Psychotherapy Brown Bag

Emotion dysregulation and suicide

by Michael D. Anestis, M.S.

I have a small window here at the end of my work week to put together a quick post, so I wanted to spend a little time talking with PBB readers about a study I just published with Thomas Joiner (Anestis & Joiner, in press) in the Journal of Affective Disorders.  The study took a new look at the interpersonal-psychological theory of suicidal behavior (IPTS), taking emotion dysregulation in general (and negative urgency in particular) into consideration.

Click on the IPTS link above for a more thorough description of the theory, but here is a quick summary of what the theory says:

• We must differentiate between the desire for death by suicide and the capability for death by suicide
• Few who desire have the capability and few with the capability have the desire.
• The desire is comprised of two variables: thwarted belongingness and perceived burdensomeness.  The former refers to a distorted belief of an individual that he or she has no meaningful connections to others and the latter refers to a distorted belief of an individual that he or she makes no meaningful contributions to the world.
• The acquired capability for suicide is comprised of a diminished fear of death and a heightened tolerance for physical pain.  This is developed through repeated exposure to painful and/or provocative events.

All of these points have been supported through extensive research and many of those studies have been written about previously on PBB (click here to access all PBB articles that discuss suicide).  Despite all of this great research on the IPTS, there are a number of important areas for which we simply do not yet have data.  Dr.Joiner and I addressed a couple of those in this study:

• What role might emotion dysregulation have in suicide risk?
• Does the IPTS work the same for everyone?

The way we approached this was by gathering data from 492 patients at an outpatient community mental health clinic on a number of variables relevant to this topic.  For emotion dysregulation, we looked at negative urgency, which is defined as the tendency to act rashly in an effort to diminish negative emotions (click here for a more thorough description of this idea).  We hypothesized that the three-way interaction of the IPTS components (perceived burdensomeness, thwarted belongingness, and the acquired capability for suicide) would predict participants' lifetime number of suicide attempts, even when controlling for sex and depression severity.  In other words, we believed that individuals with high levels of all three of those variables would have a greater number of lifetime suicide attempts and that effect would not be better accounted for by being male or female or being depressed.  This, in fact, turned out to be the case.

Going a step further, we made our own heads spin and hypothesized that the four-way interaction of the IPTS components and negative urgency would also predict lifetime number of suicide attempts.  In other words, we anticipated that individuals who not only had high levels of thwarted belongingness, perceived burdensomeness, and the acquired capability, but also high levels of negative urgency, would have the greatest number of lifetime suicide attempts. Again, the data supported our hypothesis.  Four-way interactions are not something you typically see, as they are highly complicated and a bit confusing, but think of it this way:  we understand from multiple studies now that when individuals have elevations on all three IPTS components, they're likely to be at greater risk for suicide and, as we showed here, are likely to have a more extensive history of suicidal behavior.  The question though is, do elevations on those variables have the exact same level of impact for everyone or are there some people for whom this is a bigger deal?  This is like stress and depression.  Anyone who becomes stressed is more vulnerable to becoming depressed, but folks with a genetic vulnerability to mood disorders might be more likely to become depressed in response to stress than would somebody without that vulnerability.  In this case, we're saying that anyone with elevations on the IPTS components is likely to have a more extensive history of suicide attempts, but folks with high levels of negative urgency are at particular risk in that scenario.

Why might this be?  There are a bunch of potential answers here.  The first might simply be that these folks are also more likely to have Cluster B personality disorders like borderline personality disorder.  Another might be that a lifetime of struggling to manage negative emotions leaves these individuals more likely to consider harmful methods for regulating how they feel because, faced with this problem over and over throughout the years leaves them ready to accept highly imperfect options in frequent moments of desperation.  As it turns out, I have some new data that leaves me thinking the answer is something else entirely; however, while the initial paper discussing those results is under review at a journal, I have to hold off on discussing them in order to avoid shooting my own legs out from under me.

All this being said, I will be discussing these results at the Association for Behavioral and Cognitive Therapies conference in San Francisco this November on a panel with PBB contributors Tracy Witte, Kim Van Orden, and Kelly Cukrowicz, so if you plan on attending the conference, I'll look forward to hearing your thoughts.

************

If you would like to learn more about this or other topics discussed on PBB, please consult our online store for scientifically-based psychological resources.

Mike Anestis is a resident at the University of Mississippi Medical Center and a doctoral candidate in the clinical psychology department at Florida State University

New research on suicide in the military

by Michael D. Anestis, M.S.

Suicide in the military has been one of the central components of my research over the past few years.  In doing this, I have been privileged to collaborate with some amazing psychologists, some of whom are members of the military and some of whom are not.  Late last year, Chad Morrow of the United States Air Force contributed a guest article about a study that several of us published examining suicide in Air Force personnel (click here to read the article).  Today, I would like to quickly discuss an article published  in the Journal of Clinical Psychology by PBB guest author Craig Bryan, PBB guest author Kelly Cukrowicz, Christopher West, and PBB guest author Chad Morrow (in press).  I'm not going to repeat all of the information about the interpersonal-psychological theory of suicidal behavior, so if you are unfamiliar with the theory, I encourage you to read our previous discussions before going further here.

In this particular study, Bryan and colleagues (in press) compiled a sample of 522 service members deployed in support of Operation Iraqi Freedom (OIF).  This, in and of itself, is a big deal, as previous research on the interpersonal-psychological theory in military samples have involved case studies or personnel not yet deployed.  151 of the participants were referred to an in-theater traumatic brain injury (TBI) clinic, 44 self-identified for routine services in an in-theater mental health clinic, and 327 took part in baseline psychological testing in case of future head injuries during deployment.  The sample was thus a mix of clinical and non-clinical cases.

