When It Is Darkest Understanding Suicide Risk - Mental Health Academy
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When It Is Darkest Understanding Suicide Risk Rory O’Connor PhD CPsychol AFBPsS FAcSS President, International Association for Suicide Prevention Professor of Health Psychology Suicidal Behaviour Research Laboratory Institute of Health and Wellbeing E: rory.oconnor@glasgow.ac.uk W: suicideresearch.info T: @suicideresearch
Just
Published Published
May 2021 May 2021
www.bookdepository.com
2021 I have combined the personal with the professional – by telling something of people’s stories, including my own, I have tried to convey a sense of what I have learned from my life and from my research into this most devastating of phenomena. This is my journey through research into suicide, including how suicide has touched me personally. In this book, I try to make sense of suicide by drawing from the experiences of people I’ve met and in so doing I’ll share the stories of those who have been suicidal and those who have lost loved ones to suicide.
o Scale of the challenge including COVID o Myths around suicide o Integrated Motivational-Volitional (IMV) model of suicidal behaviour o Warning signs that someone may be suicidal o Crossing the precipice: from suicidal thoughts to suicide attempts o Conclusions
We conduct interdisciplinary research including experimental research, clinical and non-clinical
studies as well as psychosocial interventions as we strive to understand and prevent suicide
www.suicideresearch.info
WHO (2021)
The ripples of suicide
c95 million potentially
affected / knew the person
Globally, every 40 seconds who died
One person dies by suicide
20 people will attempt suicide
703,000 deaths
by suicide
globally each
year
In UK, 75% of suicides are by men
Suicide leading cause of death among
men aged 35-49 and for men and women
aged 20-34 years
WHO (2021); Cerel et al. (2019); ONS (2020)
At the start of the pandemic
But… Pirkis et al. (2021) Lancet Psychiatry
UK COVID-19 Mental Health and Wellbeing study (UK COVID-MH) To investigate the immediate and medium-term impact of the COVID-19 pandemic and the required social distancing and self-isolation measures on people’s mental health and wellbeing in the UK. Using a national, non-probability sample of adults from across the UK (n=3,077) with at least 7 follow-ups over 12-15 months, we asked people questions about their mental wellbeing in the weeks and months following the COVID-19 outbreak. Research Team: Rory C O’Connor, Karen Wetherall, Seonaid Cleare, Heather McClelland, Ambrose J Melson, Claire L Niedzwiedz, Ronan E O’Carroll, Daryl B O’Connor, Steve Platt, Elizabeth Scowcroft, Billy Watson, Tiago Zortea, Eamonn Ferguson, & Kathryn A Robb
Waves 1 to 3
Trends in anxiety and depressive
symptoms
Trends in anxiety symptoms (GAD-7 % ≥ 10) Trends in depressive symptoms (PHQ-9, % ≥ 10)
waves 1 - 3 waves 1 - 3
22 27 26.1
21
21 25 24.3
23.7
20 23
19 18.6
21
18
16.8 19
17
16 17
15 15
Wave 1 Wave 2 Wave 3 Wave 1 Wave 2 Wave 3
- Anxiety symptoms (moderate cut-off GAD-7 ≥ 10) decreased significantly across wave 1 – 3
- Depressive symptoms (moderate depression cut-off PHQ-9 ≥ 10) decrease was not significantTrends in suicidal ideation in last week
Trends in suicidal ideation waves 1-3 (%) o Participants were asked: “How
11 often have you thought about
taking your life in the last
week?” (‘never’, to ‘nearly
10 9.8
everyday’)
9.2
9 o Suicidal ideation= at least one
day/week
8.2
8 o Rates of suicidal ideation in
the last week increased from
7 wave 1 to wave 2 and from
