A qualitative study of potential suicide risk factors in returning combat veterans
Predictors of the risk factors for suicide identified by the interpersonal-psychological theory of suicidal behaviour. Psychiatry Research 2 : , Most Shared. PDF Full Text. Follow on Facebook. Follow on Twitter. Follow on LinkedIn. Related references.
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The only LIWC analysis we know of in Spanish was conducted with a small number of suicide notes collected in Spain, which found language differences depending on the authors' sex, age and community However, as far as we know, Spanish suicide notes have not been qualitatively analyzed in search of indicators of risk factors proposed by the ITS. The LIWC has also not been applied to detect specific language profiles according to the presence or absence of these factors.
We therefore established the following objectives and hypotheses based on previous studies :. We hypothesized that such a relationship exists and that we would find differences by sex and age in suicide methods used and triggers of suicide. Our hypothesis was that we would find the "lack of belonging" factor more often and that these factors would be present in a high percentage of the analyzed notes.
Our hypothesis was that the "lack of belonging" factor would be more common in young individuals, the "perceived burdensomeness" factor would be more common in elderly people and in women, and men would show a higher "acquired capability for suicide". Our hypothesis was that the "perceived burdensomeness" and the "acquired capability to suicide" factors would be related with higher lethality, and that such lethality would be higher in men and elderly people.
Our hypothesis was that we would find such different language profiles and that the percentage of use of positive and negative emotion words would be different in notes which include content related to these factors and those without it. The sample of suicide notes was collected based on a review of official records of deaths registered as suicides in Chile from January to June and investigated by the Homicide Brigade of the Chilean Investigative Police.
A total of 1, The individuals whose report contained a suicide note were characterized by their demographic and forensic characteristics. The individuals were also classified according to the lethality of the method chosen for carrying out suicide, following the criteria proposed in previous studies Methods that resorted to poisoning, overdosing, asphyxiation or knives were classified as "relatively low lethality", while methods that included hanging, jumping and firearms were classified as "relatively high lethality".
All personal data were processed according to the directives of the World Health Organization and the Declaration of Helsinki. To search for ITS factors, each note was classified independently by 3 judges a clinical psychologist, a forensic psychologist and a psychiatrist, all authors of this study according to whether the contents referred to "feeling like a burden" and "lack of belonging" factors. To this end, we followed the criteria proposed in previous studies 29,30 where the presence of perceived burdensomeness was related to any reference to being a burden emotional, financial Criteria for thwarted belongingness included feelings of being isolated or disconnected from others, feelings as though they do not fit in or feeling lonely and concern about it and suicide related to a recent loss.
Each suicide note was scored for both factors, indicating whether each was "clearly present", "possibly present" or "absent". For the purposes of this study, we combined the "clearly present" and "possibly present" results. The third factor proposed by the ITS "an acquired capability for suicide" was classified as present in those individuals for whom we had proof of at least one previous suicide attempt or a history of suicide in the family of origin following previous criteria We analyzed the potential relationships between the 3 ITS factors and the relative lethality of the chosen method and between these factors and other characteristics of the suicide note authors.
For the linguistic analysis, we analyzed the written material collected in each case as a continuous text using the Spanish version of the LIWC We linked their results to their authors' gender and age, as well as to the presence or absence of the interpersonal factors of suicide risk established in the ITS 6. We performed a descriptive analysis of the data. To compare categorical variables, we employed the chi-squared test.
Kolmogorov-Smirnov normality tests were also performed. Bonferroni correction was made to the control of the Type I error. Clinical and demographic characteristics; relationship with sex and age of the deceased. The characteristics of the sample of individuals who left a suicide note are listed in the following table see Table 1. In terms of supposed suicide trigger, the individuals with physical disease had a statistically higher mean age In the analysis of ITS characteristics, initially the 3 judges completely agreed on the classification of 62 of the 80 suicide notes The "lack of belonging" factor was the most common and was detected in We found content referring to both risk factors in 14 of these notes.
The third factor or "acquired capability for suicide" was scored as present in 14 cases We analyzed the relationships between the 3 ITS factors and sex, age and living with a partner or not at the time of the death. This factor was present in more females 8 of 24; Relative lethality of the suicide method and its relationship with other variables. Of the 80 cases analyzed, 70 The analysis of the 2-to-2 relationship between "relative lethality of the chosen method" and "acquired capability", "lack of belonging" or "feeling like a burden" factors did not achieve statistical significance.
