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Childhood Adversities Associated With Risk for Suicidal Behavior

By Jochen Hardt, PhD, Jeffrey G. Johnson, PhD, Elizabeth A. Courtney, and Jitender Sareen, MD

It has been estimated that worldwide almost a million persons commit suicide every year. 1 In the United States, the annual suicide rate is approximately 12 per 100,000. 2 In Europe, the suicide rate ranges from approximately 4 per 100,000 (Greece, Italy, Spain) to 40 per 100,000 (Hungary, Finland, Sweden). 3 Intermediate suicide rates such as 22 per 100,000 have been reported in other nations (eg, China). 4 The most common immediate risk factors for suicide are mental disorders, particularly mood and substance use disorders. Almost 90% of suicide attempts take place among persons with a current mental disorder; and approximately 80% of these persons do not receive treatment before attempting suicide. 5,6 Other suicide risk factors include chronic pain or psychiatric disorder of one's partner. 7,8

Suicide rates increased in many parts of the world from 1970 to 1990, followed by a plateau or a slight decrease in recent years. 9,10 Suicide is relatively rare among children younger than 10 years (0.05 cases per 100,000). In early adolescence (10 to 14 years), there is a 30-fold increase in risk (approximately 1.5 cases per 100,000). Among 15- to 24-year-olds, an additional 10- fold rise in risk has been observed (13 cases per 100,000). 11 Although women report more suicide attempts and suicidal ideation, men have the highest rate of completed suicide. 12,13

Epidemiology of severe childhood adversities

Documented cases of childhood physical abuse, sexual abuse, and neglect are relatively common in the general population (approximately 12 victims per 1000 children). In 2004, an estimated 872,000 children were found to be victims of childhood abuse or neglect in the United States. 14 Because many cases of abuse and neglect are not reported to authorities, the actual frequency of childhood maltreatment is likely to be substantially higher. 15 Physical punishment during childhood is common (approximately 60% of adults in the United States report having experienced corporal punishment in childhood). More severe acts of physical violence and victimization during childhood (eg, being struck with objects) were reported by 11% of adults in 1985; the prevalence of childhood physical abuse was estimated to be 1.9% in 1985.

The prevalence of sexual abuse was investigated in a recent meta-analysis of 168 studies including almost 1 million persons. 16 Worldwide, about 5% of women and 3% of men reported having been sexually abused during childhood (intercourse or anal/oral contact). An additional 13% of women and 3% of men reported less severe incidents of sexual activity (unwanted physical contact without intercourse or anal/oral contact). Moreover, 7% of women and 3% of men reported incidents of childhood sexual abuse without physical contact, such as exhibitionism.

Specific childhood adversities associated with risk for suicidal behavior

Numerous studies have investigated the associations of specific childhood adversities with suicide risk. These adversities include childhood maltreatment, problematic family relationships, socioeconomic hardship, and difficult relationships with peers ( Table). 17-28 Childhood physical and sexual abuse have been found to be particularly important risk factors in retrospective 29-30 and prospective studies 31,32 in populations of young adults 20 and older adults. 33 Problematic family relationships, including certain combinations of maladaptive parental behaviors (eg, affectionless or overprotective parenting), have been reported to be associated with risk for suicide. 34-36

Other risk factors include a history of mental disorders, 9 parental psychopathology, 37 a family history of suicidal behavior, 17 and parental financial hardship or unemployment. 21 Suicidal behavior is known to be multidetermined, with many risk factors playing important contributory roles. 9,21,38 For example, one study showed that of 70 risk factors investigated in bivariate analyses, more than 50 were significantly associated with suicidal ideation or deliberate selfharm. 39 In addition, persons who have experienced a series of adversities during childhood and adolescence have been found to be at particularly elevated risk for suicide. 35,40

Several studies have examined a variety of risk factors and their differential contributions to later suicide risk. Studies using cumulative adversity indices have indicated that the predictive power for single adversities was lower than for the combined effects of multiple risk factors. 29,38 The underlying rationale of the use of summation indices is that most persons are resilient enough to cope with a certain amount of adversity, but if adversities rise above this threshold, coping abilities fail and risk for suicidal behavior increases. 21,41 When extreme groups are compared, this can result in extraordinarily large effect sizes. For example, Felitti and associates 29 found that there was a 25-fold increase in the probability of reporting a suicide attempt by persons who reported numerous childhood adversities compared with persons who reported only one risk factor or none at all. 42

