Helliwell, Layard, & Sachs, 2013). Despite many of the societal similarities between the four countries, there are certain differences regarding aspects of risky Internet use. For example, it was found that children’s and adolescents’ risky online behavior is notably higher in Finland than in the UK and Germany (Helsper, Kalmus, Hasebrink, Sagvari, & De Haan, 2013). Therefore, it may be that exposure to online pro-suicide content varies between countries among young users. Because plausible differences in happiness and pro-suicide exposure are expected, cross-national differences may also emerge in regard to the buffering effects against exposure to pro-suicide content. In terms of the independent background variables, women have a higher sense of happiness than men in most advanced countries according to the World Values Survey (Layard, Clark, & Senik, 2012). For example, being male predicts a low sense of happiness among adults in the UK and Germany (Helliwell et al., 2013). Previous research does not provide information on whether gender differences regarding pro-suicide exposure actually exist. However, statistics concerning suicide rates may give some indication, as men are three times more likely to commit suicide than women in richer countries (Hawton, Saunders, & O’Connor, 2012; World Health Organization, 2014). An association has also been found between suicide rates and prevalence of Internet use for men but not for women (Shah, 2010). Further, women and men may not benefit similarly from family support (Evans, Steel, & DiLillo, 2013; Heinonen, Aro, Aalto, & Uutela, 2004; Michalos & Orlando, 2006). Notably, heterogeneous results also concern the buffering effects of social support on mental health. Olstad, Sexton, and Søgaard (2001) found that social networks had more buffering effects for women than for men, whereas the study of Takizawa and colleagues (2006) indicated that men benefitted more from the buffering effect. Given previous research, gender differences may occur in the buffering effects of belongingness to family and friends against pro-suicide exposure.

Method The respondents of the study were from the US, UK, Germany, and Finland, aged 15–30 years. They were drawn from a pool of respondents that mirrors the geographic area and sociodemographic measures of age, gender, education level, and income of each of the four countries. The sample quota was calculated to be nationally representative on age, gender, and education for all four countries (see Näsi et al., 2014). The survey was filled out online and was optimized for both computers and mobile devices and tested separately in all of the respective countries before data collection. A total of 3,567 respondents answered the questionnaire. However, the present study consists of 3,535 respondents (1,015 from the US, 999 from the UK, 978 from Germany, and 543 from Finland) owing to missing values identifying the sense of happiness variable. © 2015 Hogrefe Publishing

543 272 271 978 488 490 999 Note. N = 3,535. Happiness range is 1–10. Belongingness to family/friends range is 1–5.

509 490 1015 512 n

503

76.6

31.5 37.9

79.0 74.2

25.1 38.2

83.6 88.5

48.4 28.2

78.8 82.4

45.0 54.2

85.9 78.8

35.5 42.1

79.6

33.8 Living with parents

50.5

70.5 Employed or student

88.9

9.8 10.3 8.2 Pro-suicide sites exposure

11.7

10.0

9.0

11.8

10.4

3.9

4.9

4.4

9.2

% % %

3.61 (1.14) 3.53 (1.05) 3.98 (.99) 4.06 (.95) 3.91 (1.01) 3.69 (1.10) 3.73 (1.05) 3.64 (1.15) 3.79 (1.09) 3.88 (1.04)

% Dummy variables

Age

3.57 (1.09) 3.70 (1.13)

25.04 (3.69) 23.17 (4.18) 24.12 (4.05) 24.37 (3.79) 22.03 (4.15) 23.18 (4.14) 24.01 (3.71) 22.39 (4.08) 23.20 (3.98) 23.82 (4.09) 23.44 (4.31) 23.63 (4.20)

Belongingness to friends

4.20 (.99)

4.21 (.99)

4.00 (1.09)

3.92 (1.13)

3.96 (1.11)

4.26 (1.03)

4.19 (1.08)

4.23 (1.05)

4.14 (.99)

4.09 (1.16)

4.12 (1.08) 4.22 (.99) Belongingness to family

6.90 (1.85) 6.66 (2.20) 6.78 (2.16) 6.54 (2.22) 6.59 (2.06) 6.44 (2.06) 6.97 (2.02)

Total Female

Male

6.73 (2.05)

Total Female

Male

M (SD)

UK US

Table 1. Descriptive statistics by country and gender

7.08 (2.09)

6.99 (1.98) 7.02 (2.07) 6.92 (1.96) Happiness

Total Total Male

M (SD)

Female

Germany Country

Analytic Approach

Male Female

We employed a total of seven variables. Happiness was measured using a single item, in which respondents were asked to indicate their numeric evaluation on a 10-point scale: “Answer the following question on a scale from 1–10, where 1 = extremely unhappy and 10 = extremely happy. All things considered, how happy would you say you are?” Pro-suicide site exposure was based on a two-option question: “In the past 12 months, have you seen any of the following types of websites? Sites about ways of committing suicide?” No was coded as 0, yes as 1. Belongingness to family and friend groups was measured by questions on 5-point scales, namely, “How close do you feel to family/ friends? Please indicate on a scale of 1–5 where 1 = not at all important and 5 = very important.” The variables of age, primary occupation, and living situation were included in the path models as potentially confounding background characteristics. Age range was, again, 15–30 years. Employed and student items were encoded as 1, other options as 0. Living with parents was encoded as 1, other options as 0. Descriptive statistics for the variables by country and gender are presented in Table 1.

M (SD)

Finland

Measures

Statistical tests were conducted in order to compare differences between countries and genders in the means of the variables of happiness, pro-suicide exposure, and social belongingness to the primary groups. We applied the path modeling approach with Bayesian estimation to test the hypothesis of the direct effects of both pro-suicide site exposure and belongingness to family and friends on happiness, and whether the link between pro-suicide site exposure and happiness is moderated by the high sense of belonging to family members and friends. Bayesian estimation was preferred here because the variables of happiness and belongingness were not normally distributed. This made the use of Bayesian inference with no distributional assumptions more appropriate, as opposed to traditional frequentist statistics (Muthén & Asparouhov, 2012). The Bayesian estimation with Monte Carlo Markov chain (MCMC) was run using Mplus 7.2 with 30,000 iterations. Three regression models were conducted separately for men and women by countries to allow for the possibility that the direct and moderated effects of belongingness vary by country and gender. The first model analyzed only the direct effects of the pro-suicide site exposure and belongingness to family and friends on happiness. The second model tested the moderating effect of belongingness to family after controlling for the effects of belongingness to friends on happiness. The protective effect of the family

M (SD)

There were no missing values in the background variables. The missing data percentages for items for belongingness to family and friends were 0.005%, and 0.005%, respectively. The missing values were imputed by the full information maximum likelihood (FIML) procedure.

Continuous variables

J. Minkkinen et al.: Does Social Belonging Protect Young People?

Crisis 2016; Vol. 37(1):31–41

J. Minkkinen et al.: Does Social Belonging Protect Young People?

Table 2. Predicting the sense of happiness (Model 1) Country US

Explanatory variables Pro-suicide site exposure Belongingness to family Belongingness to friends Age

Germany

Finland

Female

Male

Female

Male

Female

Male

Female

Male

(SD)

−.187*

−.207**

−.199**

−.215**

−.423***

(SD)

−.217**

−.211*

−.294**

(.081)

(.087)

(.084)

(.078)

(.092)

(.090)

(.106)

(.112)

.409***

.458***

.500***

.579***

.440***

.431***

.532***

.519***

(.095)

(.099)

(.089)

(.092)

(.102)

(.101)

(.114)

(.133)

.378***

.345***

.552***

.572***

.552***

.593***

.383***

.624***

(.095)

(.099)

(.091)

(.095)

(.102)

(.112)

(.127)

−.022

−.014

.042*

−.004

.045

−.049*

−.073*

.025

(.025)

(.024)

(.022)

(.029)

(.026)

(.035)

(.032)

Employed or student

−.190

.488*

.150

.121

.550*

−.236

(.183)

(.278)

(.208)

(.226)

(.225)

(.276)

(.250)

Living with parents

−.561**

−.351*

−.648***

−.171

−.135

.159

−.530*

.230

(.190)

(.208)

(.189)

(.187)

(.239)

(.210)

(.318)

(.274)

.157

.149

.246

.291

.223

.237

.210

.329

.715**

.894** (.277)

Model fit χ2 BIC n

.475

.463

.471

.477

.471

.474

. 453

10,421.261

10,105.349

10,011.963

10,166.378

9,919.669

9,753.785

5,445.285

512

503

490

509

490

488

271

.445 5,539.906 272 2

Note. Number of free parameters = 35. b = Unstandardized individual-level posterior coefficient. SD = posterior standard deviation. χ = Bayesian posterior predictive p value. BIC = Bayesian information criterion. *p < .05. **p < .01. ***p < .001 (one-tailed tests).

was detected if the interaction term of belongingness to family and pro-suicide site exposure was statistically significant. A significant association exists between pro-suicide site exposure and happiness. The third model tested the moderating effect of belongingness to friends after controlling for the effects of belongingness to family on happiness. The model fit for each of the three models was evaluated using the posterior predictive p value (Gelman, Carlin, Stern, & Rubin, 2004; Muthén & Asparouhov, 2012). The p values ranged from .428 to .482 in all subgroups showing excellent or good fit in three models.

Results Cross-Country and Gender Comparisons The average level of happiness varied across the four countries, the UK having the lowest mean (M = 6.59) and Finland the highest (M = 6.99). Finnish respondents were significantly happier on average than respondents in the UK (p < .01) and Germany (p < .05) according to the univariate analysis of variance. Further, the respondents in the Crisis 2016; Vol. 37(1):31–41

US had a higher level of happiness than those in the UK (p < .001) and in Germany (p < .01). A cross-national difference was also found through assessment of pro-suicide site exposure in four countries since German respondents were significantly less exposed to pro-suicide sites (4.4 %) compared with other countries in which approximately 10% of respondents were exposed to such material (χ2 = 29,668, df = 3, p < .001). Further, the average level of belongingness to family and friends varied significantly in the four countries according to the univariate analyses of variance. British respondents felt lower levels of belongingness to family on average compared with respondents in Germany and the US (both p < .000) and Finland (p < .05). On the other hand, German respondents felt a higher level of belongingness to their friends than respondents in the US, UK, and Finland did (all p < .000). Additionally, Finnish respondents felt significantly lower levels of belongingness to friends than did respondents in the US (p = .001; see Table 1 for further information.) Contrary to expectations, male respondents had higher levels of happiness than their female counterparts throughout the data (Mann–Whitney U test, p < .01). At the country level, the gender difference was significant only in the UK (p < .05). As expected, males were more likely to have visited pro-suicide sites (χ2 = 5.878, df = 1, p < .05), but the © 2015 Hogrefe Publishing

J. Minkkinen et al.: Does Social Belonging Protect Young People?

Figure 1. Belonging to family moderating the association between pro-suicide site exposure and happiness among US men (Model 2). a = High belonging to family (1 SD above mean) and no pro-suicide site exposure. b = High belonging to family and pro-suicide site exposure. c = Low belonging to family (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to family and pro-suicide site exposure.

Figure 2. Belonging to family moderating the association between pro-suicide site exposure and happiness among Finnish men (Model 2). a = High belonging to family (1 SD above mean) and no pro-suicide site exposure. b = High belonging to family and pro-suicide site exposure. c = Low belonging to family (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to family and pro-suicide site exposure.

difference between genders was not significant at the level of individual countries. There was no gender difference in the sense of belonging to family between genders but males had a higher level of belongingness to their friends than did females (Mannâ&#x20AC;&#x201C;Whitney U test, p = .001). At the country level, males had a higher level of belongingness to friends in the US and Germany (both p < .05; see Table 1 for further information.)

ness regardless of country and gender. This is in line with previous studies indicating that close relationships with family and friends and their social support have positive correlations with happiness and overall life satisfaction (Campbell, 1981; Gundelach & Kreiner, 2004; Layard et al., 2012; Palisia & Canning, 1986). Belongingness to family held the greatest significance among British men and belongingness to friends was most significant among Finnish men. Being employed or a student had a significant association with happiness among male respondents in all four countries. Living with parents had a negative association with happiness among females in the UK, the US, and Finland, and also among males in the US sample. (See Table 2 for further information.)

Predicting Happiness According to Model 1, pro-suicide site exposure showed a significant negative association with happiness in all subgroups after adjusting for background characteristics including age, main occupation, and living with parents (see Table 2). The strongest negative association between pro-suicide site exposure and happiness was among German female respondents according to the unstandardized coefficients. Moreover, the higher level of belongingness to family and friends had a positive association with happiÂŠ 2015 Hogrefe Publishing

The Moderating Effect of Belongingness to Primary Groups Models 2 and 3 were conducted to explore whether the sense of belonging to family and friends has a moderating Crisis 2016; Vol. 37(1):31â&#x20AC;&#x201C;41

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influence on the regression between pro-suicide site exposure and happiness. Model 2 indicated that belongingness to family moderates the effect of suicide site exposure on happiness among US and Finnish men beyond that afforded by differences in belongingness to friends and background characteristics (see Table 3 for further information). Figure 1 and Figure 2 show a closer examination aiming to determine whether the moderation was accurate across different situations. Here, we note that when belonging to family was low among US men, those who were exposed to pro-suicide sites also had a lower level of happiness when compared with those who were not exposed (see c and d in Figure 1). However, when belonging to family was high, pro-suicide site exposure did not associate with happiness (see a and b in Figure 1). Thus, the protective effect of the family was significant when user-reported belongingness to family was low. In addition, Finnish men showed a different effect of family belongingness when compared with US men. When the interaction term was included in the equation, the main effect of pro-suicide site exposure and happiness became insignificant (see Table 3). As such, pro-suicide site exposure degrades the positive association between social be-

longing to family and happiness. Further analysis showed that a low level of belongingness to family was also associated with a lower level of happiness if the respondents were exposed to pro-suicide sites (see c and d in Figure 2). Surprisingly, when belongingness to family was high, exposure to pro-suicide sites was associated with higher levels of happiness (see a and b in Figure 2). It is possible that this unexpected finding could have resulted from the relatively few observations of those Finnish men whose belonging to family was 1 SD above the mean and who were exposed to pro-suicide sites. However, the results did not support a protective effect of family among Finnish men. Model 3 shows that belongingness to friends has a moderating effect on pro-suicide site exposure and happiness among British and Finnish respondents, an effect beyond that afforded by differences in belongingness to family and background characteristics (see Table 4). These interactions detected were explored using plots and the earlier interpretations of the protective effects of friends were confirmed (see Figure 3, Figure 4, Figure 5, and Figure 6). British women and men as well as Finnish men showed moderating effects in terms of pro-suicide site exposure, since happiness was weaker regardless of the lev-

Table 3. Belongingness to family moderating the regression between pro-suicide site exposure and happiness (Model 2) Country US Female Explanatory variables Pro-suicide site exposure Belongingness to family Interaction term Belongingness to friends

UK Male

Female

Finland Male

Female

Male

(SD)

−.173*

−.180*

−.156*

−.213**

−.506***

−.262**

−.246*

−.118

(.083)

(.089)

(.088)

(.079)

(.113)

(.102)

(.112)

(.123)

.399***

.441***

.497***

.573***

(.095)

(.098)

(.088)

(.093)

(.102)

.066

.164*

.120

.020

−.085

(.071)

(.076)

(.066)

(.074)

.380*** (.096)

.331***

.538***

(.099) −.016

.457***

.435***

.559***

.464***

(.101)

(.116)

(.131)

−.072

−.082

.309***

(.079)

(.093)

.574***

.557***

(.091)

(.095)

(.101)

(.102)

(.113)

(.125)

.041*

−.003

.045

−.047*

−.071*

.023

(.023)

(.029)

(.026)

(.035)

(.031)

.111

.550*

−.207

.944***

Age

−.021 (.025)

(.025)

(.024)

Employed or student

−.185

.488*

.145

(.184)

(.276)

Living with parents

−.567**

−.359*

(.191) .161

Germany Male

.713**

.602***

.378**

.623***

(.208)

(.222)

(.224)

(.277)

(.253)

(.274)

−.639***

−.171

−.134

.164

−.513

.172

(.206)

(.189)

(.239)

(.211)

(.321)

(.271)

.159

.252

.293

.227

.241

.216

.360

Model fit χ2 BIC n

.437

.428

12,061.049

.475

11,706.560

.476

11,529.724

.482

11,823.694

.464

11,669.388

.482

11,348.695

.478

6,394.603

6,412.087

512

503

490

509

490

488

271

272

Note. Number of free parameters = 44. b = Unstandardized individual-level posterior coefficient. SD = posterior standard deviation. Interaction term = pro-suicide site exposure x belongingness to family. χ2 = Bayesian posterior predictive p value. BIC = Bayesian information criterion. *p < .05. **p < .01. ***p < .001 (one-tailed tests). Crisis 2016; Vol. 37(1):31–41

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Figure 3. Belonging to friends moderating the association between pro-suicide site exposure and happiness among UK women (Model 3). a = High belonging to friends (1 SD above mean) and no pro-suicide site exposure. b = High belonging to friends and pro-suicide site exposure. c = Low belonging to friends (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to friends and pro-suicide site exposure.

Figure 4. Belonging to friends moderating the association between pro-suicide site exposure and happiness among UK men (Model 3). a = High belonging to friends (1 SD above mean) and no pro-suicide site exposure. b = High belonging to friends and pro-suicide site exposure. c = Low belonging to friends (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to friends and pro-suicide site exposure.

el of social belongingness to friends (see c and d in Figure 3, Figure 4, and Figure 6). Similarly, the negative effect of exposure was stronger when belongingness to friends was low (see a and b in Figure 3, Figure 4, and Figure 6). Among Finnish women, happiness was also found to be lower despite a high level of social belongingness to friends. The negative effect of exposure to pro-suicide sites was stronger when a high level of belonging to friends was reported (see Figure 5). In summary, evidence was found showing that a higher level of belongingness to primary groups can buffer the harmful effect of pro-suicide sites on young people’s happiness. However, there were cross-national and gender differences in the buffering effects of belongingness to family and friends. Germany was the only country where neither women nor men benefitted from the sense of belongingness to primary groups in terms of a buffering effect. However, this result might arise from the infrequency of exposure to pro-suicide sites among German respondents (3.9% of the female respondents, n =19; 4.9% of the male respondents, n = 24), which could result in the moderator

effect having no chance of achieving any statistically significant shares of variance.

Discussion This study provides new information on protective factors against exposure to negative and harmful online content in pro-suicide sites. A considerable amount of earlier research has been devoted to different forms of online risks but studies focusing on the protective factors against such risks have received significantly less attention. The present study was conducted using cross-national data from the US, UK, Germany, and Finland in order to produce more extensive results by means of an international comparison. To date, comparative research into suicide-related web forums has been scarce with the exception of Sueki and Eichenberg’s (2012) study that indicated no difference between American and Japanese suicide bulletin board users. We found both differences and similarities between Crisis 2016; Vol. 37(1):31–41

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Figure 5. Belonging to friends moderating the association between pro-suicide site exposure and happiness among Finnish women (Model 3). a = High belonging to friends (1 SD above mean) and no pro-suicide site exposure. b = High belonging to friends and pro-suicide site exposure. c = Low belonging to friends (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to friends and pro-suicide site exposure.

Figure 6. Belonging to friends moderating the association between pro-suicide site exposure and happiness among Finnish men (Model 3). a = High belonging to friends (1 SD above mean) and no pro-suicide site exposure. b = High belonging to friends and pro-suicide site exposure. c = Low belonging to friends (1 SD below mean) and no pro-suicide site exposure. d = Low belonging to friends and pro-suicide site exposure.

the countries and genders relating to the pro-suicide sites. Firstly, we found that German respondents were exposed to pro-suicide sites significantly less often than were users in the US, UK, and Finland. This may be related to the differences in legislation concerning online content or the cross-national differences in the role of Internet usage. Secondly, young male respondents were more likely to encounter pro-suicide sites than female respondents were. Moreover, pro-suicide site exposure showed a significant negative association with young people’s happiness, a finding that was consistent regardless of country or gender. We also studied whether primary groups served as significant protective buffers against pro-suicide site exposure. Family members and friends have been found to have an important shielding role against daily life stressors (Cobb, 1976; Cohen & Wills, 1985; Joiner, 2005; Moak & Agrawal, 2009; Mueller, 2006; Takizawa et al., 2006; Thoits, 2011; Uchino, 2006). However, relatively little research exists that has examined the elements prevalent in the online context. We found direct positive effects of the primary groups in all four countries and both genders, while the buffering effects emerged only in some of the

subgroups examined. This finding is in parallel with earlier research where the indirect influence of social support against stressors is not so commonly observed compared with occurrences of direct positive impacts on mental health (Cobb, 1976; Cohen & Wills, 1985; Eom et al., 2013; Maulik et al., 2011; Moak & Agrawal, 2009; Takizawa et al., 2006). While friends created a buffering effect for only British and Finnish young people, the US was the only country where the protective effect occurred in the sense of belongingness to family. In addition, findings were contradictory among Finnish male respondents, showing that among men with high belongingness to family, visiting pro-suicide sites was associated with greater happiness. This result was, however, compromised by the sample size of the Finnish data, and we did not find any support for the existence of the protective effect of family among Finnish men. Further studies should investigate the role of family involvement among young Finnish men in particular, as previous studies have shown that overinvolvement in the family setting may also have negative consequences (Kaltiala-Heino, Rimpelä, Marttunen, Rimpelä, & Rantanen, 1999).