The 3 ITS factors analyzed jointly also were not predictors of greater relative lethality of the suicide method. More males chose relatively high lethality methods 53 of 56; This usage was greater in the notes with this factor. The most often chosen method of suicide according to sex hanging in males and poisoning in females was similar to that found in previous European studies The presence of mental illness is a significant risk factor for suicide.
It is estimated that a high percentage of individuals who die from suicide have this condition 34, Previous studies have shown that suicidal ideation is related to the presence of depression and that planned and attempted suicide is related to disorders characterized by anxiety or agitation and poor impulse control In our sample, the relatives identified the presence of mental illness as the supposed trigger in only 7 cases and more often in females, possibly because we have more females with previous suicide attempts, which makes the presence of mental health problems more visible.
Assuming that a trigger may be on the mind of the victim without being displayed in its suicide note or known by their relatives, is striking the limited election of mental illness as the trigger, given that there was a history of psychiatric treatment or untreated depressive symptoms in 47 of the deceased. This fact could be related to the stigma that surrounds mental illness 37 and the burden and stigma by association that this frequently represents for the family Of these 47 cases, 18 were female of 24 deceased , with more females than males undergoing psychiatric treatment International studies have linked this problem with the low perceived need for treatment and the negative attitudes towards the search for this treatment the desire to handle it without help, the belief that it will improve on its own, that it is not a serious problem or that treatment will not be effective, the associated stigma, etc.
Studies have also linked this problem to structural barriers such as difficulties accessing treatment The individuals for whom physical disease was considered the suicide trigger were older, an expected result given the increased morbidity associated with aging, which constitutes a risk factor for suicide per se 1 and given the presence of a positive correlation between suicide and dependence in elderly individuals In terms of the qualitative analysis of the suicide notes, we found content referring to the ITS risk factors of "lack of belonging" and "feeling like a burden" at higher rates than in the study by Gunn et al.
The "lack of belonging" factor was more common in previous studies 29,30 and was in tune with the fact that emotional problems were the more frequently indicated trigger. In general, it is commonly accepted that females attempt suicide more often than males It has been hypothesized that it is more common for females to attempt suicide as a means of communicating their discomfort or to achieve changes in their environment suggesting a lower suicidal intent.
This hypothesis is controversial, however, given that the degree of intent does not necessarily correlate with the lethality of the chosen method 43 , and the result could be determined by the selection of the method The higher rate of attempted suicide in females could explain why the ITS "acquired capability" factor was more common in our study in the cases where the deceased was a female, given that the presence of previous suicide attempts was one of the criteria we used to identify this factor.
This result does not agree with those of earlier studies, possibly because in those studies this capability was estimated by taking more variables into account We also found no correlation between content referring to the "feeling like a burden" factor and older age 8 , possibly due to the scarcity of individuals in our sample older than 61 years We found no relationship between the "lack of belonging" factor and youth in the notes 29 or between this factor and living with a partner or not at the time of death.
In contrast to previous findings 28 , there was no correlation in our sample between the relative lethality of the chosen method and other ITS factors, although this result may be influenced by the shortage of people with relatively low lethality methods of suicide in our sample. We confirmed the selection of more lethal suicide methods among males than in females Lastly, in the linguistic analysis of the notes, the higher usage of words from the LIWC category "human" in the notes written by females could indicate as noted by Newman et al.
The language used in the suicide notes of the youngest individuals showed a higher rate of affective and positive emotion words. The use of emotion words would be an indicator of greater personal immersion in the writing, and the use of the present time provides closeness and warmth 48, The greater use of words from the "cognitive mechanisms" category would indicate greater reflection and focus on the underlying meaning of the topic The language used by the elderly in their suicide notes is, in contrast, more elaborate and careful with a higher usage of grammatical particles and long words and is more focused on specific issues money, occupation and with fewer indicators of social connection and integration These results do not agree with the findings from the analysis of suicide notes from Spain, in which the notes written by females were longer and used a greater percentage of words related to feelings and emotions, more verbs in the past and future and more first-person plural pronouns than those written by males.