The authors hypothesized that combat exposure would predict the acquired capability for suicide, but would not predict either of the components of the desire for suicide (thwarted belongingness and perceived burdensomeness). In order to be sure that any relationship between combat exposure and the theory components was not better accounted for by other variables, the authors controlled for gender, past suicidality, PTSD symptoms, and depression symptoms.

So what did they find?  Combat exposure did, in fact, significantly predict the acquired capability, although it accounted for only a small portion of the variance. In other words, combat exposure accounted for some degree of why different individuals scored differently on the acquired capability, but other variables play a bigger role.  The authors raised some interesting thoughts as to why this might be the case.  First of all, it is entirely plausible that the intensive training that takes place prior to deployment into combat could elevate the average level of the acquired capability high enough that combat exposure does not add all that much to what has already been gained.  Alternatively (or additionally), it might be that individuals who enroll in the military already have the elevated physiological pain tolerance and diminished fear of death that comprise the acquired capability.  Here again, because initial levels are already so high, it might be difficult for combat exposure to account for all that much variability.  Future research utilizing a number of time points, tracing the progress of individuals' acquired capability from the time they enter the military (or before) would help us answer this question.

Bryan and colleagues (in press) also found that, as expected, combat exposure did not predict the desire for suicide.  Keep in mind that the current state of affair, in which suicide rates in the military are higher than civilian rates, is unique in history.  Traditionally, the opposite has been true and many have explained this state of affairs to the fact that soldiers often form strong bonds with fellow soldiers (increased belongingness) and feel that they are making an important contribution to the world (decreased burdensomeness).  As a result, although soldiers develop a vastly enhanced capability for suicide, they do not necessarily ever experience the desire.  Combat exposure on its own, it seems, does not account for increases in that desire.  Instead, when solders experience suicidal ideation, this is better accounted for by depression symptoms, PTSD symptoms, and a number of other related but distinct ideas.

So what does this study tell us?  It appears that when soldiers are exposed to combat, their capability for enacting lethal self-harm increases.  Their desire for suicide, on the other hand, is unrelated to combat exposure.  Future research will tell us more about the mechanisms that drive suicidal behavior both in the military and in civilian populations, but this study marks an impressive step forward in empirical investigations on suicide in this particular segment of the population.

************

If you would like to learn more about suicide or other topics discussed on Psychotherapy Brown Bag, we hope you will consult our online store for scientifically-based psychological resources.  Additionally, if you or anyone you know is experiencing thoughts of suicide, please remember that 1-800-273-TALK is a free, 24/7 service available to those in need.

Mike Anestis is a doctoral candidate in the clinical psychology department of Florida State University and an incoming resident at the University of Mississippi Medical Center.

Physicians and pain - One potential explanation for their elevated rates of death by suicide

by Michael D. Anestis, M.S.

It's been a bit of a slow week on PBB as I have attended to research projects while juggling a tricky schedule, but I have a little bit of time today to discuss an article sent to me by a colleague, Scott Braithwaite.  The article, written by Jean Decety, Chia-Yan Yang, and Yawei Cheng (2010), is from a journal called NeuroImage and examines the response to images of pain in physicians relative to individuals with no medical training.  At first glance, this might seem a bit off topic for this site, but bear with me as I try to tie it together with one of our most frequently discussed topics: suicide.

The authors of this study noted that research using functional neuroimaging strategies has shown that, when people see others experiencing pain or even simply imagine this happening, they experience an activation in a neural curcuit related to pain processing.  This response, which is fairly aversive, readies the person to respond to a potentially threatening environment.  At the same time, this sensation can elicit empathy and concern for the individual in pain.  All of these responses are relatively adaptive as long as they are experienced in moderation.  If, on the other hand, an individual chronically witnesses or imagines such imagery, he or she could ultimately experience a number of problematic outcomes, ranging from burnout to compassion fatigue to a deficit of cognitive resources that diminishes the individual's ability to effective attend to the individual in need (Decety & Lamm, 2009).

For physicians, this represents a bit of a tricky situation.  On the one hand, empathy is a healthy feeling and an aversive response to pain in other that motivates decisive action could be professionally beneficial.  On the other hand, if the job entails constant interactions with pain, physicians might use up emotional and cognitive resources and become unable to effectively manage their job. In this sense, it seems imperative that physicians be able to control their response to the sight of pain in other individuals in order to ensure that they can remain effective at their job over an extended period of time.  Along these lines, previous research by Cheng and colleagues (2007) demonstrated that, when shown images of hands and feet either being pricked by a needle or rubbed by a Q-tip, non-medical personnel experienced activation of the pain matrix in their brain whereas physicians experienced activation of the cortical regions involved in executive functions, self-regulation, and executive attention.  In other words, physicians responded in a completely different manner that enabled them to focus on the job at hand without using up cognitive resources on a more typical response to pain.

To investigate this phenomenon further, Decety and colleagues (2010) designed a study that utilized data from 30 participants, 15 of whom were physicians and 15 of whom had no medical training.  My limited medical knowledge will prevent me from providing you with a detailed description of the methods; however, the actual article describes them quite well and I encourage you to consult that resource.  Essentially what happened is that the participants were shown 120 images of various body parts either being pricked with a needle or rubbed with a Q-tip.  Additionally, each participant filled out a number of questionnaires and, as they viewed the images, an EEG was used to detect brain activity.

The authors found a number of interesting results.  First, control participants demonstrated substantial pain empathy in their EEG results (frontal N110 and late centro-parietal P3 activation) when viewing painful images relative to the Q-tip images.  Physicians, on the other hand, did not respond differently to the two types of images and also provided lower subjective ratings of pain intensity and unpleasantness than the controls did.  In other words, the painful images did not cause the physicians to react any differently than the Q-tip images did and they believed the experience of pain in the needle images to be less severe than the controls did.  Additionally, physiological response to painful images was coupled with subjective pain intensity ratings in controls, but not in physicians.  In other words, whereas control participants responded physically to a greater extent when they believed the image involved more pain, physicians' physical responses were not impacted by how painful they believed the image to be.

