Abstract
As is the case for all complex health outcomes, there are many risk factors known to increase risk of suicide. In Chapter 6, we will address the clinical assessment of suicide risk, which incorporates risk and protective factors. In the current chapter, we will show how risk factors – health and environmental – weave together and escalate risk at particular moments in a person’s life. This chapter will explore how the interaction of biological, psychological, and social/environmental risk factors can increase risk of suicide, differentiating between more enduring and more dynamic factors. We will show how these various factors intersect with life stressors to increase suicide risk. Research related to the global burden of suicide indicates that while cultural factors and available lethal means play a huge role in the suicide risk of a population, many risk and protective factors are shared cross nationally, likely simply being human risk factors for suicide.
A Introduction
As is the case for all complex health outcomes, there are many risk factors known to increase risk of suicide. In Chapter 6, we will address the clinical assessment of suicide risk, which incorporates risk and protective factors. In the current chapter, we will show how risk factors – health and environmental – weave together and escalate risk at particular moments in a person’s life. This chapter will explore how the interaction of biological, psychological, and social/environmental risk factors can increase risk of suicide, differentiating between more enduring and more dynamic factors. We will show how these various factors intersect with life stressors to increase suicide risk. Research related to the global burden of suicide indicates that while cultural factors and available lethal means play a huge role in the suicide risk of a population, many risk and protective factors are shared cross nationally.1 Understanding, as much as possible, how complex interactions between mental, physical health, and life events pave a path to acute suicide risk, lays the foundation for the preventive measures discussed in the subsequent parts of the book.
B Principles
A conceptual model for suicide risk is presented, which synthesizes a large body of research about how and when suicide risk increases and how it can be mitigated.
Risk and protective factors are in somewhat overlapping categories of biological, psychological, and social/environmental. While these are not all as distinct as the categories seem, it is helpful to recognize the kinds of factors that influence risk for suicide.
Risk and protective factors interact with each other and the interactions are multi-directional.
Protective factors are critically important and should be identified and encouraged in patient care, however, they are not a guaranteed protection against suicide risk, as protective factors are also dynamic and can be temporarily dismantled during acute crisis. That said, the more robustly the protective factors are in place, generally the more mitigating a role they can play against suicide risk. You can help your patients identify their strongest protective factors to incorporate into their self-management and safety plan.
Research has illuminated some common features of the perspective of the suicidal mindset. Understanding these findings will help clinicians communicate optimally with patients who are at risk.
Clinical Takeaways include:
facilitate your patients’ insight about their own individual risk and protective factors
continuously filter clinical information, symptoms, and history through the lens of suicide risk assessment so that your assessment remains dynamic and clinical action can be taken appropriately at key times
Inquiring about suicidal ideation on its own is not an adequate assessment of risk. It is imperative to include risk and protective factors in the clinical suicide risk assessment (outlined in Chapter 6).
Clinical Takeaways
Facilitate your patients’ insights about their own individual risk and protective factors
Help patients reflect on and hone in on their unique “triggers” for negative spirals or for suicidal ideation
Continuously filter clinical information, symptoms, and history through the lens of suicide risk assessment so that your suicide risk assessment can be dynamic and clinical action can be taken appropriately at key times
C Model for Understanding Suicide
Psychological Theories. A number of contemporary psychological theories offer frameworks for understanding and explaining why suicide occurs. While a comprehensive overview of theories is beyond the scope of the present volume, a selected review is warranted here. Historically, psychological theories of suicide have focused on suicide as a response to overwhelming pain2, isolation3, or hopelessness.4, 5 Most contemporary theories take these factors for granted and shift the focus to explaining why some people who have these experiences move from ideation to action.6 The Interpersonal Theory of Suicide was the first of these theories and remains the most well-known. The Interpersonal Theory posits that stressors of all kinds lead to suicide when three key phenomena come together and intensify to potentiate behavior: low belongingness (feeling isolated, disconnected, sense of failure to form relationship), burdensomeness (lacking sense of being valuable and valued), and acquired capability (reduced sensitivity to physical pain, fearlessness of death, and ready access to lethal means). The Integrated Motivational-Volitional Model (IMVM) builds upon and recasts the constructs of the Interpersonal Theory.7 IMVM focuses on entrapment (feeling trapped) and defeat (social humiliation) as primary drivers and explains how people with key background risks and triggering events progress from ideation to behavior. The Three-Step Theory proposes that suicide occurs (i) in the presence of pain and hopelessness, (ii) when the person’s pain is greater than their capacity for connection with others, and (iii) they acquire the capability for suicide.6
For the purposes of this handbook, we will focus on risk and protective factors that cut across different theories and where the suicide research field provides support. Our goal is to give the reader background knowledge that will be useful both for clinical practice and for delving deeper into any of the psychological theories mentioned above.