The notes of younger individuals were different from those written by older individuals only in the greater use of punctuation marks Given that Spanish is spoken by more than million individuals worldwide who live in various countries and cultures, we must consider the linguistic differences between South American Spanish which is neater and more nuanced, with longer greetings and farewells and the Spanish spoken in Spain which is shorter and more specific, among other differences.
These differences are accentuated in the popular language 52 and could explain the divergence in the results. We found differences in the language used in the notes according to the presence or absence of content related to ITS factors, but not uniquely regarding use of emotion words. The suicide notes that included these factors were longer; the notes in which the "lack of belonging" factor was detected made greater use of the second-person singular pronoun and the first-person plural pronoun, as well as words in the "human" and "negative emotions" categories words such as abandonment, grief and isolation.
These notes therefore referred more frequently to difficulties with the reference group and with the important individuals for the authors of the notes. The suicide notes that included references to the "feeling like a burden" factor included a greater percentage of words of the "cause", "optimism" and "achievement" categories.
These notes are more focused on explaining the reasons for the decision and emphasizing the benefits for those left behind, who would be "better off once the individual has gone away". These results were different from those found previously 27 although in our sample we analyzed suicide notes and not texts written by individuals without a history of suicide. More females than males were undergoing treatment. The use of poisoning as a suicide method was more common among females, while males preferred the use of hanging, choosing suicide methods with relatively greater lethality.
The families most often indicated mental illness as the trigger in females and physical disease for elderly individuals. Therefore, these factors should be considered and assessed in clinical settings to improve understanding and, above all, prevention of suicide. In particular, the theory stipulated that the combination of perceived burdensomeness and low belongingness and hopelessness about these perceptions creates desire for suicide, whereas the capability to act on suicidal desire requires that one overcome fears of death and pain that are a natural part of attempting suicide.
While the specifics of the interpersonal theory have received significant study, we propose that the framework itself is at least as important a contribution to the field. Thus, we view Joiner's theory as the first theory of suicide to be positioned within the ideation-to-action framework.
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Indeed, Joiner's theory appears to have spawned additional theories grounded in the ideation-to-action framework see Table 1. The IMV suggests that defeat and entrapment are the primary causes of suicidal ideation and that acquired capability along with other factors e. In addition to guiding research and theory, the ideation-to-action framework should also inform applied domains, such as prevention and risk assessment. For example, prevention and treatment programs should distinguish which intervention targets and mechanisms of change address ideation and which are meant to impede progression from ideation to attempts.
We believe the framework should also inform the field's approach to risk assessment. To illustrate, we consider efforts to identify and label suicide risk factors. Table 2 contrasts the traditional approach to suicide risk with the approach suggested by the ideation-to-action framework.
The traditional approach treats suicide risk as a unitary construct; all risk factors are listed in a single column. In contrast, the ideation-to-action framework distinguishes predictors of ideation from predictors of the progression from ideation to behavior. Variables such as depression, most mental disorders, hopelessness, and most forms of impulsivity are included only in the ideation column on the basis of evidence suggesting that these are strong correlates of ideation but that they poorly distinguish attempters from ideators without attempts Kessler et al.
Finally, some variables, such as a diagnosis of posttraumatic stress disorder and a history of NSSI, appear in both columns because research indicates that they are correlates of both suicidal ideation and behavior Klonsky et al. Importantly, the research summarized above is mainly correlational, and it will be necessary for future research to specifically identify risk factors for suicidal ideation and attempts using prospective designs.
The traditional approach treats suicide risk as a unitary construct; in contrast, the ideation-to-action framework distinguishes predictors of ideation from predictors of the progression from ideation to behavior a. The 3ST utilizes the ideation-to-action framework, is informed by previous research and theory, and provides a parsimonious and testable model of suicide. The key constructs of the 3ST are pain and hopelessness, connectedness, and suicide capacity.
The theory is summarized below and illustrated in Figure 1. Figure 1. According to the 3ST, the first step toward ideation begins with pain. Pain typically but not necessarily means psychological or emotional pain. All people are shaped by behavioral conditioning Skinner We engage in behaviors that are rewarded and avoid those that are punished.
Related The Interpersonal-Psychological Theory of Attempted and Completed Suicide
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