A systematic review of the predictions of the Interpersonal–Psychological Theory of Suicidal Behavior
Introduction
Suicide is a phenomenon that bears a significant public health impact worldwide. Each year it is estimated that approximately 800,000 people die by suicide, ranking it as the second leading cause of death in 15–29 year olds globally (WHO, 2014). Though preventable, suicidal thoughts and behaviors are complex phenomena influenced by several interacting factors, including personal, social, psychological, cultural, biological, and environmental (Goldston, D. B., et al., 2009, King, R. A., et al., 2001, Mann, J. J., 2003, O'Connor, R. C., 2011). As such, there is no singular underlying explanation as to why a person may attempt suicide, resulting in a highly contextual and varied picture of the barriers and facilitators to help seeking.
Recently, the Interpersonal Psychological Theory of Suicide (IPTS) (Joiner, T. E., 2005, Van Orden, K. A., et al., 2010) was developed with the aim of providing a theoretical model of suicide behavior. The theory consolidates a broad range of suicide risk factors, and provides testable predictions of who will develop desire for suicide (i.e., ideation), and from these, who will go on to attempt. As such, the theory holds much promise in regards to bettering our understanding of how certain suicide risk factors interact, and where prevention and intervention efforts may be best focused.
According to the IPTS, suicidal desire is caused by the simultaneous presence of two proximal, causal risk factors: (1) thwarted belongingness and (2) perceived burdensomeness, and hopelessness (i.e., “this will never change”) about these states (Joiner, T. E., 2005, Van Orden, K. A., et al., 2010). Thwarted belongingness refers to the experience that one is alienated from friends, family, or other valued social circles. It is said to comprise of two facets, loneliness (i.e., “I feel disconnected from others”) and the absence of reciprocal care (i.e., “I have no one to turn to and I don't support others”). It is viewed as a dynamic cognitive-affective state that is influenced by inter and intra-personal factors such as experiencing family conflict, living alone, possessing few social supports, and being prone to interpret others'behavior as rejection (Van Orden et al., 2010). Perceived burdensomeness, on the other hand, refers to the view that one's existence is a burden on friends, family members, and/or society, and comprises of two facets, self-hate (i.e., “I hate myself”) and feelings of liability (i.e., “my death is worth more than my life to others”). Like thwarted belongingness, perceived burdensomeness is conceptualised as a dynamic cognitive affect state, where risk factors such as homelessness, unemployment, physical illness, and feelings of low-self-esteem and being unwanted are said to contribute to its development (Van Orden et al., 2010). Though it is hypothesized that experiencing either perceived burdensomeness or thwarted belongingness alone will elicit passive suicidal ideation, it is their interaction coupled with the view that they are stable and unchanging (i.e., hopelessness) that will cause active suicidal desire.
The development from active suicidal desire to suicidal intent is said to only result through the presence of an additional third construct: (3) acquired capability. Acquired capability refers to one's ability to overcome the inherent drive for self-preservation and engage in lethal self-injury (Joiner, 2005). This is hypothesized as being possible due to a lowered fear of death resulting from repeated exposure and habituation to physically painful and/or fear-inducing experiences, and an elevated tolerance of physical pain. It is viewed as a continuous construct that accumulates over time, with risk factors such as family history of suicide, previous suicide attempt, exposure to combat, and childhood maltreatment contributing to its development (Ribeiro, J. D. and Joiner, T. E., 2009, Van Orden, K. A., et al., 2010). Thus, individuals who have high levels of all three constructs, thwarted belongingness, perceived burdensomeness, and acquired capability, are said to be at most risk for lethal suicidal behavior, as they possess both the desire for and capability to attempt suicide. See Fig. 1.
Since the development of the IPTS in 2005, a growing body of research has emerged testing different aspects of the theory across a range of populations. In 2009, an article on the current status and future directions of the IPTS stated that the theory has stood up to 20 direct empirical tests, with results generally substantiating the theory's main predictions (Ribeiro & Joiner, 2009). Since then, two systematic reviews on the IPTS have been published, one reporting on the role of perceived burdensomeness on suicide-related behavior within clinical samples (Hill & Pettit, 2014), and another examining support for the IPTS from studies published between 2002 and 2011 (Wachtel & Teismann, 2013).