A number of different theoretical models have been developed to explain the underlying mechanisms that lead to suicidal behavior. 21,22,26,37,38 Several of these theories have included a wide range of risk factors. In particular, some recent models have focused on the association between childhood adversities and suicide risk. For example, Bergen and associates 43 constructed a model with 2 hypothesized paths from childhood sexual abuse to suicide risk: (1) via depression and (2) via hopelessness. Suicide risk was defined as increased suicide ideation, plans, threats, and deliberate self-harm. Childhood sexual abuse was associated with suicide attempts through the mediation of hopelessness and depressive symptoms. Findings indicated that hopelessness was more strongly linked with sexual abuse in boys, while depression was more strongly linked with high suicide risk in girls.

Developmental theorists have hypothesized that negative life events and interpersonal difficulties may play an important role in determining whether childhood adversities contribute to the onset of suicidal behavior. Case-control research has suggested that interpersonal conflict or separation during adulthood may play a role in determining whether neglectful and overprotective parenting during childhood predicts suicidal behavior during adulthood. 44

Longitudinal studies have suggested that low family cohesion, low family expressiveness, and high family conflict may mediate the association between maternal depression and adolescent suicidality, 45 that adolescents' relationships with their parents may moderate the association between stressful life events and depressive symptoms, 46 and that stressful life events may mediate the association between certain types of childhood adversity and risk for suicidal behavior during adolescence or early adulthood. 47 These findings and research indicating that disruption of interpersonal relationships is a predominant risk factor for suicide 21,23 suggest that suicide attempts may often be attributable to severe chronic or episodic interpersonal difficulties among persons who had particularly problematic relationships with their parents during childhood. 18,26

An interpersonal model of suicide, based on research indicating that major problems in interpersonal relationships contribute to the onset of suicidality, was developed by Johnson and colleagues. 48 This model hypothesizes that childhood maltreatment and problematic family relationships during childhood contribute to a persistent elevation in risk for suicide during adolescence and adulthood. Persons with a history of childhood maltreatment or highly problematic family relationships are hypothesized to be at particularly elevated risk for suicidal behavior when they experience severe disruptions in current interpersonal relationships during adolescence or adulthood (Figure 1 [see June 2006 Psychiatric Times, page 33] ). Research has provided support for the interpersonal model of suicide ( Figure 2). 48

Suicidal behavior is often attributable to a combination of proximal and distal risk factors. Several diathesis-stress theories have been advanced regarding biologic, psychological, and social diatheses or vulnerability factors that may contribute to increased risk for suicidal behavior in the context of elevated stress (chronic stress or stressful life events). Proposed biologic diatheses include genetic factors, prenatal factors, and persistent alterations in neurobiologic function and structure that may result from severe traumatization during childhood. 49,50 Learning and conditioning may also contribute to the development of diatheses for depression and suicidality, such as learned helplessness, hopelessness, and a persistent suppression of the will to live. 51-54

Treatment implications

Research on childhood adversities and suicidality has important clinical implications. Standard medical management of the psychiatric disorders that are typically associated with risk for suicidal behavior (eg, major depressive disorder) is appropriate and, in almost all cases, necessary. A biopsychosocial approach is likely to be particularly helpful in assessing the suicidal patient and determining the most appropriate treatment. This approach includes ruling out potential physiologic causes of psychiatric problems (eg, thyroid disease), determining whether pharmacotherapeutic intervention is appropriate, and assessing the likelihood of future suicidal behavior. In addition to treating the psychiatric symptoms that may have helped precipitate a suicidal act, clinicians should assess the history of interpersonal problems and childhood adversities that may have played an important causative role in the development of a patient's suicidal ideation and behavior.

Following a systematic assessment of a patient's history of adversities and interpersonal difficulties, appropriate treatment may often require psychotherapeutic or psychosocial intervention. Patients who are in a state of acute despair about their life situation, based on a history of profound interpersonal difficulties (eg, failed romantic, peer, or occupational relationships), often originating in childhood adversities, may need assistance in developing improved interpersonal skills and becoming more hopeful about the future.

