Fallon B. Ringer

The interpersonal theory of suicide: A systematic review and meta-analysis of a decade of cross-national research.

Over the past decade, the interpersonal theory of suicide has contributed to substantial advances in the scientific and clinical understanding of suicide and related conditions. The interpersonal theory of suicide posits that suicidal desire emerges when individuals experience intractable feelings of perceived burdensomeness and thwarted belongingness and near-lethal or lethal suicidal behavior occurs in the presence of suicidal desire and capability for suicide. A growing number of studies have tested these posited pathways in various samples; however, these findings have yet to be evaluated meta-analytically. This paper aimed to (a) conduct a systematic review of the unpublished and published, peer-reviewed literature examining the relationship between interpersonal theory constructs and suicidal thoughts and behaviors, (b) conduct meta-analyses testing the interpersonal theory hypotheses, and (c) evaluate the influence of various moderators on these relationships. Four electronic bibliographic databases were searched through the end of March, 2016: PubMed, Medline, PsycINFO, and Web of Science. Hypothesis-driven meta-analyses using random effects models were conducted using 122 distinct unpublished and published samples. Findings supported the interpersonal theory: the interaction between thwarted belongingness and perceived burdensomeness was significantly associated with suicidal ideation; and the interaction between thwarted belongingness, perceived burdensomeness, and capability for suicide was significantly related to a greater number of prior suicide attempts. However, effect sizes for these interactions were modest. Alternative configurations of theory variables were similarly useful for predicting suicide risk as theory-consistent pathways. We conclude with limitations and recommendations for the interpersonal theory as a framework for understanding the suicidal spectrum.

A meta-analytic review of the association between agitation and suicide attempts.

Agitation has been implicated as an acute risk factor for suicidal behavior, yet the literature to date has not been consolidated to better understand this relationship. We conducted a meta-analysis of the association between agitation and suicidal behavior to synthesize the existing literature (k=13 studies) and point out future directions for research. Results indicated that the association between agitation and suicidal behavior is moderate (Hedges g=0.40, p=0.007, 95% CI [0.08, 0.72]). Follow-up meta-regressions revealed that age, gender, and year of publication were not significant moderators of the magnitude of this relationship. However, there was evidence of publication bias, as shown by a funnel plot and Eggers test. These findings suggest the importance of future research that examines the nature of the association between agitation and suicidal behavior longitudinally and with novel research designs, as implications for clinical practice and suicide risk assessment may be substantial.

Mental Health Service Use Among Firefighters With Suicidal Thoughts and Behaviors

OBJECTIVE This study aimed to characterize rates and correlates of mental health service use, as well as barriers to care, among a sample of firefighters reporting a history of suicide ideation, plans, or attempts during their firefighting careers. METHODS Participants (N=483) completed a Web-based survey assessing history of suicidal thoughts and behaviors, prior mental health service utilization, and barriers to treatment. RESULTS Overall, 77% of participants reported receipt of mental health services during their firefighting careers (attempt history, 93%; plan but no attempt, 77%; and ideation only 68%). Firefighters with fewer years of service were less likely than those with more years to have accessed treatment. Service nonusers were more likely than service users to report concerns regarding reputation and embarrassment as barriers to care. CONCLUSIONS Findings from this preliminary investigation suggest that the majority of firefighters with a history of elevated suicide risk have received mental health services.

Is Insomnia Lonely? Exploring Thwarted Belongingness as an Explanatory Link between Insomnia and Suicidal Ideation in a Sample of South Korean University Students

