_______________________________________________________________________ Depression and Suicide
Holiday Suicide Myth The idea that suicide is more frequent during the holiday season is a debunked myth partially perpetuated by the media [373]. Suicide rates are lowest in December and highest in the spring and fall [422]. The holiday suicide myth is important to counter because it provides misinformation about suicide that may interfere with prevention efforts [423]. SUICIDE MODELS AND RISK FACTORS As discussed, the lack of predictive value for risk factors is now recognized [424]. The predictive disparity of traditional suicide risk factors (strong for ideation, poor for behavior) suggests that development of suicide ideation and movement from ideation to potentially lethal attempts are distinct processes, with distinct explanations and predictors. This has prompted efforts to identify novel, more effective risk factors guided by strong theoretical models [350; 425]. Other lines of research have identified the need to address acute and immediate factors influencing suicide risk. Many patients have long-term (i.e., one to five years) ideation or tentative planning before a suicide attempt, but almost all proximal planning occurs within two weeks and the majority occurs within 12 hours of a suicide attempt [426]. Assessment of outpatients with past-year suicide attempts and inpatients admitted for suicidality over two to four weeks showed sui- cidal ideation, hopelessness, burdensomeness, and loneliness varied dramatically over the course of most days in nearly all patients [427]. The suicide prevention field is in transition. Suicide risk fac- tors, assessment tools, and risk level stratification are largely ineffective in short-term prediction of suicide but have not yet been replaced by more effective methods. Resources for suicide prevention are available from the CDC at https://www.cdc. gov/suicide/resources. The Interpersonal-Psychological Theory of Suicide The Interpersonal-Psychological Theory of Suicide posits that persons will not make lethal suicide attempts unless they have developed the desire (i.e., low belongingness, high bur- densomeness) and ability to do so [377]. Thwarted belonging- ness is defined as the experience of having little or no social connectedness, a result of living alone, death of a spouse, or disabling physical or psychiatric illness. The need to belong is a core aspect of human nature; when unfulfilled, suicide risk increases [428]. Perceived burdensomeness is evident when per- sons feel their family members and the world in general would be better off if they were no longer living, and this can initiate suicidal ideation [428]. Acquired capability for suicide refers to reaching the point at which a patient overcomes his or her innate fears of pain, injury, and death with suicide. Opponent process theory suggests with repeated exposure, the effects of previously noxious, aversive, or provocative stimuli may recede, and the opposite effect of the stimuli becomes strengthened
and amplified [429]. Persons can habituate to pain, injury, or death through previous suicide attempts, exposure to trauma, armed combat, violence, or death and diverse experiences related to psychologic and physical pain [350; 351]. The Cubic Model The cubic model defines psychologic pain—psychache—as one of three essential dimensions in suicide risk (along with stress and perturbation) [430]. Psychache often underlies the desire to escape from unbearable pain and represents a state of anguish sufficiently aversive to over-ride innate fears of pain, injury, and death [351]. Psychologic pain distinguished attempters from ideators among 378 adults with history of suicidality [350]. Non-Suicidal Self-Injury Non-suicidal self-injury (NSSI) is intentional, non-socially accepted damage to the bodily surface, without suicidal intent, by cutting, scratching, hitting/banging, carving, or scraping. Roughly 17% to 18% of teens have one or more NSSI event; up to 60% of adolescent psychiatric patients have one NSSI event and 50% have repetitive NSSI [431; 432]. NSSI prevalence is higher in girls and women. It rises from late childhood to early adolescence, peaks in mid- to late-adolescence, and generally declines by young adulthood [383]. NSSI can occur without a psychiatric diagnosis [433]. NSSI serves as a means to escape aversive emotional (e.g., sad- ness, anxiety) or cognitive (e.g., negative thoughts or memories) states, relieve tension or anger, or regain perception of control [383; 434]. Adolescents with repetitive NSSI remain at high risk of dysfunctional emotion regulation strategies after ceas- ing the behaviors and show increased substance abuse as the behaviors decrease [435]. Those who cut themselves on body areas other than arms or wrists have the greatest risk of subse- quent suicide [436]. Identifying with “goth” or “emo” youth subculture, sexual minority status, social media exposure to self-injury behaviors, bullying, and childhood emotional abuse are risk factors for NSSI [437]. There is a temporal relationship between nonsuicidal and sui- cidal self-injury in adolescent outpatients and inpatients. On average, suicide ideation occurs before initial NSSI behavior, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than sequentially from nonsui- cidal to suicidal self-injury. The transition from nonsuicidal to suicidal self-injury is relatively fast, and a key period for intervention and prevention is within the first 6 to 12 months after the onset of suicidal thinking [438]. Chronic Pain Chronic uncontrolled pain is second only to bipolar disorder as a medical cause of suicide [439; 440; 441]. The distress, exhaustion, and hopelessness of chronic unrelieved pain can invite intended overdose. Death is no longer feared, but
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