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Table 4. Belongingness to friends moderating the regression between pro-suicide site exposure and happiness (Model 3) Country US

Explanatory variables Pro-suicide site exposure Belongingness to friends Interaction term Belongingness to family Age

Germany

Finland

Female

Male

Female

Male

Female

Male

Female

Male

(SD)

−.189*

−.224**

−.194*

−.199**

−.398***

−.209*

−.223*

−.272**

(.082)

(.090)

(.084)

(.079)

(.102)

(.108)

(.106)

(.112)

.378***

(SD)

.347***

.544***

.556***

.545***

.591***

.363**

(.096)

(.099)

(.090)

(.095)

(.102)

(.112)

−.019

−.065

.126*

.154*

.036

.008

−.281**

(.080)

(.081)

(.075)

(.069)

(.065)

(.070)

(.112)

.642*** (.126) .277** (.107)

.409***

.465***

.488***

.569***

.440***

.431***

.557***

.481***

(.095)

(.098)

(.089)

(.092)

(.102)

(.101)

(.112)

(.132)

−.022

−.013

.040*

−.007

.045

−.049*

−.079*

.033

(.025)

(.024)

(.022)

(.029)

(.026)

(.035)

(.031)

Employed or student

−.188

.487*

.170

.124

.546*

−.230

.921**

(.184)

(.277)

(.208)

(.221)

(.224)

(.278)

(.249)

(.276)

Living with parents

−.564**

−.352

−.629***

−.165

−.141

.160

−.591*

.254

(.191)

(.207)

(.190)

(.187)

(.240)

(.211)

(.318)

(.273)

.160

.151

.253

.300

.225

.239

.232

.349

.476

.482

.466

.482

.478

.437

.429

.726**

Model fit χ2 BIC n

11940.477

11653.469

11542.669

11778.934

11683.782

11405.598

6198.191

6347.374

512

503

490

509

490

488

271

272

Note. Number of free parameters = 44. b = Unstandardized individual-level posterior coefficient. SD = posterior standard deviation. Interaction term = pro-suicide site exposure x belongingness to friends. χ2 = Bayesian posterior predictive p value. BIC = Bayesian Information criterion. *p < .05. **p < .01. ***p < .001 (one-tailed tests).

Thus, it seems that friends serve as a greater buffering factor than family among young people in terms of pro-suicide exposure. It may be that as young people are in the transitional phase involving moving away from home and living without a spouse or children, friends’ buffering effects are more significant on average than those of the family. It is also possible that support from close friends is more available against the risk content of the Internet if young people are more connected to their friends through social media than they are with family members. Given that earlier empirical research has also shown varying results concerning the buffering hypothesis, the exact explanation for the discrepancy between countries in this study is a challenge. The sociocultural characteristics of the four societies may play a part in these cross-national differences. For example, the higher geographic mobility in the US has been offered as an explanation for why Americans meet their kin less often than do Britons and Germans (Höllinger & Haller, 1990). However, reduced face-to-face contacts do not inevitably mean that family members could not give a meaningful sense of belongingness to young people. The difference between genders was present in the buffering result among young people in the US. In practice, the © 2015 Hogrefe Publishing

finding indicates that males have a greater advantage from a high level of belongingness to family against the negative effects of pro-suicide exposure than women have. Notably, this inconsistency between genders is a challenge also found in earlier studies, which have shown that women and men do not necessarily benefit equally from the direct and indirect effects of social support (Evans et al., 2013; Olstad et al., 2001; Takizawa et al., 2006).

Limitations and Future Directions The limitation concerning the cross-sectional data of this study should be taken into account. Our research design included the assumption that pro-suicide sites are a potential risk for young people’s mental health and that young people who visit such sites will leave the experience with lower levels of happiness. This was a theoretically reasonable causal direction based on an earlier Japanese longitudinal study (Sueki et al., 2014). However, cross-sectional data do not allow for true cause-and-effect analyses and the other causal direction is theoretically possible as well; namely, that people who visit pro-suicide sites are Crisis 2016; Vol. 37(1):31–41

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more likely to be unhappy compared with users who do not visit such sites. It is perhaps even more plausible that visiting pro-suicide sites is one part of a multifaceted pattern of unhealthy behavior; that suicidal content appeals to mentally unwell users, with the connections to a pro-suicide community reducing their sense of happiness further. Because the associations between happiness and pro-suicide sites are not fully understood yet, this is one important direction for future research. Further, it is possible that the results in this study involve the effect of the measurement error by one-item indicators and therefore several-item indicators should be considered in future studies.

Conclusion This cross-national study offered new insights into online risk material and young people’s mental health across the US and three countries in Europe. According to the results, pro-suicide sites can harm mental health in a wide-reaching manner, not merely increasing the risks of suicide-related behavior. However, close relationships with primary groups can also function as a buffer and thus protect young people’s mental health in situations of pro-suicide exposure. As young people’s happiness is increasingly affected by experiences and feedback gained through social media, greater knowledge of both protective and resiliency factors concerning the Internet’s risks is needed, toward improving the effectiveness of interventions while also taking into consideration other demographic and social factors of suicide-related behavior in society as a whole. Acknowledgments This research was supported by a grant from the Kone Foundation.

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Uchino, B. N. (2006). Social support and health: A review of psychological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377–387. World Health Organization. (2014). Preventing suicide. A global imperative. Executive Summary. Luxembourg: Author. Yang, B., & Clum, G. A. (1994). Life stress, social support, and problem-solving skills predictive of depressive symptoms, hopelessness, and suicide ideation in an Asian student population: A test of a model. Suicide and Life-Threatening Behavior, 24, 127−139. You, S., Van Orden, K. A., & Conner, K. R. (2011). Social connections and suicidal thoughts and behavior. Psychology of Addictive Behaviors, 25, 180–184.

Received March 25, 2015 Revision received July 9, 2015 Accepted July 9, 2015 Published online December 1, 2015

About the authors Jaana Minkkinen, DSocSc, is a postdoctoral researcher at the University of Tampere in Finland. Her research interests are social relationships in mental health and well-being and well-being theory. Atte Oksanen is an associate professor of social psychology at the University of Tampere, Finland. Dr. Oksanen’s research focuses on mass violence, emerging technologies, and youth. He has published in a variety of areas including youth studies, drug and alcohol research, and criminology. Matti Näsi, DSocSc, is a postdoctoral researcher in economic sociology at the University of Turku, Finland. His research focuses on the impacts of information and communication technologies on society and social life, with current emphasis on implications concerning harmful online content. Teo Keipi, MSocSc, is a doctoral researcher of economic sociology at Turku University in Finland. His research interests include identity, anonymity, and Internet use with a current emphasis on the effects of harmful online content on young people. Markus Kaakinen, MSocSc, is a doctoral researcher at the School of Social Sciences and Humanities, University of Tampere, Finland. His research focuses on the social psychology of education and online interaction, with a current emphasis on the social integration and conflict in online social networks. Pekka Räsänen is a professor of economic sociology at the University of Turku, Finland. He has studied a variety of topics connected with mass violence, culture, and consumer behavior. His research focuses on the ways that contemporary social life is affected by the new information and communication technologies. Jaana Minkkinen School of Health Sciences University of Tampere 33014 Finland Tel. +358 50 318-7671 E-mail jaana.minkkinen@uta.fi Crisis 2016; Vol. 37(1):31–41

Research Trends

General Practitioners’ Accounts of Patients Who Have Self-Harmed A Qualitative, Observational Study Amy Chandler1, Caroline King2, Christopher Burton3, and Stephen Platt4 1

Centre for Research on Families and Relationships, University of Edinburgh, Edinburgh, UK 2 Institute for Applied Health Research, Glasgow Caledonian University, Glasgow, UK 3 Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK 4 Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK

Abstract. Background: The relationship between self-harm and suicide is contested. Self-harm is simultaneously understood to be largely nonsuicidal but to increase risk of future suicide. Little is known about how self-harm is conceptualized by general practitioners (GPs) and particularly how they assess the suicide risk of patients who have self-harmed. Aims: The study aimed to explore how GPs respond to patients who had self-harmed. In this paper we analyze GPs’ accounts of the relationship between self-harm, suicide, and suicide risk assessment. Method: Thirty semi-structured interviews were held with GPs working in different areas of Scotland. Verbatim transcripts were analyzed thematically. Results: GPs provided diverse accounts of the relationship between self-harm and suicide. Some maintained that self-harm and suicide were distinct and that risk assessment was a matter of asking the right questions. Others suggested a complex inter-relationship between self-harm and suicide; for these GPs, assessment was seen as more subjective. In part, these differences appeared to reflect the socioeconomic contexts in which the GPs worked. Conclusion: There are different conceptualizations of the relationship between self-harm, suicide, and the assessment of suicide risk among GPs. These need to be taken into account when planning training and service development. Keywords: self-harm, suicide, general practice, risk assessment

Nonfatal self-harm and suicide are generally understood to be related, but distinct, behaviors. While many people who have self-harmed deny any intent to die (Adler & Adler, 2011), there is considerable evidence that self-harm is a major risk factor for subsequent completed suicide (Hawton, Zahl, & Weatherall, 2003). This presents a challenge for frontline health-care professionals who see patients with a wide range of self-harming behavior and must assess risk of subsequent suicide in each case. In addition to increased risk of suicide, individuals who have self-harmed appear likely to be at greater risk of a range of other clinical and social challenges, including substance misuse and mental health problems (Hasking, Momeni, Swannell, & Chia, 2008). The findings of a recent longitudinal study of a general population sample of young adults suggests that the association between selfharm and such adverse outcomes is stronger where selfharm has been identified as suicidal in nature (Mars et al., 2014). The relationship between self-harm and suicidality is highly contested among researchers. While some argue that it is possible to differentiate between self-harming acts that are suicidal and those that are not (Plener & Fegert, 2012), others point to the difficulty of making meaningful Crisis 2016; Vol. 37(1):42–50 DOI: 10.1027/0227-5910/a000325

distinctions (Kapur, Cooper, O’Connor, & Hawton, 2013). The inclusion of nonsuicidal self-injury (NSSI) as a proposed diagnosis in the latest version of the American Psychiatric Association’s Diagnostic and Statistical Manual has triggered a heated debate (American Psychiatric Association, 2013; De Leo, 2011; Gilman, 2013; Kapur et al., 2013). Published commentary on this issue highlights enduring differences between European and US perspectives (Arensman & Keeley, 2012; Claes & Vandereycken, 2007). In the UK the most widely used definition of self-harm is “self-injury or self-poisoning irrespective of the apparent purpose of the act” (National Institute for Clinical Excellence, 2011). However, there is evidence that, among lay groups in the UK, self-harm is often understood to refer to self-cutting that is accompanied by no or only minimal suicidality (Scourfield, Roen, & McDermott, 2011). Some studies have found differences in stated suicidal ideation between young people who have taken overdoses and those who have engaged in self-cutting (Rodham, Hawton, & Evans, 2004). However, the relationship between self-harm and suicide is not straightforwardly related to the method used (Fortune, 2006). Whitlock and Knox (2007) found that rates of suicidal ideation were higher among those who had engaged in self-injurious © 2015 Hogrefe Publishing. Distributed under the Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

A. Chandler et al.: General Practitioners’ Accounts of Patients Who Have Self-Harmed

behavior than among those who had taken overdoses in a community sample of college students. They argued that this finding underlined the importance of ongoing suicide risk assessment for young people who self-harm using any method. Further, Bergen et al. (2012), conducting research on hospital-treated self-harm, found that self-cutting was more closely related to completed suicide than self-poisoning was. Evidence from psychological autopsy investigations suggests that a history of self-harm is one of the strongest risk factors for suicide, present in about 40% of cases (Cavanagh, Carson, Sharpe, & Lawrie, 2003). However, there is considerable variation in the prevalence of previous self-harm across studies (the range in the Cavanagh et al. review is 16–68%), reflecting heterogeneity in the samples being investigated (e.g., female nurses, Hawton et al., 2002; individuals not engaged with mental health services, Owens, Booth, Briscoe, Lawrence, & Lloyd, 2003) and limitations of the methodology (Pouliot & De Leo, 2006). The complex and sometimes contradictory nature of research evidence regarding the relationship between self-harm and suicide means that debates are unlikely to be resolved soon. This raises questions, however, as to how such complexities should be managed in clinical practice, particularly in primary care, where the range of selfharm that is treated may be more diverse and less clearly life-threatening than that seen in secondary care. In the UK, rates of hospital-treated self-harm and suicide vary according to socioeconomic context and sociodemographic characteristics. People living in areas of socioeconomic deprivation have a higher likelihood of both dying by suicide and being treated in hospital for self-harm (Mok et al., 2012; Platt, 2011; Redley, 2003). Little is known about self-harm that is not treated in hospital, with most community-based research focusing on adolescent or college populations. Some studies indicate that there is little to no variation in reported self-harm among young people living in different socioeconomic contexts (Ross & Heath, 2002). Others have found that those living in areas of deprivation (Jablonska, Lindberg, Lindblad, & Hjern, 2009) and, in some areas of the US, those from African American groups (Gratz, 2012) are more likely to report self-harm. Studies of self-harm treatment in primary care are limited; consequently, the frequency and features of self-harm in such settings are relatively unknown. Although there is a dearth of research in primary care, this setting would appear to offer clear opportunities for contributing to suicide prevention (Appleby, Amos, Doyle, Tomenson, & Woodman, 1996; Cole-King & Lepping, 2010; Pearson et al., 2009; Saini et al., 2010). About half of patients who go on to die by suicide visit their general practitioner (GP) in the month leading up to their death (Luoma, Martin, & Pearson, 2002; Pearson et al., 2009). Further, following hospital treatment for self-harm, patients in the UK are usually referred back to their GP for follow-up (Mitchell, Kingdon, & Cross, 2005). Outcomes relating to a primary care intervention for patients who have engaged in suicidal self-harm have been explored (Bennewith et al., 2002), while other studies have examined GP responses to suicidal self-harm using qualitative © 2015 Hogrefe Publishing. Distributed under the Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

(Kendall & Wiles, 2010) and quantitative (Rothes, Henriques, Leal, & Lemos, 2014) approaches. To date, there has been no research on GPs’ responses to self-harm as defined in UK clinical guidelines, that is, including cases of self-harm that are not treated in hospital and are not deemed suicidal. This study is the first – to our knowledge – to explore GPs’ accounts of self-harm in general, avoiding a narrow focus on suicidal self-harm. The aims of the study were: to explore how GPs talked about responding to and managing patients who had selfharmed; to identify potential gaps in GPs training; and to assess the feasibility of developing a multifaceted training intervention to support GPs in responding to self-harm in primary care. We focus here on GPs’ accounts of the relationship between self-harm and suicide and approaches to carrying out suicide risk assessments on patients who had self-harmed. (A separate paper will address accounts of providing care for patients who had self-harmed; the present paper should not be taken as evidence that GPs talked only about managing suicide risk among these patients.)

Method A narrative-informed, qualitative approach (Riessman, 2008) was adopted, in order to explore in depth how GPs talked about patients who had self-harmed, including how they addressed suicide risk. Through this we sought to examine GPs’ understandings of self-harm, and reflect upon how the meanings attached to self-harm, including the relationship with suicide, might affect clinical practice. Participants were GPs recruited from two health boards in Scotland. We obtained a sample of interviewees working in practices from diverse geographic and socioeconomic areas. Recruitment was in two stages: an initial mailing via the Scottish Primary Care Research Network, followed by a targeted approach, using personal networks to recruit GPs working in practices located in areas of socioeconomic deprivation. We did not selectively recruit participants based on particular experience of self-harm or psychiatry either in training or practice. An overview of the characteristics of the final sample of 30 GPs is shown in Table 1. The socioeconomic characteristics of the practice were calculated using the Scottish Index of Multiple Deprivation. Those classed as deprived were located in areas in deciles 1–3; middle-income practices were in deciles 4–6; affluent practices in deciles 7–10. Rural/urban practices were classified using the Scottish Government sixfold urban/rural classification. All participants gave informed, written consent. Participants were reimbursed for practice time spent on the research study, and were provided with a package of educational materials for use toward continuing professional development at the end of the study period. GPs participated in a semistructured interview with one of the authors (King). They were offered either telephone or face-to-face interviews, with all but one opting for a telephone interview. No particular reason was proCrisis 2016; Vol. 37(1):42–50

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Table 1. Overview of the characteristics of the final sample of 30 GPs Characteristics

Number of participants

Practitioner gender Male

Female

Geography of practice area Urban

Rural

Socioeconomic status of area Deprived Middle-income Affluent Mixed Total sample

12 3 13 2 30

Table 2. Overview of deductive codes (bold) with inductive codes within self-harm and suicide Practice examples Reflecting on self-harm Self-harm and suicide Relationship between self-harm and suicide −− Distinct relationship – self-harm indicates low risk −− Complex relationship – self-harm may indicate high risk, relationship difficult to untangle Assessing suicide risk in the context of self-harm −− Straightforward −− Challenging −− Just ask them −− Identify risk/protective factors Best practice Training needs and experience

vided for preferring a face-to-face interview, and the interview did not differ substantially from those conducted via telephone. During the interview, and leading from our narrative approach, participants were invited to discuss two or more recent cases (suitably anonymized) where they had treated a patient who had self-harmed. This approach allowed us to generate rich narratives from GPs regarding the types of patients they understood to have self-harmed, along with their accounts of treating such patients. Subsequently, the following topics were explored: understandings of self-harm; assessment of suicide risk in the context of self-harm; and training and education needs and experiences. The topic guide was developed directly from the research aims. Interviews were planned to last 30 min and ranged from 20 to 40 min. Interviews were recorded, transcribed verbatim, and entered into the NVivo 10 qualitative data analysis package (NVivo, version 10) to facilitate data management and content coding. Analysis was thematic, informed by narrative approaches that sought to avoid fracturing participants’ responses and retained a focus on each GP participant as a Crisis 2016; Vol. 37(1):42–50

case. Chandler carried out deductive coding, based on the interview schedule, followed by inductive, open coding to identify common themes in the data (Hennink, Hutter, & Bailey, 2011; Spencer, Ritchie, & O’Connor, 2005). Table 2 presents an overview of the deductive codes, along with the inductive subcodes within the code on self-harm and suicide, which are the focus of this paper. Proposed themes were shared, discussed, and agreed on within the research team. In relation to the coding presented in this paper, theoretical data saturation was achieved. The present paper is based on analysis of a deductive code containing all talk about the relationship between self-harm and suicide, and the assessment of suicide risk in the context of self-harm.

Results The Relationship Between Self-Harm and Suicide When asked to reflect on the relationship between selfharm and suicide, GPs’ accounts tended to embody one of two understandings: (a) that there was a very weak relationship between the practices; and (b) that there was a close and complex relationship between the practices. Some GPs’ accounts introduced elements of each of these understandings. Self-Harm and Suicide as Distinct Some GPs portrayed self-harm and attempted suicide as distinct in several ways, addressing differences with intent, methods used, and help-seeking behavior. GPs sometimes identified a theoretical link between self-harm and risk of completing suicide; however, this formal knowledge was contrasted with practice experience of treating patients who had self-harmed as a way of “releasing” problematic emotions: Their [people who have self-harmed] risk of actual suicide is more than the general population, as far as I can remember, going back to teaching days […] most people don’t want to kill themselves. […] this is just, again, an anecdotal – cases we’ve looked after, that most people don’t want to kill themselves. That it’s a sense of frustration and danger in themselves, and it’s a form of releasing anger. (GP5, F, mixed socioeconomic area)

Thus, unlike attempted suicide, which entailed an intense wish to die, self-harm was believed to be carried out for other, different, reasons, in particular tension release: It seems like there’s two different sides to the coin: those that it’s sort of [a] response to stress and that’s how they deal with their anxiety and they get some, you know, instant relief from their anxieties and stresses with that, and then you’ve got the other ones where it’s maybe a more serious sort of cry for help and it’s not something that they’ve done on a regular basis. (GP7, F, rural, affluent area) © 2015 Hogrefe Publishing. Distributed under the Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

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GP7 suggests that there are differences between self-harm and suicide, both in terms of intent (anxiety relief vs. a serious cry for help) and frequency (nonsuicidal self-harm would be likely to recur more regularly than a suicide attempt). Framing self-harm and suicide in this manner led to a perception that certain methods of self-harm were especially likely to be associated with low suicidality, in particular self-cutting: “The people cutting their forearms and things, they’re definitely not trying to kill themselves I don’t think” (GP15, F, rural, deprived area). The phrase cry for help was often used in GPs’ accounts, although the meaning ascribed to this appeared to vary. Thus, in the account of GP7, the cry for help indicated a serious act (attempted suicide); other GPs associated the cry for help with nonfatal self-harm, which posed a lower risk of eventual suicide:

When GPs talked about self-harm and suicide as related, reference was often made to patients’ difficult lives. GPs mentioned the adverse structural and interpersonal conditions in which many of their patients lived, emphasizing high levels of poverty and financial uncertainty, drug or alcohol dependence, lack of stable accommodation, and poor or abusive relationships. In the context of such challenges, GPs suggested it was particularly hard to separate self-harm from suicidality.