STUDY OBJECTIVES Suicide is a serious public health problem, and suicide rates are particularly high in South Korea. Insomnia has been identified as a risk factor for suicidal ideation; however, little is known about the mechanisms accounting for this relationship in this population. Based on the premise that insomnia can be lonely (e.g., being awake when everyone else is asleep), the purpose of this study was to examine whether greater insomnia severity would be associated with higher levels of thwarted belongingness and suicidal ideation, and whether thwarted belongingness would mediate the relationship between insomnia and suicidal ideation. METHODS Predictions were tested in a sample of 552 South Korean young adults who completed self-report measures of insomnia severity, suicidal ideation, and thwarted belongingness. RESULTS Greater insomnia symptom severity was significantly and positively associated with thwarted belongingness and suicidal ideation. Mediation analyses revealed that thwarted belongingness significantly accounted for the relationship between insomnia severity and suicidal ideation. CONCLUSIONS These findings highlight the potential importance of monitoring and therapeutically impacting insomnia and thwarted belongingness to help reduce suicide risk.

Examination of MMPI-2-RF Substantive Scales as Indicators of Acute Suicidal Affective Disturbance Components.

ABSTRACT A new suicide-specific diagnostic entity, acute suicidal affective disturbance (ASAD), was recently proposed to fill a void in the nomenclature. Although several studies have examined the reliability, validity, and potential clinical utility of ASAD, no studies have examined personality indicators of ASAD. This study sought to examine the association between personality and psychopathology factors, as assessed by the Minnesota Multiphasic Personality Inventory–2–Revised Form (MMPI–2–RF), and constructs that comprise ASAD in a sample of 554 psychiatric outpatients who completed all measures prior to their intake appointments. A smaller subset of patients (N = 58) also completed a measure designed to assess lifetime ASAD symptoms. Results indicated that ASAD symptoms were associated with traits characterized by emotional turmoil and atypical cognitive processes. Further, suicide-related criteria that comprise ASAD were related to low positive emotionality and hopelessness, whereas the overarousal criteria were associated with somatic symptoms and an inability to tolerate frustration and stress. These findings expand on previous research that examines the convergent and discriminant validity of ASAD and could inform clinical treatment by providing insight into personality traits that might be associated with acute suicide risk.

Initial Validation of Brief Measures of Suicide Risk Factors: Common Data Elements Used by the Military Suicide Research Consortium.

The Military Suicide Research Consortium (MSRC) developed a 57-item questionnaire assessing suicide risk factors, referred to as the Common Data Elements (CDEs), in order to facilitate data sharing and improve collaboration across independent studies. All studies funded by MSRC are required to include the CDEs in their assessment protocol. The CDEs include shortened measures of the following: current and past suicide risk, lethality and intent of past suicide attempts, hopelessness, thwarted belongingness, anxiety sensitivity, posttraumatic stress disorder symptoms, traumatic brain injury, insomnia, and alcohol abuse. This study aimed to evaluate the psychometric properties of the CDE items drawn from empirically validated measures. Exploratory factor analysis was used to examine the overall structure of the CDE items, and confirmatory factor analyses were used to evaluate the distinct properties of each scale. Internal consistencies of the CDE scales and correlations with full measures were also examined. Merged data from 3,140 participants (81.0% military service members, 75.6% male) across 19 MSRC-funded studies were used in analyses. Results indicated that all measures exhibited adequate internal consistency, and all CDE shortened measures were significantly correlated with the corresponding full measures with moderate to strong effect sizes. Factor analyses indicated that the shortened CDE measures performed well in comparison with the full measures. Overall, our findings suggest that the CDEs are not only brief but also provide psychometrically valid scores when assessing suicide risk and related factors that may be used in future research.

Cross-cultural relevance of the Interpersonal Theory of suicide across Korean and U.S. undergraduate students