Risk Factors
Psychological autopsy method research studies consistently find multiple risk factors present and interacting just prior to the suicide decedent’s untimely death. So, although family members and friends left behind search for reasons for their loved one’s death, external observations are not always able to capture the full multi-dimensional changes that were occurring prior to death.
Case Example: John – Part 1
His name was John. He was a 53-year-old executive with a loving wife of more than 20 years, two children in college, a solid career with the same firm, and by his own admission to his doctor, “no reason to be more depressed than any other guy.” He had some health issues – he had recently been diagnosed with hypercholesterolemia and borderline diabetes – but they could be addressed. He had been disappointed with being passed over for promotions at work, but he told his wife and friend he had come to terms with his career, saying not everyone can be lucky. A long-time firearm owner having grown up in a hunting and shooting sports-oriented family, he began to feel increasingly ashamed, and like he was a burden on his family. One morning, when his wife was away, he ended his life.
E Risk Factors
What are the drivers of suicide risk? Why do people kill themselves? One narrative that can be dispelled immediately is the idea of the calamitous event, the life tragedy that on its own pushes the person over the edge. In fact, suicide is the result of the convergence of several risk factors and life stressors.
Suicide risk factors are characteristics or conditions that increase the chance a person may take their life. Just like someone who is at risk for heart disease because of high blood pressure, or a history of heart disease in the family, some people are at higher risk for suicide than others.
Risk factors can be more enduring, i.e., chronic or distal and therefore may seem disconnected to the suicide, such as childhood abuse, or more dynamic, i.e., more short term and changing, often proximally connected to the suicide in time and/or space. A dynamic risk factor, for example, could be a recent job stressor or worsening pain condition or depression, both of which have been shown to increase the likelihood of suicide.
Figure 4.1 Model for understanding suicide risk
Multiple risk and protective factors interact dynamically to create periods when risk increases or subsides for an individual. Suicide is not a one-cause/effect phenomenon. While life events can serve as precipitating factors, they are not the sole cause of suicide.
Biological Risk Factors
The first of the three general categories of risk factors is biological in nature – numerous factors related to the biological make-up of a person, everything from genes to inflammation to brain structure to brain functions such as stress response. Note that the categories are not actually distinct, since many risk and protective factors have several roots and can be quite intertwined. For example, genetics and environmental influences can impact biological (including cellular, neurophysiological, and meta-physiological functions) and psychological traits (including behavioral and cognitive functions).
Biological risk factors tend to be on the more enduring side, especially when chronic in nature. However, even the most seemingly static risk factors can sometimes have the potential to be influenced and mitigated. The most important health/biological risk factors for suicide are psychiatric conditions.1 Those that are known to increase suicide risk, especially when they co-occur with other conditions, include MDD, bipolar disorder, substance use disorders, anxiety disorders, psychotic disorders, borderline personality disorder, impulse control disorders, eating disorders, and PTSD.8 Research has shown that 85% – 95% of people who die by suicide have a diagnosable mental health condition at the time of their death.9 Depression is by far the most common mental health condition in general, and is the one that most commonly increases suicide risk, as found in postmortem psychological autopsy studies.10, 11 Bipolar disorder is also associated with a very high risk for suicide, but is less prevalent than depression (3.9% lifetime prevalence for bipolar disorder versus 16.6% for MDD in the general population).12
(Conditions often co-occur in cases of suicide risk therefore the prevalence rates do not add to 100%.)
