Jessica D. Ribeiro

Main Predictions of the Interpersonal-Psychological Theory of Suicidal Behavior: Empirical Tests in Two Samples of Young Adults

The interpersonal-psychological theory of suicidal behavior (T. E. Joiner, 2005) makes 2 overarching predictions: (a) that perceptions of burdening others and of social alienation combine to instill the desire for death and (b) that individuals will not act on the desire for death unless they have developed the capability to do so. This capability develops through exposure and thus habituation to painful and/or fearsome experiences and is posited by the theory to be necessary for overcoming powerful self-preservation pressures. Two studies tested these predictions. In Study 1, the interaction of (low) family social support (cf. social alienation or low belonging) and feeling that one does not matter (cf. perceived burdensomeness) predicted current suicidal ideation, beyond depression indices. In Study 2, the 3-way interaction among a measure of low belonging, a measure of perceived burdensomeness, and lifetime number of suicide attempts (viewed as a strong predictor of the level of acquired capability for suicide) predicted current suicide attempt (vs. ideation) among a clinical sample of suicidal young adults, again beyond depression indices and other key covariates. Implications for the understanding, treatment, and prevention of suicidal behavior are discussed.

Risk Factors for Suicidal Thoughts and Behaviors: A Meta-Analysis of 50 Years of Research.

Suicidal thoughts and behaviors (STBs) are major public health problems that have not declined appreciably in several decades. One of the first steps to improving the prevention and treatment of STBs is to establish risk factors (i.e., longitudinal predictors). To provide a summary of current knowledge about risk factors, we conducted a meta-analysis of studies that have attempted to longitudinally predict a specific STB-related outcome. This included 365 studies (3,428 total risk factor effect sizes) from the past 50 years. The present random-effects meta-analysis produced several unexpected findings: across odds ratio, hazard ratio, and diagnostic accuracy analyses, prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction. The homogeneity of existing research means that the present meta-analysis could only speak to STB risk factor associations within very narrow methodological limits—limits that have not allowed for tests that approximate most STB theories. The present meta-analysis accordingly highlights several fundamental changes needed in future studies. In particular, these findings suggest the need for a shift in focus from risk factors to machine learning-based risk algorithms.

Sleep problems outperform depression and hopelessness as cross-sectional and longitudinal predictors of suicidal ideation and behavior in young adults in the military

BACKGROUND Sleep problems appear to represent an underappreciated and important warning sign and risk factor for suicidal behaviors. Given past research indicating that disturbed sleep may confer such risk independent of depressed mood, in the present report we compared self-reported insomnia symptoms to several more traditional, well-established suicide risk factors: depression severity, hopelessness, PTSD diagnosis, as well as anxiety, drug abuse, and alcohol abuse symptoms. METHODS Using multiple regression, we examined the cross-sectional and longitudinal relationships between insomnia symptoms and suicidal ideation and behavior, controlling for depressive symptom severity, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse symptoms in a sample of military personnel (N=311). RESULTS In support of a priori hypotheses, self-reported insomnia symptoms were cross-sectionally associated with suicidal ideation, even after accounting for symptoms of depression, hopelessness, PTSD diagnosis, anxiety symptoms and drug and alcohol abuse. Self-reported insomnia symptoms also predicted suicide attempts prospectively at one-month follow up at the level of a non-significant trend, when controlling for baseline self-reported insomnia symptoms, depression, hopelessness, PTSD diagnosis and anxiety, drug and alcohol abuse symptoms. Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms and hopelessness were controlled. LIMITATIONS The assessment of insomnia symptoms consisted of only three self-report items. Findings may not generalize outside of populations at severe suicide risk. CONCLUSIONS These findings suggest that insomnia symptoms may be an important target for suicide risk assessment and the treatment development of interventions to prevent suicide.

Fearlessness about death: the psychometric properties and construct validity of the revision to the acquired capability for suicide scale.

The Interpersonal Theory of Suicide proposes that suicidal behavior is so frightening that in order for an individual to engage in suicidal behavior, desire for suicide must be accompanied by the capability to do so. The capability for suicide is characterized by both a sense of fearlessness about death and elevated physiological pain tolerance. The primary aim of the current project was to reevaluate and revise the Acquired Capability for Suicide Scale (ACSS; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and offer a revision to the scale. Expert review of the scale items resulted in retaining 7 items assessing fearlessness about death. The recommendation is made to refer to the revised scale as the ACSS-Fearlessness About Death (ACSS-FAD) to reflect its content more specifically. A model with the 7 retained items provided good fit to the data across 3 independent samples of young adults. Multiple-group analyses examining measurement invariance across men and women found that the latent structure of the scale is comparable across gender. Data are also presented demonstrating convergent and discriminant validity for the scale in young adults and an inpatient psychiatric sample. Findings support the viability of the ACSS-FAD, indicating the scale has a replicable factor structure that generalizes across males and females and is substantively related to the construct of fearlessness about death. Taken together, the present work extends knowledge of the psychometrics of the ACSS-FAD in particular and the nature of fearlessness about death in general.

Overcoming the fear of lethal injury: Evaluating suicidal behavior in the military through the lens of the Interpersonal-Psychological Theory of Suicide

Suicide rates have been increasing in military personnel since the start of Operation Enduring Freedom and Operation Iraqi Freedom, and it is vital that efforts be made to advance suicide risk assessment techniques and treatment for members of the military who may be experiencing suicidal symptoms. One potential way to advance the understanding of suicide in the military is through the use of the Interpersonal-Psychological Theory of Suicide. This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide. This review analyzes the various ways that military service may influence suicidal behavior and integrates these findings into an overall framework with relevant practical implications. Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide. Future research directions, ways to enhance risk assessment, and treatment implications are also discussed.

Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies

BACKGROUND A history of self-injurious thoughts and behaviors (SITBs) is consistently cited as one of the strongest predictors of future suicidal behavior. However, stark discrepancies in the literature raise questions about the true magnitude of these associations. The objective of this study is to examine the magnitude and clinical utility of the associations between SITBs and subsequent suicide ideation, attempts, and death. METHOD We searched PubMed, PsycInfo, and Google Scholar for papers published through December 2014. Inclusion required that studies include at least one longitudinal analysis predicting suicide ideation, attempts, or death using any SITB variable. We identified 2179 longitudinal studies; 172 met inclusion criteria. RESULTS The most common outcome was suicide attempt (47.80%), followed by death (40.50%) and ideation (11.60%). Median follow-up was 52 months (mean = 82.52, s.d. = 102.29). Overall prediction was weak, with weighted mean odds ratios (ORs) of 2.07 [95% confidence interval (CI) 1.76-2.43] for ideation, 2.14 (95% CI 2.00-2.30) for attempts, and 1.54 (95% CI 1.39-1.71) for death. Adjusting for publication bias further reduced estimates. Diagnostic accuracy analyses indicated acceptable specificity (86-87%) and poor sensitivity (10-26%), with areas under the curve marginally above chance (0.60-0.62). Most risk factors generated OR estimates of <2.0 and no risk factor exceeded 4.5. Effects were consistent regardless of sample severity, sample age groups, or follow-up length. CONCLUSIONS Prior SITBs confer risk for later suicidal thoughts and behaviors. However, they only provide a marginal improvement in diagnostic accuracy above chance. Addressing gaps in study design, assessment, and underlying mechanisms may prove useful in improving prediction and prevention of suicidal thoughts and behaviors.

The interpersonal-psychological theory of suicidal behavior: current status and future directions

The interpersonal-psychological theory of suicidal behavior (Joiner, 2005) holds that an individual will die by suicide if he or she has both the desire for suicide and capability to act on that desire. According to the theory, suicidal desire results from the convergence of two interpersonal states: perceived burdensomeness and thwarted belongingness. However, desire alone is not sufficient to result in death by suicide--a third component must be present: the acquired capability for suicide, which develops from repeated exposure and habituation to painful and provocative events. The purpose of this article is to discuss four viable and timely directions for future research, given the current status of the theory.

Nonsuicidal Self-Injury, Suicidal Behavior, and Their Co-occurrence as Viewed Through the Lens of the Interpersonal Theory of Suicide

Suicidal and nonsuicidal self-injurious behaviors represent perplexing yet highly prevalent public health problems. Though the behaviors are differentiable, they frequently co-occur. The nature of the association between them, however, remains poorly understood. The interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) offers one viable framework for enhancing our understanding in this domain. In this review, we provide an overview of the literature on nonsuicidal self-injury, its relation to suicidal behavior, and how the interpersonal theory of suicide conceptualizes this relationship. Alternative perspectives and future directions are also discussed.

An examination of environmental and genetic contributions to the determinants of suicidal behavior among male twins

The purpose of the present study was to examine the relative association of genetic and environmental factors with individual differences in each of the proximal, jointly necessary, and sufficient causes for suicidal behavior, according to the Interpersonal-Psychological Theory of Suicide (IPTS; Joiner, 2005). We examined data on derived scales measuring acquired capability, belongingness, and burdensomeness (the determinants of suicidal behavior, according to theory) from 348 adolescent male twins. Univariate biometrical models were used to estimate the magnitude of additive genetic (A), non-additive genetic (D), shared environmental (C), and non-shared environmental (E) effects associated with the variance in acquired capability, belongingness, and burdensomeness. The best fitting model for the acquired capability allowed for additive genetic and environmental effects, whereas the best fitting model for burdensomeness and belongingness allowed for shared and non-shared environmental effects. The present research extends prior work by specifying the environmental and genetic contributions to the components of the IPTS, and our findings suggest that belongingness and burdensomeness may be more appropriate targets for clinical intervention than acquired capability as these factors may be more malleable or amenable to change.

Exercise caution: over-exercise is associated with suicidality among individuals with disordered eating.

We conducted four studies to examine the relationship between over-exercise and suicidality. Study 1 investigated whether over-exercise predicted suicidal behavior after controlling for other eating disorder behaviors in a patient sample of 204 women (144 with Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) Bulimia Nervosa [BN]). Study 2 tested the prospective association between over-exercise and acquired capability for suicide (ACS) in a sample of 171 college students followed for 3-4 weeks. Study 3 investigated whether pain insensitivity accounted for the relationship between over-exercise and ACS in a new sample of 467 college students. Study 4 tested whether ACS accounted for the relationship between over-exercise and suicidal behavior in a sample of 512 college students. In Study 1, after controlling for key covariates, over-exercise was the only disordered eating variable that maintained a significant relationship with suicidal behavior. In Study 2, Time 1 over-exercise was the only disordered eating behavior that was associated with Time 2 ACS. In Study 3, pain insensitivity accounted for the relationship between over-exercise and ACS. In Study 4, ACS accounted for the relationship between over-exercise and suicidal behavior. Over-exercise appears to be associated with suicidal behavior, an association accounted for by pain insensitivity and the acquired capability for suicide; notably, this association was found across a series of four studies with different populations.