So what does this all mean and why am I writing about it on PBB?   Perhaps even more importantly, why did I mention suicide in the title of this post?  Think back to our article describing Joiner's interpersonal-psychological theory of suicidal behavior (2005).  You'll remember that Joiner differentiates between those who desire suicide and those who are capable of it.  In order to acquire the capability for suicide - which entails an elevated tolerance for physical pain and a diminished fear of death - an individual must encounter a substantial number of painful and provocative events (e.g., Van Orden et al., 2008).  Doing this enables the individual to habituate to stimuli in their environment that previously would have been frightening or overwhelming.  For instance, some research has demonstrated that individuals who have engaged in non-suicidal self-injury over an extended period of time no longer feel pain while self-injuring (e.g., Nock & Prinstein, 2005).  Similarly, Orbach and colleagues (1997) found that individuals with multiple suicide attempts were able to tolerate more physical pain that were individuals with zero or one attempt.  Put simply, the more an individual encounters and/or experiences pain, the less frightened they become of it and the more able they become to lethally harm themselves.  The experience of doing so becomes less daunting (keep in mind, however, the majority of individuals capable of lethal self-injury have no desire to end their own lives).

As it turns out, physicians have one of the highest suicide rates of any occupation.  They also regularly encounter substantial amounts of pain in their patients.  In order to protect themselves from burnout, emotional distress, and limited cognitive capacity in emergent situations, physicians need to develop the ability to push through such situations and remained focused on the task at hand.  In doing so, it appears that they might change their relationship with and response to pain, which in turn would elevate their acquired capability for suicide.  This is an untested hypothesis with physicians; however, the situation is not unlike that of the military and, in a study I was fortunate to work on with PBB guest authors Craig Bryan and Chad Morrow as well as Thomas Joiner (2010), we found that US Air Force personnel who had recently completed basic training had higher levels of the acquired capability than did an outpatient community clinic sample.  In both professions, there is a need to habituate to pain and fear in order to accomplish a task that is innately frightening and dangerous.  There is nothing inherently wrong with becoming able to accomplish such noble tasks; however, it is important to keep in mind that, along with the benefits of such a shift, there comes the cost of increased risk.  In this case, the risk takes the form of an increased acquired capability for suicide, meaning that these individuals immediately fall into the severe risk category any time they experience thoughts of suicide.

There are a couple of issues that were not relevant to the authors' goals, but which need to be considered when thinking about these results within the context of the interpersonal-psychological theory (keep in mind that these authors were not even looking at suicide risk - that is simply an issue I am bringing to the table).  First, because this was not a longitudinal design, we cannot be certain that a selection bias was not in place.  In other words, it remains possible that people who already respond to pain this way are more likely to become physicians and that these results do not actually represent change on the part of the participants.  Second, another important variable to keep in mind here would be psychopathy.  You might remember from previous discussions we've had about psychopathy that individuals who fit within that category have very low emotional reactivity and almost no risk of suicide.  That being said, if a psychopath develops the acquired capability for suicide, and the behavioral tendencies characteristic of psychopathy render that possibility almost certain, he or she would still not be a great risk for suicide, as thoughts of suicide are unlikely to ever occur.

So, what is the take home point here?  These data indicate that physicians do not respond to images of pain in others like non-medical personnel do.  Instead, their response is dampened and their pain empathy is diminished, which allows them to avoid becoming emotionally overwhelmed and using all of their cognitive resources on processing emotions rather than planning and administering the appropriate medical intervention.  This is a reasonable response for individuals in their position; however, it is also likely to result in an increased acquired capability for suicide, which places them at greater risk should they ever experience suicidal ideation.  The point here is not that physicians should avoid this shifting view of and response to pain, but rather that mental health practitioners should be aware of its impact on suicide risk and carefully assess these variables when determining the safety of the client.

************

If you would like to learn more about this and other topics discussed on PBB, we hope you will consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center

Thinking about suicide whether or not you know it: The utility of implicit associations in predicting behavior

by Michael D. Anestis, M.S.

They've done it again...Matt Nock and his colleagues have designed, written-up, and published a study that leaves me feeling like a scientific minor leaguer.  This morning, a colleague of mine - April Smith - forwarded along this document, which I immediately recognized as the type of information that should be passed along to PBB readers and hopefully many others who do not fall within that umbrella.

The study, published in Psychological Science, takes a look at implicit thoughts about death and their ability to predict both past and future suicidal behavior.  Nock and his colleagues (2010) gave a thorough review of the literature on suicidal behavior and noted that, because most studies rely upon self-report, they are burdened by a fairly substantial weakness: individuals are not always aware of their own suicidal thoughts and, when they are, they are not always honest about reporting them.  They noted that this is evidenced by the fact that one study found that 78% of patients who died by suicide deny experiencing suicidal thoughts during their last verbal communication prior to taking their own lives (Busch, Fawcett, & Jacobs, 2003) and that suicide risk is amplified in the days immediately following release from inpatient hospitalization, which theoretically must have been precipitated by the patient indicating that he or she did not have any suicidal desire or intent (Qin & Nordentoft, 2005).

This is not to say that reports of suicidal ideation are meaningless.  As much of the research we have discussed on the site notes, when an individual reports thoughts of suicide, this is very meaningful information.  The point instead is simply that reporting a lack of suicidal ideation does not necessarily mean that the thoughts are not really there and the individual is not at risk.  To adjust for this type of situation, researchers have developed what are termed "implicit association tasks."  These tasks present participants with a number of stimuli, sometimes images, sometimes words and ask them to press a particular key indicating the category in which the stimulus fits.  In this particular task, participants were presented with words on a computer screen representing "death" (e.g., die, dead, suicide, lifeless), "life" (e.g., alive, survive, thrive, breathing), "me" (e.g., I, myself, mine, self), and "not me" (e.g., they, them, their, other).  During one part of the task, participants were told to hit one key if the word presented represented "life" or "me" and another key if the word represented "death" or "not me."  During the other part of the task, participants were told to hit one key if the word represented "death" or "me" and another key if the word represented "life" or "not me."  The order of those two sets of instructions was randomized across participants.  When participants responded more quickly to the "death/me" blocks relative to the "life/me" blocks, they were said to have displayed a stronger implicit association between death and self.  The idea here is that the individual is better able to quickly recognize, categorize, and respond to stimuli that fit well together in their mind.

