Post-traumatic stress disorder and suicidal behavior: A narrative review

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Abstract

There is a large literature investigating the underlying mechanisms, risk factors and demographics of suicidal thoughts and behaviors across a number of psychiatric disorders, such as, major depression, anxiety and schizophrenia. However, less research has focused on the relationship between Post-Traumatic Stress Disorder (PTSD) and suicide. There were two broad aims of this review. The first was to assess the extent to which PTSD is associated with suicide, and the second was to determine the effects of co-morbid disorders on this relationship. Overall, there was a clear relationship between PTSD and suicidal thoughts and behaviors irrespective of the type of trauma experienced. Very few studies directly examined whether depression was a mediating factor in the relationships reported. However, where this was investigated, the presence of co-morbid depression appeared to boost the effect of PTSD on suicidality. It was noteworthy that hardly any studies had investigated concepts thought to be key in other domains of research into suicidality, such as, feelings of entrapment, defeat and hopelessness.

Introduction

Suicidal behavior is considered a major clinical and social problem especially in developed countries (Haukka, Suominen, Partonen, & Lonnqvist, 2008). Accurate information reflecting suicide rates is not always available, however where it is, suicide is included in the ten leading causes of death across different age groups (Bertolote & Fleischmann, 2005). Previous research has estimated the lifetime prevalence of suicidal ideation to range from 4.8% (Paykel, Myers, Lindenthal, & Tanner, 1974) to 18.5% (Weissman et al., 1999) and the lifetime prevalence of suicide attempts to range from 1.1% (Paykel et al., 1974) to 5.9% (Weissman et al., 1999). Recently, a 7.8% lifetime prevalence of suicidal ideation and a 1.3% lifetime prevalence of suicide attempts was reported in a large epidemiological community study in Europe (Bernal et al., 2007). Sociodemographic factors have been identified as significant predictors of suicidal behavior including female gender, being of younger age, and being divorced or widowed (Bernal et al., 2007) and some work indicates that these predictors apply to both Western and Asian cultures (e.g., Thanh, Tran, Jiang, Leenaars, & Wasserman, 2006). Psychiatric diagnoses have also been strongly related to suicidality with major depression, dysthymia, substance use disorders, general anxiety disorders (GAD) and PTSD having a strong association with suicidal behavior (Bernal et al., 2007, Weissman et al., 1999). Of these disorders, the impact of PTSD on suicidal behavior has received the least attention in the literature. The overall aim of this review is to redress this by examining the impact of PTSD on suicidal acts, behaviors and thoughts.

PTSD is commonly conceptualized as an anxiety disorder occurring subsequent to a traumatic event which is perceived as highly threatening. An individual does not have to experience the traumatic event directly, but can develop the disorder after witnessing such an event (American Psychiatric Association, 2000, Yehuda, 2002). PTSD is multi-faceted, comprising three distinct symptom clusters: a) repeated and persistent intrusive memories related to the experienced trauma (thoughts, dreams/ nightmares), b) avoidance of situations that are reminders of the trauma and psychological numbing, and c) hyper-arousal, such as, irritability, reduced concentration, exaggerated startle response (DSM IV-TR; American Psychiatric Association, 2000). Estimates from general population samples indicate that PTSD is a common disorder with a lifetime prevalence ranging from 8% to 9%, with the incidence of the disorder being twice as common in women than men (Breslau, 2002, Kessler et al., 1995, Seedat and Stein, 2001). The prevalence rate of PTSD is influenced by severity, duration and proximity of the experienced trauma. Specific types of trauma such as sexual/physical abuse and combat exposure appear to be more robustly associated with the subsequent development of PTSD (Adams & Lehnert, 1997). Other risk factors related to the development of PTSD include pre-existing anxiety disorders, depression and somatoform disorders (Frans et al., 2005, Hapke et al., 2006).

PTSD is associated with severe emotional disturbances such as intense feelings of anger and irritability, feelings of being alienated, guilt, shame or mistrust and frequent co-morbid psychiatric disorders. Higher prevalence or incidence rates of suicidal behavior have been documented in individuals with PTSD (Bullman and Kang, 1994, Davidson et al., 1990, Ferrada-Noli et al., 1998, Krammer et al., 1994). In a study examining suicidal behavior after severe trauma, Ferrada-Noli et al. (1998) reported that 57% of the PTSD participants reported suicidal behavior compared with 29% of the participants with other psychiatric diagnoses (e.g., depressive disorders, anxiety disorders, personality disorders). Co-morbidity of PTSD with other psychiatric disorders heightens the risk of suicide. In one study, which assessed co-morbidity patterns in a large sample of young people (aged 14–24) with a history of previous suicide attempts, the highest risk for a suicide attempt was found among those suffering from PTSD, followed by dysthymia and simple phobias (Wunderlich, Bronisch, & Wittchen, 1998).