In my experience it seems like the majority of self-harmers didn’t seem to have that high a risk of completing a suicide. In my experience most of them are fairly low risk […] A lot of them were cry for helps. (GP10, M, rural, affluent area)

I think many of them have a wish not to be there. You know, they have passive suicidal ideation; they just wish they didn’t exist anymore. (GP29, F, urban, deprived area)

GPs used the term cry for help to describe both the perceived intention of an act of self-harm (communication of distress) and also the help-seeking behavior of the patient. Some of these accounts suggested that those patients who were seriously suicidal would be less likely to seek (or cry for) help. By contrast, patients whose actions were characterized as self-harm were framed as “seeking help” and therefore “not really trying to kill themselves” (GP6, M, urban, middle-income area). It’s a very gray area […] people who are really suicidal, you often don’t find out, because they just go and do it […] the population I see is enormously skewed towards people who have a lower degree of suicidality in it, if you like, are seeking help from me […] they’re using these attempts at self-harm as a way of expressing how bad they feel. (GP20, M, urban, affluent area) It’s a classic cliché that self-harm is a cry for help […] whereas true suicide […] folk who kill themselves the chances are they are going to do it, and the folk who are really serious about doing it will do it, and you won’t know about it. (GP13, M, semi-urban, affluent area)

While GPs differed in their use of the term cry for help, particularly whether this was infused with positive or negative connotations, in most cases it served to differentiate self-harm from suicide. Self-Harm and Suicide as Related Unlike the accounts above, which constructed self-harm and suicide as distinct practices, other GPs emphasized the difficulty of distinguishing meaningfully between selfharm and suicide. One way in which this was accomplished was through accounts that framed suicide as an ongoing concern when treating patients who had self-harmed:

My feeling would be that most people who are self-harming have at some point had more suicidal thoughts. (GP19, M, mixed socioeconomic area)

I think it’s very difficult, actually, in my patients, because I think there’s just a gross ambivalence about being alive. (GP28, M, urban, deprived area)

GPs providing these accounts challenged interview questions that asked them to consider self-harm and suicidality as distinct. Researcher: How often in your experience is self-harm accompanied by some degree of suicidality? […] GP: I’m sorry not to answer your question very helpfully, but that’s the trouble. There are degrees of suicidality and often teasing out whether somebody who’s referring to suicidal thoughts of one kind or another is actually meaning to selfharm with no actual intention to kill themselves, or they are truly meaning to kill themselves. That’s not particularly easy. (GP18, M, semi-urban, deprived practice)

Such accounts questioned whether concepts of suicidality or suicidal ideation were useful when treating patients who had self-harmed, because the issue of intent was often unclear (including to the patients themselves) and the separation between self-harm and suicide was indistinct. The majority of GPs providing these accounts were working in practices located in socioeconomically deprived areas, or had significant experience working with marginalized patient groups. There were exceptions, however. For instance, GP22 (F, urban, affluent area) suggested that one of her patients was self-harming: “Probably more a cry for help but I think she is so vulnerable that she could make mistakes, a mistake easily enough to kill herself […] we always live with uncertainty.” Establishing the presence or absence of suicidal intent among patients with difficult lives was described as problematic. GPs noted that such patients might live with suicidal thoughts over long periods and/or be at high risk of accidental self-inflicted death. In combination, these factors undermined any attempt to distinguish clearly between suicidal and nonsuicidal self-harm.

I think it’s always a fear that’s in the background for us. (GP4, F, semi-urban, deprived area) © 2015 Hogrefe Publishing. Distributed under the Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

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The Challenges of Suicide Risk Assessment Among Patients Who Had Self-Harmed All GPs were asked how they assessed suicide risk in patients who had self-harmed. In contrast to their responses to questions about the relationship between self-harm and suicide, GPs’ accounts in relation to this issue were more similar. The majority emphasized the difficulty of assessing suicide risk among patients who self-harmed, although different explanations for this difficulty were given. Challenges: Time Constraints and Establishing Intent Time constraints were frequently identified as presenting a barrier in assessing suicide risk: In a ten-minute consultation, under enormous working pressure, yes, [assessing suicide risk is] very difficult actually. (GP26, M, urban, deprived area)

Indeed, time constraints were described more generally as posing a challenge when treating patients who had selfharmed and who were therefore framed as being complex or difficult cases. GPs’ accounts suggested the adoption of different approaches to managing time constraints, which may have been shaped by local contexts and resources. The problem of assessing intent among patients who self-harmed was raised, with some GPs highlighting the limitations of asking patients direct questions: So, it’s easy for the ones who are willing to speak about it, but it’s very difficult for the ones who are really wanting to do it […]. In one [patient] there was contact with a complaint of depression, but they had basically said that they weren’t suicidal but unfortunately they were. (GP12, M, urban, middle-income area)

As with GP12, some of these accounts drew on understandings of suicide as a practice that was generally difficult to identify and prevent, since people who “really want to do it” may not disclose their plans. GPs working with marginalized, disadvantaged patient groups were particularly like to suggest that assessing suicide risk was an inherently imprecise endeavor, since people’s lives were volatile and dangerous. You can never be confident I guess with a mental health assessment, about when someone feels like they are genuinely at acute risk of suicide or when they’re at risk of self-harm and possible death through misadventure. (GP10, F, urban, deprived area)

Again, this type of account emphasized the limitations of asking patients about suicidal thoughts, since absence of such thoughts may not necessarily preclude future self-inflicted death in the context of inherently risky living.

of how they carried out assessments. These narratives emphasized the importance of asking patients about suicidal thoughts and plans, but also addressed wider risk and protective factors, such as social isolation and drug and alcohol use, as well as relying on what was often described as gut feeling (a mixture of intuition and experiential learning). Yeah, I know, it’s not easy. When you think about it, it’s … I think I just sort of go with my gut feeling. I think you sort of get a feeling about a person when you meet them as to whether it’s a cry for help, is it just a stress response, it is something more serious. (GP7, F, rural, affluent area) To be honest, I tend to go more on … well, if I know a patient, then I would go more on my gut feeling […]. I don’t think always because people have suicidal ideas or even suicide intent… I’m not always sure that we need to intervene, and I think a lot of what I try and do is to reflect back to the patient in terms of them taking responsibility […]. So in terms of assessment, I don’t use a risk assessment tool or anything, and I kind of weigh what they’re actually saying, in terms of what they’re planning and what’s their history, so I guess I do take that into consideration, and their social situation as well. (GP27, M, urban, deprived area)

While GP7 and GP27 both referred to using gut feeling to guide suicide risk assessments, there were differences in their accounts. GP7 indicated a preference for referring patients who self-harmed to specialists, as she felt that carrying out suicide risk assessments was not well-supported in primary care. By contrast, GP27 provides a more assured account that suggests a greater level of comfort in responding to patients who self-harm and who may experience continuing suicidality. Further, the account of GP7 indicated a view that self-harm and suicide were distinct, while GP27 emphasized the difficulty of making such distinctions. GPs’ accounts of assessing suicide risk among patients who self-harmed were diverse. Some, such as GP7, indicated that the difficulty lay in a lack of specialist knowledge to ascertain whether self-harm was serious (suicidal) or a cry for help (nonsuicidal); such accounts were based on an understanding of self-harm and suicide as distinct. Others, such as GP12, highlighted that patients may not be able, or feel able, to disclose suicidality even when present. Again, these accounts tended to assume that suicide and self-harm were distinct practices. By contrast, others suggested suicide risk assessment was difficult because of the close and complex relationship between self-harm and suicide. GP27 noted that intention was not necessarily the most important factor in understanding completed suicide among disadvantaged patient groups, where risk of death in general was perceived as heightened, and disclosure of suicidality pervasive.

Challenges: Carrying Out Suicide Risk Assessments

Straightforward Accounts of Risk Assessment

While GPs often noted the difficulty and limitations of assessing suicide risk, they nevertheless provided accounts

A minority of GPs provided confident, assured accounts of carrying out suicide risk assessments.

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How easy it is to assess risk? I don’t think it’s difficult to assess risk. I’ve been a GP for over 20 years, and I’ve done a bit of psychiatry as well, so I don’t think it’s a too difficult thing to do. (GP16, M, urban, affluent area)

GP16 emphasized his comfort and capability in treating patients who had self-harmed, and in assessing suicide risk. GPs providing such accounts highlighted the importance of asking direct questions about suicidality to patients who had self-harmed: I think a lot of the time it [assessing suicide risk] is relatively straightforward if you just ask them the right questions and always distract them away from the self-harm bit and talk about normal things […] you have to be direct to them about killing themselves. (GP2, M, urban, affluent area)

GP2 highlighted the importance of getting a sense of patients’ wider life circumstances, using these, along with direct questions about suicidal intent, to build up a picture of suicide risk. These accounts did not necessarily downplay the complexity of assessing suicide risk, but nonetheless indicated a greater level of comfort, and confidence, in doing so. The context in which these accounts were provided is significant here. GPs taking part in the study were opening themselves up to potential or perceived critique, and not all participants may have been comfortable discussing uncertainty. Descriptions of suicide risk assessment that focused on asking about intent may have been limited by being grounded in an understanding of self-harm and suicide as distinct practices. If a patient referred to self-harm as a form of coping with emotions or tension release, and denied any wish to die, suicide risk was interpreted as low. However, these descriptions of straightforward suicide risk assessment sit uneasily with the accounts provided by other GPs, which problematized the role of intent when assessing suicide risk.

Discussion Our research suggests that GPs have diverse understandings of the relationship between self-harm and suicide, paralleling the plurality of views on this topic in other disciplines (Arensman & Keeley, 2012; Gilman, 2013; Kapur et al., 2013). These findings indicate the importance of attending to GPs’ working definitions of suicide and self-harm, and point to the potential limitations of previous work that has focused narrowly on suicidal self-harm (Bennewith et al., 2002). GPs may have very different opinions on what constitutes suicidal self-harm, or indeed whether it is practical to make distinctions between suicidal and nonsuicidal selfharm. Understandings are likely to be shaped in part by different practice contexts and patient characteristics.

Defining Self-Harm and Suicide

accounts further unsettle attempts to define suicidality. Is it is a facet of personality (trait) that is found to greater or lesser degree in each individual; a transient state that fluctuates according to external circumstances and context; or a post hoc description of someone who goes on to die by suicide? Our findings resonate with work on the sociological construction of suicide, in problematizing the process whereby deaths come to be understood as suicides (Atkinson, 1978; Timmermans, 2005). However, rather than debating whether a death was a true suicide, GPs in our sample were engaged in deliberating about the extent to which self-harming patients’ practice was truly suicidal. These discussions reflect wider debates about the categorization of self-harm: as deliberate self-harm, nonsuicidal self-injury, a psychiatric diagnosis, a symptom of distress, or a sign of a difficult patient. Crucially, our analysis indicates variation in understanding of the relationship between self-harm and suicide, and the consequent impact on practice in the primary care setting.

Practice Context and Suicide Risk Assessments Among Patients Who Self-Harm GPs’ accounts of treating patients who self-harm, and especially of addressing suicide risk assessments with highrisk groups of patients, highlight a potential challenge for current approaches to responding to self-harm in primary care. The question of intent is, for instance, central to some proposed treatment guidelines for patients in general practice who self-harm. Thus, Cole-King and colleagues suggest that establishing whether self-harm is oriented toward suicide or the relief of emotional pain should be the “first priority” (Cole-King, Green, Wadman, Peake-Jones, & Gask, 2011, p. 283). This approach reflects the accounts of many of the GPs in our sample, who similarly indicated a focus on distinguishing between nonsuicidal self-harm and self-harm with suicidal intention. However, other GPs highlighted significant problems with ascertaining intent, particularly when treating high-risk populations who have a generally higher risk of premature death and where the presence or absence of suicidal intent may be unclear. It may be significant that GPs working in more deprived, disadvantaged areas appeared more likely to describe suicidal self-harm and nonsuicidal self-harm as intertwined, fluid, and unstable categories, thus making suicide risk assessments especially difficult. By contrast, GPs working in areas that were more rural or affluent tended to discuss suicidal self-harm and nonsuicidal self-harm as distinct, separate practices, characterized by very different methods and intent. It is likely that these differences are rooted in the socioeconomic patterning of rates of both self-harm and suicide (Gunnell, Peters, Kammerling, & Brooks, 1995; Mok et al., 2012), thus highlighting the importance of context in shaping GPs’ experience with, and interpretation of, self-harming patients.

As well as demonstrating that defining self-harm continues to be a challenge (Chandler, Myers, & Platt, 2011), GPs’ © 2015 Hogrefe Publishing. Distributed under the Hogrefe OpenMind License http://dx.doi.org/10.1027/a000001

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Limitations This was a study of 30 GPs’ accounts of treating patients who had self-harmed in two regions of Scotland. It thus carries risks of insufficient sampling and of over-generalization. We addressed these by: (a) purposively sampling from very diverse practices within these regions and ensuring participants varied in age, gender, and experience; as with all such studies, participants may have had a particular interest in psychiatry or suicide; however, interviewees reported a range of experiences and levels of interest in these topics; (b) conducting in-depth analysis of the GPs’ accounts; and (c) obtaining data saturation on several key themes. The finding that GPs differ substantially in the way in which they conceptualize associations of self-harm and suicide occurred independently of context, so is likely to be generalizable. Our cautious proposal that the differences in accounts may relate to socioeconomic setting may be more sensitive to context and certainly warrants further investigation in order to confirm or refute this suggestion. Our research used a fairly blunt and imprecise measure of socioeconomic context (matching the postcode of the practice with the Scottish Index of Multiple Deprivation). Future research should adopt a more sensitive measure that takes more account of the socioeconomic characteristics of the patient population, rather than the location of the practice itself.

Conclusions GPs in our sample understood self-harm in different ways, reflecting definitional inconsistency and uncertainty in the academic literature. GPs varied in their account of the relationship between self-harm and suicide and in how they described suicide risk assessment. Some patterns emerged in our findings. In particular, GPs who provided accounts of self-harm and suicide as related in complex ways also tended to frame suicide risk assessment as a challenging, continuing process. GPs providing such accounts were more likely to describe working in practices that served populations with high levels of social isolation and economic deprivation. On the basis of these findings, we suggest that there is a clear need for enhanced and accessible support, training, and education for GPs regarding the assessment and management of self-harm and suicidality. Such support, which could be provided as part of continuing professional development, should be responsive to GPs’ practice experience, as this appears to shape attitudes toward, and views about, the nature of self-harm, how it relates to suicide, and the role of general practice in contributing to suicide prevention. Acknowledgments This study was funded by the Chief Scientists’ Office of the Scottish Government (CZH/4/783). We would like to Crisis 2016; Vol. 37(1):42–50

thank all of the GPs who participated in the research, and the Scottish Primary Care Research Network who supported recruitment. Thanks are also due to Tineke Broer, Emma Davidson, Fiona Morrison, and Carrie Purcell who commented on an early draft of the paper. The manuscript was much improved by comments and suggestions from two anonymous reviewers. The authors declare that they have no conflicts of interest.

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NVivo (Version 10) [Computer software]. Doncaster, VIC, Australia: QSR International. Redley, M. (2003). Towards a new perspective on deliberate selfharm in an area of multiple deprivation. Sociology of Health and Illness, 25(4), 348–373. Riessman, C. K. (2008). Narrative methods for the human sciences. Thousand Oaks, CA: Sage. Rodham, K., Hawton, K., & Evans, E. (2004). Reasons for deliberate self-harm: Comparison of self-poisoners and self-cutters in a community sample of adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43(1), 80–87. doi:10.1097/00004583-200401000-00017 Ross, S., & Heath, N. (2002). A Study of the frequency of self-mutilation in a community sample of adolescents. Journal of Youth and Adolescence, 31(1), 67–77. Rothes, I. A., Henriques, M. R., Leal, J. B., & Lemos, M. S. (2014). Facing a patient who seeks help after a suicide attempt. Crisis, 35(2), 110–122. doi:10.1027/0227-5910/ a000242 Saini, P., Windfuhr, K., Pearson, A., Da Cruz, D., Miles, C., Cordingley, L., … Kapur, N. (2010). Suicide prevention in primary care: General practitioners’ views on service availability. BMC Research Notes, 3(1), 246. Scourfield, J., Roen, K., & McDermott, E. (2011). The non-display of authentic distress: Public-private dualism in young people’s discursive construction of self-harm. Sociology of Health & Illness, 33(5), 777–-791. Spencer, L., Ritchie, J., & O’Connor, W. (2005). Analysis: Practices, principles and processes. In J. Ritchie & J. Lewis (Eds.), Qualitative research practice (pp. 199–218). London, UK: Sage. Timmermans, S. (2005). Suicide determination and the professional authority of medical examiners. American Sociological Review, 70(2), 311–333. doi:10.1177/000312240507000206 Whitlock, J., & Knox, K. L. (2007). The relationship between self-injurious behavior and suicide in a young adult population. Archives of Pediatrics & Adolescent Medicine, 161(7), 634–640. doi:10.1001/archpedi.161.7.634

Received September 30, 2014 Revision received February 11, 2015 Accepted February 12, 2015 Published online November 17, 2015

About the authors Amy Chandler is a sociologist and Research Fellow at the Centre for Research on Families and Relationships, University of Edinburgh, UK. Her work spans sociology, health policy, and medical humanities. She specializes in using qualitative methods to explore professional and lay accounts of marginalized practices including self-harm, suicide, and drug use. Caroline King is Research Associate with the Institute for Applied Health Research at the Glasgow Caledonian University, UK. Her research interests include sociological research on health and well-being across the life course. She is interested in using qualitative research methods to inform policy and practice. Chris Burton is a general practitioner and head of research in the Centre of Academic Primary Care at the University of Aberdeen, UK. His research focuses on the intersection between physical and mental health in primary care and on how doctors and patients create constructive explanations in uncertain situations. Crisis 2016; Vol. 37(1):42–50

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Stephen Platt is Emeritus Professor of Health Policy Research at the University of Edinburgh, UK. He has published widely on social, epidemiological, and cultural aspects of suicide and self-harm. He is Vice-President of the International Association of Suicide Prevention and an adviser to the Scottish and Irish Governments on suicide prevention.