The participants in this study were 157 adults who had presented to a psychiatric emergency department in a northeastern hospital. 43 of those individuals reported having attempted suicide within the past week.  Once the patients had been stabilized and given consent to participate, they were administered the implicit associations task, as well as a number of other questionnaires.  These included a measure of past suicidal behavior and non-suicidal self-injury, the participants' and clinician's predictions regarding the likelihood that the individual will attempt suicide within the next six months, and the presence of depressive symptoms.  Participants were approached again six months later, at which point they were assessed for suicidal behavior and non-suicidal self-injury since the initial experiment time and hospital records were checked to determine if the participant had been admitted due to suicidal behavior.

The authors found a number of interesting results.  First, individuals who had been admitted to the hospital due to a suicide attempt demonstrated a stronger implicit association between self and death.  In other words, it is not simply that they reported having such thoughts, but rather that they demonstrated this tendency in a task that moves too quickly for them to be able to manipulate their performance.  Taking this even further, this finding was specific to suicidal behavior.  In other words, individuals who engaged in self-injurious behavior without the intent to die did not show a stronger implicit association between self and death than did individuals admitted to the hospital for other psychiatric emergencies.

As impressive as these findings are, they do not quite compare to the follow-up results.  14 individuals in the study attempted suicide in the six months between the initial experiment time and the follow-up appointment.  As it turns out, individuals who demonstrated a positive association between death and self (they responded more quickly in that condition than in the condition in which words representing life and self were paired together) also demonstrated a six-fold increase in risk for suicide attempts in the six months immediately following the experiment.  The implicit measure made this prediction above and beyond the effects of other well-known predictors of suicide risk, including depressive disorders and previous suicidal behavior.  Participants' predictions about the likelihood of making a future attempt significantly predicted future suicidal behavior but was not a stronger predictor than the implicit measure.

The final finding I wanted to discuss was the prediction of future suicidal behavior by clinicians.  In this particular study, clinicians predictions were not significantly related to outcome.  Clinicians were asked to base their predictions on clinical intuition and all that they knew about the patients.  It is not entirely clear how each clinician weighted intuition versus data (e.g., number of previous attempts, presence of plans and preparation, access to means), but the non-significant finding is an important parallel to the work of Dawes, Faust, and Meehl (1989) who demonstrated so clearly that clinical judgment simply does not outperform actuarial methods.  Given the importance of being able to predict and thus prevent suicidal behavior, this is a particularly important consideration with respect to how we as clinicians conduct proper risk assessments.  Fortunately, we do have empirically tested methods for assessing risk, so hopefully findings like this will encourage clinicians to consider utilizing actuarial methods in an effort to mitigate risk.

************

If you would like to learn more about suicide or other topics discussed on PBB, we recommend that you consult our online store of scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center

"Pulling together" and suicide: Some thoughts on baseball's Opening Day

by Michael D. Anestis, M.S.

In celebration of baseball's Opening Day - and as a Pirates fan, today is Day 1 - I want to take a quick look at some research that has considered sports and mental health.  Specifically, I would like to review a paper published by several of my colleagues - Thomas Joiner, Daniel Hollar, and PBB guest author Kim Van Orden - in the Journal of Social and Clinical Psychology (2006).  In an effort to demonstrate the importance of shared positive experiences in reducing suicide risk, Joiner and colleagues (2006) conducted three small studies.  In each, their goal was to examine the degree to which suicide rates could be predicted by sporting events around which communities "pulled together."

In study 1, the authors wanted to look at the relationship between national rankings of college football teams and local suicide rates.  Joiner and colleagues hypothesized that, in communities in which college football was "the only game in town," meaning that there were not other similar forms of entertainment (e.g., professional sports teams), local suicide rates would be lower in years in which the local college football team achieved a higher national ranking.  To test this, they examined the relationship between suicide rates and national rankings between 1990 and 2002 for Franklin County, Ohio - home of Ohio State University - and Alachua County, Florida - home of the University of Florida.  In an effort to demonstrate that the relationship would be stronger in areas in which college football is the "only game in town," they also examined the relationship between suicide rates and national rankings in Miami-Dade County, Florida - home of the University of Miami as well as a number of other forms of similar entertainment.  In years in which any of the teams was unranked, a ranking of 26 was entered (which is actually likely to suppress any effect, as the actual "ranking" in a poor season might be substantially higher than that).  

Overall, the correlation between suicide rates and national rankings when the two teams were considered together was .55, which was statistically significant (p < .01).  When they controlled for US Gross Domestic Product (GDP); however, the relationship was no longer significant (p = .072).  When the two counties were considered separately, the correlation between local suicide rates and national football rankings was significant for the University of Florida (r = .66, p < .05), but not for Ohio State University (r = .4, p > .10).  These results indicate that national ranking and suicide rates in general are correlated, but that this impact might be better accounted for by the economic situation at the moment.  When considered on the level of individual teams, however, the relationship stands on its own in the smaller area - Gainesville, Florida - indicating that when the area is truly saturated by the team, the impact of "pulling together" around the team might be more pronounced.  The relationship between suicide rates and national ranking was not significant in Miami.  Importantly, the authors were looking at suicide rates for the entire year even though college football season comprises only a small portion of the year.  As such, any relationship between these variables is actually fairly remarkable.

