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Life events: a complex role in the timing of suicidal behavior among depressed patients

Molecular Psychiatry volume 19, pages 902–909 (2014)Cite this article

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Abstract

Suicidal behavior is often conceptualized as a response to overwhelming stress. Our model posits that given a propensity for acting on suicidal urges, stressors such as life events or major depressive episodes (MDEs) determine the timing of suicidal acts. Depressed patients (n=415) were assessed prospectively for suicide attempts and suicide, life events and MDE over 2 years. Longitudinal data were divided into 1-month intervals characterized by MDE (yes/no), suicidal behavior (yes/no) and life event scores. Marginal logistic regression models were fit, with suicidal behavior as the response variable and MDE and life event score in either the same or previous month, respectively, as time-varying covariates. Among 7843 person–months, 33% had MDE and 73% had life events. MDE increased the risk for suicidal behavior (odds ratio (OR)=4.83, P⩽0.0001). Life event scores were unrelated to the timing of suicidal behavior (OR=1.06 per 100 point increase, P=0.32), even during a MDE (OR=1.12, P=0.15). However, among those without borderline personality disorder (BPD), both health- and work-related life events were key precipitants, as was recurrent MDE, with a 13-fold effect. The relationship of life events to suicidal behavior among those with BPD was more complex. Recurrent MDE was a robust precipitant for suicidal behavior, regardless of BPD comorbidity. The specific nature of life events is key to understanding the timing of suicidal behavior. Given unanticipated results regarding the role of BPD and study limitations, these findings require replication. Of note, that MDE, a treatable risk factor, strongly predicts suicidal behaviors is cause for hope.

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References

  1. Oquendo MA, Currier D, Mann JJ . Prospective studies of suicidal behavior in major depressive and bipolar disorders: what is the evidence for predictive risk factors? Acta Psychiatr Scand 2006; 114: 151–158.

    Article  CAS  PubMed  Google Scholar 

  2. Holma KM, Melartin TK, Haukka J, Holma IA, Sokero TP, Isometsa ET . Incidence and predictors of suicide attempts in DSM-IV major depressive disorder: a five-year prospective study. Am J Psychiatry 2010; 167: 801–808.

    Article  PubMed  Google Scholar 

  3. Spijker J, de Graaf R, Ten Have M, Nolen WA, Speckens A . Predictors of suicidality in depressive spectrum disorders in the general population: results of the Netherlands Mental Health Survey and Incidence Study. Soc Psychiatry Psychiatr Epidemiol 2010; 45: 513–521.

    Article  PubMed  Google Scholar 

  4. ten Have M, de Graaf R, van Dorsselaer S, Verdurmen J, van ’t Land H, Vollebergh W et al. Incidence and course of suicidal ideation and suicide attempts in the general population. Can J Psychiatry 2009; 54: 824–833.

    Article  PubMed  Google Scholar 

  5. Brent DA, Kolko DJ, Wartella ME, Boylan MB, Moritz G, Baugher M et al. Adolescent psychiatric inpatients’ risk of suicide attempt at 6-month follow-up. J Am Acad Child Adolesc Psychiatry 1993; 32: 95–105.

    Article  CAS  PubMed  Google Scholar 

  6. Pfeffer CR, Klerman GL, Hurt SW, Kakuma T, Peskin JR, Siefker CA . Suicidal children grow up: rates and psychosocial risk factors for suicide attempts during follow-up. J Am Acad Child Adolesc Psychiatry 1993; 32: 106–113.

    Article  CAS  PubMed  Google Scholar 

  7. Wong JP, Stewart SM, Claassen C, Lee PW, Rao U, Lam TH . Repeat suicide attempts in Hong Kong community adolescents. Soc Sci Med 2008; 66: 232–241.

    Article  PubMed  Google Scholar 

  8. Lewinsohn PM, Rohde P, Seeley JR . Psychosocial risk factors for future adolescent suicide attempts. J Consult Clin Psychol 1994; 62: 297–305.

    Article  CAS  PubMed  Google Scholar 

  9. Borg SE, Stahl M . Prediction of suicide. A prospective study of suicides and controls among psychiatric patients. Acta Psychiatr Scand 1982; 65: 221–232.

    Article  CAS  PubMed  Google Scholar 

  10. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H et al. Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 2003; 301: 386–389.

    Article  CAS  PubMed  Google Scholar 

  11. McKeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL . Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. J Am Acad Child Adolesc Psychiatry 1998; 37: 612–619.

    Article  CAS  PubMed  Google Scholar 

  12. Neeleman J, de Graaf R, Vollebergh W . The suicidal process; prospective comparison between early and later stages. J Affect Disord 2004; 82: 43–52.