Major depression (present in 50–60% of suicides)
Bipolar disorder (10%)
Substance use disorders (25%)
Psychosis (15%)
Borderline personality disorder (10%)
Anxiety disorders and PTSD (6%)
Impulse control disorders
Eating disorders
These psychiatric risk factors have been found in suicide studies globally. A study of cross national suicide risk factors showed that, in addition to demographic factors, the presence of a mental disorder, often with psychiatric comorbidity, is one of the most strongly contributing risk factors that remains consistent throughout the world.13
A second set of more enduring biological factors relates to genetics, reflected for example in a family history of suicide or mental illness. Researchers have identified several candidate genes that predispose a person to suicide, which could help explain how suicidal behavior is transmitted across generations. This research is in a relatively early phase however, and the results of smaller studies have not been replicated in large-scale genome-wide studies.14
There is also epigenetic research indicating that genes and environmental events can interact to increase suicidal behavior. For example, research shows that childhood adversity is associated with the epigenetic regulation of genes, which in turn can alter an individual’s stress response system.15, 16 Specifically, an individual’s coping and resilience strategies, such as regulating one’s emotions or making decisions, can be weakened by early adversity, leading to the potential for increased suicidal behavior in response to stress, even stress that has occurred in the distant past. The literature related to adverse childhood events (ACEs) demonstrates the impact of early stress on multiple outcomes including suicide, mental health, and other health outcomes. The good news is the ACEs studies also demonstrate that risk can be mitigated even in children who have experienced more than six ACEs, for example by the presence of one caring adult in the child’s life.12
Examples of other more enduring biological risk factors are:
Neurobiological risk factors (e.g., HPA axis dysfunction, serotonin neurotransmitter systems, other neurotransmitter systems – dopamine, norepinephrine, epinephrine, GABA, glutamate, opioid, and acetylcholine receptors – have also been implicated; stress regulation, fronto-cingulo-striatal network is implicated in suicide risk, reward system, and emotion control, low brain derived neurotrophic factor levels, corticotrophin level alterations, cellular CNS differences in astrocytes and oligodendrocytes)
Past history of suicidal behavior
While these risk factors tend to be longer term and less dynamic, they can be mitigated by the epigenetic influence of positive environmental factors like social and family support, and brain health interventions, i.e., effective mental health treatment.
Case Example Continuation: John – Part 2
While John did not show early signs of major depressive disorder, in the two years before his death, he had seemed to family and friends to become more distant, possibly indicating a change in mood that may have stemmed from burgeoning but cloaked clinical depression. Although he dismissed the importance of his loss of promotion, his wife felt that he remained frustrated, possibly interpreting being passed over as a sign of failure or incompetence. Concerning his family history, a key historical biological factor, there had been deaths from both suicide and drug overdose among older relatives. In addition, his mother had shown signs of severe depression after John’s brother died in early childhood. His mother’s history of depression could represent risk both in terms of genetic history of a mood disorder, as well as related to the psychological, developmental, and environmental impact of being raised by a depressed parent – another known risk factor for poor outcomes such as anxiety and disruptive behavior during childhood and other psychopathology later in life.
More Dynamic Biological Risk Factors
Dynamic risk factors tend to be more short term or proximal, and more readily modifiable. They can serve as an impetus for further destabilization and have the potential to increase suicide risk unless addressed. A recent onset, recurrence, or worsening of a psychiatric condition – for example, a major depressive or bipolar mood episode, or relapse of substance use disorder or a psychotic disorder – could begin a cascade of diminished coping strategies and cognitive changes/distortions, and can “activate” previously “latent” distal risk factors leading to acute suicide risk. A physical medical illness (e.g., pain condition or autoimmune illness flare) could also contribute to increased risk, especially in concert with other suicide risk factors.
New or worsening symptoms related to suicide risk, such as hopelessness, insomnia, agitation, aggression, impulsivity, shame, or burdensomeness, may also serve as proximal biological/psychological risk factors.
Other examples of more dynamic biological risk factors include the following. In each instance the importance of addressing the risk factor as quickly and aggressively as possible cannot be overstated, since the impact on suicide risk is almost never immutable:
Recently diagnosed or new onset physical health condition (e.g., diabetes, seizure disorder, pain conditions, multiple sclerosis, cancer, infection, HIV/AIDS). These can directly impact physiological brain functioning increasing suicide risk, and can additionally increase suicide risk via the psychological effects of having a newly diagnosed serious health condition.
Increased use of alcohol or other substances, which have a CNS depressant/ agitating effect, and can worsen other risk factors such as impulsivity and disinhibition.
New or changing dose of a psychotropic medication – in some cases it can produce usually time-limited side effects of anxiety, agitation, or insomnia. If suicide risk is latent (may not be recognized), negative side effect-related symptoms can increase the potential for suicidal ideation and, rarely, for suicidal behavior. It should be noted, however, that psychiatric medications more often reduce suicide risk when they are used effectively and appropriately monitored. The key is close monitoring at initiation and dose change (see Chapter 9).
Epigenetic changes (DNA methylation, gene expression) may produce an increased (or decreased) risk for suicide by impacting neurobiology, cognition, or stress regulation. This means that negative experiences such as trauma and conversely positive experiences such as social support or psychotherapy can actually change gene expression, and can significantly impact an individual’s resilience and risk for suicide.
Case Example Continuation: John – Part 3
In the months leading up to his death, John’s drinking increased, and his wife noticed that he seemed increasingly “on edge,” losing his temper at home more frequently. She thought his sleep had become more fitful. John presented to his primary care physician for weight gain three to four months prior to his death, and he was diagnosed with hypercholesterolemia and borderline diabetes. His increased intake of alcohol and emerging symptoms of insomnia, agitation, and low frustration tolerance may have been the tip of the iceberg heralding underlying mood, cognitive, and coping changes. The newly diagnosed medical conditions may have contributed to his suicide, again via potentially direct biological changes or via individual psychological interpretations of having chronic illness.