Explanations of suicidal behavior have been mainly derived from identifying psychologically relevant correlates of suicide rather than from a theoretical perspective. It has been noted that the generic nature and the weak theoretical foundation of the proposed correlates hamper their applicability across a wide range of different clinical populations and limit their efficiency in generating clear and testable predictions (Westefeld et al., 2000). Consequently, it can be argued that there is a paucity of theoretically driven, clearly defined, empirically testable models of the psychological pathways leading to suicide in general (O'Connor & Sheehy, 2001) and to suicide in PTSD in particular.

A recent paper suggested three broad theoretical alternatives in understanding suicidal behavior (Bolton, Gooding, Kapur, Barrowclough, & Tarrier, 2007).

First, suicidal behavior may occur as a consequence of the enactment of a unitary transdiagnostic, albeit multi-factorial, causal mechanism which operates across a number of disorders and is, therefore, common across a range of mental illnesses.

Second, suicidal behavior may result from factors which are specific to particular diagnoses implying non-unitary, diagnosis-specific mechanisms which underlie suicidal behavior.

Third, in contrast to the first alternative, a cluster of symptoms, apparent in one type of disorder may account for the presence of suicidal behavior. For example, high rates of major depression have been observed in individuals diagnosed with PTSD (Kessler et al., 1995) and this has been found to compound the risk for suicide (Tarrier and Gregg, 2004, Freeman et al., 2000). Therefore, an increased incidence or prevalence of suicidal behavior in persons with a PTSD diagnosis may be due to co-morbid depression and not to PTSD per se.

A combination of any of the three theoretical possibilities proposed above may also apply. For instance, a fourth possibility is that there may be factors which are part of a transdiagnostic general mechanism that are common to a range of psychological disorders, but they are moderated by specific features of a particular disorder. For example, appraisals of an individual's future may be devoid of any positive factors in those who are suicidal but it is amplified in PTSD by feelings that previously experienced traumas will re-occur, that this is inevitable, and that there is no escape. Clarifying the above alternatives is essential from both theoretical and clinical perspectives. Treatment implications will differ according to whether suicidal behavior in PTSD is evoked by a transdiagnostic set of factors, and/or by factors specific to PTSD.

Although the research evidence for heightened rates of suicidal behavior among individuals diagnosed with PTSD has increased recently, reviews assessing the association between PTSD and suicidal behavior are absent from the literature. This is surprising taking into account the great burden suicidal behavior constitutes for individuals, communities and society in general. Thus, the main goal of the present paper is to provide a comprehensive account of the available research findings in the area of PTSD and suicidal behavior. The particular objectives of the present review are:

  • 1.

    To determine if there is a significant association between PTSD and suicidal behavior, and if so, to investigate whether this association is direct or whether it is influenced by other factors.

  • 2.

    To examine the possible effects of co-morbid psychiatric disorders on the relationship between PTSD and suicidal behaviors, with a focus on co-morbid depression.

Section snippets

Eligibility Criteria of the studies included in the review

Studies were selected for inclusion in this review if they met the following criteria1:

  • 1.

    They were published in a peer reviewed journal in the English language.

  • 2.

    They included any measure of PTSD (e.g., self report, clinician rated) and any measure of suicidality.

  • 3.

    The

Results

A total of 65 studies were identified and reviewed in terms of i) the type of trauma experienced (combat veterans, individuals exposed to physical or sexual victimization or intimate partner violence, individuals exposed to natural disasters and participants whose PTSD diagnosis resulted from a mixture of different traumas); ii) community-based surveys which have examined links between PTSD and suicide; iii) the presence of other Axis I or Axis II psychiatric diagnoses, in particular, major

Clinical implications

There has been considerable evaluation of the treatment of PTSD with strong evidence for the efficacy of trauma-focused cognitive behavior therapy (Harvey, Bryant & Tarrier, 2003). However, there has been little attention in the treatment literature to reducing suicide risk in PTSD patients. Thus any recommendations for treatment will be largely speculative. A recent systematic review and meta-analysis concluded that overall there was a highly significant effect for CBT in reducing suicide

Conclusions, implications and recommendations

The majority of the research discussed in the present paper clearly demonstrates an important relationship between PTSD and suicidal behavior. These findings have been replicated both in clinical and in general population samples. There is evidence that the association between PTSD and suicidal behavior pertains, irrespective of the type of trauma that led to PTSD. For example, high rates of suicidal behavior have been consistently reported among PTSD patients exposed to combat trauma,

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