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Amy Chandler CRFR, 23 Buccleuch Place University of Edinburgh Edinburgh, EH8 9LN UK Tel. +44 (0)131 650-3981 Fax +44 (0)131 651-1833 E-mail a.chandler@ed.ac.uk

Research Trends

Dating Violence Victimization, Interpersonal Needs, and Suicidal Ideation Among College Students Caitlin Wolford-Clevenger, JoAnna Elmquist, Meagan Brem, Heather Zapor, and Gregory L. Stuart Psychology Department, University of Tennessee-Knoxville, TN, USA Abstract. Background: Victims of dating violence experience suicidal ideation at a higher rate than the general population. However, very few studies have examined the relationship between dating violence and suicidal ideation within an empirically supported theory of suicide. The interpersonal-psychological theory of suicide posits that thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness) are proximal antecedents to suicidal ideation. The experience of dating violence may thwart such interpersonal needs, thus increasing risk for suicidal ideation. Aims: We aimed to examine the relationships among dating violence, thwarted interpersonal needs, and suicidal ideation and test the interpersonal-psychological theory of suicide. Method: We conducted two cross-sectional studies on college students in dating relationships to examine these research questions. Results: Study 1 indicated positive correlations among dating violence (i.e., physical and psychological), thwarted belongingness, and perceived burdensomeness. Study 2 generally replicated the bivariate relationships of Study 1 and demonstrated that, at high levels of thwarted belongingness, perceived burdensomeness was correlated with suicidal ideation, while accounting for the effects of depressive symptoms and drug use. Conclusion: These results highlight the importance of using theory-guided research to understand the relationship between dating violence and suicidal ideation. Keywords: intimate partner violence, partner abuse, thwarted belongingness, perceived burdensomeness, suicidal ideation, interpersonal theory, physical assault, psychological aggression, dating violence

Suicidal ideation among college students is a precursor to suicide, a leading cause of death in young adults (Centers for Disease Control and Prevention [CDC], 2013). Thus, it is imperative to assess suicidal ideation and provide appropriate intervention. College students experience suicidal ideation at an alarmingly higher rate (10% in past month; Garlow et al., 2008) than the general population (3.7% in past year; Crosby, Han, Ortega, Parks, & Gfroerer, 2011). Identifying factors that facilitate the trajectory to suicidal ideation in college students is essential for improving suicide prevention efforts in this population. Dating violence (DV) victimization, particularly physical assault and psychological aggression, is a well-documented risk factor for suicidal ideation in men and women (Afifi et al., 2009; Chan, Straus, Brownridge, Tiwari, & Leung, 2008; Devries et al., 2011; Golding, 1999; Heru, Stuart, & Recupero, 2007; Leone, 2011; Randle & Graham, 2011; Wolford-Clevenger & Smith, 2015; Wolford-Clevenger et al., 2015). Indeed, men and women who are victimized by DV exhibit elevated rates of suicidal ideation (17.6–68.7%; Golding, 1999; Pico-Alfonso et al., 2006; Schneider, Burnette, Ilgen, & Timko, 2009) compared with the general population (3.7%; Crosby et al., 2011). DV victimization is pervasive in college students, with 37% and 90% of college student relationships involving © 2015 Hogrefe Publishing

physical assault and psychological aggression, respectively (Shorey, Cornelius, & Bell, 2008). Yet, very few studies have examined the connection between DV victimization and suicidal ideation in college students. Furthermore, research on the relationship between DV victimization and suicidal ideation has been largely atheoretical. For example, a majority of the literature has identified psychiatric symptoms, such as depression, as explaining the high rates of suicidal ideation among DV victims (Chan et al., 2008; Iverson et al., 2012; Leiner, Compton, Houry, & Kaslow, 2008; Stein et al., 2010). Investigation of the DV–suicidal ideation connection guided by an empirically supported theory of suicide will aid in a more clinically useful understanding of suicide risk in college students. The interpersonal-psychological theory of suicide (IPTS; Joiner, 2005; Van Orden et al., 2010) offers an understanding of the relationship between DV victimization and suicidal ideation. According to the IPTS, suicidal ideation results from the product of feelings of liability and self-hatred (i.e., perceived burdensomeness) and feelings of loneliness and low reciprocal care (i.e., thwarted belongingness; Van Orden et al., 2010). The theory’s predictions about thwarted interpersonal needs interacting to predict suicidal ideation have been supported in clinical and nonclinical samples (Christensen, Batterham, Soubelet, Crisis 2016; Vol. 37(1):51–58 DOI: 10.1027/0227-5910/a000353

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& Mackinnon, 2013; Cukrowicz, Cheavens, Van Orden, Ragain, & Cook, 2011; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). While the IPTS offers a potentially useful explanation for the relationship between DV victimization and suicidal ideation, the relationships among these constructs have yet to receive sufficient scrutiny (Van Orden et al., 2010). Victims of DV may be at elevated risk for suicidal ideation owing to increased feelings of burdensomeness and disconnectedness. Psychological aggression involves verbal maltreatment, humiliation, and controlling tactics (Saltzman, Fanslow, McMahon, & Shelley, 2002), which have the potential to promote thwarted belongingness and perceived burdensomeness (Van Orden et al., 2010). Empirical data support this suggestion, demonstrating that psychological aggression impairs victims’ self-esteem and social support, increases depressive symptoms, and facilitates emotional and financial dependence on their violent partners (Davidson, Wingate, Grant, Judah, & Mills, 2011; Dutton & Goodman, 2005; Golding, 1999; Johnson & Leone, 2005). Such emotional, social, and financial damage may impact the degree of intimacy in the relationship (Heru et al., 2007) and increase victims’ feelings of loneliness, low reciprocal care, liability, and self-hatred. Physical assault, involving behaviors such as hitting, punching, shoving, or harming one’s partner with an object, also conceivably increases feelings of burdensomeness and low belongingness (Saltzman et al., 2002; Van Orden et al., 2010). Physical assault can result in a number of physical health consequences (e.g., injuries) for which victims seek help for from law enforcement or health-care professionals (Campbell et al., 2002). Victims, especially men, may encounter unhelpful responses during help-seeking experiences, such as disbelief, apathy, minimization, victim-blaming attitudes, and being denied help (Douglas & Hines, 2011; Garimella, Plichta, Houseman, & Garzon, 2000; Stephens & Sinden, 2000). These experiences likely intensify victims’ feelings of liability, self-hatred, and disconnectedness from others. One study has supported this hypothesis, demonstrating that both physical assault and psychological aggression positively correlated with perceived burdensomeness and thwarted belongingness in a college student sample (Lamis, Leenaars, Jahn, & Lester, 2013). This study further demonstrated that perceived burdensomeness, but not thwarted belongingness, predicted suicidal ideation while controlling for DV victimization and other risk factors (Lamis et al., 2013). However, the study did not test the main prediction of the IPTS: that thwarted belongingness and perceived burdensomeness interact to predict suicide ideation. Further work is needed to test this critical tenet of the IPTS. In sum, the literature regarding the connection between DV and suicidal ideation in college students is severely underdeveloped, and existing studies have typically examined this relationship from an atheoretical standpoint. The literature has suggested that physical assault and psychological aggression may result in mental health, physical health, and social and financial difficulties, which have potential to increase feelings of burdensomeness and disconnectedness (Campbell et al., 2002; Crisis 2016; Vol. 37(1):51–58

Davidson et al., 2011; Douglas & Hines, 2011; Dutton & Goodman, 2005; Garimella et al., 2000; Golding, 1999; Stephens & Sinden, 2000). However, only one published study has examined the relationships among DV victimization, thwarted interpersonal needs, and suicidal ideation (i.e., Lamis et al., 2013). Additional theory-guided research is necessary to advance the understanding of the relationship between DV victimization and suicidal ideation, especially in college students. We conducted two studies examining the relationship between DV victimization and suicidal ideation among college students within the context of the IPTS.

Study 1 Aims and Hypotheses Study 1 aimed to test the basic relationships among physical assault victimization, psychological aggression victimization, and thwarted interpersonal needs (i.e., perceived burdensomeness and thwarted belongingness). We hypothesized that both forms of DV victimization would positively correlate with thwarted belongingness and perceived burdensomeness.

Method Participants Undergraduate students (n = 502) volunteered for the study in exchange for research credit for an introduction to psychology course. Inclusion criteria were being 18 years of age or older and being in a dating relationship for at least 2 months. The sample was M = 18.80 years old (SD = 1.93), 65.7% female, and 76.1% freshmen. The race/ethnicity composition of the sample was as follows: White/Caucasian (81.2%), Black/African American (9.1%), Asian American (3.5%), Hispanic/Latino (2.1%), Indian/Middle Eastern (1.7%), Native American (0.8%), and “Other” (1.6%). The composition of the sample by family income level was as follows: less than US $50,000 (23.4%), $50,000–$100,000 (32.3%), $100,000–$150,000 (20.6%), $150,000–$200,000 (12.4%), greater than $200,000 (11.2%). A majority of the sample reported having a heterosexual orientation (95.6%) and not living with their partner (94.4%). The average relationship length was 14.37 months (SD = 14.55). Procedure The university’s Institutional Review Board approved the study procedures. Participants responded to an online battery of surveys. Given the sensitive nature of the items related to abuse and interpersonal problems within the survey, the last page of the survey displayed mental health © 2015 Hogrefe Publishing

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resources including contact information for the first author in the event that any distress resulted from the study.

mis et al., 2013) and good to excellent internal consistency in this sample (αs = 0.95 and .87, respectively).

Measures

Results and Discussion

Demographics. Demographic variables including age, gender, racial/ethnic identity, academic level, family income, and relationship characteristics were collected. Dating Violence. The Revised Conflict Tactics Scale (CTS2; Straus, Hamby, Boney-McCoy, & Sugarman, 1996; Straus, Hamby, & Warren, 2003) was used to measure physical assault and psychological aggression experienced by the respondent in their relationship within the past 12 months. The CTS2 is a 78-item measure that assesses the frequency (0 to more than 20 times) of relationship conflict tactics of negotiation, physical assault, psychological aggression, sexual coercion, and injury. Past studies have demonstrated the CTS2 to have good reliability and validity in various samples (Straus et al., 1996; Straus, Hamby, & Warren, 2003; Vega & O’Leary, 2007). The internal consistency for the subscales used in the current study ranged from questionable to good (psychological abuse victimization, α = 0.63; physical assault victimization, α = 0.79). Interpersonal Needs. The Interpersonal Needs Questionnaire (INQ; Van Orden, Cukrowicz, Witte, & Joiner, 2012) is a 15-item measure of perceptions of thwarted belongingness and perceived burdensomeness on 7-point Likert scale that ranges from not at all true for me to very true for me. The measure instructs participants to report on how they have been feeling recently. This measure has demonstrated convergent validity in samples of young and older adults (Van Orden et al., 2012). The subscales of perceived burdensomeness and thwarted belongingness have demonstrated excellent internal consistency in a prior undergraduate sample (αs = 0.90 and 0.92, respectively; La-

See Table 1 for means and standard deviations of the original study variables. Original variables were used for descriptive statistics. Given that the DV and interpersonal needs variables exhibited positive skew, log transformations were performed on these variables prior to conducting t tests and correlational analyses. Twenty-three percent of the sample reported having experienced some level of physical assault in the past year. A majority of the sample (67%) reported having experienced some level of psychological aggression in the past year. To explore potential gender differences in DV victimization, thwarted belongingness, and perceived burdensomeness, we conducted t tests. Results indicated that men reported experiencing greater feelings of thwarted belongingness, M = 1.31, SD = 0.22, than women, M = 1.26, SD = 0.21, t(499) = 2.43, p = .015 (means and standard deviations are of the log-transformed variables). Men and women did not differ in perceived burdensomeness or DV victimization. Next, we computed Spearman’s rho correlations as our data are on an ordinal scale. Perceived burdensomeness was positively correlated with physical assault victimization and psychological aggression victimization (see Table 1). Thwarted belongingness was positively correlated with physical assault victimization but not with psychological aggression victimization. In sum, bivariate results support that physical assault victimization is associated with increased feelings of burdensomeness and thwarted belongingness, whereas psychological aggression victimization is associated with increased perceived burdensomeness, but not thwarted belongingness.

Table 1. Bivariate correlations and descriptive statistics for Study 1 and 2 measures Thwarted belongingness

–

.44**

.05

.16**

–

Perceived burdensomeness

.54**

–

.14**

.12**

–

Psychological aggression victimization

.18*

.28**

–

.42**

–

Physical assault victimization

.20*

.23**

.49**

–

Drug use

.07

.17*

.26**

.15

–

Alcohol use

.14

.07

.23**

.06

.41**

–

Depressive symptoms

.58**

.45**

.08

.14

.20*

.19*

–

Suicidal ideation

.20*

.29**

.04

.06

.26*

.04

.23**

–

Study 1 mean (SD) Study 2 mean (SD)

20.58

8.03

7.18

2.13

(11.36)

(4.96)

(13.13)

(9.32)

19.65

7.72

10.47

3.49

15.72

5.34

31.60

0.29

(10.97)

(4.15)

(17.91)

(15.87)

(3.84)

(4.90)

(8.90)

(1.06)

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Study 2 Aims and Hypotheses Study 2 aimed to replicate the basic relationships in Study 1: Perceived burdensomeness will positively correlate with physical assault and psychological aggression victimization, and thwarted belongingness will positively correlate with physical assault victimization. Study 2 also aimed to test, as posited by the IPTS, whether thwarted belongingness and perceived burdensomeness interacted to predict suicidal ideation, such that, as perceived burdensomeness increases, the relationship between thwarted belongingness and suicidal ideation strengthened. We hypothesized that this interaction would emerge while accounting for variables that exhibit bivariate correlations with suicidal ideation in the study (e.g., DV victimization, depressive symptoms, and alcohol and drug use; Garlow et al., 2008; Wu et al., 2004).

Method Participants Undergraduate students (n = 155) volunteered for the second study, also in exchange for research credit in an introduction to psychology course. Inclusion criteria were the same as Study 1 (i.e., 18 years of age or older and being in a dating relationship for at least 2 months). The sample was M = 19.76 years old (SD = 3.20), 57.8% female, and 51.7% freshmen. The race/ethnicity composition of the sample was as follows: White/Caucasian (74.8%), Black/ African American (14.2%), Hispanic/Latino (2.6%), Asian American (1.3%), Indian/Middle Eastern (2.6%), Native American (0.6%), and “Other” (3.2%). The composition of the sample by family income level was as follows: less than US $50,000 (24.5%), $50,000–$100,000 (33.3%), $100,000–$150,000 (22.4%), $150,000–$200,000 (11.6%), greater than $200,000 (8.2%). A majority of the sample reported having a heterosexual orientation (97.3%) and not living with their partner (83.0%). The average relationship length was 15.20 months (SD = 17.42). Procedure The procedures for the second study were identical to the first study. Measures The same measures used in Study 1 were included in Study 2. The internal consistency coefficients for the subscales of the Conflict Tactics Scale-Revised ranged from questionable to good: psychological aggression victimization (α = 0.69); physical assault victimization (α = 0.84). Good internal consistency coefficients were demonstrated for the Crisis 2016; Vol. 37(1):51–58

thwarted belongingness subscale (α = 0.87) and perceived burdensomeness subscale of the INQ (α = 0.90). Depressive Symptoms. The Center for Epidemiological Studies-Depression Scale (CES-D) was used to assess depressive symptoms over the past week. The CES-D is a reliable and valid 20-item measure of depressive symptoms on a 4-point Likert scale from rarely/none of the time to most/all of the time (Radloff, 1977). The internal consistency for the CES-D in the sample of Study 2 was good (α = 0.86). Alcohol Use. The Alcohol Use Disorders Identification Test (AUDIT; Saunders, Aasland, Babor, de la Fuente, & Grant, 1993) is a 10-item questionnaire used to assess frequency, intensity, and negative consequences of alcohol use in the previous year. The AUDIT has demonstrated to be a reliable and valid measure of alcohol use (Reinert & Allen, 2007). The internal consistency for the AUDIT in the sample of Study 2 was good (α = 0.80). Drug Use. The Drug Use Disorders Identification (DUDIT; Stuart, Moore, Kahler, & Ramsey, 2003; Stuart, Moore, Ramsey, Kahler, 2004) is a 14-item questionnaire used to assess frequency and intensity of drug use in the previous year. The DUDIT assesses seven classes of drugs (e.g., stimulants). The DUDIT has demonstrated good reliability and validity (Stuart et al., 2008). The internal consistency for the DUDIT in the sample of Study 2 was acceptable (α = 0.74). Suicidal Ideation. Suicidal ideation was measured in Study 2 by the suicidality subscale of the Hopelessness Depression Symptom Questionnaire (HDSQ-SI; Metalsky & Joiner, 1997). The HDSQ-SI assesses suicidal ideation using four items measuring the frequency, planning aspects, controllability, and impulsive quality of suicidal ideation experienced over the past 2 weeks. Each item contains four statements ranging from 0 (absence of suicidal ideation) to 3 (high degree of suicidal ideation aspect being measured). The total score for the four items ranges from 0 to 12, with higher scores indicating greater severity of suicidal ideation. The HDSQ-SI has demonstrated excellent internal consistency in a college sample (α = 0.96; Metalsky & Joiner, 1997) as well as in this second study’s sample (α = 0.94).

Results and Discussion See Table 1 for means and standard deviations. Given the positive skew observed in the DV victimization, interpersonal needs, depressive symptoms, alcohol use, drug use, and suicidal ideation variables, log-transformations were performed prior to the t test, correlational, and regression analyses. Thirteen percent of the sample reported having experienced some level of physical assault in the past year. Forty-seven percent reported having experienced some level of psychological aggression in the past year. Ten percent of the sample reported having some level of suicidal ideation in the past 2 weeks. In an attempt to replicate the gender differences demonstrated in Study 1, we conducted t tests examining gender differences in DV victimization, thwarted belongingness, perceived burden© 2015 Hogrefe Publishing

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Table 2. Study 2 results of regression predicting suicidal ideation Variable

Depressive symptoms

0.0004

0.18

Drug use

0.73

3.71**

Thwarted belongingness

0.09

0.27

Perceived burdensomeness

0.14

0.60

Thwarted belongingness*perceived burdensomeness 1.71

2.38*

Note. Perceived burdensomeness and thwarted belongingness are mean centered. *p < .05. **p < .001.

someness, depressive symptoms, and suicidal ideation. Results indicated that men and women did not differ on these variables. Next, we computed Spearman’s rho correlations to replicate the correlations demonstrated in Study 1. Perceived burdensomeness was correlated with depressive symptoms, physical assault victimization, and psychological aggression victimization. Thwarted belongingness was correlated with depressive symptoms, physical assault victimization, and psychological aggression victimization. Suicidal ideation was correlated with thwarted belongingness, perceived burdensomeness, and drug use, but not DV victimization or alcohol use. See Table 1 for correlations for Study 2. Next, we examined whether thwarted belongingness and perceived burdensomeness interacted to predict suicidal ideation while controlling for the potential effects of depressive symptoms and drug use, as these were the sole bivariate correlates of suicidal ideation. We used

Hayes & Matthes’s (2009) macro for testing interactions in SPSS. Suicidal ideation was entered as the criterion variable, thwarted belongingness as the focal predictor, and perceived burdensomeness as the moderating variable. Thwarted belongingness and perceived burdensomeness were mean centered. The depressive symptoms and drug use subscales were entered as covariates. The overall model fit was significant, explaining 36% of the variance in suicidal ideation, R2 = .36, F(5,126) = 14.01, p < .001. The thwarted belongingness*perceived burdensomeness interaction term was significant, contributing a significant increase in R2, ΔR2 = .03, F = 5.67, p = .02 (see Table 2 for regression results. The interaction was probed at the mean, and 1 SD above and below the mean of perceived burdensomeness, which demonstrated that only at high levels of perceived burdensomeness was thwarted belongingness significantly associated with suicidal ideation. The associations of thwarted belongingness with suicidal ideation at low, average, and high levels of perceived burdensomeness are as follows: low (B = −0.13, p = .21), average (B = 0.09, p = .27), and high (B = 0.31, p = .03). See Figure 1 for a visual depiction of the interaction. Results from Study 2 generally supported the bivariate relationships found in Study 1, lending further support that physical assault and psychological aggression victimization may increase perceived burdensomeness and feelings of disconnectedness. We were unable to replicate the finding that men experienced greater levels of thwarted belongingness; this may be due to the small sample size and consequently lower statistical power. Results supported the IPTS position that suicidal ideation results as a product of thwarted interpersonal needs; only at high levels of perceived burdensomeness was thwarted belongingness associated with suicidal ideation. Figure 1. Thwarted belongingness predicts suicidal ideation at high levels of perceived burdensomeness.

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General Discussion The current studies are among the first to investigate the well-documented relationship between DV victimization and suicidal ideation within the framework of the IPTS (Joiner, 2005; Van Orden et al., 2010). Study 1 demonstrated that physical assault and psychological aggression victimization were associated with increases in perceived burdensomeness, whereas solely physical assault victimization was associated with increases in thwarted belongingness. Study 2 generally replicated these findings but found psychological aggression victimization to correlate with thwarted belongingness. Study 2 also supported the IPTS tenet that only at high levels of perceived burdensomeness was thwarted belongingness associated with suicidal ideation, while accounting for depressive symptoms and drug use. Although Study 2 did not replicate the well-supported relationship between DV and suicidal ideation (e.g., Afifi et al., 2009; Devries et al., 2011; Golding, 1999), Study 1 and Study 2 replicated associations between DV and thwarted interpersonal needs that are indicative of suicidal desire (Lamis et al., 2013; Van Orden et al., 2008). Psychological aggression may facilitate feelings of self-hatred and liability owing to its effects on victims’ self-esteem, depressive symptoms, and emotional and financial dependence on their violent partners (Davidson et al., 2011; Golding, 1999; Johnson & Leone, 2005). Psychological aggression was not associated with increases in thwarted belongingness in Study 1 but was associated with increases in thwarted belongingness in Study 2. This finding may be due to our measurement of psychological aggression being more reliable in Study 2. Physical assault victimization, however, was associated with both perceived burdensomeness and thwarted belongingness in each study. Although the current studies did not examine potential mechanisms underlying this association, we speculate that victims may feel like a burden on their perpetrator in order to explain the violence. That is, victims may blame themselves for the violence, which increases their sense of burdensomeness. For example, victims may believe that if they were not such a burden or difficult to care for, they would not experience DV. Finally, another explanation for the relationship between thwarted interpersonal needs and DV is that individuals who feel like a burden on or disconnected from others may be vulnerable to entering relationships with violent partners. Further research is needed to explicate these findings. Finally, Study 2 demonstrated that at high levels of perceived burdensomeness, thwarted belongingness was associated with suicidal ideation while controlling for depressive symptoms and drug use. This finding partially supported our hypothesis and past findings (e.g., Van Orden et al., 2008), as well as a past study finding perceived burdensomeness, but not thwarted belongingness, to predict suicidal ideation in a college student sample (Lamis et al., 2013). Taken together, these findings suggest that perceived burdensomeness may play a crucial role in the development of suicidal ideation in college students. Perhaps Crisis 2016; Vol. 37(1):51–58

college students place much importance on independence and pride given the stage in their life of developing autonomy and are therefore much more affected by events that would heighten perceptions of liability and self-loathing. Future work should examine potential explanations for the salience of perceived burdensomeness in relation to suicidal ideation in this population.