The findings from this first study were admittedly a bit mixed, so Joiner and colleagues (2006) conducted two other studies to enhance their confidence.  In Study 2, the authors looked at the number of suicides in the United States on February 22, 1980 - the day of the "Miracle on Ice" - relative to February 22 of other years during the 1970s and 1980s.  The authors theorized that, in response to the sense of community the developed around the United States hockey team's victory of the Soviet Union in the Olympic Games, deaths by suicide would be reduced, thereby highlighting the importance of feeling as though we belong to a group.  The results of this study supported the authors' hypotheses, with the February 22, 1980 suicide total proving to be lower than that of any other year on the same day.  This was true even in the 1970s, when the US population was smaller (thereby theoretically lowering the number of suicides without lowering the actual suicide rate).  One possible response to these findings could be that individuals became less likely to die by suicide due to "vicarious efficacy," meaning that they felt better about themselves due to the performance of somebody else.  To control for this possibility, the authors designed Study 3 to examine a phenomenon for which this is not a legitimate interpretation.

In Study 3, Joiner and colleagues (2006) examined suicide rates on Super Bowl Sunday from 1984 on, relative to the Sundays immediately preceding and following Super Bowl Sunday.  The authors chose to begin their analyses in the mid-1980s because, at that point, substantial advertising became more prominent and the Super Bowl itself became a much larger phenomenon.  As it turns out, there was, in fact, a time by day interaction, meaning that fewer suicides occurred on Super Bowl Sundays than on comparison Sundays during the same years.

So what can we conclude from these studies?  Obviously, the answer is not simply that everyone needs to follow sports and hope that their team does well.  Instead, these studies provide supportive (although by no means conclusive) evidence that, when people can pull together around a shared event, they feel connected to their community.  A host of variables need to be considered when thinking about suicide risk and we have covered a number of them on PBB, but there is a message to take home from this work: when people can feel connected to others, even through a distant event, their risk levels decrease.  So, as you sit down and watch baseball today and wonder whether rooting passionately for a team is silly, think about the times that you have shared with others directly as a result of being a fan and know that those experiences are, in fact, meaningful.

Enjoy the day everyone - even the Pirates are in contention right now, so reasons for optimism abound.

************

If you would like to learn more about the topics covered on PBB, please consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center.

Guns and suicide

by Michael D. Anestis, M.S.

Today's topic is a bit of a sensitive one, as it touches upon a controversial topic that tends to inspire rather strong emotional responses on both sides: gun ownership.  That being said, it is not my goal to have a heated political discussion or to point out the righteousness of one side or the other.  Instead, my intention is to discuss some sobering facts and ask you about your thoughts on the matter.  The following numbers were obtained in large part from a review of the literature in a study published in the most recent issue of Suicide and Life Threatening Behavior by Karen Slovak and Thomas Brewer.

• In 2006, firearms were involved in 47.2% of deaths by suicide in individuals between 15 and 24 years of age and in 72.7% of deaths by suicide in adults over the age of 65 (Centers for Disease Control and Prevention [CDC], 2009).
• In areas in which there are more guns, there are more deaths by suicide (Miller, 2005)
• There are approximately three times as many guns in rural areas as there are in urban areas (Connor, 2005) and suicide rates are higher in rural areas (Branas, Nance, Elliot, Richmond, & Schwab, 2004).
• The presence of a firearm in the home increases suicide risk even when controlling for poverty, urbanization, unemployment, substance dependence and abuse, and mental illness (Miller, Azrael, Hepburn, Hemenway, & Lippman, 2006).

The above numbers paint a fairly clear picture.  Suicide rates are higher in areas in which there are more guns and the predictive utility of gun ownership with respect to suicide is significant above and beyond important variables including whether or not an individual is known to meet criteria for a mental illness.

Part of the reason why these numbers are so powerful is the lethality of guns as a method.  As noted in the Slovak and Brewer (2010) study, guns result in death far more often than other methods.  For instance, one study demonstrated that, while poisoning was involved in 74% of attempts, it only had a case fatality rate of 2%.  Guns, on the other hand, were involved in only 5% of attempts, but had a case fatality rate of 91%.  In other words, guns are not used as frequently as other methods, but when they are used, they almost always result in death.

Given these facts, many psychologists have advocated for gun restriction as an effective means for decreasing suicide rates.  Not surprisingly given the controversial nature of this topic, this approach has been far from universally accepted.  In fact, legislation was proposed in Virginia and West Virginia that would have prevented clinicians from asking patients about gun ownership, possession, or storage.  This legislative effort failed; however, it highlighted the degree to which political positions and empirical data are, at times, at odds with one another.  

Opposition to restricting gun access is not purely political, however.  Some believe that if guns were made less accessible, individuals would simply choose another method, thereby negating any gains made by infringing upon what is considered a constitutional right within the United States (this same argument is often made by individuals opposed to building higher fences along the Golden Gate Bridge, which is the location with the greatest number of suicides worldwide).  There have certainly been some studies that have demonstrated that restricting guns resulted in an immediate jump in deaths by other means that at least partially negated the decrease in suicide deaths by firearms; however, these studies have been very short term examinations that did not include a look at the bigger, longer term picture (I recommend reading Conwell et al., [2002] for a thorough review of the literature on this topic).  For instance, Carrington and Moyer (1994) found that suicide rates decreased significantly over 12 years after stricter gun control legislation was implemented in Canada.  After gun legislation was implemented in Washington, DC in 1968, an immediate and sustained decrease in suicide deaths occurred with no subsequent increase in suicide deaths by other means (Loftin et al., 1991).  A similar pattern emerged in Australia (Rich et al., 1990).