    Article  PubMed  Google Scholar 

  13. Yen S, Pagano ME, Shea MT, Grilo CM, Gunderson JG, Skodol AE et al. Recent life events preceding suicide attempts in a personality disorder sample: findings from the collaborative longitudinal personality disorders study. J Consult Clin Psychol 2005; 73: 99–105.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Oquendo MA, Galfalvy H, Russo S, Ellis SP, Grunebaum MF, Burke A et al. Prospective study of clinical predictors of suicidal acts after a major depressive episode in patients with major depressive disorder or bipolar disorder. Am J Psychiatry 2004; 161: 1433–1441.

    Article  PubMed  Google Scholar 

  15. Oquendo MA, Kamali M, Ellis SP, Grunebaum MF, Malone KM, Brodsky BS et al. Adequacy of antidepressant treatment after discharge and the occurrence of suicidal acts in major depression: a prospective study. Am J Psychiatry 2002; 159: 1746–1751.

    Article  PubMed  Google Scholar 

  16. Sokero TP, Melartin TK, Rytsala HJ, Leskela US, Lestela-Mielonen PS, Isometsa ET . Prospective study of risk factors for attempted suicide among patients with DSM-IV major depressive disorder. Br J Psychiatry 2005; 186: 314–318.

    Article  PubMed  Google Scholar 

  17. Valtonen HM, Suominen K, Haukka J, Mantere O, Leppamaki S, Arvilommi P et al. Differences in incidence of suicide attempts during phases of bipolar I and II disorders. Bipolar Disord 2008; 10: 588–596.

    Article  PubMed  Google Scholar 

  18. Riihimaki K, Vuorilehto M, Melartin T, Haukka J, Isometsa E . Incidence and predictors of suicide attempts among primary-care patients with depressive disorders: a 5-year prospective study. Psychol Med 2013; 1–12.

  19. Oquendo MA, Bongiovi-Garcia ME, Galfalvy H, Goldberg PH, Grunebaum MF, Burke AK et al. Sex differences in clinical predictors of suicidal acts after major depression: a prospective study. Am J Psychiatry 2007; 164: 134–141.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Mann JJ, Waternaux C, Haas GL, Malone KM . Toward a clinical model of suicidal behavior in psychiatric patients. Am J Psychiatry 1999; 156: 181–189.

    CAS  PubMed  Google Scholar 

  21. Oldham JM . Borderline personality disorder and suicidality. Am J Psychiatry 2006; 163: 20–26.

    Article  PubMed  Google Scholar 

  22. Leichsenring F, Leibing E, Kruse J, New AS, Leweke F . Borderline personality disorder. Lancet 2011; 377: 74–84.

    Article  PubMed  Google Scholar 

  23. Spitzer RL, Williams JBW . Structured Clinical Interview for DSMIII-R—Patient Version (SCID-P). Biometrics Research, New York State Psychiatric Institute: New York, NY, USA, 1985.

    Google Scholar 

  24. Loranger AW, Sartorius N, Andreoli A, Berger P, Buchheim P, Channabasavanna SM et al. The International Personality Disorder Examination. The World Health Organization/Alcohol, Drug Abuse, and Mental Health Administration international pilot study of personality disorders. Arch Gen Psychiatry 1994; 51: 215–224.

    Article  CAS  PubMed  Google Scholar 

  25. First MB, Gibbon M, Spitzer RL, Williams JB . Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II), version 2. Biometrics Research, New York Psychiatric Institute: New York, NY, USA, 1996.

    Google Scholar 

  26. Hamilton M . A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23: 56–62.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J . An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561–571.

    Article  CAS  PubMed  Google Scholar 

  28. Beck AT, Weissman A, Lester D, Trexler L . The measurement of pessimism: the hopelessness scale. J Consult Clin Psychol 1974; 42: 861–865.

    Article  CAS  PubMed  Google Scholar 

  29. Brown GL, Goodwin FK, Ballenger JC, Goyer PF, Major LF . Aggression in humans correlates with cerebrospinal fluid amine metabolites. Psychiatry Res 1979; 1: 131–139.

    Article  CAS  PubMed  Google Scholar 

  30. Buss AH, Durkee A . An inventory for assessing different kinds of hostility. J Consult Psychol 1957; 21: 343–349.

    Article  CAS  PubMed  Google Scholar 

  31. Barratt ES . Factor analysis of some psychometric measures of impulsiveness and anxiety. Psychol Rep 1965; 16: 547–554.

    Article  CAS  PubMed  Google Scholar 

  32. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA . Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 1983; 51: 276–286.

    Article  CAS  PubMed  Google Scholar 

  33. Beck AT, Kovacs M, Weissman A . Assessment of suicidal intention: the Scale for Suicide Ideation. J Consult Clin Psychol 1979; 47: 343–352.

