Protective factors against suicidal acts in major depression:Reasons for living, Journal Club Presentation in the Dept of Psychiatric Nursing, Kothamangalam

1. Journal Club Presentation
Department of Psychiatric/Mental
Health Nursing

2. Protective factors against
suicidal acts in major
depression:
Reasons for living
Kevin M. Malone, M.D.
(Am J Psychiatry 2010; 157:1084–
1088)

3. Background
• Prior attempted
suicide and
hopelessness
are the most
powerful clinical
predictors of
future completed
suicide.

4. Background (Cont.)
• Previously hypothesized: a stress-
diathesis model for the expression of both
suicidal behavior and completed suicide.
• Stressors or trigger domains, are state
dependent
• A diathesis or threshold domain, which is
more trait dependent.

5. Background (Cont.)
• There are significant religious or
cultural modulators in suicidal
acts among people.
• Facilitating those modulators
would be an important clinical
strategy for reducing the risk for
suicidal acts

6. Objective
• Verify hypothesis
– Does number of reasons to live reduce the
proportionate intensity of suicidal acts?
– Why depressed patients want to want to live?

7. Method
• Examined the demographic and clinical
correlates of history of suicide attempts in
patients with major depression.
• Patients with or without history of
attempted suicides were compared.

8. Method (Cont.)
• Subjects
– were recruited from patients admitted to two
urban university psychiatric hospitals
– aged between 18 and 80 years
– met the DSM IV criteria for current major
depressive episode during the intake clinical
assessment, and
– were free of severe, unstable medical &
neurologic disorders

9. Method (Cont.)
• Evaluation tool :
1. SCID-P (Structured Clinical Interview For
Diagnoses-Psychiatry)（Diagnosis）
2. Hamilton Depression Rating Scale
（objective )
3. Beck Depression Inventory II（subjective)
4. Hopelessness Scale （Hopelessness）
5. Brief Psychiatric Rating Scale (BPRS)
（General psychopathology ）
6. Reasons for Living Inventory

10. Method (Cont.)
7. St. Paul Ramsay Life Experience Scale &
Recent Life Changes Questionnaire （quantity
& severity of life events ）
8. Comprehensive lifetime history of lifetime
suicidal acts
9. Scale for Suicide Ideation（current ideation）
10. Suicide Intent Scale （intent at the most lethal
and most recent suicide attempt）
11. Medical Lethality Scale （medical injury
resulting from suicidal acts）

11. Results
• Demographic features
– Age(p=0.16), Gender (p=0.41), education
(p=0.38), religion (p=0.16), Race (p=0.03) and
Marital status (p=0.55).
– Depressed non-Caucasians were significantly
less likely to have attempted suicide than
were the depressed Caucasians
– No difference in the distribution of unipolar
versus bipolar depression (Fishers two-tailed
p=0.59)- (SCID-P)

12. Results (Cont.)
• Clinical features
– Of the 84 patients, 45 had attempted suicide
and 39 had not
– The suicide attempters reported significantly
greater subjective depression (p=0.007),
hopelessness (p=0.009), and suicidal ideation
(p=0.0004), than the nonattempters.
– Details as follows

13. Results (Cont.)
Characteristi
cs
Attempters
Mean±SD
Non-
attempters
Mean±SD
Test value p value
Hamilton
Depression
Rating scale
28.9±8.2 30.5±7.9
0.93 0.35
St Paul
Ramsay Life
Experience
Scale
4.00±1.10 3.70±1.2 1.21 0.23
BPRS 38.4±7.0 39.2±7.4 0.50 0.62
Hopelessness
scale
12.2±5.8 8.8±5.5 2.66 0.009
BDI II 31.4±11.9 23.9±11.8 2.79 0.007
Scale for
suicidal
ideation
20.6±10.5 12.1±10.1 3.68 0.0004

14. Reasons for Living
Reason for
living
inventory
Attempters
Mean±SD
Non-
attempters
Mean±SD
Test value p value
Total score
138.6±43.4 181.0±40.1
4.22 0.0001
Factor-wise scores
Responsibility
toward family
21.1±8.9 26.9±6.6 3.40 0.001
Fear of social
disapproval
9.0±2.9 12.8±3.6 5.31 0.0001
Moral objections 9.7±5.8 14.8±6.7 3.79 0.0003
Survival and
coping beliefs
70.1±26.8 92.3±23.8 3.79 0.0003
Fear of suicide 21.3±6.4 24.5±7.5 2.02 0.05
Child related concern
All subjects 9.3±5.8 10.2±5.9 0.67 0.51
Subjects with
children
12.6±5.5 14.6±3.9 1.36 0.18

15. Results (Cont.)
• Correlation analysis
– Pearson correlation analysis:
– The total score for reasons for living was
significantly inversely correlated with the
scores for hopelessness (r=–0.58;p<0.0001),
suicidal ideation (r=–0.48;p<0.0001), and
subjective depression (r=–0.42;p<0.0005).
– Clinical suicidality was significantly inversely
correlated with reasons for living (canonical
correlation=–0.64, ; p<0.0001).

16. Discussion
• Findings are consistent with results in a study
of BPD
• A higher total score for reasons for living was
associated with less hopelessness（may
modulate the threshold for acting on suicidal
thoughts）
• Subjective perception of stressful life events
may be more germane to suicidal expression
than objective quantitative measures of such
events.

17. Discussion (Cont.)
• Chinese patients : depression, rather than
hopelessness, was related to suicidal intent
(Chiles JA, Strosahl KD, Ping ZY, Michael MC, Hall K, Jemelka R, & Senn B,
Reto C; 1998).
• Reasons for living, like hopelessness, may
reflect a cultural or environmental component
to determine the suicide threshold.
• Repeated exposure to depression, rather
than the duration of depression, may be an
additional risk factor for suicidal acts in
patients who experience suicidality when
depressed

18. • Religion (not differentiate;p=0.16); the
scores for moral objections to suicide
(differed stronglyp=0.0003).
• Greater moral objection to suicide
protected against higher-lethality suicidal
acts.
Reasons for living may be a more
sensitive indicator of enduring
moral/religious beliefs than is “religion of
origin” per se.

19. Recommendations
• Caution is required when generalizing the
results(the study group was small and
confined to patients with major
depression).
• Assessment of reasons for living should
be included in the evaluation of suicidal
patients.
• Treatment strategies that reduce clinical
suicidality, or that increase awareness of
reasons for living, may be complementary,
and they can be explored.

20. Critique
• The time range of the study was not told.
• Samples came from two different hospital,
however the distribution of the patient in them
wasn’t described
• The sample size was small, further more, the
process of case enrollment was not introduced
in detail
• This study used a series of scale with good
reliability and validity but the author didn’t give
message about the evaluating members & the
consistency of measurement (?)

21. Critique (Cont.)
• t-test and chi-square test were used when
comparing the subjects; (advanced
statistics method (such as logistics
regression) could be adopted ?)
• Every variables in table 1 were described
in the article except the marital status
variable.
• This paper had mentioned about
“ duration of depressive episodes ”,
however no data were shown in the table
for comparison.

22. Critique (Cont.)
• Focus on the
protective factors.
• The new discovery
• The method of this
study can be
replicated
Plus
• Representativeness
of samples
Minus

23. Further reading
• Joanne McLean, Margaret Maxwell,
Stephen Platt, Fiona Harris, Ruth Jepson
(2008). Risk and protective factors for
suicide and suicidal behavior: a literature
review. Available at
http://www.scotland.gov.uk/Resource/Doc/
251539/0073687.pdf cited on 28.04.2014