So, the above findings present us with another interesting set of facts:

• Guns are a highly lethal method and account for a disproportionately high number of deaths by suicide given the proportion of attempts involving this method
• Legislation that restricts access to guns does appear, in large part, to decrease suicide rates over a sustained period
• Gun restriction does not generally result in an increase in deaths by suicide through other means that would negate gains made through the legislation

Before turning the conversation over to you, I wanted to quickly present the actual findings of the Slovak and Brewer (2010) study that I mentioned above.  The authors were interested in learning how social workers in various areas within the United States feel about assessing for firearm ownership and counseling clients about the risks.  Here is what they found:

• Social workers who had received training in how to make such assessments and counseling efforts felt more favorably towards using such interventions
• Social workers in urban areas felt more favorable towards such assessments and counseling than did social workers in rural areas.

Now, the first finding could simply reflect that people who already feel favorably towards this approach are more likely to seek training in the method.  The second finding, however, is a bit more interesting as gun-based deaths by suicide are significantly more common in rural areas than in urban areas (homicide rates present an opposite pattern).

All of this leaves us with a tricky situation.  The fact of the matter is that gun ownership increases suicide rates above and beyond the impact of important risk factors like poverty and mental illness.  This presents a particularly troubling issue in rural areas, where guns are more prevalent and clinicians appear to be less willing to assess for their presence.  That being said, gun ownership is a constitutionally protected right, meaning that implementing gun control legislation is going to upset a large number of people. 

I suspect that this conversation could quickly turn ugly, so I will be monitoring comments more closely than normal and will have no reservation in deleting comments likely to prove offensive.  That being said, I am interested in hearing calm and cogent thoughts on how we can resolve this situation.  Is there a way to restrict access to guns as a method for suicide without offending a sizable portion of the country?  What is the best way to navigate this situation?

************

If you would like to learn more about this or other topics discussed on PBB, we encourage you to consult our online store for scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center.

Reflections on the situation at Cornell

by Michael D. Anestis, M.S.

A sad situation has unfolded on the campus of Cornell.  A number of student deaths have been ruled as suicides or are under consideration as possibly fitting within that category.  The distressing nature of this clustering of deaths by suicide has been amplified by the method of those who have died, as a number of students have jumped to their deaths from bridges on campus.  Writers all over the internet have discussed this situation and I first learned about it when a colleague emailed me an article in the New York Times (click here to read that article).

I do not want to spend today discussing the personal situation of those who have died or of their grieving families and I ask that anyone who responds to this article maintain that same level of respect.  The approach I want to take instead is to reflect upon some issues that I have either seen come up in coverage or anticipate will come up as time goes by.  For some of these issues, I will link to articles we have previously written on PBB.  For topics not yet covered on the site, I will briefly explain what we know from research. In the meantime, I also encourage you to click here to learn more about Cornell's efforts to address this situation.

Is suicide contagious?

We have previously written about the idea of suicide contagion (click here to read our original article on this topic).  When a number of deaths by suicide occur in a short period of time within a small area, people understandably begin to fear an epidemic.  Implicit in this fear is that idea that, had one individual not died by suicide, another individual who subsequently died by suicide would not have attempted.  In other words, the idea is that one individual "catches" the behavior from another like people catch physical illnesses through exposure to the germs of other individuals.  As it turns out, the evidence for this idea is at most ambiguous and seems to favor a very different idea: that deaths by suicide cluster together but are not contagious.

So, if suicide is not contagious, does that mean that we are saying that the death of one individual did not impact the other individual who later died by suicide?  Not at all.  The loss of a peer, whether by suicide or any other means, constitutes as severe life stress and, in the presence of stress (and the absence of social support), risk for suicide increases.  The thing is, if an individual is not already vulnerable in the first place - perhaps due to a diagnosis of a mental illness - this stress is highly unlikely to result in a suicide attempt.  In an earlier article, we discussed the diathesis-stress model of mental illness, which says that a combination of innate vulnerabilities and environmental stress represent the clearest path to problematic mental health outcomes.  I would recommend clicking on this link and reading that article to develop a clearer sense of what I mean here.

Could developing a campus-wide risk assessment procedure be dangerous?

Here again, a lot of people express an entirely understandable concern: could assessing for suicide risk cause people to think about suicide when they otherwise would not?  It would obviously be a horrific idea to assess for risk if our efforts to increase safety were actually doing harm.  Fortunately, research indicates that this is not the case.  In earlier PBB articles, we discussed landmark studies by Madelyn Gould and PBB contributor Craig Bryan demonstrating in a number of different samples that assessing for suicide risk and educating people about risk factors not only does not cause harm, but actually decreases risk (click here and here to read those articles).  As such, Cornell's efforts to intervene are an excellent idea.  Now, I am not aware of the specifics of the interventions taking place on that campus, so I can not speak to their procedures, but regardless, the data indicate that assessing for risk as absolutely the right thing to do.  Openly discussing this topic, providing accurate, data-driven information, and offering effective treatment resources to those in need are healthy steps for a campus seeking to recover for a devastating series of events.

Once somebody's mind is made up to die by suicide, is there nothing we can do?

This is another important question to consider.  Some people believe that, once somebody has decided to attempt suicide, nothing can be done.  There are a couple of important points to consider here.  If you have a loved one who considers or attempts suicide, it is not your fault and you should not carry the weight of the world on your shoulders.  After all, even if we do everything right, we can not control the behaviors and thoughts of other people.  That being said, there are steps that you can take to help that individual.  For one thing, if an individual appears to be at risk to him or herself or to others, you can encourage them to seek help or, if risk is imminent, you can call the police or take them to a hospital for an emergency evaluation.  Different states have different laws regarding involuntary mental health holds, so you should be sure to educate yourself on how your state handles these situations. Keep in mind that, unless you are trained to assess for suicide risk, it is a difficult procedure, particularly if you are close to the person at risk.  That being said, in these types of situations, I highly encourage you to seek the help of professionals capable of providing informed guidance and intervening effectively.  The National Suicide Prevention Lifeline, which you can reach at 1-800-273-TALK, provides anonymous, free support 24 hours per day, 7 days per week.  Additionally, dialing 911 will connect you with authorities capable of providing help.  So, you certainly cannot provide a full proof intervention to your loved ones, but there are opportunities to connect your loved one with professionals who can then provide evidence-based treatments to reduce risk.