Wave 1 Wave 2 Wave 3 wave 1 to wave 3Trends in suicidal ideation by age
and gender
Trends in suicidal ideation waves 1-3 by age Trends in suicidal ideation wave 1 - 3 by
group (%) gender (%)
16 14.3 14.4 10.5 10.1
14 12.5 10 9.6
12 10.6 9.5
9.5 9 8.6 9.4
10 8.4
8.5 8.7
8
8
6 7.5 7.7
4 2.5 2.7 7
1.9
2 6.5
0 6
Wave 1 Wave 2 Wave 3 Wave 1 Wave 2 Wave 3
18- 29 yrs 30- 59 yrs 60+ yrs Men Women
- Young people (18-29 year olds) reported the highest rates of suicidal ideation, and older adults reported
the lowest levels
- Women reported slightly higher levels of suicidal ideation, but this was not significantly differentTrends in suicidal ideation by socio-
economic grouping (SEG)
Trends in suicidal ideation waves 1 -3 by SEG (%)
o Participants were split
12 into high and low SEG
11 based upon the
11 10.6
10.3
occupation of the main
10
8.9 earner
9 8.3
8 o Those of a lower socio-
7 6.6 economic grouping
6 reported higher suicidal
5 ideation over each wave
4
Wave 1 Wave 2 Wave 3
HighSEG LowSEGTrends in suicidal ideation by pre-
existing mental health condition (MH)
Trends in suicidal ideation waves 1 - 3 by pre-existing
mental health condition (%) o Participants were asked if they
25 had a pre-existing mental health
20.4 condition
19.3 19
20
15
o Of those who did (n=852) more
people reported anxiety (21.5%)
10 or depression (18%)
5.8 6
4.1 o Those with a MH condition
5
reported higher suicidal ideation
0 over each wave
Wave 1 Wave 2 Wave 3
No MH MHSuicidal ideation Waves 1 to 7
Depressive symptoms
Changes in suicidal ideation (% in the last week)
12.0%
and loneliness increased
10.0% 9.1% 9.1%
9.9% 9.6% 9.5% from wave 6 to 7. Defeat
8.0%
7.6% and entrapment
6.0%
6.5%
increased from wave 5 to
6 and remained elevated
4.0%
at wave 7. Anxiety
2.0%
symptoms, mental
0.0%
Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Wave 6 Wave 7 wellbeing and suicidal
ideation did not change.
Preliminary analyses: please do not tweet/circulate - includes those Wave 7
who completed all waves 4 Feb to 2 March 2021
UK STUDYSuicidal ideation: subgroup analysis
Changes in suicidal ideation by age group Changes in suicidal ideation by mental health condition
20.0% 18.1% 25.0%
17.6% 17.6%
18.0% 20.5%
15.7% 19.7%
16.0% 14.9% 15.1% 20.0% 18.3% 18.4%
17.5% 17.0% 17.5%
14.0%
11.8%
12.0% 10.8% 10.7% 15.0%
10.1% 9.9%
9.4%
10.0%
8.0%
8.0% 7.1% 10.0%
6.7% 7.3% 7.0%
6.0% 5.8% 6.2%
4.8%
4.0% 2.3% 2.6% 2.3% 2.6% 2.6% 2.6% 5.0% 3.0%
1.9%
2.0%
0.0% 0.0%
Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Wave 6 Wave 7 Wave 1 Wave 2 Wave 3 Wave 4 Wave 5 Wave 6 Wave 7
18-29 30-59 60+ No MH MH
Wave 7
4 Feb to 2 March 2021 Preliminary analyses: please do not tweet/circulatePublished May 2021
Biopsychosocial model
of suicide risk
2019Integrated motivational-volitional
(IMV) model of suicidal behaviour
O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour
Philosophical Transactions of the Royal Society B. 373: 201702682020
Mediation analysis of the relationship of
baseline defeat and entrapment with 12
month (Time 2) suicidal ideation
Time 1 Internal
Entrapment
Time 2 Suicidal
Time 1 Defeat
0.012 Ideation
**p < 0.01, ***pDevelopment of the 4-item Entrapment Scale Short-Form (E-SF)
Both classical & modern test Correlations between the 4-item
theory methods applied to short-form and the 16-item full
Gilbert & Allan (1998) 16 item scale were nearly perfect:
Entrapment Scale
Clinical sample (n= 497) patients 0.94 for the clinical sample
following self-harm 0.97 for the population-based
sample
Population sample (n= 3457)
De Beurs, Cleare, Wetherall, Byrne, Ferguson, O’Connor & O’Connor (2020).