Limitations and Future Directions

The studies have limitations that future research may improve upon. First, the studies were of cross-sectional design. Longitudinal studies will help inform whether DV precedes thwarted interpersonal needs or if thwarted interpersonal needs predispose individuals to violent relationships. Furthermore, longitudinal studies will specify if thwarted interpersonal needs increase suicidal ideation, if suicidal ideation predisposes individuals to interpersonal problems, or if there is a reciprocal relationship. Second, the CTS-2 psychological aggression subscale does not include controlling violence items. Controlling violence may be a subtype of psychological aggression that is more associated with suicidal ideation (Wolford-Clevenger & Smith, 2015). Future work should consider using measures that assess each facet of psychological aggression, including verbal abuse and coercive control (Saltzman et al., 2002). Third, the current study did not assess sexual violence in intimate relationships, an important aspect of DV that deserves future attention. Fourth, the current study did not test whether the combined or unique effects of physical assault and psychological aggression are most influential in developing suicide risk. Fifth, Study 2 had a relatively small sample size, which likely limited its statistical power. Finally, the study investigated violence among primarily heterosexual college students in dating relationships. Future studies should replicate these findings in samples of cohabitating/married and/or same-sex couples experiencing intimate partner violence. Future work with larger samples will be able to statistically control for more variables that are associated with increased suicidal ideation in order to further evaluate the unique relations between thwarted interpersonal needs and suicidal ideation.

Clinical Implications

Despite these limitations, these studies’ findings provide some tentative clinical implications. First, the finding in Study 2 that 10% of the sample experienced suicidal ideation in the past 2 weeks suggests that suicidal ideation is a significant concern for college students. University student health and counseling centers should implement routine suicide risk assessments in their intake procedures in order to prevent suicidal ideation from developing into suicidal behaviors. Campus-wide initiatives to reduce college students’ risk for suicide have been pilot-tested and recommended in detail elsewhere (Kaslow et al., 2012). In particular, feelings of burdensomeness and disconnected© 2015 Hogrefe Publishing

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ness appear to be important targets for suicide risk reduction among college students. Suicide prevention programs on college campuses may implement methods to increase college students’ feelings of autonomy while also fostering their sense of social connectedness. Finally, given that psychological aggression and physical assault were associated with thwarted interpersonal needs that are indicative of suicidal desire, clinicians should inquire about such experiences and attend to potential suicide risk. Acknowledgments This work was supported, in part, by grant K24AA019707 from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded to the last author. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAAA or the National Institutes of Health.

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Received March 18, 2015 Revision received June 6, 2015 Accepted June 22, 2015 Published online December 1, 2015 About the authors Caitlin Wolford-Clevenger, MS, is pursuing her PhD in Clinical Psychology at the University of Tennessee-Knoxville, TN. She received her BA and MS in Psychology at the University of South Alabama. Her research interests focus on understanding and preventing self- and other-directed aggression. JoAnna Elmquist, BA, is a doctoral student in clinical psychology at the University of Tennessee, TN. She received her BA from Trinity University. Her research interests focus on family violence across the lifespan, including intimate partner violence and child maltreatment. Meagan J. Brem, MA, is a clinical psychology doctoral student at the University of Tennessee, TN. She received her BA from Southwestern University and her MA from Midwestern State University. Her research interests include risk and protective factors for intimate partner violence, including jealousy, mindfulness, and cyber abuse. Heather Zapor, BA, is a doctoral student in clinical psychology at the University of Tennessee, TN. She received her BA from the University of Akron. Her research interests include risk and resilience factors for intimate partner violence. Gregory L. Stuart, PhD, is Professor of Clinical Psychology at the University of Tennessee-Knoxville, TN, and Director of Family Violence Research at Butler Hospital. He is also an adjunct professor in the Department of Psychiatry and Human Behavior at the Warren Alpert Medical School of Brown University, RI. Caitlin Wolford-Clevenger University of Tennessee Knoxville Psychology Department 204 Austin Peay Building Knoxville TN 37996 USA E-mail cwolfor2@vols.utk.edu

Research Trends

Too Much to Bear Psychometric Evidence Supporting the Perceived Burdensomeness Scale Nicole J. Peak3, James C. Overholser1, Josephine Ridley2, Abby Braden4, Lauren Fisher5, James Bixler6, and Megan Chandler7 1

Department of Psychology, Case Western Reserve University, Cleveland, OH, USA 2 Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA 3 School of Professional Psychology, University of the Rockies, Colorado Springs, CO, USA 4 Center for Healthy Eating and Activity Research, University of California, San Diego, CA, USA 5 Depression Clinical and Research Program, Department of Psychiatry Massachusetts, General Hospital, Boston, MA, USA 6 Counseling and Psychological Services, Frostburg State University, MD, USA 7 The Sexual Responsibility and Treatment Program, Torrance State Hospital, Derry, PA, USA Abstract. Background: People who feel they have become a burden on others may become susceptible to suicidal ideation. When people no longer feel capable or productive, they may assume that friends and family members would be better off without them. Aim: The present study was designed to assess preliminary psychometric properties of a new measure, the Perceived Burdensomeness (PBS) Scale. Method: Depressed psychiatric patients (N = 173) were recruited from a veterans affairs medical center. Patients were assessed with a structured diagnostic interview and self-report measures assessing perceived burdensomeness, depression severity, hopelessness, and suicidal ideation. Results: The present study supported preliminary evidence of reliability and concurrent validity of the PBS. Additionally, perceived burdensomeness was significantly associated with higher levels of hopelessness and suicidal ideation. Conclusion: It is hoped that with the aid of the PBS clinicians may be able to intervene more specifically in the treatment of suicidality. Keywords: perceived burdensomeness, assessment, depression, hopelessness, suicide

Perceived burdensomeness is a belief specific to depressed individuals where they suppose that they negatively impact others as a result of their permanent, stable ineffectiveness and incompetence (Joiner, 2005). When people perceive themselves as a burden to others, especially close relations, the natural human tendency toward self-preservation is disrupted (de Catanzaro, 1995). Instead, people who perceive themselves to be a burden become susceptible to suicidal ideation as they no longer believe they are productive members of society and assume that others would be better off without them. The relationship between perceived burdensomeness and suicidal behavior has been supported in multiple studies (Joiner et al., 2002; Van Orden, Lynam, Hollar, & Joiner, 2006; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). The interpersonal-psychological theory of suicide (IPTS) incorporates earlier research on perceived burdensomeness and cognitive risk factors more specific to suicidal ideation and suicide attempts (Joiner, 2005; Van Orden et al., 2010). The theory proposes three main criteria that © 2015 Hogrefe Publishing

increase the chances of suicidal behavior, including (1) the ability to self-injure or “acquired capability,” (2) thwarted belongingness, and (3) perceived burdensomeness (Joiner, 2005; Van Orden et al., 2010). The combination of perceived burdensomeness and thwarted belongingness contribute to suicidal ideation, while the addition of the final component, the acquired capability for suicide, entails the extent of one’s ability to enact a lethal suicide attempt. Current research has focused on examining each of the component parts of the IPTS model as they relate to suicidality (Kanzler, Bryan, McGeary, & Morrow, 2012; Lamis & Malone, 2011; Rasmussen, Slish, Wingate, Davidson, & Grant, 2012). Thus, perceived burdensomeness has only recently been the primary focal point of research endeavors, as previously it was a secondary or tertiary focus to larger study aims examining the IPTS theory as a whole. As a main variable, perceived burdensomeness has been found to have a strong relationship with suicidality. It has been found to be an important mediating variable between depression and suicidal ideation in community samples of Crisis 2016; Vol. 37(1):59–67 DOI: 10.1027/0227-5910/a000355

N. J. Peak et al.: The Perceived Burdensomeness Scale

older adults (Jahn, Cukrowicz, Linton, & Prabhu, 2011). Perceived burdensomeness has also been shown to be strongly related to suicidal ideation in patients with chronic pain, even when other well-established risk variables were controlled for (Kanzler et al., 2012; Wilson, Kowal, Henderson, McWilliams, & Peloquin, 2013). Likewise, in college student samples, perceived burdensomeness has been shown to be a significant mediator between alcohol-related problems and suicidality (Lamis & Malone, 2011), and between maladaptive perfectionism and suicidal ideation (Rasmussen et al., 2012). In older adults, perceived burdensomeness predicted lack of meaning in life, which may contribute to risk for suicide (Van Orden, Bamonti, King, & Duberstein, 2012). Furthermore, significant correlations between perceived burdensomeness and a past suicide attempt have also been demonstrated in a variety of samples (Hill & Pettit, 2014). Finally, some studies suggest that perceived burdensomeness (in comparison with thwarted belongingness) may be a stronger predictor of suicidal ideation and suicide-related behaviors (Bryan, Morrow, Anestis, & Joiner, 2010; Hill & Pettit, 2014; Van Orden, Witte, Gordon, et al., 2008). Both active-duty and veteran members of the military population often experience a sense of thwarted belongingness, a sense of perceived burdensomeness, and an acquired ability to engage in suicidal behavior (Brenner et al., 2008). Additionally, with the consistent rise of suicide rates in this group (Department of Veterans Affairs, 2012), many studies have recently examined the IPTS as it applies to this population (Brenner et al., 2008; Bryan et al., 2010; Monteith, Menefee, Petitt, Leopoulos, & Vincent, 2013; Selby et al., 2010). Among active-duty personnel, the relationship between suicidal ideation and acquired capability is strengthened as perceived burdensomeness increases (Bryan, Clemans, & Hernandez, 2012). Among US Air Force personnel, the interaction between perceived burdensomeness and acquired capability has been found to be significantly associated with a history of suicide attempts (Bryan et al., 2010). Joinerâ&#x20AC;&#x2122;s (2005) initial evaluation of perceived burdensomeness resulted from information expressed in suicide notes written by attempters versus completers (Joiner et al., 2002) and the sense of burden that was inferred from assorted (non-burden) questionnaires administered to unemployed adults (Brown & Vinokur, 2003). Another version was derived from combining four items from the Suicide Probability Scale (Joiner et al., 2009). Many recent studies have examined a subjective sense of burdensomeness as measured by a questionnaire called the Interpersonal Needs Questionnaire (INQ; Joiner et al., 2009), which includes subscales for thwarted belongingness and perceived burdensomeness. The INQ was originally proposed as a 4-factor structure (Van Orden, 2009); however, subsequent research has focused solely on the two subscales, thwarted belongingness and perceived burdensomeness. In general, the INQ has displayed adequate psychometric properties (Van Orden, Cukrowicz, Witte, & Joiner, 2012). A problem arises because there are numerous versions of the perceived burdensomeness subscale making it difficult to know which version has been supported by prior research. Crisis 2016; Vol. 37(1):59â&#x20AC;&#x201C;67

The INQ perceived burdensomeness subscale has been tested using: a single item that was rated on a 3-point scale (Van Orden et al., 2006), a 5-item version (Bryan, 2011; Bryan et al., 2012), and a 7-item version (Van Orden, Witte, Gordon, et al., 2008). For the 7-item version, only two of the seven items were found to load on the perceived burdensomeness subscale (Freedenthal, Lamis, Osman, Kahlo, & Gutierrez, 2011). Another version of the INQ includes a 15-item version of the burdensomeness subscale that was then reduced to six items (Van Orden, Cukrowicz, et al., 2012). Some studies have used a version of the INQ where the perceived burdensomeness subscale was not even mentioned in the report (Van Orden, Witte, James, et al., 2008; You, Van Orden, & Conner, 2011). From a scale development perspective, it is not appropriate to evaluate the basic psychometric properties of a new scale by averaging across the five or more versions of the INQ that have been examined in recent studies. Instead, each variation should be treated as its own new scale. Research examining perceived burdensomeness is limited by the reliance on the INQ subscale. The majority of studies evaluating the psychometric properties of the INQ have included samples composed of university/college students (Freedenthal et al., 2011; Van Orden et al., 2012; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and difficulties in generalizing findings from such samples have been discussed elsewhere (Henrich, Heine, & Norenzayan, 2010; Peterson, 2001). The INQ has also been used in military populations of junior Air Force personnel (Bryan et al., 2010) and deployed soldiers (Bryan, 2011; Bryan et al., 2012) that primarily include young, Caucasian males. Furthermore, items on the INQ were originally found to perform differently across samples (Van Orden, 2009) suggesting that the construct of perceived burdensomeness may be multidimensional with different aspects of perceived burdensomeness being salient for different groups of people. Studies that have examined the INQ in actual clinical samples recruited the subjects through residential substance abuse treatment programs (You et al., 2011) or VA inpatient settings (Monteith et al., 2013), or they have been composed of Caucasian university psychology clinic outpatients (Van Orden, Cukrowicz, Witte, & Joiner 2012; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). It may be difficult to generalize the findings from these studies to more psychologically severe and racially diverse populations. Moreover, many of these samples of psychiatric patients have included no diagnostic information thus merging all forms of psychiatric conditions. For example, one prior study that examined the INQ in a sample of inpatient veterans recruited veterans with various Axis I diagnoses (Monteith et al., 2013). Finally, these samples of outpatients have displayed low lifetime history of suicidal behavior (e.g., 15%; Van Orden, Witte, Gordon, Bender, & Joiner, 2008). Given the aforementioned limitations of the INQ perceived burdensomeness subscale, specifically its multiple variations across studies, its overreliance on nonsuicidal study populations, and the lack of generalizability to more racially diverse and psychiatrically severe populations, the present study examines a measure that may better ÂŠ 2015 Hogrefe Publishing

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assess for this substantial predictor of suicide risk. The present study was designed to examine the psychometric properties, specifically aspects of reliability and validity, of a new Perceived Burdensomeness Scale in a clinical sample composed of racially diverse outpatients and partial hospitalization patients. First, it was hypothesized that the Perceived Burdensomeness Scale would display a sufficient amount of internal consistency. This entailed an examination of how related the individual scale items were with one another. Second, it was hypothesized that the Perceived Burdensomeness Scale would show a sufficient amount of construct validity. Although the items were formulated to capture several different types of perceived burdensomeness (i.e., family, friends, and society), it was expected that most of the items would load onto one underlying construct. Lastly, it was hypothesized that the Perceived Burdensomeness Scale would demonstrate convergent validity as evidenced by a strong association with other related constructs.

Method Participants A sample of 366 adult psychiatric patients was recruited from both an outpatient psychiatry clinic and a partial hospitalization program at a local Veterans Affairs Medical Center (VAMC) in Cleveland, Ohio. The current study was part of a larger study designed to examine psychosocial correlates of suicidal behaviors in psychiatric patients with major depressive disorder. Criteria for inclusion included a primary Structured Clinical Interview for DSM-IV (SCID) diagnosis of a depressive disorder. Criteria for exclusion included: (a) age less than 18 years, (b) non-English speaking, and (c) patients with a current diagnosis of bipolar disorder, dementia, schizophrenia, psychosis, or an organic brain syndrome. Of the original 366 potential participants, 60 were ineligible to participate based on inclusion/exclusion criteria, 32 could not be reached to schedule an appointment for the clinical interview, 33 declined to participate or repeatedly failed to attend the clinical interview, and 68 potential participants only completed some of the questionnaires. This left a final sample of 173 adult, depressed, psychiatric patients with informed consent and complete data. Participants met the diagnostic criteria for a depressive disorder based on the SCID structured interview (First, Spitzer, Gibbon, & Williams, 1995). Diagnoses included major depression (64.7%), dysthymia (11.0%), depression, not otherwise specified (3.5%), and adjustment disorder with depressed mood (20.8%). Additionally, 43 patients also met the diagnostic criteria for a comorbid psychiatric diagnosis, including generalized anxiety disorder (58.1%), posttraumatic stress disorder (18.6%), substance abuse/ dependence (9.4%), alcohol abuse/dependence (7%), panic disorder (4.7%), and obsessive compulsive disorder (2.3%). © 2015 Hogrefe Publishing

Measures

Demographic information collected included age, gender, race, marital status, and employment status. Information regarding known suicide risk factors was also collected. Suicidality was assessed by asking the question, “Have you ever attempted suicide?” Past psychiatric hospitalizations were assessed by asking the question, “Have you ever been previously hospitalized for psychiatric problems?” The Structured Clinical Interview for DSM-IV (SCID; First et al., 1995) is a diagnostic interview used to evaluate Axis I major mental disorders as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 2000). The SCID has high test–retest reliability for all Axis I disorders and κ values ranging from .84 to 1.0 (Schneider et al., 2004). The Perceived Burdensomeness Scale (PBS; see Figure A1 in the Appendix) is a new scale that includes 30 items to evaluate the degree to which each person perceives themselves to be a burden on (a) their family, (b) their friends, and (c) society. Participants are asked to rate the degree to which they agree with each statement, and items are scored 0 (not at all), 1 (a little bit), 2 (somewhat), 3 (quite a bit), or 4 (a great deal). PBS total scores can potentially range from 0 to 120. Items for the PBS were developed through several steps. First, the literature on burden was reviewed. Unfortunately, the available research was limited at the time, and often relied on data that had been collected on college students or the general public (de Catanzaro, 1984) or other nonpsychiatric samples (de Catanzaro, 1995). Published measures of burden were examined for their relevance to depression and suicidality. Next, items from the Family Burden Scale were selected and adapted into a preliminary scale. The Family Burden Scale was developed by Coyne and colleagues (1987; Benazon & Coyne, 2000) and includes 23 items designed to assess the subjective burden experienced by family members of depressed patients. Although the Family Burden Scale provided a starting point, its focus is exclusively on the sense of burden being placed on the respondent’s family. Other attempts to study burden also focused exclusively on perceived family reactions (de Catanzaro, 1984) mostly within terminal illness or dementia populations. Furthermore, many items on the Family Burden Scale involved topics of an overly subjective nature that reflected symptoms of depression (e.g., feeling upset about the patient’s fatigue, irritability, restlessness, or worthlessness). Finally, several new items were generated based on the theoretical definition of perceived burdensomeness and by adapting these issues into language and a reading level that would be appropriate for the typical adult outpatient. The Beck Depression Inventory (BDI-II; Beck, Steer, & Brown, 1996) includes 21 items to evaluate the presence and severity of different symptoms of depression. Items are presented in a multiple-choice format and are scored on a scale value of 0 to 3, with total scores ranging from 0 to 63. Higher total scores indicate more severe depressive symptoms. The BDI-II has strongly established psychometric properties (Ball & Steer, 2003; Steer, Brown, Beck, & Sanderson, 2001). In the current study, a high reliability Crisis 2016; Vol. 37(1):59–67

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estimate was found for the BDI-II total scale score for the sample (α = 0.91). The Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, & Trexler, 1974) assesses a person’s expectations about the future, loss of motivation, and overall hopelessness. The BHS includes 20 statements to be rated as true or false, with total scores ranging from 0 to 20 and has demonstrated adequate reliability and validity (Alford, Lester, Patel, Buchanan, & Giunta, 1995; Steed, 2001). In the current study, a high reliability estimate was found for the BHS total scale score for the sample (α = 0.94). The Beck Scale for Suicidal Ideation (BSSI; Beck, Kovacs, & Weissman, 1979; Beck, Steer, & Ranieri, 1988) includes 21 items designed to evaluate the presence and severity of suicidal thoughts. The first 19 items measure the severity of suicidal wishes, attitudes, and plans. The last two items address the number of previous suicide attempts and the intention to die associated with the last attempt. In comparison with other measures of suicidal ideation, the BSSI has been found to have some of the strongest psychometric properties and is often used in clinical research (Batterham et al., 2015). In the current study, a high reliability estimate was found for the BSSI total scale score for the sample (α = 0.93).

The alpha level for statistical significance was set at p < .05 unless otherwise specified. Prior to analyses, all variables were examined for accuracy of data entry, missing values, and outliers.

Demographics and Descriptives The 173 psychiatric adults represented a combination of patients from the partial hospitalization program (n = 49) and outpatients (n = 124). The two groups were compared on the demographic variables of age, gender, race, marital status, employment, suicidality, and the PBS questionnaire. No significant differences were found (all p values > .007, Bonferroni corrected for seven tests) and thus the two groups were considered equivalent and combined into one group. The age of the patients ranged from 24 to 79 years. Most of the patients were African American (56.6%) or Caucasian (39.9%). Most of the patients were male (89.0%). Approximately 17.4% of the patients were married and 12.7% were working. Across the entire sample, 40.5% had attempted suicide at least once in their lifetime, and 43.6% had been previously hospitalized for psychiatric problems.

Procedures

Flyers advertising the study were posted throughout the VAMC’s facility asking qualified patients to contact the research team via telephone. An HIPAA waiver was approved by the VA IRB so that when treatment providers (e.g., VAMC psychiatrists, psychologists, social workers, and nurses) referred patients who met criteria for the study, a research assistant could screen the medical record to determine whether the patient met preliminary criteria for study inclusion. Patients who contacted the research team directly were asked for permission to review their medical record to see if they met criteria for participation. Patients recruited by telephone were scheduled for an information session where they were explained the purpose of the study. If they agreed to participate, patients were consequently interviewed. The SCID interview was administered to determine whether the patient met criteria for a depressive disorder and any additional Axis I disorders. Research assistants administering the SCID were highly trained clinical psychology graduate students who were required to demonstrate competence prior to conducting interviews. All participants completed the same packet of questionnaires in the same order and were compensated for their participation in the study.