This study investigated the cross-cultural relevance and validity of the Interpersonal Theory of Suicide (ITS) utilizing young adult samples from South Korea (n =554) and the United States (U.S.; n =390). To examine the ITS, all participants completed self-report questionnaires measuring Thwarted Belongingness, Perceived Burdensomeness, and Capability for Suicide. We examined whether each construct significantly predicted the severity of suicidal risk in both samples. We also determined whether the strength of the effects of Thwarted Belongingness and Perceived Burdensomeness on suicidal ideation differed between the two samples due to the greater degree of importance placed on interpersonal relationships in collectivistic cultures such as South Korea. Structural equation modeling was used to examine these hypotheses. Thwarted Belongingness, Perceived Burdensomeness, and Capability for Suicide significantly predicted elevated suicidal risk. However, there were no significant differences in the paths from Thwarted Belongingness or Perceived Burdensomeness to suicide risk between the South Korean and U.S. SAMPLES These findings support the cross-cultural relevance and applicability of the ITS, whereby Thwarted Belongingness and Perceived Burdensomeness serve as indicators of suicide risk in both Western (U.S.) and East Asian (Korean) samples.

The Associations Between Army National Guard Versus Active Duty Soldier Status and Perceived Burdensomeness, Thwarted Belongingness, and Acquired Capability

OBJECTIVE This study aimed to examine if levels of thwarted belongingness, perceived burdensomeness, and acquired capability significantly differed between guardsmen and active duty soldiers. METHOD Multivariate analysis of covariance was used to test for differences between active duty Army (n = 1,393) and Army National Guard (n = 623) groups, before and after controlling for the effects of age, gender, race, marital status, level of education, and deployment history. RESULTS Guardsmen reported significantly higher mean levels of thwarted belongingness and perceived burdensomeness than did active duty soldiers, even after adjusting for demographic differences. Guardsmen also reported slightly lower levels of acquired capability, though this effect was accounted for by demographic differences. CONCLUSION These findings support the notion that National Guard and active duty soldiers differ on perceived burdensomeness and thwarted belongingness. Additional research investigating sources of perceived burdensomeness and thwarted belongingness among guardsmen is needed.

Thwarted Belongingness in Relation to Face-to-Face and Online Interactions

Suicide is ranked as the tenth leading cause of death for all ages in the United States (Centers for Disease Control and Prevention, 2012). Joiners (2005) interpersonal theory of suicide stated thwarted belongingness-the feeling of being alienated from others-and perceived burdensomeness-the feeling of being a liability to others-are the primary proximal factors leading to suicidal desire. The current study focused on thwarted belongingness and examined its relationship to face-to-face interactions and online interactions in both an undergraduate and community sample. We hypothesized that negative face-to-face and online interactions would be independently associated with higher levels of thwarted belongingness. Furthermore, we hypothesized that face-to-face interactions would moderate the relationship between online interactions and thwarted belongingness and that online interactions would moderate the relationship between face-to-face interactions and thwarted belongingness. Three hundred eighty-seven participants (79.6% female) at a southern university and 209 (62.7% male) participants recruited from Amazons Mechanical Turk website completed an online survey. Results only partially supported hypotheses, with only face-to-face interactions shown to be independently related to higher levels of thwarted belongingness. These findings indicated that negative face-to-face interactions may contribute to higher levels of risk factors for suicide ideation and highlighted the importance of assessing for negative interactions across all contexts.

The association between suicidal ideation and lifetime suicide attempts is strongest at low levels of depression

Suicidal ideation and depression alone are poor predictors of subsequent engagement in suicidal behavior. Evidence suggests, however, that the lethargy associated with depression may serve as a protective factor against suicide attempts. The purpose of this study was to examine whether suicidal ideation and depression symptoms interact in relation to lifetime suicide attempts among a sample of psychiatric outpatients. A sample of 739 psychiatric outpatients (Mage = 27.26, 60.8% female, 73.3% White/European American) from a university-affiliated clinic completed a battery of self-report measures prior to their initial intake appointments. Consistent with hypotheses, a significant interaction emerged between suicidal ideation and depression symptoms in association with lifetime suicide attempts, such that the relationship between suicidal ideation and lifetime suicide attempts was strongest at low, as opposed to high, levels of depression. These findings align with previous research suggesting that lethargy may be a protective factor against suicide attempts, and conversely, that heightened arousal may serve as a suicide risk factor. Our results also point to a configuration of suicidal ideation and depression symptoms that might reflect higher suicide risk.