Thus, while it is important to effectively treat the psychiatric disorders that might precede suicidal behavior, it is equally important to address interpersonal problems or crises that may lead to attempted suicide. 22

Counseling has been found to play an important role in suicide prevention among individuals with and without a history of suicidal behavior. 55 Research indicates that psychotherapeutic interventions often play an important role in the effective treatment of depressed and suicidal persons. For example, a recent large study demonstrated that patients with chronic major depression who had a history of childhood adversity were more likely to respond to psychotherapy than to medication. 56

Some types of psychological interventions, including cognitive therapy, have been found to be effective in preventing suicide attempts by persons who have attempted suicide in the past. 57 Another approach that may be helpful in treating suicidal persons is dialectic behavior therapy, 58 an approach that was developed for treating individuals with borderline personality disorder, a condition often characterized by suicidal or self-destructive behavior.

Community- and school-based suicide prevention intervention programs have been developed, although the effectiveness of such programs has not yet been well established. 59-61 Follow-up care is also likely to play an important role in effective suicide prevention. 62 Because persons who have previously attempted suicide are at particularly elevated risk for subsequent suicidal behavior, monitoring a patient's functioning and well-being during the first few weeks and months after a suicide attempt may be of critical importance.

Serious suicidal ideation is relatively common in the general population. For example, a recent large-scale epidemiologic study has indicated that approximately 16% of the adolescents in the United States may have had serious thoughts of killing themselves within the past year. 63 It has been estimated that approximately 3% of the adults in the United States have had serious suicidal ideation within the past year. 64 Most persons in the general population who have serious suicidal ideation do not receive psychological or emotional counseling. 63,64 Improved recognition and treatment of moderate to severe suicidal ideation may contribute to a reduction in the prevalence of suicidal behavior. 55

Conclusion

Research has supported the inference that childhood adversities are associated with elevated risk for suicidal behavior during adolescence and adulthood. Although several theories have been developed to explain these associations, further research is needed to test these hypotheses and to identify optimal interventions. Further research is also needed to improve our understanding of the causal mechanisms underlying these associations. 28 Acute suicide prevention strategies should focus on the effective treatment of psychiatric disorders that contributed to attempted suicide and on the interpersonal, occupational, and other psychosocial crises that may precipitate suicidal behavior.

Many patients who attempt suicide are in a profound state of despair about their life situation, and this kind of despair often develops in persons who are hopeless about their ability to overcome the challenges that they face. 59 In order to increase the patient's will to live, and to decrease the patient's wish to die, it is often necessary to assess the history of childhood adversities and interpersonal difficulties that may have caused the patient to become profoundly hopeless about the future. In addition to assessing these types of adversities, it is important to (1) establish a strong therapeutic alliance with the patient, (2) focus on helping the patient become more hopeful about the future, (3) maintain ongoing contact with the patient, and (4) monitor the patient's will to live, feelings of despair and hopelessness, and ongoing suicidal ideation.

Dr Hardt is with the Clinic for Psychosomatic Medicine and Psychotherapy at the Johannes Gutenberg University of Mainz in Germany . He reports that he has no conflicts of interest concerning the subject matter of this article.

Dr Johnson is associate professor of clinical psychology in the department of psychiatry of the College of Physicians and Surgeons at Columbia University and a research scientist at the New York State Psychiatric Institute in New York City. He reports that he has no conflicts of interest concerning the subject matter of this article.

Ms Courtney is a researcher at the New York State Psychiatric Institute in New York City . She reports that she has no conflicts of interest concerning the subject matter of this article .

Dr Sareen is with the department of psychiatry and community health sciences at the University of Manitoba in Canada . He reports that he is on the speakers' bureau for GlaxoSmithKline, Wyeth-Ayerst, Lundbeck, and AstraZeneca.

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Evidence-based References

• Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563- 570.
• Simpson EB, Pistorello J, Begin A, et al. Use of dialectical behavior therapy in a partial hospital program for women with borderline personality disorder. Psychiatr Serv. 1998;49:669-673.