Results Analyses were performed using the Statistical Package for the Social Sciences for Windows (SPSS, version 18.0). Crisis 2016; Vol. 37(1):59–67

Initial Internal Consistency and Factor Analysis of the PBS

The PBS was evaluated for internal consistency reliability, and item analyses were conducted. The PBS demonstrated a satisfactory level of internal consistency (α = 0.96). It has been suggested that an item-total score correlation above .30 is acceptable (Nunnally, 1978). On the PBS, item-total correlations were calculated and ranged from .28 to .84, with only one item having an item-total correlation less than .30. In order to examine the underlying relationship among the items on the PBS, a factor analysis was conducted on all 30 items. Prior to performing the factor analysis, the suitability of data for factor analysis was assessed. Inspection of the correlation matrix revealed the presence of many coefficients of .30 and above. The Kaiser–Meyer– Oklin value was .95, exceeding the recommended value of .60 (Kaiser 1970, 1974), and Bartlett’s Test of Sphericity (Bartlett, 1954) reached statistical significance, supporting the factorability of the correlation matrix. A principal axis factoring with an oblique (direct oblimin) rotation was performed and revealed the presence of four factors with eigenvalues exceeding 1, explaining 50.75%, 5.87%, 4.37%, and 3.67% of the variance, respectively. Multiple criteria for determining the final number of factors were considered (Henson & Roberts, 2006). Results of parallel analysis revealed two factors with eigenvalues exceeding the corresponding criterion values for a randomly generated data matrix of the same size (30 variables × 173 participants). However, one factor far exceeded the corresponding criterion value while the second factor barely did. An © 2015 Hogrefe Publishing

N. J. Peak et al.: The Perceived Burdensomeness Scale

inspection of Cattell’s screeplot (1966) revealed a clear break after the first component. Finally, the rotated solution showed all but one of the items loading most strongly on one component. When all the items were loaded onto the single factor, many of the items retained strong loadings. The single factor solution explained a total of 50.75% of the variance. Taking these different methods into account, it was decided that a one-factor solution best fit the data. Factor loadings were mostly adequate and ranged from .28 to .87 and the communality estimates ranged from .08 to .75.

Shortening the PBS In order to increase the efficiency of the PBS for use in clinical and research settings, it was determined that the PBS could be shortened without compromising its preliminary reliability psychometric properties. The initial 30 items were reviewed and those with the lowest factor loadings and item-to-total correlations were subsequently dropped. Additionally, the inter-item correlation matrix was examined and items with the highest correlations were further evaluated for redundancy. In this way, the PBS was shaped into a 12-item scale (see Figure A1 in Appendix).

The shortened PBS was evaluated for internal consistency reliability, and item analyses were, once again, conducted. The PBS maintained a satisfactory level of internal consistency (α = 0.96). Item-total correlations were calculated and ranged from .54 to .86 (Table 1). Additionally, a Pearson product–moment correlation was computed and there was a strong correlation between the original PBS and the shortened version (r = .98, p < .01). A factor analysis was conducted on the shortened 12item PBS revealing the presence of a single extracted factor with an eigenvalue exceeding 1, explaining 67.67% of the total variance. Results of parallel analysis revealed one factor with an eigenvalue exceeding the corresponding criterion values for a randomly generated data matrix of the same size (12 variables × 173 participants). An inspection of Cattell’s screeplot (1966) revealed a clear break after the first component. All 12 items retained strong factor loadings (Table 1) and ranged from .70 to .89 with communality estimates ranging from .49 to .78.

Convergent Validity Analyses

In order to investigate preliminary convergent validity, intercorrelations between the final PBS, BDI-II, BHS, and

Table 1. Principal axis factoring with factor loadings, communalities, means, standard deviations, and item-total correlations for the Perceived Burdensomeness Scale items Item

Factor loadings

Item-total

.89

.78

1.26

1.37

.86

Family better off without me Friends better off without me

.86

.75

1.20

1.32

.84

I feel like a waste of space

.83

.69

1.28

1.32

.81

I am more trouble than I am worth

.83

.68

1.80

1.37

.81

People would feel better if I wasn’t around

.83

.68

1.24

1.29

.81

I am a burden to others

.83

.68

1.72

1.36

.81

I create problems for other people

.81

.65

1.19

1.21

.79

I have nothing to offer people

.80

.64

1.45

1.39

.67

I weigh down others with problems

.78

.60

1.34

1.29

.76

Burden on society

.77

.59

1.43

1.37

.75

Problems with friends are my fault

.72

.52

1.17

1.31

.70

Tired of bringing others down

.70

.49

1.71

1.44

.54

Note. N = 173 and α = 0.96 for entire measure.

Table 2. Intercorrelations, means, and standard deviations for study measures (N = 173) Measure Perceived Burdensomeness Scale

Perceived Burdensomeness Scale

Beck Depression Inventory-II

Beck Hopelessness Scale

Beck Scale for Suicidal Ideation

–

Beck Depression Inventory-II

.69*

–

Beck Hopelessness Scale

.61*

.66*

–

Beck Scale for Suicidal Ideation

.52*

–

16.79

13.16

28.68

12.35

10.43

6.36

5.42

7.40

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the BSSI were calculated (Table 2). There were significant and positive relationships between the four measures with Pearson product–moment correlation coefficients ranging from .52 to .69 thus providing preliminary evidence for convergent validity.

Discussion People who perceive themselves to be a burden often become susceptible to suicidal ideation as they no longer believe they are productive members of society and assume that others would be better off without them. A vast amount of research has found perceived burdensomeness to be significantly associated with suicidality (Joiner et al., 2002; Van Orden et al., 2006; Van Orden, Witte, Gordon, et al., 2008). Many studies that have examined perceived burdensomeness have done so using 1- to 2-item scales or, most recently, the INQ (Joiner et al., 2009). The current study examined a new scale, the PBS, as an alternative, clinically useful measure, that was investigated in a clinical population of depressed veterans. The final PBS displayed an adequate level of internal consistency. A factor analysis revealed the presence of one primary component with strong factor loadings. Lastly, the PBS displayed preliminary evidence of concurrent validity. Thus, perceived burdensomeness was significantly associated with higher levels of suicide risk including depression, hopelessness, and suicidal ideation. Hopefully, the PBS can be used in future research to continue to explore the risk of suicide that derives from a sense of burden on friends, family, and society. It is important to note that the PBS differs from the INQ perceived burdensomeness subscale in several ways. First, the foundation research on the INQ was derived from questionnaires mainly administered to freshman college students (e.g., Van Orden, Cukrowicz et al., 2012; Van Orden, Witte, Gordon, et al., 2008). Other studies have examined the INQ as used with general psychiatric outpatients treated through a campus clinic but without any diagnostic information (Van Orden et al., 2006; Van Orden, Witte, Gordon, et al., 2008) and patients being treated through a residential substance abuse program (You et al., 2011). Although the INQ has been used with veteran psychiatric inpatients, the study sample included adults with various psychiatric diagnoses (Monteith et al., 2013). Limited research has examined the INQ for use with patients who are diagnosed with a current major depressive disorder using structured diagnostic interviews. Second, the perceived burdensomeness subscale of the INQ has varied in its length, ranging from a 1-item to a 7-item version (Van Orden, Witte, Gordon, et al., 2008) to 15-items depending on the variation of the scale being used in the particular study. In general, the PBS may extend beyond other studies on burdensomeness by remaining directly relevant to clinical work with depressed adults. The present study had several limitations including the small sample size that limited statistical power. Additionally, the INQ was not included as a comparison measure. Crisis 2016; Vol. 37(1):59–67

This was owing to limited information on the INQ at the time; however, future studies could compare the psychometric qualities of the INQ with those of the PBS. Also, the current sample included an over-representation of African American male veterans, which may have limited the generalizability to other racial/ethnic populations. However, the inclusion of depressed, minority veterans who represent a population not often investigated in research (Hohmann & Parron, 1996) is a relevant strength of this study. An additional strength of the present investigation is the inclusion of a clinical sample with a variety of depressive diagnoses such as major depression single and recurrent episodes, with melancholia, without melancholia, and dysthymia. Furthermore, a large percentage of the patients carried comorbid diagnoses that make the findings generalizable to more realistic clinical populations. Future studies should consider examining the PBS (made available in Figure A1 in the Appendix) in even broader groups of psychiatric patients to assess its utility in other patient groups at high risk of suicide (e.g., adults with bipolar disorder). In light of the findings of the present study, future research warrants a continued investigation into the contribution of perceived burdensomeness to suicidality. Of interest would be the comparison of perceived burdensomeness to hopelessness, which has consistently been found to be a strong predictor of eventual suicide (Beck, Steer, Kovacs, & Garrison, 1985; Brown, Beck, Steer & Grisham, 2000). Future investigations might also consider examining whether burdensomeness is a cognitive distortion of the depressed individual or a realistic side effect of the depression that negatively impacts others around the depressed individual. Such efforts may aid in preventing deaths by suicide via more focused interventions. Acknowledgments This material is the result of work supported with resources and the use of facilities at the Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.

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fear of lethal injury: Evaluating suicidal behavior in the military through the lens of the interpersonal–psychological theory of suicide. Clinical Psychology Review, 30(3), 298–307. doi:10.1016/j.cpr.2009.12.004 Steed, L. (2001). Further validity and reliability evidence for Beck Hopelessness Scale scores in a nonclinical sample. Educational and Psychological Measurement, 61, 303–316. Steer, R. A., Brown, G. K., Beck, A. T., & Sanderson, W. C. (2001). Mean Beck Depression Inventory-II scores by severity of major depressive disorder. Psychological Reports, 88, 1075–1076. Van Orden, K. A. (2009). Construct validity of the interpersonal needs questionnaire (Doctoral dissertation). Retrieved from http://search.proquest.com/docview/304884339?accountid=39364 Van Orden, K. A., Bamonti, P. M., King, D. A., & Duberstein, P. R. (2012). Does perceived burdensomeness erode meaning in life among older adults? Aging Mental Health, 16(7), 855–860. Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner, T. E. J. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the interpersonal needs questionnaire. Psychological Assessment, 24(1), 197–215. doi:10.1037/a0025358; 10.1037/ a0025358.supp Van Orden, K. A., Lynam, M. E., Hollar, D., & Joiner, T. E. (2006). Perceived burdensomeness as an indicator of suicidal symptoms. Cognitive Therapy and Research, 30, 457–467. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. J. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. doi:10.1037/a0018697 Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E. J. (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal-psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 76(1), 72–83. doi:10.1037/0022006X.76.1.72 Van Orden, K. A., Witte, T. K., James, L. M., Castro, Y., Gordon, K. H., Braithwaite, S. R., Hollar, D. L., & Joiner, T. J. (2008). Suicidal ideation in college students varies across semesters: The mediating role of belongingness. Suicide and Life-Threatening Behavior, 38(4), 427–435. doi:10.1521/suli. 2008.38.4.427 Wilson, K. G., Kowal, J., Henderson, P. R., McWilliams, L. A., & Peloquin, K. (2013). Brief report: Chronic pain and the interpersonal theory of suicide. Rehabilitation Psychology, 58(1), 111–115. You, S., Van Orden, K. A., & Conner, K. R. (2011). Social connections and suicidal thoughts and behavior. Psychology of Addictive Behaviors, 25(1), 180–184. doi:10.1037/a0020936

About the authors Nicole J. Peak, PhD, is an adjunct faculty member of the University of the Rockies and works on a clinical research study at Fort Carson, CO, USA. She is also actively involved in her private practice. Her research and clinical interests include working with individuals with suicidal tendencies and comorbid diagnoses such as eating disorders and trauma-related disorders. James Overholser, PhD, ABPP, is Professor of Psychology at Case Western Reserve University, OH, USA, and a psychotherapist at the Catholic Charities Services outpatient mental health clinic in Cleveland, OH, USA. His research and clinical work focuses on reducing depression and suicide risk in adults. Josephine Ridley, PhD, is a clinical psychologist at the Louis Stokes Cleveland VA Medical Center and Associate Professor of Psychology at Case Western Reserve University, OH, USA. She is Master Trainer for the SPRC’s Assessing and Managing Suicide Risk and works with individuals with serious mental illness. Abby Braden, PhD, is a postdoctoral fellow at the University of California, San Diego, CA, USA. Her research focuses on the intersection between obesity and emotional factors, including emotional eating. Lauren Fisher, PhD, is a staff psychologist at the Depression Clinical and Research Program in the Department of Psychiatry at Massachusetts General Hospital in Boston, MA, USA. Her research and clinical interests include depression, suicide, cognitive behavioral therapy, and traumatic brain injury. James Bixler, MA, is currently a predoctoral intern at Frostburg State University Counseling and Psychological Services in Frostburg, MD, USA. He is looking forward to graduating from the University of the Rockies with his doctorate degree in clinical psychology. His research interests include interdisciplinarity. Megan Chandler, MA, is a Colorado native currently completing her predoctoral internship at Torrance State Hospital in Pennsylvania, PA, USA. Her professional interests are trauma-informed care, personality disorders, and psychological assessment. Nicole J. Peak The University of the Rockies 1201 16th St. Suite 200 Denver, CO 80202 USA Tel. +1 (719) 623-2356 E-mail nj.peak@gmail.com

Received September 23, 2014 Revision received June 26, 2015 Accepted July 9, 2015 Published online December 1, 2015

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Appendix Figure A1. Perceived Burdensomeness Scale (PBS) Name

Date

How much do you agree with the following statements? Not at all

A little bit

Somewhat

Quite a bit

A great deal

In general, I feel my family would be better off without me.

I often think that I am more trouble than I am worth.

I feel like I “weigh down” others with my problems.

I feel like I am a burden to others.

I feel like I create problems for other people.

In general, I feel my friends would be better off without me.

I often feel like I’m a “waste of space.”

I feel like I am a burden on society.

I feel like I have nothing to offer other people.

10.

I am tired of bringing others down.

11.

The problems with my friendships are all my fault.

12.

People would feel better off if I wasn’t around.

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Clinical Insights

Self-Injury, Help-Seeking, and the Internet Informing Online Service Provision for Young People Mareka Frost1, Leanne Casey1,2, and Natalie Rando1 1

School of Applied Psychology, Mt. Gravatt Campus, Griffith University, Brisbane, QLD, Australia 2 Menzies Health Institute, Brisbane, QLD, Australia

Abstract. Background: Although increasing numbers of young people are seeking help online for self-injury, relatively little is known about their online help-seeking preferences. Aims: To investigate the perspectives of young people who self-injure regarding online services, with the aim of informing online service delivery. Method: A mixed-methods exploratory analysis regarding the perspectives of a subsample of young people who reported a history of self-injury and responded to questions regarding preferences for future online help-seeking (N = 457). The sample was identified as part of a larger study (N = 1,463) exploring self-injury and help-seeking. Results: Seven themes emerged in relation to preferences for future online help-seeking: information, guidance, reduced isolation, online culture, facilitation of help-seeking, access, and privacy. Direct contact with a professional via instant messaging was the most highly endorsed form of online support. Conclusion: Young people expressed clear preferences regarding online services for self-injury, supporting the importance of consumer consultation in development of online services. Keywords: deliberate self-harm, self-injury, eHealth, Internet, consumer participation

Many young people who self-injure attempt to seek help online (Frost & Casey, 2013b; Whitlock, Later, & Conterio, 2007); however, little is known about their expectations or preferences in relation to the types of assistance that may be offered via the Internet. Existing online crisis support for self-injury is mostly provided through general crisis intervention services, such as Kids Helpline (Kids Helpline, 2006), and there are currently no known online interventions for young people that are specific to self-injury and linked to professional support. In order to develop effective online interventions for self-injury, it is important to understand the needs and preferences of young people who self-injure when they seek help online. There are several lines of research that suggest that the development of online services for self-injury may be beneficial. Observational studies of the online behavior of young adults who self-injure have identified a growing number of Internet message boards devoted to the topic of self-injury (Whitlock, et al., 2007; Whitlock, Powers, & Eckenrode, 2006). In addition, the number of participants on message boards dedicated to self-injury has also been found to be rapidly increasing (Boeckmann, 2008). Researchers have suggested a shift toward the use of the Internet to provide interventions to adolescents (Campbell, 2004; Sawyer et al., 2012) and specifically to young people at risk of suicide (Gilat & Shahar, 2009). Online interventions may reduce barriers to help-seeking (Frost & Casey, 2013b; Powell & Clarke, 2006), address unmet Crisis 2016; Vol. 37(1):68â&#x20AC;&#x201C;76 DOI: 10.1027/0227-5910/a000346

needs in the area of youth mental health (Patel, Flisher, Hetrick, & McGorry, 2007), and act as an adjunct to existing forms of therapy (Christensen & Griffiths, 2000; Moyer, Haberstroh, & Marbach, 2008). It is also important to acknowledge the potential for harm associated with use of the Internet by this population (Frost & Casey, 2013a; Whitlock, et al., 2007). Online communication may encourage self-injury by normalizing the behavior (Rodham, Gavin, & Miles, 2007). Young people who visit websites containing material demonstrating or discussing self-injury may obtain increased information, including exposure to potentially lethal behaviors (Lewis, Heath, St. Denis, & Noble, 2011; Misoch, 2011). This contact may increase susceptibility to social contagion (Jarvi, Jackson, Swenson, & Crawford, 2013). Indeed, one third of young people attempting to seek help online for self-injury report increased desire to self-injure after going online (Frost & Casey, 2013a). However, there is some preliminary evidence that the involvement of professionals may mitigate this risk. Previous trials of professionally moderated online communities for self-injury indicate that young people will seek support from moderators and adjust their online behavior when the guidelines of the service require this (Smithson et al., 2011). Development of evidence-based services online may not only provide an important addition to existing services, but also reduce the risks for young people who already seek help for self-injury via the Internet. ÂŠ 2015 Hogrefe Publishing

M. Frost et al.: Self-Injury, Help-Seeking, and the Internet

To date, there has been relatively limited engagement of individuals who self-injure in exploring appropriate interventions for prevention and management of self-injury (Hume & Platt, 2007). However, inclusion of consumers at all stages of research and program development is vital in facilitating effective and appropriate interventions (Harris, McLean, & Sheffield, 2009). Actively involving consumers may increase engagement with services, reduce barriers to help-seeking in young people (Warner & Spandler, 2012), and ensure that online interventions are appropriately tailored to this population. As such, the aim of this study was to survey young people with a history of self-injury about their perceptions and preferences in regard to development of online services for self-injury. Specifically, young people were surveyed about preferred sources of online support and their use of the Internet as a tool to facilitate help-seeking or as a distinct avenue for support. Given the increasing use of mobile devices, it was considered important to examine the extent to which services need to be smart-phone accessible. Finally, young people who self-injure (hereafter referred to as young people) were invited to comment on what they perceive as the most important aspects of online services for self-injury.

Method Data for this study were collected as part of a large-scale survey conducted in 2012 in Australia examining the relationship between self-injury, help-seeking, and the Internet and have not been reported in any other publications arising from that survey.

Participants Participants were recruited to complete an Internet survey via a variety of online and offline sources including: posters, flyers, a first-year psychology subject pool, youth mental health-related websites (Reach Out Australia and Kids Help Line Australia), through word of mouth, and “snowballing” via social media (Facebook, Twitter, and Tumblr). Recruitment was strategically conducted throughout all states of Australia, including regional areas, with the assistance of young people volunteering with one of the partner organizations. Information regarding the nature of the survey and links to support services were provided and participants were invited to consent to participation via clicking into the survey. A survey link was provided through all methods of recruiting. In total, 1,799 individuals entered the survey and read the information sheet. Of the participants who entered the initial link, 336 were outside the age range (14–25) or failed to proceed beyond the initial screening question. A sample of 1,463 remained, with 679 of these participants reporting a history of self-injury. The qualitative question of relevance in the current paper was completed by 457 © 2015 Hogrefe Publishing

of the young people with a history of self-injury. The project was approved by the Griffith University Human Ethics Committee.

Measures Demographic Questions Demographic questions were developed by the research team based on existing measures used by partner organizations and the Australian Bureau of Statistics. The questions were brief to reduce the burden on participants, and assessed the following: age; gender; Aboriginal and Torres Strait Islander heritage; languages spoken at home; sexual orientation; and location. Self-Injurious Behavior Self-injurious behavior was measured using an adapted version of the Self-Harm Behaviour Questionnaire (SHBQ; Gutierrez, 2006). In order to reduce participants’ exposure to self-injury and suicide-related questions, only the subscale of the SHBQ dealing with nonsuicidal self-injury was used (NSSI; Plener, Libal, Keller, Fegert, & Muehlenkamp, 2009). This was adapted for the online context. Questions assessed the following: lifetime history of self-injury, “Have you ever hurt yourself on purpose (without intending to kill yourself)?”; method of self-injury, “What did you do?”; frequency, “Approximately how many times did you do this?”; onset and recency of self-injurious behavior, “Approximately when did you first do this to yourself (list your age)?”; “When was the last time you did this to yourself (list your age)?”; and disclosure of self-injury, “Have you ever told anyone that you had done these things?”; “Who did you tell (list all)?” Need for medical assistance was also assessed: “Have you ever needed to see a doctor after doing these things?” Risks associated with detailing methods of self-injury to young people were reduced by using an open question regarding lifetime history of self-injury taken from the SHBQ. Young people gave a yes/no response to the initial question: “Have you ever hurt yourself on purpose (without intending to kill yourself)?” To ensure consistent identification of self-injurious behavior, the open-ended follow-up question “What did you do?” was coded by two of the authors (MF and NR) using De Leo and Heller’s (2004) criteria. The inter-rater agreement for self-injurious behavior was high (.93). Only 11 participants were found to have inaccurately reported their self-injurious behavior. Given that young people appeared to be accurately able to report self-injury and to avoid loss of data, the relevant analyses were run initially with the original and later the recoded data. As no differences were found in the results, the original (non-recoded) self-report data were used in the final results.