    Article  CAS  PubMed  Google Scholar 

  34. Miller MA, Rahe RH . Life changes scaling for the 1990s. J Psychosom Res 1997; 43: 279–292.

    Article  CAS  PubMed  Google Scholar 

  35. Rahe RH . Epidemiological studies of life change and illness. Int J Psychiatry Med 1975; 6: 133–146.

    Article  CAS  PubMed  Google Scholar 

  36. Paykel ES . Methodological aspects of life events research. J Psychosom Res 1983; 27: 341–352.

    Article  CAS  PubMed  Google Scholar 

  37. O’Carroll PW, Berman AL, Maris RW, Moscicki EK, Tanney BL, Silverman MM . Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav 1996; 26: 237–252.

    PubMed  Google Scholar 

  38. Reducing Suicide:A National Imperative. The National Academies Press, 2002.

  39. Oquendo MA, Halberstam B, Mann JJ . Risk factors for suicidal behavior: the utility and limitations of research instruments. In: First MB (ed). Standardized Evaluation in Clinical Practice. American Psychiatric Publishing: Washington, DC, 2003 pp 103–130.

    Google Scholar 

  40. Posner K, Oquendo MA, Gould M, Stanley B, Davies M . Columbia Classification Algorithm of Suicide Assessment (C-CASA): classification of suicidal events in the FDA’s pediatric suicidal risk analysis of antidepressants. Am J Psychiatry 2007; 164: 1035–1043.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA et al. The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry 2011; 168: 1266–1277.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Andersen PaG R . Cox’s regression model for counting processes, a large sample study. Ann Stat 1982; 10: 1100–1120.

    Article  Google Scholar 

  43. Liu RT, Alloy LB . Stress generation in depression: a systematic review of the empirical literature and recommendations for future study. Clin Psychol Rev 2010; 30: 582–593.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Zanarini MC, Frankenburg FR . The essential nature of borderline psychopathology. J Pers Disord 2007; 21: 518–535.

    Article  PubMed  Google Scholar 

  45. New AS, aan het Rot M, Ripoll LH, Perez-Rodriguez MM, Lazarus S, Zipursky E et al. Empathy and alexithymia in borderline personality disorder: clinical and laboratory measures. J Pers Disord 2012; 26: 660–675.

    Article  PubMed  Google Scholar 

  46. Cooper J, Appleby L, Amos T . Life events preceding suicide by young people. Soc Psychiatry Psychiatr Epidemiol 2002; 37: 271–275.

    Article  CAS  PubMed  Google Scholar 

  47. Mazza JJ, Reynolds WM . A longitudinal investigation of depression, hopelessness, social support, and major and minor life events and their relation to suicidal ideation in adolescents. Suicide Life Threat Behav 1998; 28: 358–374.

    CAS  PubMed  Google Scholar 

  48. Chang HJ, Yang CY, Lin CR, Ku YL, Lee MB . Determinants of suicidal ideation in Taiwanese urban adolescents. J Formos Med Assoc 2008; 107: 156–164.

    Article  PubMed  Google Scholar 

  49. Lapierre S, Boyer R, Desjardins S, Dube M, Lorrain D, Preville M et al. Daily hassles, physical illness, and sleep problems in older adults with wishes to die. Int Psychogeriatr 2012; 24: 243–252.

    Article  PubMed  Google Scholar 

  50. Joiner TE Jr., Van Orden KA, Witte TK, Selby EA, Ribeiro JD, Lewis R et al. Main predictions of the interpersonal-psychological theory of suicidal behavior: empirical tests in two samples of young adults. J Abnorm Psychol 2009; 118: 634–646.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Oquendo MA, Ellis SP, Greenwald S, Malone KM, Weissman MM, Mann JJ . Ethnic and sex differences in suicide rates relative to major depression in the United States. Am J Psychiatry 2001; 158: 1652–1658.

    Article  CAS  PubMed  Google Scholar 

  52. Blasco-Fontecilla H, Baca-Garcia E, Duberstein P, Perez-Rodriguez MM, Dervic K, Saiz-Ruiz J et al. An exploratory study of the relationship between diverse life events and specific personality disorders in a sample of suicide attempters. J Pers Disord 2010; 24: 773–784.

    Article  PubMed  PubMed Central  Google Scholar 

  53. APA. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. American Psychiatric Association: Washington, D.C., 2013.

  54. Yen S, Shea MT, Battle CL, Johnson DM, Zlotnick C, Dolan-Sewell R et al. Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders: findings from the collaborative longitudinal personality disorders study. J Nerv Ment Dis 2002; 190: 510–518.