Psychiatry ResearchThe 4-item Entrapment Scale Short-Form (E-SF)
1. I often have the feeling that I
would just like to run away
2. I feel powerless to change
things
3. I feel trapped inside myself
4. I feel I’m in a deep hole I can’t
get out of
De Beurs, Cleare, Wetherall, Byrne, Ferguson, O’Connor & O’Connor (2020).
Psychiatry ResearchLoneliness and Suicide Risk
Loneliness was a significant predictor of both suicidal ideation and behaviour and there was evidence that depression acted as a mediator.
2021
O’Connor (2021). When It Is Darkest
From Suicidal
Thoughts to Suicidal
Behaviour:
Volitional Factors
O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour
Philosophical Transactions of the Royal Society B. 373: 20170268Scottish Wellbeing Study: Differentiating Suicide
Ideation from Suicide Attempts
• Representative sample of young adults (18-34 years)
from across Scotland (n=3508)
• Three groups identified within the sample:
• Controls with no suicidal history (n=2534)
• lifetime suicide ideation (n=498)
• lifetime suicide attempt (n=403)
• According to IMV model, volitional phase factors most
important in differentiating IDEATION from ATTEMPTS
Wetherall et al. (2018). Journal of Affective DisordersMultivariable multinomial logistic regression
Demographics and Mood
Age and gender ATTEMPTS significantly older and female
Ethnicity, marital status, economic activity No difference between IDEATION vs ATTEMPTS
Depressive symptoms No difference between IDEATION vs ATTEMPTS
Motivational Phase Factors (ideation)
No difference between IDEATION vs ATTEMPTS
Defeat
No difference between IDEATION vs ATTEMPTS
Entrapment
Burdensomeness No difference between IDEATION vs ATTEMPTS
Belongingness No difference between IDEATION vs ATTEMPTS
Goal regulation No difference between IDEATION vs ATTEMPTS
Social support No difference between IDEATION vs ATTEMPTS
Resilience No difference between IDEATION vs ATTEMPTS
Volitional Phase Factors (attempts)
ATTEMPTS significantly higher than IDEATION
Impulsivity
ATTEMPTS significantly higher than IDEATION
Acquired capability
Mental images of death ATTEMPTS significantly higher than IDEATION
Exposure to suicidal attempt of friend ATTEMPTS significantly higher than IDEATION
Exposure to suicidal attempt of family No difference between IDEATION vs ATTEMPTS
Exposure to suicide death No difference between IDEATION vs ATTEMPTS
Wetherall et al., (2018) Journal of Affective DisordersCortisol: the Stress Hormone
Childhood trauma, stress and cortisol in individuals vulnerable to suicide?