Another consideration here is whether intervening simply delays the inevitable.  Cornell is now posting monitors on campus bridges to watch for students at risk.  This type of situation and intervention is not unique.  In fact, at the Golden Gate Bridge - which is the location with the most suicides worldwide - individuals have debated whether installing larger fences would reduce suicide rates or simply lead to individuals thwarted in their attempts finding another method.  As it turns out, all the evidence points to the idea that restricting access to the intended method decreases risk without a subsequent rebound.  In other words, when a common method is made unavailable, individuals who would have used that method do not appear to then use alternative approaches (e.g., Seiden, 1978).  The point here is not that posting monitors on bridges will make the suicide rate drop to zero but rather that doing so will substantially reduce the risk for a number of individuals.

The bottom line

Suicide is a heart wrenching phenomenon, but it is not nearly as mysterious as many believe it to be.  Through science, we have learned a lot about this behavior and how to prevent it.  Although it is certainly not the only perspective on suicide, I am a firm believer in the utility of Joiner's interpersonal-psychological theory of suicidal behavior and the data that supports it and I highly encourage you to click here and to type that phrase into the search bar at the top of the page in order to learn more about it.  What you'll find is that there are a lot of people out there devoting their professional lives to uncovering more about suicide and that they are making substantial progress in that pursuit.  We cannot control the thoughts, feelings, and behaviors of others, but we can educate ourselves on mental health issues and learn about the resources available to us and our loved ones.  By equipping ourselves in this manner, we can be fully prepared to do everything possible to prevent tragedies from occurring.

************

If you would like to learn more about this and other topics discussed on PBB, we encourage you to consult our online store of scientifically-based psychological resources.

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center. 

"Myths about Suicide" - A new book by Thomas Joiner

by Michael D. Anestis, M.S.

Over the past year or so, Thomas Joiner has been working on a book entitled Myths about Suicide that aims to debunk common misunderstandings about suicidal behavior.  I have looked forward to the book's arrival for quite some time now, as it is aimed at the general public, thereby providing greater access to scientific information for a broader audience.  PBB, after all, is based upon the premise that we need to stop hiding science in scientific journals and disseminate accurate information in order to help as many people as possible to better understand mental illness and the effective treatments that are available.  My hope is that people will read this book and come to a better understanding of the nature, causes, and treatment of suicidal behavior.

Yesterday, Dr.Joiner sent out an email regarding the book and granted me permission to paste the text of his note on PBB.  As a matter of disclosure, you should know that I am a doctoral student in Dr.Joiner's lab and have published a number of papers about suicide with him, so I am not unbiased in my praise for his theory and work.  That being said, my positive view of the theory stems from empirical results, many of which we have detailed on this site, and not simply personal allegiance.  Also, keep in mind that Dr.Joiner's book is in no way associated with PBB and neither Joye nor I will receive any compensation from its sales (other than referral fees should somebody order it through our site).  Below is Dr.Joiner's note and the publisher's synopsis of his book.

************

I wanted to let you know about a new book I have out, a follow up to “Why People Die By Suicide,” called “Myths About Suicide.” The publisher is the same – Harvard University Press – the book is widely available from them as well as the usual places like amazon.com and barnesandnoble.com.

A main goal of the book is to increase genuine understanding of suicidal behavior, and thereby increase compassion. I view increased understanding and compassion as helpful in many ways, including the two essential activities of preventing future deaths by suicide and aiding the bereaved in healing. I’ll paste below a brief summary of the book.

I hope you’ll mention the book to others who may be interested.

PUBLISHER’S SYNOPSIS: Around the world, more than a million people die by suicide each year. Yet many of us know very little about a tragedy that may strike our own loved ones—and much of what we think we know is wrong. This clear and powerful book dismantles myth after myth to bring compassionate and accurate understanding of a massive international killer. Drawing on a fascinating array of clinical cases, media reports, literary works, and scientific studies, Thomas Joiner demolishes both moralistic and psychotherapeutic clichés. He shows that suicide is not easy, cowardly, vengeful, or selfish. It is not a manifestation of "suppressed rage" or a side effect of medication. Threats of suicide, far from being idle, are often followed by serious attempts. People who are prevented once from killing themselves will not necessarily try again.

The risk for suicide, Joiner argues, is partly genetic and is influenced by often agonizing mental disorders. Vulnerability to suicide may be anticipated and treated. Most important, suicide can be prevented. An eminent expert whose own father's death by suicide changed his life, Joiner is relentless in his pursuit of the truth about suicide and deeply sympathetic to such tragic waste of life and the pain it causes those left behind.

************

If you would like to learn more about Dr.Joiner's theory of suicidal behavior, we recommend that you click on this link.  Additionally, we recommend that you consult the following texts, each of which is available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• Myths about Suicide by Thomas Joiner
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University and an incoming resident at the University of Mississippi Medical Center.

Psychotherapy Brown Bag YouTube Channel Update - 2-18-10

We just added some new content to the PBB YouTube channel.  In this video, we discuss Madelyn Gould's 2005 study that debunked the myth that assessing for suicide risk is dangerous and likely to increase depression and/or thoughts of suicide (click here to read our full article).

Beliefs about suicide in depressed individuals with alcohol use disorders

by Michael D. Anestis, M.S.