Although not illustrated in John’s case, one of the strongest predictors of future suicide attempts is a history of suicidal behavior (a prior suicide attempt as a risk factor is considered multifactorial itself, being influenced by several potential layers – biological, psychological, and social/environmental). Research has shown that people who make suicide attempts are significantly (37–40 times) more likely to eventually die by suicide than those who have never attempted suicide before.11, 18 It is also true, however, that the majority of people who survive an attempt do not go on to die by suicide.19, 20 Another predictor of future suicidal behavior is a history of non-suicidal self-injury (NSSI).21, 22 These findings were reported in the 24- and 28-week follow-ups to the Adolescent Depression Antidepressants and Psychotherapy Trial and the Treatment of Selective Serotonin Reuptake Inhibitors-Resistant Depression in Adolescents studies.21, 23, 24 So, while NSSI behavior should not be misconstrued as suicidal in intent, and does not necessarily require emergent medical attention, individuals who engage in NSSI can benefit from mental health treatment such as psychotherapy (e.g., Dialectical Behavior Therapy (DBT)) or medications targeting specific diagnoses or symptoms, and sustained treatment can help in short-term ways (symptom and NSSI reduction) as well as long term (can decrease suicide risk.)
Psychological Risk Factors
Numerous psychological factors can increase suicide risk. It should be emphasized that research shows, as with biological risk factors, that it is not any of these singularly, but rather factors in combination with other risk factors and life events, that increases an individual’s risk for suicide.
Psychological risk factors can be subjectively reported or objectively measured. A good patient history will provide information on previous patterns such as impulsivity, aggression, perfectionism, all-or-none thinking, neuroticism (worrying, overthinking), tendency to become hopeless or anhedonic (the inability to feel pleasure).
Less apparent to the patient but equally important are neurocognitive factors, that are more likely to be revealed through objective measurements. In studies of people with suicidal behavior, compared with controls, they tend to have specific differences in decision making, problem-solving, and other cognitive functions.25
These risk factors come into play when they intersect with other risk factors and stressors, such as a current major depressive episode or a traumatic experience or loss.
Specifically, psychological risk factors may operate by:
Intensifying or distorting negative perceptions and feelings in response to life events and interpersonal interactions
Increasing the intensity of negative emotions, such as feeling overwhelmed
Decreasing the ability to flexibly solve problems or seek help
Increasing the likelihood of responding impulsively rather than pausing to allow intense emotions to recalibrate or to see a future where the problem has subsided
Deficits in executive functioning, often part of ADHD, mood disorders, and head injuries, produce impairments in the ability to plan multiple steps for complex problems or situations
As a result, some psychological risk factors can be quite invisible or insidious to the individual and possibly to the people in their life. Some are also not necessarily the factors one might expect (e.g., “the least likely person to take their life” – the “high functioning” student or executive, with high degrees of perfectionism and drive, who may also experience recurrent depression or have hidden addiction or PTSD, or “the life of the party, larger than life” individual, which sometimes stems from an underlying bipolar or personality disorder), but they are potentially dangerous when they occur in a patient with other suicide risk factors.
Distal or Longer Term Psychological Risk Factors
Many distal psychological risk factors, such as neuroticism, perfectionism, or extreme sensitivity to humiliation or rejection, can contribute to a pathway that leads to suicide. Cognitive rigidity, either as a baseline trait or in response to stress, can increase the likelihood that suicide will be narrowed in on and considered the sole solution or way to cope with the current situation.26
To summarize, more enduring psychological risk factors include:
Neuroticism (intrinsic high anxiety trait that is likely inherited, longstanding, usually starting in childhood)
Perfectionism
Inflexible or rigid cognitive style
Innate pessimism/low optimism
Sensitivity to experiences such as humiliation or perceived rejection leading to bursts of hopelessness or anger
Case Example Continuation: John – Part 4
John did not show any obvious signs of enduring psychological risk factors. However, upon further inspection, he did display a stoic style of coping with disappointment, which while normalized especially for men in many cultures, is not the most adaptive or helpful when mental health needs are on the rise, and especially when other latent suicide risk factors such as family history and childhood adversity are present. While his career setbacks contributed to his suicide, on the surface he did not appear to react to these events, at least overtly or immediately. On the contrary, he may have lacked self-awareness of the psychological impact on his internal dialog and likely tried to tame his despair with alcohol, although this effort likely worsened his mood, sleep, and coping abilities, and buried feelings that resulted in proximal psychological risk states such as shame and hopelessness, as discussed in the next section.
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