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Online Help-Seeking for Self-Injury

Results

Questions for the online survey relating to online help-seeking for self-injury were developed by the research team and then amended based on feedback from a small pilot study of young people (N = 22). Previous online help-seeking was assessed using a single item question requiring a yes/ no response: “Have you ever used the Internet to get help for having intentionally harmed yourself?” Participants were asked a series of questions investigating preferred presentation of online services for self-injury (e.g., text, game, direct links to professionals, self-help, peer support, and the importance of smart-phone access in online services for self-injury). The extent to which young people preferred to use the Internet to facilitate offline help-seeking versus online help-seeking was also assessed with the following question: “Thinking about the future, if you were to access information or support for self-harm using the Internet, which do you think would be most helpful to you?” Three options were provided: (a) “Get information online that helps me immediately talk to my family or friends or a professional about my self-harm”; (b) “Get all the help I need online, so that I don’t have to talk to anyone else about my thoughts of self-harm”; (c) “Access support online to begin with, but eventually speak to someone offline (e.g., friend or counsellor) about my self-harm.” Moreover, participants were also invited to nominate any other way in which help-seeking could be facilitated online Another open question –“What is most important to you in an online support service for self-harm?” – was included to enable qualitative analysis of young people’s views on the most important aspects of online services for self-injury. There was no limit on the length of the open responses, with most young people providing a response ranging from one to two sentences to a paragraph.

Differences Between Nonrespondents and Respondents

Analytic Procedure A mixed-methods approach was used. Independent-samples t tests and descriptive analyses were used to investigate responses relating to demographic variables, history of self-injury, and help-seeking experiences. Thematic analysis as outlined by Braun and Clarke (2006) was used as a basis for the analysis of responses to the open question, “What is most important to you in an online support service for self-injury?” An inductive approach was taken to the development of categories and themes (Braun & Clarke, 2006; Hsieh & Shannon, 2005) and latent concepts were coded. To ensure that responses were being coded consistently and in line with the scoring key, over 10% of the responses were coded by a second rater. The initial rater was the first author, and the second rater the third author. The overall interrater reliability was acceptable (0.88). Chi-square tests were then used to examine the relationship between endorsement of each theme and previous online help-seeking for self-injury.

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Of the 679 young people who reported a history of self-injury, 457 provided responses in relation to preferences for future online help-seeking by answering the question, “What is most important to you in an online support service for self-harm?” The young people who did not respond to the question (N = 222) were significantly younger (M = 17.47, SD = 2.84) than those who did answer the question (N = 457, M = 18.01, SD = 2.02); t(677) = 2.22, p = < .05. There was no difference in the hours spent online between the two groups, assessed using the question, “On average, how many hours a day would you spend using the Internet?” Those who answered the question regarding what is important in an online service for self-injury had significantly greater scores (M = 13.71, SD = 2.29) on the SHBQ (Gutierrez, Osman, Barrios, & Kopper, 2001), compared with those who did not answer the question (M = 13.28, SD = 2.20); t(652) = 2.27, p = < .05, indicating a greater degree of self-injury. Results reported in the remainder of the article refer to young people with a history of self-injury who provided responses relating to preferences for future online help-seeking (N = 457).

Differences Between Online Help-Seekers and Non-Help-Seekers Online help-seeking for self-injury was reported by 36.8% (N = 168) of the sample, while 63.2% (N = 289) had not sought help online. Young people with a history of online help-seeking for self-injury were significantly less likely (M = 1.23, SD = .42) to have disclosed their self-injury to anyone offline, compared with those who had not sought help online (M = 1.37, SD = .48), t(389.24) = −3.27, p = .001. However, no significant differences were found in the levels of endorsement of any of the potential forms of online support between young people who had and had not previously been online to seek help for self-injury.

Demographic and Self-Injury-Related Characteristics of Respondents The average age of the sample was 18.01 years (SD = 3.01). The majority of the sample (87.3%, N = 399) identified as female and 64.8% (N = 296) identified as heterosexual. Most (62.6%, N = 286) indicated that they lived in a city or town. A small subsample (12%, N = 55) reported that they spoke a language other than English at home and 2.6% (N = 12) identified as Aboriginal or Torres Strait Islander .When compared with the Australian population aged 14–25, females were substantially over-represented (48% nationally) and young people speaking a language other than English at home underrepresented (20% nationally; Muir et al., 2009). © 2015 Hogrefe Publishing

M. Frost et al.: Self-Injury, Help-Seeking, and the Internet

On average, young people in the sample first engaged in self-injury at the age of 13.9 years (SD = 2.57). One quarter of young people (25.6%, N = 117) needed to see their general practitioner after an episode of self-injury. The number of episodes of self-injury ranged from one (9.5%, N = 43) to “too many times to count” (47.0%, N = 214). Almost half of young people (45.7%, N = 209) reported that the only method of self-injury they had engaged in was self-cutting, a further 31.9% (N = 146) reported that they had engaged in multiple methods of self-injury (e.g., cutting and overdosing). Head banging, hitting, or punching self or objects was reported by 5.3% (N = 24) of participants. Engaging in another single method of self-injury (e.g., overdosing, burning), without engaging in multiple methods of self-injury, was reported by less than 5% of participants.

Preferences in Potential Online Support for Self-Injury Participants were asked to identify preferred sources of potential online support for self-injurious behavior, using a list of possible online sources (see Figure 1). The most popular suggestion was for “an online service with direct links to professionals in real time via instant messaging,” which was endorsed by 54.1% (N = 247) of the young people. Other highly endorsed online sources were peer support such as online forums and chat rooms (48.6%, N = 222), online self-help programs (43.5%, N = 199), and information provided in text or fact sheets (41.8%, N = 19).

Using the Internet as a Proximal Step to Offline Help-Seeking

to begin with, but to eventually speak to someone offline about their self-injurious behavior. A further 13.8% (N = 63) reported a desire for information online that would help them to immediately talk to family, friends, or a professional about their self-injurious behavior. However, 35.1% (N = 160) indicated that they would ideally like to get all the help that they need online, so that they would not need to speak to anyone else about their self-injurious behavior. Ten young people (2.2%) indicated that their intentions did not fit with any of these options.

Importance of Smart-Phone Accessibility Smart-phone ownership among young people was high, with 71.7% (N = 325) of young people in the sample responding yes when asked the question, “Do you have a mobile phone with access to the Internet?” Just over half of young people in the sample reported that being able to access Internet-based services for self-injurious behavior via mobile phones or mobile applications would be somewhat important to extremely important (52.0%, N = 237), 25.1% (N = 114) were neutral, while 22.8% (N = 104) reported that it was unimportant for them.

Qualitative Analysis of Preferences for Self-Injury Services Online Thematic analysis was used to analyze responses to an open question: “What is most important to you in an online support service for self-injury?” Seven themes emerged: information; guidance; reduced isolation; online culture; facilitation of help-seeking; access; and privacy. The frequency of responses within each of these themes is outlined in Table 1.

The Internet was frequently endorsed as a proximal step to offline help-seeking: Almost half of the young people (48.9%, N = 223) reported a desire to access support online Figure 1. Desired future support online for self-injurious behavior by source. IM = instant messaging.

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Endorsement of Themes Guidance The most frequently endorsed theme related to guidance, with 45.7% (N = 209) of young people indicating a desire for advice (n = 68) or help and support (n = 155) when seeking help online. Young people reported a need for advice on how to help themselves, suggestions for reducing self-injury, or strategies to avoid self-injury: Ideas on what to do instead of self-harming, or what to do when the thought comes across your mind.

They also indicated a need for harm minimization in the form of advice about first aid and less damaging self-injury: Information on first aid, how to minimize damage, how to hide bruises/scars.

A desire for personalized support from both professionals and peers emerged. The concept of “someone there” was mentioned frequently, as was the desire to have contact with a “real person”: Someone that is real and that I can talk to. It not being an automated response system and is an actual person. Knowing that there is someone to listen to you and perhaps help you to stop no matter where you are.

Reduced Isolation In addition to a desire for guidance, many young people (22.8%, N = 104) endorsed the potential role of online support services in reducing isolation. Young people identified a general desire for understanding (n = 57) and a specific desire to know others had a shared experience (n = 44). Community feeling – not just facts and figures. I want to feel like there are other people experiencing this, and how they got/ get through it. But at the same time, I want personal help. I want someone to understand my situation.

A number of young people specifically identified a need for information on why they self-injure or what might cause self-injury. Information of what constitutes self-harm (different types) and possible causes. Possible treatments available and effectiveness. The researched psychological common reasons why people self-harm.

Online Culture The need for appropriate online culture in online support services was endorsed almost as frequently as the need for information, with 17.3% (N = 79) of young people identifying the need for a nonjudgmental (n = 68) and safe (n = 14) environment and interactions. Many young people used the term nonjudgmental, while others indicated that they needed support in a way that was not stigmatizing, did not stereotype them, blame them, or label them as an attention seeker. An openness to self-injury as a coping strategy and the absence of pressure to stop self-injuring were also identified as important by a number of young people. That it acknowledges that self-harm is sometimes a survival strategy. That it does not stigmatize self-harm, blame people who self-harm, or ignore the underlying causes of self-harm.

Safety in online services for self-injury centered around the need for moderation, warnings about triggering content, and the risks of self-injury becoming competitive. That it is safe and not people just talking graphically about how they self-harm or flaming others or triggering others.

Access Access was mentioned by 16% (N = 73) of young people. Access related to the need for 24/7, free services with instant access and real-time support, no wait, available anywhere and accessible (i.e., clear and easy to navigate) when in crisis. Being able to instant message a professional 24/7. Being able to access online counselling on mobile Internet.

Information The importance of provision of information was endorsed by 18.8% (N = 86) of young people. Many young people specifically identified a need for information about self-injury, research, statistics, and fact sheets and highlighted the importance of relevance and reliability of such information. Being able to find information that I am too scared to ask for. Relevant, recent and important information, facts and research. Crisis 2016; Vol. 37(1):68–76

Many young people mentioned the need for immediate support without long waiting periods as particularly important in providing online support for self-injury. That the people can talk straight away and you wouldn’t have to wait for over 5 min to talk to a professional.

M. Frost et al.: Self-Injury, Help-Seeking, and the Internet

and confidentiality. A small number also mentioned the importance of knowing that duty of care would not be enacted.

online support for self-injurious behavior; however, the effect size was small (φ = .132). Similarly, these individuals were more likely to identify a safe and nonjudgmental online culture as important, but the effect size was also small (φ = .108).

That I have the opportunity to remain anonymous. Anonymity is something that is very important to me, especially in relation to such a private and personal topic such as self-harm. I would not use an online support service to talk about self-harm if I did not have the option to remain anonymous.

Discussion

No judgment... too many services are boxed around a duty of care and won’t let you hurt yourself without calling someone... real help comes in the form of people allowing you to hurt yourself and talking to you about what is causing the need and just being there with you for a while... helping you feel and think about what is so painful rather than making you feel in trouble or naughty for needing to do it.

The results of this study suggest that young people are highly receptive to professional support provided online, and indicate distinct preferences in regard to how this help is provided. Services delivered online may need to incorporate contact with professionals and peers in order to be most effective. Instant messaging and e-mail were preferred over video conferencing. In addition to professional and peer support, self-help was also highly endorsed. Knowing that others had similar experiences appeared to be a priority in reducing a sense of isolation for many young people experiencing self-injury. Young people may be able to communicate with peers actively (e.g., through forums) or passively (e.g., through reading others’ stories) and, thus, feel less alone in their experience. Indeed, previous research indicates that young people who seek peer help online in relation to self-injury report that it is easier to speak to a stranger online than to speak with family and friends or to see someone face to face (Jones et al., 2011). Providing opportunities for young people to connect with peers in safe moderated environments may reduce the risks associated with social contagion (Jarvi et al., 2013) while meeting the needs of young people seeking help online. In addition to the provision of direct support, the Internet may act as a proximal step to help-seeking. When asked about their intentions when seeking help online, over half of the sample indicated a desire to use the Internet as a first step, but to later gain support offline. By accessing help online, young people may be able to seek information and advice in a manner that is private and then make a decision regarding accessing further help. In the current sample, young people with a history of seeking help online for

Facilitation of Help-Seeking The need for assistance with help-seeking was mentioned in a small but distinct group of responses, with 9% (N = 41) of responses identifying this as important. Understanding that others have had the same thoughts (peer comments) and what you can do about it (provides links to support sites or professionals). Advice on how to seek help from my GP and bring up the subject with family/partner.

Relationship Between Endorsement of Each Theme and Previous Online Help-Seeking As Table 1 indicates, a series of chi-square tests revealed no statistically significant relationship between previous online help-seeking and likelihood of endorsing the importance of information, guidance, facilitation of help-seeking, access, or privacy. A significantly higher proportion of individuals who had previously been online to seek help in relation to self-injurious behavior endorsed the importance of reduced isolation as an aspect of future

Table 1. Frequency of endorsement of identified themes Online help-seeking (N = 168 )

No online help-seeking (N = 289)

χ2 Comparisons χ2

χ2

.421

.516

−.030

.052

.820

.011

.003

.138

.022

.108

Themes

(%)

Information

(17.3)

(19.7)

Guidance

(46.4)

131

(45.3)

Reduced isolation

(30.4)

(18.3)

8.73

Online culture

(22.6)

(14.2)

5.28

Facilitation of help-seeking

(8.9)

(9.0)

.980

−.001

Access

(19.0)

(14.2)

1.87

.171

.064

Privacy

(11.9)

(16.3)

1.61

.204

−.059

.001

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self-injury were less likely to have disclosed their self-injury to anyone. It is unclear whether online help-seeking was acting to replace offline help-seeking for these young people or whether the Internet facilitates help-seeking in young people who otherwise would not disclose their self-injury to anyone. Similarly, it is unclear whether the failure of these young people to seek help offline may reflect a lack of linking to offline support in current forms of online support for self-injury. Key themes that emerged in relation to preferences for online services for self-injury were: information; guidance; reduced isolation; online culture; facilitation of help-seeking; access; and privacy. When seeking guidance online, a need for contact with a real person was emphasized. This desire to connect with others online highlights an important message about the way services should be delivered online. In spite of the anonymity of the Internet, young people identified the need for a nonjudgmental and safe environment in order to seek help online, which is in line with research indicating that trust is a key factor in facilitating help-seeking in young people (Peacocke, 2007; Wilson & Deane, 2001). There appeared to be an overlap in the way young people discussed issues of privacy and those of online culture, with many young people indicating that safety is associated with anonymity, a nontriggering environment, and also an experience of being accepted without stigma or judgement. The Internet may provide a way of accessing support that is perceived as remaining private and within the control of the young person. However, young people still indicated a concern about online helpers making a judgment regarding a need to cease self-injury or actively intervening by enacting duty-of-care. A number of young people indicated that they did not want to be labelled or forced to stop harming themselves. Previous research indicates that the majority of young people would like to stop self-injuring (Warm, Murray, & Fox, 2002). Consistent with this, the current study found that a need for strategies and support to stop self-injurious behavior was frequently endorsed in the open responses. In addition, some young people also identified a desire for links to offline services or assistance managing the process of seeking help from offline supports. Comparisons in the endorsement of themes were made between young people who did and did not have a previous experience of online help-seeking for self-injurious behavior. Although less than half of the sample had previously been online seeking help for self-injury, there were relatively few differences in the endorsement of themes between young people who had and had not sought help online. Overall, previous online help-seeking did not appear to impact on the proportion of young people who endorsed each theme. However, the exception was that young people with a previous experience of online help-seeking were more likely to endorse the importance of reduced isolation and a supportive online culture. This may reflect previous online help-seeking experiences. Much of the current help available online is in the form of online forums or peer-to-peer chat rooms (Whitlock et al., 2007). These supports have been found to provide a Crisis 2016; Vol. 37(1):68–76

perceived sense of community and belonging for young people who self-injure (Rodham, et al., 2007). However, previous research also identifies risks associated with such communities (Lewis & Baker, 2011; Whitlock, et al., 2006). Young people in the current sample went beyond discussion of the positive aspects of online communities and online culture, expressing concerns about triggering content, unmoderated discussions and the “glorification” of self-injury. Some young people suggested specific strategies to increase their safety online, such as increased moderation, warnings on “triggering” content, contact with professionals online, personalized help and support, and no comparisons of self-injurious behavior online. Therefore, it is possible that previous negative or triggering experiences when attempting to seek help online for self-injury may have prompted young people with a history of online help-seeking to endorse the importance of a supportive online culture and a sense of reduced isolation, compared with their peers with no previous experiences of seeking self-injury-specific help online. A number of limitations in relation to the present study should be noted. Recruiting was not randomized and occurred through a range of sources, including crisis support services, which may have led to a sample that is not representative. Specifically, previous contact with a mental health professional online may have been overrepresented and led to increased willingness for future contact with mental health professionals online. There was a high percentage of female participants. The rate of self-injurious behaviour is known to be higher for females than for males (Madge et al., 2008) and young females have different patterns of help-seeking for self-injury compared with males (Fortune, Sinclair, & Hawton, 2008). Therefore, the preferences of young women in relation to online services for self-injury may differ from those of young men. Similarly, replication with a larger sample would allow investigation of potential differences in preferences for online help-seeking across a range of demographic variables in order to ensure generalizability of the findings. Pilot testing and further consultation with young people after they trial services may also assist in ensuring that young people are clear regarding their needs when seeking help online.

Conclusion The current study explored the perspectives of young people who self-injure regarding key factors in online services for self-injury, with the aim of informing online service delivery for self-injury. The key themes that emerged were: information; guidance; reduced isolation; online culture; facilitation of help-seeking; access; and privacy. The results indicated that young people are receptive to professional help and support offered online. Involving young people in research and service development is likely to improve service uptake and accelerate the process of moving research into service delivery. © 2015 Hogrefe Publishing

M. Frost et al.: Self-Injury, Help-Seeking, and the Internet

Acknowledgments The publication of this research was funded through a grant provided by the au. Domain Administration (auDA) Foundation. The authors also wish to acknowledge the contribution of a number of people in this research project. The young people who took the time to complete the online survey and assist with recruiting; BoysTown’s Kids Helpline service and The Inspire Foundation’s Reach Out service, who partnered on this research project; Christian Frost for assistance with editing; and Emeritus Professor John O’Gorman for his assistance with statistical consultation.

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Warner, S., & Spandler, H. (2012). New strategies for practice-based evidence: A focus on self-harm. Qualitative Research in Psychology, 9(1), 13–26. doi:10.1080/14780887. 2012.630631 Whitlock, J., Later, W., & Conterio, K. (2007). The internet and self-injury: What psychotherapists should know. Journal of Clinical Psychology, 63(11), 1135–1143. doi:10.1002/ jclp.20420 Whitlock, J., Powers, J. L., & Eckenrode, J. (2006). The virtual cutting edge: The Internet and adolescent self-injury. Developmental Psychology, 42(3), 407–417. doi:10.1037/00121649.42.3.407 Wilson, C. J., & Deane, F. P. (2001). Adolescent opinions about reducing help-seeking barriers and increasing appropriate help engagement. Journal of Educational and Psychological Consultation, 12(4), 345–364. doi:10.1207/S1532768XJEPC1204_03

About the authors Dr. Mareka Frost completed a Professional Doctorate in Clinical Psychology at Griffith University, Australia, and currently works in private practice. Her research interests include self-harm, suicide prevention, and the role of technology in reducing barriers to help-seeking. Dr. Leanne Casey is Director of Clinical Psychology Programs at Mt. Gravatt Campus, Griffith University, QLD, Australia. Her research interests include uses of technology and addressing barriers to accessing psychological interventions. Natalie Rando completed a Bachelor of Psychology degree at Griffith University, QLD, Australia. Her research interests include suicide prevention and help-seeking behaviors. Leanne Casey

Received June 24, 2013 Revision received April 23, 2015 Accepted April 24, 2015 Published online November 17, 2015

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Griffith University School of Applied Psychology Messines Ridge Mt. Gravatt Campus Brisbane, QLD Australia Tel. +61 07 3735-3314 E-mail l.casey@griffith.edu.au

Erratum Correction to Youssef et al., 2015

In the article “Exploratory Investigation of Biomarker Candidates for Suicide in Schizophrenia and Bipolar Disorder: Preliminary Findings of Altered Neurosteroid Levels” by Nagy A. Youssef et al. (Crisis, 2015, Vol. 36, No. 1, pp. 46–54, doi:10.1027/0227-5910/a000280) the last name of the 9th author was misspelled on the title page. The correct spelling is Mira Brancu. The authors regret any inconvenience the error may have caused.

