Dr. Beautrais, you have extensive experience studying suicide. Can you tell us a little about yourself and how you got interested in this subject?Dr. Beautrais: I was working on a large research study following a birth cohort when I was invited to work as the project manager on a large psychological autopsy study of suicide. From there, I became involved in studies of cluster suicide, media reporting of suicide, means of suicide, and interventions to reduce further suicidal behavior in those who had made at least one suicide attempt. I also helped to develop suicide prevention guidelines used for media, schools, colleges, emergency departments, social workers, prison officers and other groups, and became involved in policy development.
Tell us a little bit about how you designed that first study.Dr. Beautrais: I suggested that, since we could not get follow-up data on those who had died by suicide, we should design the study to include a group of people who had made medically serious suicide attempts (MSSAs), and follow them to look at outcomes and trajectories after MSSAs. So we developed a three-arm case control study of completed suicides (2020 cases), MSSAs (302 cases), and control subjects (1500), the latter selected at random from the community. We included people of all ages in all three groups. The numbers in each of our subject groups were large enough that we had stand alone studies of youth and older adult suicide. We also included interviews with significant others for each subject in our suicide, MSSA, and control groups (Borges G et al, J Clin Psychiatry 2010;71(12):1617–1628). We followed the MSSAs for five years with personal interviews, and then we checked their hospital admission and mortality records at 10 years after their index suicide attempts.
What are the risk factors for completed suicide?Dr. Beautrais: In our research, and using the research of others, we have developed a model that shows risk factors for suicidal behavior ranging from micro-level genetic factors (such as family history of mood or anxiety disorders), to meso-level family influences (such as childhood abuse and adversity, parental pathology, financial stressors), to macro-level social influences (eg, unemployment rates) and global issues (eg, cyber-supported social networking), all of which can lead directly or indirectly to suicidal behavior (Borges ibid). An individual’s vulnerability to suicide is strongly influenced by genetic susceptibility to mental health problems and, notably, to mood disorders, substance abuse, anxiety disorders and antisocial and offending behaviors. Contextual factors (means of suicide, media climate, peer suicide attempts) and life stresses are additional influences.
So why is it that only some kids with risk factors attempt suicide and some do not?Dr. Beautrais: According to this model, the reason that only some young people and not all of those who experience adversity or psychiatric illness attempt suicide is because there is variability in the predisposition to suicidal behavior. Both the stressors to which people are subject and their individual traits have to combine to result in suicide. Both stressor and the traits are potential targets for treatment to the extent that each can be modified.
Are there differences in risk factors for children and adolescents compared with adults?Dr. Beautrais: The classes of risk factors are similar in youth and in adults but have different strengths: for example, in adult suicide, childhood adversity plays a lesser role, while mental health problems play a larger role.
How about girls compared to boys?Dr. Beautrais: Females are generally protected from suicide, compared to males, because they tend to choose the less lethal methods to attempt suicide, such as overdose, while males choose more violent, lethal methods such as firearms, hanging, and vehicle exhaust. This difference in method choice may reflect male predisposition to anger and violence (Beautrais AL, Emerg Med (Fremantle) 2002;14(1):35–42.) The exception is in China, where females tend to use pesticides to overdose rather than the typical Western choice of the contents of the medicine cabinet, and since pesticides have high lethality, their suicide attempts tend to be converted to completed suicides. Overall females tend to make twice as many attempts as males, but males in western countries tend to die at three to four times the rate of females.
What are the most likely factors that lead kids to commit suicide?Dr. Beautrais: Childhood adversity. Those children and young adolescents most at risk of suicide tend to be those exposed to greatest childhood adversity—foster home and welfare care, parental separation or divorce, multiple changes of parental figures, high residential mobility, exposure to childhood physical and sexual abuse and neglect, bullying. Immediately precipitating events include bullying, relationship problems or breakups, or family or personal stressors.
We hear that issues around “coming out” and homosexuality are among the most common causes of adolescent suicide attempt. You were involved in an expert panel on suicide and suicide risk in GLBT (gay, lesbian, bisexual, and transgender) populations. Can you tell us about that?Dr. Beautrais: Beginning with our paper in The Archives of General Psychiatry in 1999, we have repeatedly shown that young people who are GLBT have a five- to six-fold increased risk of suicide attempt, as well as increased risk of mental health problems with which suicide is associated (Fergusson DM et al, Arch Gen Psychiatry 1999;62(1):66–72). This increased risk has not been demonstrated for completed suicide. It is likely to exist but be obscured by sample size and reporting biases.
And the increased risk is presumably because of the adversity of harassment and bullying issues?Dr. Beautrais: Although such findings are frequently interpreted as suggesting the role of homophobic attitudes and social prejudice in provoking mental health problems in GLBT youth, it has been considered that alternative explanations are possible. These include 1) the possibility that associations are artifactual as a result of measurement and other research design problems, 2) the possibility of “reverse causality” in which young people prone to psychiatric disorder are more prone to experience homosexual attraction or contact, and 3) the possibility that lifestyle choices made by GLBT young people place them at greater risk of adverse life events and stresses that increase risks of mental health problems, independent of sexual orientation. More research is needed to explain the reported associations.
You recently published an article about the contribution of parent pathology to suicide. Can you tell us about that?Dr. Beautrais: I have published a number of papers linking parental psychopathology with elevated suicide risk in offspring, as have colleagues like David Brent from Pittsburgh. A large body of research suggests that any parental psychopathology is associated with increased risk of suicidal behavior in offspring. Independently, parental mood and anxiety disorders tend to be associated with offspring suicide ideation and plans, while parental disorders characterized by impulsive aggression (for example, antisocial personality) and anxiety/agitation (for example, panic disorder) tend to be linked with offspring progression from suicidal ideation to attempt. A dose-response relationship between parental disorders and their children’s risk of suicide ideation and attempt has been found. Parental suicide predicts persistence of offspring suicide attempts (Goodwin RD et al, Psychiatry Res 2004;126(2):159–165; Brent DA et al, Acta Psychiatr Scand 1994;89(1):52–58).
Are there ways we clinicians can better predict or assess risk of suicide in our patients? For example, are there standardized instruments or specific questions we can ask other than, “Are you planning on killing yourself?”Dr. Beautrais: The Columbia Scale has a series of questions to explore suicide risk, and the FDA has mandated use of this scale in research, so it will likely follow that it becomes ”standardized” in clinical practice. [You can learn more about this scale at www.cssrs.columbia.edu.] Child psychiatrists need to ask patients about plans for suicide, including how many, how recently, and what kept them from following through with plans; access to means of suicide to carry out those plans, like guns, for example; and who the patient knows who has made attempts or died by suicide, and how recently.
What community interventions are effective for preventing suicide?Dr. Beautrais: Restricting access to means of suicide may prevent impulsive suicides (Nordentoft M, Danish Med Bull 2007;54(4):306-369). The U.S. Air Force has a program that combines aggressively educating commanding officers (the gatekeepers) to recognize the early signs of mental illness and refer for treatment, while at the same time equally aggressively educating service personnel to combat the stigma of mental health treatment by reframing depression, anxiety, and PTSD as natural occupational hazards. They assure soldiers that there will be no adverse career consequences to mental health treatment (Knox K et al, Am J of Public Health 2010;100(12):2457–2463). There is little else that has been shown to be effective, although many community programs are funded and implemented as if they were effective.