Right now, I'm approximately two-thirds of the way through the portion of my Abnormal Psychology course during which I teach my students about suicide.  As I have mentioned on PBB many times before, suicide is topic plagued by misinformation and, as a result, I spend a good portion of this lecture discussing specific studies that refute commonly held but mistaken beliefs about suicide (e.g., suicide is an impulsive behavior, assessing for suicide risk causes people to become suicidal).  In today's lecture, I spent a bit of time talking with my students about the fact that religious and cultural beliefs that discourage suicide are considered by many to be a protective factor, meaning that maintaining such beliefs indicates a lower risk that an individual will attempt and die by suicide.  As we talked about this, I cautioned them not to leap to conclusions about the meaning of that data, as other factors often better explain the relationship between two variables.

Today, I would like to describe a study conducted by Randall Richardson-Vejlgaard and colleagues at the Columbia University College of Physicians and Surgeons and the Columbia University School of Social Work that was published in late 2009 in the Journal of Affective Disorders.  In this study, the authors looked at view of suicide in depressed individuals with and without alcohol use disorders (AUDs).  Their goal was essentially to see if those with AUDs maintained different views towards suicide than individuals without AUDs and whether those views were related to suicidal ideation and behavior.

To do this, this authors recruited a sample of 521 participants diagnosed with depression (73% of sample) or bipolar disorder (currently in the depression phase; 27% of sample) as determined through a structured diagnostic interview.  42% of the sample reported a past history of AUD and 50% had attempted suicide in the past.  60% of the sample with a history of AUDs had a previous suicide attempt compared to 42% of the non-AUD sample. 

The key finding in this study, as indicated by the authors, was that individuals with AUDs had fewer moral objections to suicide than did individuals without AUDs.  Additionally, a lack of moral objections to suicide was associated with higher levels of suicidal ideation and prior suicidal behavior.  The authors were careful not to overstate the implications of their findings, but the general assumption was that the lack of moral objections facilitates suicidal behavior in individuals with AUDs.  Certainly this viewpoint is worthy of consideration; however, I found myself a bit frustrated by the data and conclusions here.

In order to determine whether or not one variable explains the relationship between two others (statistical mediation), there are very specific procedures that can be conducted.  In this case, to test whether having fewer moral objections to suicide explains why individuals with AUDs report more lifetime suicide attempts, the authors simply needed to run a specific analytical procedure; however, this test was not run.  Because of this, we can see that these variables are related, but we can not tell whether or not one explains any of the others.  In this situation, we are left to simply make educated guesses, which is a dangerous game when we are discussing suicide, as so many misguided beliefs are so prominent.  Given that the individuals in this sample with AUDs had a higher rate of bipolar disorder relative to those without AUDs, it is entirely possible that the greater degree of severe mental illness accounted for all of these findings.  The authors did not control for diagnostic status, however, so we can not know for certain whether or not that is the case.

Let me explain what I mean with these issues more directly.  One interpretation of the data here is that depressed individuals with AUDs report greater levels of suicidal ideation and behavior because they have fewer moral objections to the behavior and, as such, have fewer reasons to choose alternative options.  Another interpretation, however, is that moral obligations to the behavior fade as the behavior itself occurs, and that individuals may have changed their views (and started drinking) after they made an attempt.  In other words, it would be difficult to find a sample of individuals who have repeatedly engaged in a behavior and admitted to that who also report that they are morally against it.  As such, "moral objections" could simply represent an untested theory on the part of individuals who have not yet been faced with that situation and lower objections could simply be a way for individuals to adapt their viewpoints to be more consistent with their reality.

Yet another interpretation, and one I tend to favor, is that moral objections to suicide (particularly when measured using the specific scale used in this study) tend to be a proxy measure for religiosity.  As we discussed in an earlier PBB article (click here to read the article), data indicate that the reason religiosity and its associated beliefs are protective against suicidal behavior is that the individuals who tend to maintain such beliefs also tend to be a part of a tight nit community.  When individuals maintain highly religious beliefs but do so only in private (e.g., through private prayers or meditation), they are no less likely to think about suicide or to engage in suicidal behavior than are individuals without such beliefs; however, when individuals with high levels of religiosity engage in public worship (e.g., regularly attend church services), they are, in fact, protected.  Such data - and there is much, much more to that study - indicate that it is not the beliefs themselves that impact the behavior, but rather the social support inherent in being a part of a community.  Taking it a step further, in another prior PBB article (click here to read the article), I detailed data that indicates that individuals who tend to drink heavily while alone are more prone to suicidal ideation and that individuals who engage in solitary heavy drinking tend to do so in an effort to cope with negative emotions. So, if individuals with AUDs tend to have fewer moral objections to suicide, this might actually represent a tendency to be less active with respect to public worship.  As such, they be more inclined to become isolated and to drink alone (as they do not have social support to help them deal with negative emotions), which is also associated with suicidal ideation.

My point here is not to dismiss the findings of Richardson-Vejlgaard and colleagues (2009), but rather to point out that, when we think about suicide and the risk factors that contribute to such behaviors, we have to be careful not to leap to conclusions.  Richardson-Vejlgaard et al (2009), in fact, did not jump to conclusions.  They were very modest in their interpretation of the data, but the study nonetheless represents a good teaching point in data analysis and suicide.  Much like the link between impulsivity and suicide is indirect (e.g., suicide itself is not an impulsive behavior, but impulsive people are more likely to attempt and die by suicide), moral objections to suicide might be only indirectly related to suicidal outcomes (e.g., moral objections indicate membership in a tight nit religious community, which offers social support, which lowers suicide risk).  If we overlook that point and assume the link is direct, we can lose sight of the importance of social support, overstate the importance of viewing suicide in a particular manner, and ultimately further stigmatize individuals who attempt and die by suicide (or even those who devote their lives to preventing suicide but do not see it as a sin or a sign of weakness). Ultimately, what matters here are the facts, and the data thus far seem to indicate that we need to consider the role of religion in suicide a bit differently than many have in the past.

************

If you or anyone you know are experiencing thoughts of suicide, we encourage you to call 1-800-273-TALK or to find somebody to take you to the emergency room.

If you would like to learn more about suicide, we encourage you to read the following items, each of which is available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University