In their systematic review of 27 empirical studies testing the association between perceived burdensomeness and suicide ideation, suicide attempts, or suicide within clinical samples, Hill & Pettit (2014) found perceived burdensomeness to have statistically significant bivariate associations with both suicide ideation and past suicide attempt. Perceived burdensomeness was also found to be a predictor of suicidal ideation beyond the effects of other well established risk factors, and played a role as both moderator and mediator between suicide-related behaviors and other risk and protective factors. The authors noted that the majority of studies conducted focused on the relationship between perceived burdensomeness and suicide ideation, with results highlighting the role of perceived burdensomeness as a potential route for suicide intervention in clinical populations. A limitation of this review, however, is that it focused exclusively on the role of perceived burdensomeness within clinical samples, to the exclusion of the theory's more critical interaction predictions and applicability within other sample types.
The other systematic review, by Wachtel & Teismann (2013), was more comprehensive, in that it reviewed the results of 29 studies (published between 2002 and 2011) that examined support for all three interpersonal risk factors in relation to suicide-related behaviors. The authors found perceived burdensomeness, thwarted belongingness, and acquired capability to be associated with different facets of suicidality, concluding that there was a lack of studies investigating the interrelation of the theory's constructs. However, this review was published solely in German with its findings being inaccessible to non-German readers in the field. Additionally, the review was limited to articles published up to 2011, with a considerable proliferation of IPTS studies since that time.
Thus, the aim of the present review was to provide the first English systematic review of the full set of predictions of the IPTS across multiple populations. To assess the predictive power of the IPTS constructs independently of the contribution of other major suicide risk factors, the review focused specifically on the results of studies that adjusted for the presence of other IPTS variables (i.e., thwarted belongingness, perceived burdensomeness, and acquired capability) and/or mental health-related measures (e.g., depression, anxiety, hopelessness) to provide a rigorous test of these predictions. In doing so, the current review aims to identify whether empirical research supports the theory, and to highlight critical gaps in the evidence base by reviewing what populations and what aspects of the theory have been most tested and supported.
Section snippets
Methods
On the 8th of July 2015, the Medline and PsycInfo databases were electronically searched for English-language, human, peer reviewed articles published from January 2005 up to July 2015 using the search terms: “Interpersonal psychological OR interpersonal–psychological OR Joiner* OR thwarted belong* OR perceived burden* OR acquired capability AND suicid*.” With limits imposed, 315 records were identified through database searching, and two additional articles from reference list searches. After
Results
A total of 66 studies were identified that tested the IPTS constructs in relation to suicide ideation or attempt (See Appendix A for study characteristics). In order to present the results categorically under either suicide ideation or suicide attempt, composite measures such as “suicide risk”, “suicide potential”, “suicide proneness”, “suicidal symptoms,” “suicide behavior”, “future likelihood of behavior”, and “suicidality” were classified under suicide ideation, as they all encompassed a
Overview of the support for the Interpersonal Psychological Theory of Suicide's main predictions
The current review aimed to systematically examine current evidence testing the effects of thwarted belongingness, perceived burdensomeness, and acquired capability on suicide ideation and attempt. Contrary to our expectations, the studies provided mixed support across the theory's main predictions. The main effect of perceived burdensomeness on suicide ideation was the most tested and supported relationship, with over three-quarters (82.6%) of the studies found to be significant across
Conclusions
The review indicates that the relationship between perceived burdensomeness and thwarted belongingness on suicide ideation, and their interaction with acquired capability on suicide attempt appears to be less straightforward than originally stated in the IPTS. There is a need for more high powered studies examining the two-way and three-way interactions of the theory's constructs, use of longitudinal designs, and further tests of alternative interaction and mediation effects identified by some
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