Reference Youssef, N. A., Bradford, D. W., Kilts, J. D., Szabo, S. T., Naylor, J. C., Allen, T. B., … Marx, C. E. (2015). Exploratory investigation of biomarker candidates for suicide in schizophrenia and bipolar disorder: preliminary findings of altered neurosteroid levels. Crisis, 36(1), 46–54. doi:10.1027/0227-5910/ a000280

Crisis 2016; Vol. 37(1):77 DOI: 10.1027/0227-5910/a000397

News, Announcements, and IASP Obituary Norman Farberow, 1918–2015 Morton M. Silverman Suicide Prevention Resource Center, Waltham, MA, USA On September 10, 2015 (World Suicide Prevention Day), Norman L. Farberow, PhD, died at the age of 97 years in Los Angeles, CA, USA. He was a founding father of modern American suicidology and a founding member of the International Association for Suicide Prevention (along with Erwin Ringel). He was instrumental in helping to bring the study of suicide into the academic mainstream and to create the academic discipline known as suicidology. Norman Louis Farberow was born in Pittsburgh, PA, USA, on February 12, 1918. He earned his bachelor’s and master’s degree in psychology from the University of Pittsburgh and served in Europe with the Army Air Forces in World War II. Farberow earned his PhD in psychology from the University of California, Los Angeles, USA, in 1950 and wrote his doctoral dissertation on the personalities of suicidal patients. He was one of the very first psychologists in the US to focus his professional career on working with and understanding suicidal patients. Norm Farberow moved from being a psychotherapist to focusing on how communities treated those who were suicidal. During the 1950s, Farberow and Edwin Shneidman worked together at the Veterans Administration (VA) Hospital in Los Angeles and sought answers for the sudden doubling of suicides among the VA’s psychiatric hospital patients. Their observations and investigations about suicide notes culminated in the publication of Clues to Suicide in 1957. They detected ambivalence and doubt in these suicide notes that suggested that suicides could be prevented by discovering the roots of the self-destructive behavior. His book, The Cry for Help, written with Edwin Shneidman in 1961, documented the taboos related to suicide and argued that the cry for help should be more readily voiced and more easily heard by those in a position to provide help. Farberow identified a broad range of behaviors that he characterized as indirect self-destructive behaviors (ISDB), which he considered integral to understanding the continuum of self-destructive behaviors. This work resulted in his book entitled The Many Faces of Suicide (1980). Crisis 2016; Vol. 37(1):78–79 DOI: 10.1027/0227-5910/a000395

In 1958, Farberow was among the three founders of the Los Angeles Suicide Prevention Center (LASPC), along with Robert Litman and Edwin Shneidman. The LASPC was the first comprehensive suicide prevention center in the US, if not in the world. Initially conceived to be a center for the follow-up care of suicidal patients discharged from inpatient treatment in the Los Angeles County Hospital, it soon expanded to include crisis intervention and the first 24-hour suicide prevention crisis line in the US, staffed with professional counselors and trained volunteers. These efforts led to the development of the L. A. Scale for Assessment of Suicidal Potential and the crisis hotline model. As the mission of the LASPC expanded, it began to collaborate with the coroner’s office, mental health professionals, police, probation officers, schools, and other organizations to create awareness of suicide and suicide prevention, and to give hope to those who were suffering from suicidal thoughts and behaviors. As a result of the L. A. County Coroner seeking collaboration with the LASPC to help determine equivocal cases of suicide, Farberow, Litman, and Shneidman created the psychological autopsy method as a procedure to identify and evaluate the psychological factors that contribute to suicide and to study how personality differences affect the mode of death. The method of psychological autopsy was used to determine whether suicide was the cause of death for such Hollywood celebrities as Marilyn Monroe and Robert Walker. Over time the Center developed into a base of research into the causes and prevention of suicide. It became an international model for the organization and operation of a community-based crisis center, a teaching and training program, and a suicide prevention center. Norm Farberow’s interests spanned multiple realms, including how suicide is depicted in paintings, sculpture, illustrations, and in literature, including the Bible. He championed providing assistance to the chronically suicidal individual, and developed multiple models of group therapy to address their needs. He recognized that survivors of the loss of a loved one to suicide not only experience feelings of loss and grief, but are also subject to © 2016 Hogrefe Publishing

News, Announcements, and IASP

additional complications because of the taboo associated with suicide and the commonly experienced intense feelings of shame and guilt. He developed programs for the bereaved to address the stigma of suicide and to provide needed support and empathy and an opportunity to talk about their feelings and struggles without guilt or embarrassment. This focused therapeutic model emphasized caring, sharing, support, and interactive discussion. The model for the Survivors After Suicide program quickly spread throughout North America and then to Europe. Farberow examined suicide risk within a number of groups, including police officers, gay men, schizophrenic patients, other psychiatrically ill patients, adolescents, the aged, and the chronically and terminally ill. He evaluated and developed scales for assessing suicide risk in public schools and universities. His work in the field of crisis intervention included publishing guidelines for human services organizations and child health care workers in response to large-scale natural disasters. He was a mentor, a teacher, and a professional colleague to hundreds of suicidologists worldwide. Farberow wrote or cowrote 16 books, 50 book chapters, 93 articles, three monographs, four manuals, and 13 book reviews. His books and articles have been translated into Japanese, Finnish, German, Swedish, French, Spanish, and Korean. Dr. Lanny Berman, the former Executive Director of the American Association of Suicidology and the immediate past President of IASP commented, Norman Farberow was a pioneer in bringing suicide into the light of scientific inquiry and suicide survivors into the arms of the suicidology community. He was a mentor and role model – a compassionate scientist who deeply understood the pain of those suicidal and those impacted by suicide. (personal communication)

Prof. Ella Arensman, the current President of IASP, remarked, The significant and fundamental contributions of Norman Farberow to the work of IASP and suicide prevention globally are invaluable. His work and lectures were most inspiring to me when I started as a young student exploring the area of suicide research and prevention, and certainly for me contributed to continuing in this important area of work. In ways, it may not be a coincidence that Norman left us on World Suicide Prevention Day. A legend of nearly a century, his impact on the work of suicide research and prevention will remain forever. (personal communication)

In 1997, IASP established the Farberow Award to recognize his treatment model for survivors of suicide committed by loved ones. It is presented to those who provide outstanding contributions in the field of bereavement work with survivors of suicide. Prof. Onja Grad, the first recipient of the Farberow Award, reflected on her long-term relationship with Norm Farberow as follows,

In 1997 the IASP biannual conference was held in Adelaide, Australia, where the first Farberow Award was given, and I was asked by the organizers to prepare a contribution entitled, “Meet the Legend – Who is Norman Farberow?” I was humbly thrilled with the opportunity to speak about this important man who was my role model, teacher and good colleague, friend, and a much admired man whom I had known, at that time, for 18 years. Yes, the title of the session was appropriate. He was a real legend for the last forty years of his life. How did he earn this appreciation and admiration from everybody he met in his long and fruitful life? His biography and bibliography tell us about his immense and important cognitive production, his broad span of professional interests, and visionary novelties in suicidology. What it does not reveal is what we felt when we came closer to him – it was his absolute personal charisma, tolerance and warm emotional stability that radiated in different relationships and made him a persona grata everywhere he appeared. His charm spread to everybody he came in contact with – patients and colleagues, students and volunteers, friends and passing acquaintances alike. In the seventies and in the eighties, when I was at the Los Angeles Suicide Prevention Center, I observed Norm’s gentle, but determined, nature when he talked with patients, led different groups, led and mediated team meetings, and supervised young clinicians. It was obvious how people in distress trusted him when he attentively listened to them and tried to help them. His benevolent nature eased the team conflicts and supported the cooperation among many different professional personalities with a great success for the well-known and flourishing institution. His noble manner, with which he approached everyone alike, was always evident, no matter if he talked with an influential politician, a dear colleague, a young student or a marginalized psychotic patient. This made him so liked and admired. He really was A Living Legend. (personal communication)

Norman Farberow died on Word Suicide Prevention Day. Many have commented that without the contributions of Norman Farberow such a day would almost certainly not exist. He was a pioneer in helping to erase the stigma of suicide by easing the cultural and social shame attached to those who die by suicide and those who survive the death of their loved one. He will be remembered as a gentle and humble man, full of intellectual curiosity, a clinician, researcher, teacher, advocate, and friend to many. He will be missed. Dr. Farberow’s wife died in 2008. His survivors include a son and daughter, three grandchildren, and three great-grandchildren.

Morton M. Silverman msilverman@edc.org

Crisis 2016; Vol. 37(1):78–79

News, Announcements, and IASP Announcements The 49th Annual Conference of the American Association of Suicidology (AAS), entitled “Suicidology: A Place for Everyone,” is taking place March 30–April 2, 2016, in Chicago, IL, USA. For more information go to http://www. suicidology.org/annual-conference/49th-annual-conference The American Counseling Association Conference & Expo is taking place March 31–April 3, 2016, in Montréal, Canada. For more information go to http://www. counseling.org/conference/montreal-aca-2016 The Annual Conference of the organization Kevin's Song, entitled “The Silent Epidemic: A Conference on Suicide,” is taking place April 7–9, 2016, in Plymouth, MI, USA. For more information go to http://kevinssong.org/ conference/ The 7th Asia Pacific Regional Conference of the International Association for Suicide Prevention (IASP), entitled “Building Bridges for a New Start Beyond Bor-

Crisis 2016; Vol. 37(1):80–81 DOI: 10.1027/0227-5910/a000392

ders,” is taking place May 18–21, 2016, in Tokyo, Japan. For more information go to http://www2.c-linkage.co.jp/ iasptokyo2016/en/ The National Suicide Prevention Conference 2016 of Suicide Prevention Australia is taking place July 24–27, 2016, in Canberra, ACT, Australia. For more information go to http://suicidepreventionaust.org/conferences/ The 16th European Symposium of Suicide and Suicidal Behavior (ESSB16) is taking place September 8–10, 2016, in Oviedo, Spain. For more information go to http:// esssb16.org/ The XXIX World Congress of the International Association for Suicide Prevention (IASP), entitled “Preventing Suicide: A Global Commitment, From Communities to Continents,” is taking place July 18–22, 2017, in Kuching, Malaysia. For more information go to https://www.iasp. info/

International Association for Suicide Prevention Would you like to join IASP? IASP is a nonprofit organization for those interested and working in suicide prevention. The membership consists of individuals (clinicians, scientists, crisis workers, volunteers and persons who have lost a family member by suicide) and community, national and international organizations. At this moment the membership extends over 50 countries and is affiliated with the World Health Organization as the key organization concerned with suicide prevention.

The main objectives of IASP are:

– to provide a common platform for all representatives of the many pro– – – – –

fessions who are engaged in the field of suicide prevention and crisis intervention; to allow interchange of acquired experience in this area in various countries, especially through the exchange of literature; to promote the establishment of national organizations for suicide prevention; to facilitate the wider dissemination of the fundamentals of effective suicide prevention to professional groups and to the general public; to arrange for specialized training of selected persons in the area of suicide prevention in selected training centers; to carry out programs of research, especially those which can be pursued through international joint cooperation.

The activities of the association focus on the importance of sharing information, research and knowledge in order to address the issues of suicide and its prevention. The biennial congress, the bimonthly journal Crisis, biannual newsletter and the website serves as a medium for international exchange and a directory of members involved in suicidology is made available. Candidates for IASP membership may apply directly to the Central Administration Office admin@iasp.info or join IASP online at http:// www.iasp.info Membership consists of: – Regular membership for individuals regularly engaged in suicide studies, clinical management of suicidal patients, and/or suicide prevention activities, and who are interested in furthering the work of the Association. – Organizational membership is for national or international voluntary or other nonprofit organizations (incorporated or unincorporated) working in the field of suicide studies, clinical management of suicidal patients and/or suicide prevention activities under the terms of their governing document. – Associate membership is for individuals and organizations who are interested in working toward the goals of the Association, but who are not qualified for regular membership. Please contact the IASP Central Administration Office at admin@ iasp.info.; on the web at http://www.iasp.info

IASP membership fees (include a subscription to Crisis): Zone Zone 1 Zone 2 Zone 3 Zone 4 All zones: students, volunteers, & retirees (online access only)

Individuals US $190 (early bird US $180.50, 3 years US $515) US $160 (early bird US $152, 3 years US $430) US $135 (early bird US $128, 3 years US $365) US $115 (early bird US $109, 3 years US $310) US $115 (early bird US $109, 3 years US $310)

Organizations US $235 (early bird US $225, 3 years US $635) US $180 (early bird US $170, 3 years US $485) US $160 (early bird US $150, 3 years US $430) US $125 (early bird US $120, 3 years US $340) For Advanced Organization Membership fees go to https://www.iasp.info/application.php

All fees include hard copy and online access to Crisis. For prices for online only access go to https://www.iasp.info/application.php

IASP Executive Committee 2015–2019 President: Prof. Ella Arensman Vice President 1: Prof. Murad M. Khan Vice President 2: Prof. Steve Platt

Vice President 3: Prof. Maurizio Pompili General Secretary: Prof. Jane Pirkis Treasurer: Dr. Mort M. Silverman

Representative of the Council of Presidents: Prof. Diego de Leo

IASP National Representatives 2013–2015 Co-Chairs: Dr. Loraine Barnaby and Prof. Thomas Niederkrothentaler Argentina Australia Austria Bangladesh Belgium Brazil Canada China Chile Columbia Denmark Estonia Finland France Germany Ghana Greece Hong Kong

Dr. Ernesto Ruben Paez Dr. Jo Robinson Prof. Thomas Niederkrothentaler Prof. Zahidul Islam Prof. Kees Van Heeringen Prof. Humberto Correa Prof. Brian Mishara Prof. Michael Phillips Dr. Alejandro Chamorro Dr. Marta Ardilla Dr. Annette Erlangsen Dr. Merike Sisask Prof. Erkki Isometsa Prof. Jean-Pierre Soubrier Dr. Reinhard Lindner Dr. Charity Akotia Dr. Kyriakos Katsadoros Dr. Frances Yik Wa Law

Dr. Sandor Fekete Hungary India Prof. R. Sateesh Babu Indonesia Prof. Nalini Muhdi Iran Dr. Seyed Kazem Malakouti Ireland Mr. Gerry Raleigh Israel Dr. Avshalom Aderet Italy Dr. Marco Innamorati Jamaica Dr. Loraine Barnaby Japan Dr. Chiaki Kawanishi Lithuania Dr. Paulius Skruibis Malaysia Prof. T. Maniam Mexico Dr. Ana-Maria Chavez Hernandez Mr. Dhruba Pathak Nepal Netherlands Dr. R. F. P. De Winter New Zealand Prof. Annette Beautrais Nigeria Dr. Olatunde Ayinde Norway Dr. Erlend Mork Pakistan Dr. Uzma Irfan

French Polynesia Dr. Stephane Amadeo Portugal Dr. Alexandre Teixeira Dr. Layachi Anser Qatar Romania Prof. Doina Cosman Slovenia Dr. Saska Roskar South Africa Dr. Jason Bantjes Spain Mr. Andoni Anscan Ramos Sri Lanka Ms. Anura Wijemanne Suriname Prof. Toby Graafsma Sweden Dr. Vladimir Carli Switzerland Ms. Barbara Weil Taiwan Dr. Ying-Yeh Chen Dr. Prakarn Thomyangkoon Thailand Trinidad Dr. Gerard Hutchinson Uganda Dr. James Mughisha UK Dr. Gill Green Ukraine Prof. Vsevolod Rozanov Dr. Silvia M. Pelaez Remigio Uruguay USA Dr. Dan Reidenberg Crisis 2016; Vol. 37(1):80–81

Instructions to Authors – Crisis: The Journal of Crisis Intervention and Suicide Prevention Crisis – The Journal of Crisis Intervention and Suicide Prevention is an international periodical that publishes original articles on suicidology and crisis intervention. Papers presenting basic research as well as practical experience in the field are welcome. Crisis also publishes potentially life-saving information for all those involved in crisis intervention and suicide prevention, making it important reading for clinicians, counselors, hotlines, and crisis intervention centers. Crisis: The Journal of Crisis Intervention and Suicide Prevention publishes the following types of articles: Research Trends, Short Reports, and Clinical Insights. Manuscript Submission: All manuscripts should be submitted electronically at http://www.editorialmanager.com/cri Detailed instructions to authors are provided at http://www. hogrefe.com/periodicals/crisis-the-journal-of-crisis-inter vention-and-suicide-prevention/advice-for-authors/ Copyright Agreement: By submitting an article, the author confirms and guarantees on behalf of him-/herself and any coauthors that he or she holds all copyright in and titles to the submitted contribution, including any figures, photographs, line drawings, plans, maps, sketches and tables, and that the article and its contents do not infringe in any way on the rights of third parties. The author indemnifies and holds harmless the publisher from any third-party claims. The author agrees, upon acceptance of the article for publication, to transfer to the publisher on behalf of him-/herself and any coauthors the exclusive right to reproduce and distribute the article and its contents, both physically and in nonphysical, electronic, and other form, in the journal to which it has been submitted and in other independent publications, with no limits on the number of copies or on the form or the extent of the distribution. These rights are transferred for the duration of copyright as defined by international law. Further-

more, the author transfers to the publisher the following exclusive rights to the article and its contents: 1. The rights to produce advance copies, reprints, or offprints of the article, in full or in part, to undertake or allow translations into other languages, to distribute other forms or modified versions of the article, and to produce and distribute summaries or abstracts. 2. The rights to microfilm and microfiche editions or similar, to the use of the article and its contents in videotext, teletext, and similar systems, to recordings or reproduction using other media, digital or analog, including electronic, magnetic, and optical media, and in multimedia form, as well as for public broadcasting in radio, television, or other forms of broadcast. 3. The rights to store the article and its content in machine-readable or electronic form on all media (such as computer disks, compact disks, magnetic tape), to store the article and its contents in online databases belonging to the publisher or third parties for viewing or downloading by third parties, and to present or reproduce the article or its contents on visual display screens, monitors, and similar devices, either directly or via data transmission. 4. The rights to reproduce and distribute the article and its contents by all other means, including photomechanical and similar processes (such as photocopying or facsimile), and as part of so-called document delivery services. 5. The right to transfer any or all rights mentioned in this agreement, as well as rights retained by the relevant copyright clearing centers, including royalty rights to third parties. Online Rights for Journal Articles: Guidelines on authors’ rights to archive electronic versions of their manuscripts online are given in the Advice for Authors on the journal’s web page at www.hogrefe.com.

February 2016

Suicidal behavior and its prevention in immigrants and their descendants

“This book succeeds in offering a broad perspective on different aspects of suicidal behaviour among immigrants and ethnic minorities in Europe.” Sofie Bäärnhielm, in Transcultural Psychiatry, 2016

Diana van Bergen / Amanda Heredia Montesinos / Meryam Schouler-Ocak (Editors)

Suicidal Behavior of Immigrants and Ethnic Minorities in Europe 2015, viii + 190 pp., hardcover US $54.00 / € 38.95 ISBN 978-0-88937-453-9 Also available as an eBook Nearly half of the inhabitants of several large European cities, such as London, Berlin, or Amsterdam, and a rising proportion of many countries’ overall population, are immigrants or from an ethnic minority. However, this fact has been understudied in research and prevention of suicidal behavior. This volume addresses this gap.

www.hogrefe.com

Leading experts describe rates and risk factors of suicidal behavior among immigrants and ethnic minorities, looking at high-risk groups such as female immigrants and refugees, as well as examining the role of cultural factors. They also show how epidemiology, theory, and other research findings can be translated into solid prevention and treatment programs.

An innovative and highly effective brief therapy for suicidal patients “ASSIP is perhaps the most significant innovation we have seen in the assessment and treatment of suicidal risk...” David A. Jobes, PhD, Professor of Psychology, The Catholic University of America, Washington, DC, USA Past President, American Association of Suicidology

Konrad Michel / Anja Gysin-Maillart

ASSIP – Attempted Suicide Short Intervention Program A Manual for Clinicians

2015, x + 114 pp. US $59.00 / € 41.95 ISBN 978-0-88937-476-8 Also available as an eBook Attempted suicide is the main risk factor for suicide. The Attempted Suicide Short Intervention Program (ASSIP) described in this manual is an innovative brief therapy that has proven in published clinical trials to be highly effective in reducing the risk of further attempts. ASSIP is the result of the authors’ extensive practical experience in the treatment of suicidal individuals. The emphasis is on the therapeutic alliance with the suicidal patient, based on an initial video-recorded narrative interview and the

www.hogrefe.com

development of personalized safety strategies. The three to four therapy sessions are followed by continuing contact with patients by means of regular letters. This clearly structured manual starts with an overview of suicide and suicide prevention, followed by a practical, step-by-step description of this patient-oriented treatment. It includes numerous clinical vignettes, handouts, and standardized letters for use by health professionals in various clinical settings.