    Article  PubMed  Google Scholar 

  55. Fang F, Fall K, Mittleman MA, Sparen P, Ye W, Adami HO et al. Suicide and cardiovascular death after a cancer diagnosis. N Engl J Med 2012; 366: 1310–1318.

    Article  PubMed  Google Scholar 

  56. Scott KM, Hwang I, Chiu WT, Kessler RC, Sampson NA, Angermeyer M et al. Chronic physical conditions and their association with first onset of suicidal behavior in the world mental health surveys. Psychosom Med 2010; 72: 712–719.

    Article  PubMed  Google Scholar 

  57. Woo JM, Postolache TT . The impact of work environment on mood disorders and suicide: evidence and implications. Int J Disabil Hum Dev 2008; 7: 185–200.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Beck AT, Brown GK, Steer RA, Dahlsgaard KK, Grisham JR . Suicide ideation at its worst point: a predictor of eventual suicide in psychiatric outpatients. Suicide Life Threat Behav 1999; 29: 1–9.

    CAS  PubMed  Google Scholar 

  59. Lizardi D, Currier D, Galfalvy H, Sher L, Burke A, Mann J et al. Perceived reasons for living at index hospitalization and future suicide attempt. J Nerv Ment Dis 2007; 195: 451–455.

    PubMed  PubMed Central  Google Scholar 

  60. Beck AT, Steer RA, Beck JS, Newman CF . Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. Suicide Life Threat Behav 1993; 23: 139–145.

    CAS  PubMed  Google Scholar 

  61. David Klonsky E, Kotov R, Bakst S, Rabinowitz J, Bromet EJ . Hopelessness as a predictor of attempted suicide among first admission patients with psychosis: a 10-year cohort study. Suicide Life Threat Behav 2012; 42: 1–10.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Links P, Nisenbaum R, Ambreen M, Balderson K, Bergmans Y, Eynan R et al. Prospective study of risk factors for increased suicide ideation and behavior following recent discharge. Gen Hosp Psychiatry 2012; 34: 88–97.

    Article  PubMed  Google Scholar 

  63. Raphael KG, Cloitre M, Dohrenwend BP . Problems of recall and misclassification with checklist methods of measuring stressful life events. Health Psychol 1991; 10: 62–74.

    Article  CAS  PubMed  Google Scholar 

  64. Paykel ES . Life events and affective disorders. Acta Psychiatr Scand Suppl 2003; 418: 61–66.

    Article  Google Scholar 

  65. Brown GW, Harris TO . Social Origins of Depression. Tavistock: London, 1978.

    Google Scholar 

  66. Paykel ES . The interview for recent life events. Psychol Med 1997; 27: 301–310.

    Article  CAS  PubMed  Google Scholar 

  67. Hintikka J, Koivumaa-Honkanen H, Lehto SM, Tolmunen T, Honkalampi K, Haatainen K et al. Are factors associated with suicidal ideation true risk factors? A 3-year prospective follow-up study in a general population. Soc Psychiatry Psychiatr Epidemiol 2009; 44: 29–33.

    Article  PubMed  Google Scholar 

  68. McEwen BS . Mood disorders and allostatic load. Biol Psychiatry 2003; 54: 200–207.

    Article  PubMed  Google Scholar 

  69. Gibbons RD, Brown CH, Hur K, Davis J, Mann JJ . Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012; 69: 580–587.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

This work was supported by P50 MH62185, MH48514, MH59710, AA15630, Nina Rahn Fund, Medical Research Service, Veterans Affairs James J Peters VAMC, Veterans Affairs NY/NJ (VISN3), and Mental Illness Research Education and Clinical Center.

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  1. Department of Psychiatry, Columbia University College of Physicians & Surgeons, New York, NY, USA

    M A Oquendo, E Poh, G Sullivan, A K Burke, M E Sublette, J J Mann & H Galfalvy

  2. Veterans Affairs Medical Center, Bronx, NY, USA

    M M Perez-Rodriguez

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  1. M A Oquendo
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Correspondence to M A Oquendo.

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Competing interests

Dr Oquendo receives royalties from the Columbia Suicide Severity Rating Scale and received educational grants from Astra Zeneca, Pfizer, Eli Lilly, Shire, Janssen. Her family owns Bristol-Myers Squibb stock. Dr Mann received grants from GlaxoSmithKline and Novartis. Dr Sullivan is on the SAB of TONIX Pharmaceuticals and consulted to Ono Pharma USA. Dr Sublette received a grant from Unicity International of nutritional supplements. The remaining authors declare no conflict of interest.

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Oquendo, M., Perez-Rodriguez, M., Poh, E. et al. Life events: a complex role in the timing of suicidal behavior among depressed patients. Mol Psychiatry 19, 902–909 (2014). https://doi.org/10.1038/mp.2013.128

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