Prospective prediction of first lifetime suicide attempts in a multi-site study of substance users
Introduction
Suicide rates in the US have increased by 24% over the past 15 years (Curtin et al., 2016). This trend highlights the increasing importance of understanding risk factors for suicidal behavior. Although considerable empirical work has been devoted to identifying risk factors for suicide attempts, most longitudinal research in this area has studied recurrent attempts, with relatively few studies to date on the prospective prediction of first lifetime attempts. The distinction between first lifetime suicide attempts and repeated attempts is important, however, as empirical evidence suggests caution against assuming identical processes of risk for both. Although there are likely several risk factors of equal relevance to first and recurrent suicide attempts, these behaviors may also be defined by notable differences in others. Specifically, cross-sectional studies have noted differences in sociodemographic characteristics, psychopathology, and history of childhood abuse among first versus repeat attempters, implying distinct psychological profiles between these groups (Clark and Fawcett, 1992, Forman et al., 2004, Maris, 1992, Rudd et al., 1996). Given these differences in first versus repeat attempts, it is imperative that research clarify risk factors that predict first lifetime attempts, specifically. Such work is clinically important insofar as it may inform efforts to better prevent first onset of suicidal behavior. These efforts may have considerable clinical impact as the often escalating course of recurrent suicide attempts (Goldston et al., 2015, Goldston et al., 1999, Leon et al., 1990) makes the alternative of intervening later in this course substantially more difficult.
The notable paucity of studies examining first lifetime suicide attempts prospectively is largely due to the formidable challenges in collecting longitudinal data on this low base rate behavior in the general population. And yet, prospective analyses are necessary to elucidate the temporal nature of the relation between suicide attempts and related risk factors (i.e., to distinguish predictors from correlates). One solution to this challenge is to examine first lifetime suicide attempts within a sample that has been identified as being at high risk for suicidality, such as substance users (Borges et al., 2000, Wilcox et al., 2004).
The present study therefore sought to examine prospective predictors of first lifetime suicide attempts in a large sample of adults receiving treatment for substance use problems. We evaluated sociodemographic characteristics, physical and mental health indicators, substance use characteristics, and early adversity in the form of childhood abuse as potential risk factors. Specifically, and based on prior research documenting associations with suicidality more generally, the current investigation focused particularly on gender (Nock et al., 2008), limitations in physical health functioning (Kaplan et al., 2007), mental health treatment use (Luoma et al., 2002), depression (Nock et al., 2009), suicidal ideation (Brown et al., 2000), intravenous drug use (Cheek et al., 2015, Liu et al., 2014), polysubstance use (Borges et al., 2000, Lynskey et al., 2006, Smith et al., 2011), childhood physical abuse (Norman et al., 2012), and childhood sexual abuse (Maniglio, 2011) as potential risk factors for first lifetime suicide attempts.
Section snippets
Participants and procedures
Data for the current study were drawn from the National Treatment Improvement Evaluation Study (NTIES; Gerstein et al., 1997), a large, five-year (1992–1997), multi-site study of addiction treatment programs receiving public funding in the United States. The NTIES study includes 4526 clients who completed all intake, treatment discharge, and follow-up interviews, and all participants provided informed consent following an explanation of study procedures. Participants were recruited from 78
Preliminary analyses
Correlations among the primary study variables are presented in Table 1. Prospectively occurring suicide attempts were correlated with sex, baseline health-related work impairment, history of psychiatric service use, history of depressive symptoms, history of suicidal ideation, childhood physical abuse, and childhood sexual abuse. Approximately 110 (3.1%) of the participants experienced their first lifetime suicide attempt within the longitudinal follow-up phase of the study. Additional
Discussion
The goal of the present study was to prospectively examine risk factors specific to first lifetime suicide attempts in a large, high-risk sample (i.e., substance users). We found that physical health-related work impairment, history of suicidal ideation, and childhood physical abuse were each uniquely associate with the first occurrence of a suicide attempt. This study fills an important gap in the empirical literature on suicide; to date, there is a paucity of longitudinal studies on risk
Footnotes
None.
Contributors
The study was conceived by Zoë Trout and Richard Liu, both of whom were involved in the design of the study as well as interpretation of the data, with input from Evelyn Hernandez and Evan Kleiman. Zoë Trout composed the Introduction, Methods, and Discussion sections of the manuscript, Richard Liu conducted the analyses, Evan Kleiman composed the Results section and constructed the tables, and Evelyn Hernandez prepared the abstract and contributed to the tables. All authors were substantially
Funding/support
Preparation of this manuscript was supported in part by the National Institute of Mental Health of the National Institutes of Health under Award Number R01MH101138. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.
Acknowledgements
None.
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