Childhood trauma & suicidal history
Suicide attempt history
scored sig. higher on all
scales compared to both
those in ideation and
control groups
Ideation group
intermediate to the other
two groups
Ideation group different
from controls on
physical neglect
Ideation Attempt
(pExposure to “moderate to Severe”
childhood trauma
Ideation Attempt
O’Connor et al., 2020Effects of childhood trauma on cortisol reactivity to
stress (AUCg)
O’Connor, D., Green, J., Ferguson, E., O’Carroll, O’Connor, R. (2018) PsychoneuroendocrinologyDaily Stress and Wellbeing Study
O’Connor et al., 2020Methods for 7 day study
Visit 1 At-home Assessments
Baseline Assessments 7 days Visit 2
1 hour study visit • Self-sample saliva to measure Sample Return
CAR (+00, +15, +30 & +45 mins) 10 minute visit
and daily cortisol levels (3, 6, 9
Complete SITBI (Self-Injurious & 12 hrs)
Thoughts & Behaviours • Report daily • Return all materials
Interview) stressors/emotions online • Discussion and debrief
& Questionnaires • Wear activity monitor to
improve protocol adherence
1&6
month
FUEffects of childhood trauma on CAR AUC
across 7 days Emotional abuse, p=0.008
Emotional neglect, p=0.004
12.0 Sexual abuse, p=0.085
10.0
Cortisol
Cortisol (nmol/L)
8.0
None to minimal
Awakening 6.0
Response 4.0
Low to moderate
(CAR) Moderate to
severe
2.0
0.0
0 15 30 45
Time (mins)
Main effects of total CTQ on CAR AUC, p=0.01
All analyses controlled for age, BMI, medication, smoking, genderDaily cortisol predicts suicide ideation &
depression at 1 month
Low CAR
Ideation
Depression
Note: Baseline suicide ideation/depression entered at Step 1
AUCg/WP-12 adjusted for age, BMI, medication, smoking, genderResilience & vulnerability factors
Resilience Social perfectionism Trait worry Trait impulsivity
Key role played by Trait Worry
O’Connor et al., 2021From Thinking To Doing
Interventions to Interrupt the Transition
from Suicidal Thoughts to Suicide
Attempts2019
o Patients in the SPI+ condition were less likely to engage in suicidal behavior (n = 36 of 1186; 3.03%) than those receiving usual care (n = 24 of 454; 5.29%) during the 6-month follow-up period. o The SPI+ was associated with 45% fewer suicidal behaviors o Those in SPI+ condition more likely to have treatment engagement
The relative risk of suicidal behaviour among patients who received an SPTI compared with control was 0.570 (95% CI 0.408– 0.795, P = 0.001) Results support the use of SPTIs to help preventing suicidal behaviour and the inclusion of SPTIs in clinical guidelines for suicide prevention. SPTI: Safety Planning-type interventions
Safety Planning is so much more than this form: importance of compassion & collaboration
Safety Plan… …Is …Isn’t • A written, dynamic document • A long-term tool for mood • A list of internal and social distractions & people to call for help • For someone at imminent risk of • Easy to read suicide • Collaborative • To fill important gaps in care/ end of • For individuals with cognitive care impairment (unless adapted)
SAFETEL: Follow-up call engagement (n=80)
O’Connor et al. (submitted)Use of Safety Plan in SAFETEL study • During the telephone calls, at least 81% of participants discussed the content of their Safety Plan and reflected on the relevance of any people and activities they had listed on their Safety Plan. • 79% of the intervention group participants who completed a Safety Plan said they had used it at least once since baseline • Participants were most likely to report using their Safety Plan between their second and third follow-up calls, approximately 1-2 weeks after their recruitment to the study • 47.4% of participants who made a Safety Plan, made changes during the follow-up call phase • Across all calls, the most commonly changed step was Step 4 (‘People in their personal lives to contact for support’). O’Connor et al. (submitted)
Safetel participant describing using
the safety plan
“Everything was just there for you, on one sheet of paper, or on
your phone, you could have it with you all the time, if you felt you
needed it…I've never felt it was difficult to use. I thought the way it
was laid out was really good, had all the information there. The
stress is kind of off you, as soon as you got that, a lot of it.” PE011
O’Connor et al. (submitted)Approaches for preventing suicide 2019
o Suicide is more about ending pain than ending one’s life o Trapped by mental pain o To prevent suicide takes more than treating mental health problems o Tackling inequality, stigma, discrimination, COVID-19 o We can support each other o Compassion and collaboration are key o The factors that lead to suicidal thoughts are different from those associated with suicide attempts/death o Brief interventions such as safety planning are important in preventing suicidal behaviour in individuals who are at high risk
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